That this House takes note of the future of adult social care given (1) the recent reports from the House of Lords Adult Social Care Committee (HL Paper 99) and the Archbishops’ Commission on Reimagining Care, (2) the Care Quality Commission s local authority assessment duties which commence from 1 April, and (3) His Majesty’s Government’s stated intention to publish a social care plan in Spring 2023.
My Lords, I am extremely grateful for this opportunity to introduce a debate which has a particular resonance in this House and a real urgency. I am very pleased that so many Members of the House have been able to take part today, particularly members of the Adult Social Care Committee. I am delighted to share the debate with the Church, alongside the right reverend Prelate the Bishop of Carlisle and the most reverend Primate the Archbishop of Canterbury. We are considering two reports, in respect of which Church and state are joined in values and prescriptions. We are also anticipating some of the changes coming down the track. I regret that we do not have the national care plan today, as we had hoped, but we can anticipate the CQC changes. There is a lot to discuss, and the debate will go far wider than the two reports before us.
We have not yet had a reply to our Select Committee report, A “Gloriously Ordinary Life”, which was published last December, but I hope the Minister will be able to say something about the national care plan, not least when it will be published and when we can debate it. Perhaps he could answer one or two of the outstanding questions, such as: will the £500 million workforce funding plan be halved?
I said that this debate has a particular resonance in this House, and there can be very few noble Lords who have not had the experience of caring for someone close to them. It is estimated that one in two of us is likely to become an unpaid carer by the time we reach 50. For some people, it is a lifetime’s commitment; for others, it is an overnight change in circumstances that leaves them with a future which is darker and very different. Overall, at any one time about 10 million adults of all ages come into contact with adult social care. When it matters so much to so many people, we are bound to ask why, as a whole, it has been out of sight and off the public radar for so long. Perhaps a better question is: why do we not care more about it—sufficient to make it the social and political priority it needs to be? What do we need to change in order to care more, and to plan and provide more effectively for a fairer and more robust service? Why is it not a national imperative? The answers to these questions are rooted partly in human frailty and partly in the history of the NHS and the time in which it was born: a time when women did not work and people did not live as long.
What is significant about the two reports is not that they reach similar conclusions, but that they are rooted in similar values which start from the assumption that adult social care has so far been denied the opportunity to be what it could and should be: a service that enables people to live a gloriously ordinary life which is fruitful, active and valuable. The support provided is not transactional or contractual; it is based on a generous and mutually supportive set of relationships which reflect what, at best, being cared for and caring mean. The Archbishops’ Commission’s report, Care and Support Reimagined, describes it as a fulfilled life based on love, mutuality and interdependence, embedded in the concept of a national care covenant.
My Lords, it is a privilege to follow the noble Baroness, Lady Andrews, and to have a chance to thank her for her outstanding chairmanship of the committee. I also thank our superb professional team.
Our report’s introduction describes adult social care as
“largely out of sight and off the public agenda until we need it.”
That is in strong contrast to the NHS, despite there having been, in the last 25 years, no fewer than eight Green Papers, four White Papers, three cross-parliamentary committees and two full government inquiries. We should ask ourselves why it is that a sector so vital to one in five of our population at any one time, to the overall health of the nation and to the functioning of the NHS has been so overstudied and, as we found, so underresolved over such a long period.
It is mostly, I suggest, because it has “just grown”, and is now highly and almost unmanageably complex. I give just three examples. The first is funding. Public spending on adult social care, which is around £22 billion, is a mix of central government grant and council tax. Some £11 billion comes from private expenditure. At least £132 billion is contributed by an army of unpaid carers, often family. Actual funding arrangements vary, from self-funding care home residents, through a mix of local authority or NHS top-ups, to the fully publicly funded.
The second example is commissioning. Commissioning responsibility is split, in England, between 152 local authorities and the NHS.
The third example is provision, which is equally complicated, with 95% of residential and nursing beds being in the independent sector. Agencies provide some home care, and, in all, 18,000 organisations run around 34,000 establishments. National accountability and responsibility are, of course, divided between the levelling-up department, the NHS and the Treasury.
My Lords, I have had the privilege of being a member of the Adult Social Care Committee, chaired by the noble Baroness, Lady Andrews, and I am now a member of the Select Committee on the Integration of Primary and Community Care, chaired by the noble Baroness, Lady Pitkeathley, so I have come to think of the noble Baroness, Lady Shephard, as my partner in crime on both of those, as we question a series of professionals coming in to try to tell us just how bad the situation is currently.
We are having this discussion in the run-up to a general election, nearly a decade on from the passing of the Care Act and more than two decades on from the royal commission on the future of long-term care, and I suspect we are no nearer a resolution now than we were then. But I think it is important, as we are in the run-up to a general election, to make a few recommendations to all those people in political parties who are drawing up their manifestos.
The first is that there needs to be an update of the Dilnot commission proposals. We need a realistic assessment of the needs of older people and adults with disabilities for long-term care and the extent to which that can be funded by individuals’ capital assets. A crucial element of that assessment has to be the availability and cost of trained skilled staff, because that is a huge issue in the sector. For the first time, a further element needs to be the number of people ageing without children—that is a phrase which covers a number of different circumstances. We have now got to the point where Secretaries of State for Health admit openly that we have a health and social care system predicated on the fact that the majority of care, and management of care, will be done by families. There are at least 1 million people who do not have children, and it is children we are talking about. We do not even record the number of men who do not have children; we do not have that basic data, and yet we are expecting them to manage care. Unless and until we do that, there will be a profound effect on those people when they come to moments of crisis, such as hospital discharge. We need the Government to start to really look at this issue.
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The Archbishop of Canterbury
My Lords, I am very grateful to the noble Baroness, Lady Andrews, for securing this important debate, for her Select Committee’s outstanding report on adult social care and for including the recent report of the Archbishops’ Commission on Reimagining Care in the debate title. I am also very grateful to my noble friend the right reverend Prelate the Bishop of Carlisle, who co-chaired the commission. He will be addressing some of its specific recommendations later. I would like to speak about the motivation for its commissioning by the most reverend Prelate the Archbishop of York and myself.
First, in common with those of almost every political, religious or social belief, we think the current care system is broken. It cannot be tweaked; it needs reimagining. We have had the same reason for the Church reports on housing and, I regret to say, the same indifference to them from the Government, despite the enthusiasm of the industry in both cases.
Secondly, each of the reports we commissioned is based in Christian values which have guided this country at its best for centuries but overlap almost exactly with those of other faith groups and those of humanists. We were discussing this, over an Iftar meal on Monday evening, with Muslim leaders from across the country. Anything like housing, care, households, families, ethnicity or race has to have a value base which is realistic, mitigates possible harms and exalts the value of human dignity. The values must also maintain a healthy realism on the tendency of individuals and institutions, including government and the Church, to look for short-term fixes in their own interests, not long-term solutions for the common good. The list of reports and White Papers, so eloquently put by the noble Baroness, Lady Shephard, which really should have ended with “and a partridge in a pear tree”, illustrates this point finely.
Thirdly, each report makes demands of government but also of every other aspect of society. In terms of care, it may be companies and businesses, charities, families and households, and we always point to the needs for the Church of England to improve and up its game. Every part of society is needed to be involved in care.
This commission was started in April 2021 and produced its final report in January of this year. We need an understanding that care and support is not an end in itself but the means by which every person can begin to fulfil their potential as a human being as it varies through life. The commission’s central recommendation is for the development of a national care covenant. This would clarify the mutual responsibilities of us all—individuals, families and communities, alongside local and national government—in relation to care and support.
My Lords, I, too, start by thanking the noble Baroness, Lady Andrews, for securing this debate today, for her very sensitive chairing of the Adult Social Care Committee, on which I was privileged to serve, and for her tireless commitment to improving the landscape of care, which is a real conundrum of our time. We must “reimagine” it, as the most reverend Primate urges, and, while many have claimed that they will fix it, it remains unfixed.
No one chooses to be cared for, or to become an unpaid carer. If the noble Lord, Lord Laming, was here, he would tell us that either could happen to any one of us at any time. But, as our report points out, both are invisible. This invisibility leads to confusion around what social care is and who delivers it. While the NHS is there “from cradle to grave”, individuals who do not currently need care cannot imagine they ever will and therefore fail to plan for such a time.
I draw your Lordships’ attention to my interests as laid out in the register, in particular my work as chief executive of Cerebral Palsy Scotland and also with people with neurological conditions. My lived experience says that we must not view social care through the prism of the NHS. Many of the people I work with are neither ill nor old; they just need help to be able to live what our committee’s report called
“a gloriously ordinary life”.
I know people who choose to study with the Open University and miss out on all those extracurricular experiences that I am sure many of us look back on with fond nostalgia, because they cannot be confident that they will be properly supported to get around campus and get to lectures like their contemporaries. I know parents who have to give up their own professional lives when their adult child leaves formal education because the system assumes that they will; and I know people who remain living with elderly parents because there is no suitable accommodation for people under the age of 65. Our committee heard from many witnesses who were not ill or old but could not get the right support. Worse than that, they were worried that, if they contacted their local authority for a review, the support they did have would be reduced.
My Lords, as another member of the Adult Social Care Committee and declaring my interests in the register, I am pleased to make a short contribution to this very important debate. I too congratulate my noble friend Lady Andrews on securing this debate and, more importantly, I praise her knowledgeable and passionate chairing of the committee and her opening speech today, which I fully endorse.
The evidence we received throughout our inquiry was for recognition and support for social care in general and unpaid carers in particular, as a largely hidden workforce. The evidence was compelling, inspiring but also at times harrowing, and I praise all the contributors. As the committee stated at the beginning of our report:
“Creating a sustainable social care system in which people, their families and friends can thrive is a national imperative”.
A sustainable adult social care service must be seen as
“an indispensable partner to the health service”
and clearly and genuinely integrated with it. Surely no one can disagree with that. As we further noted, the new integrated care boards and systems must be at the forefront of realising this ambition.
As we have heard, to achieve it, investment and resources must be forthcoming. Again, the committee made clear that the Government must increase the financial settlement for adult social care over three years and then commit to sustaining realistic, long-term and protected funding for the sector to enable the robust planning of services. So it was clearly disappointing that there was no mention of sustained funding in the Budget, or any recognition of the need to reform the social care funding system based on the laudable principles established by the Dilnot inquiry.
Linked to this funding settlement is, as we have heard, access to the key benefit for carers—carer’s allowance. It is the lowest benefit rate of its kind—I do not apologise for repeating that—and it is not reflective of the extraordinary value of unpaid carers, as we have already heard today. Some of the most shocking evidence we heard from unpaid carers was about families’ lives being suddenly and unexpectedly overturned by some catastrophic event, perhaps a critical or terminal illness or a life-changing accident, with their immediate income and long-term financial planning in absolute turmoil.
My Lords, I declare an interest as the recipient of a personal health and social care budget. It was a great pleasure to serve on the Adult Social Care Committee last year, and I congratulate the noble Baroness, Lady Andrews, on her very skilful chairing, which ensured that the voices of all those involved in social care were heard and listened to.
One of our significant recommendations is that the Government work with local authorities, the voluntary sector and social care providers to embed the principles of co-production. That will give staff the necessary skills and the balance of power to the individual receiving care.
Co-production bloomed with the passing of the Community Care (Direct Payments) Act 1996, which was initiated by the noble Lord, Lord McColl of Dulwich, in his 1993 Private Member’s Bill. I remember watching the late Baroness Masham of Ilton championing the legislation with skill and wisdom; I think I can speak on behalf of all of us when I say that we miss her fierce presence today and I pay tribute to her inspirational legacy.
The Act enabled disabled adults to purchase social care tailored to our individual needs, giving us choice and control; it is what enables me to be a Member of your Lordships’ House today. Under the Act, disabled people established local centres for independent living and worked with their LAs to educate and support other disabled people in employing personal assistants to meet their needs using the co-production model. Regretfully, the committee heard evidence that this essential support has eroded with a lack of investment. Older, disempowering models of social care provision such as institutional care and threadbare support at home are now commonplace—we need to get back to co-production.
Our report proposes specific funding to ensure that local authorities commission peer-led, independent organisations to promote innovation and capacity building. Information, advice, advocacy and peer support are key; local authorities already have duties under the Care Act 2014 to provide information and advice. Part of the funding identified in the current White Paper should also be allocated to making direct payments and personal assistance a realistic option.
My Lords, it is an honour to follow the noble Baroness, Lady Campbell. I learned so much from her. It was also an honour to have served on the Adult Social Care Committee under the expert chairmanship of the noble Baroness, Lady Andrews, and I also pay tribute to the excellent support staff that we had. When I joined the committee, I thought it would be an important learning experience in an area that I was not particularly familiar with. However, as we met and listened to witnesses, it became apparent that this was not an academic exercise but, sadly, a practical guide for me and my family, as it is in one way or another for every family in the country.
I will concentrate on just one area of the report, on page 45 with the heading “Navigating the social care system: a constant fight”. Paragraph 147 states:
“Whether it is trying to get support for themselves or for the person they provide care for, unpaid carers often find that they are left to their own devices when it comes to navigating the adult social care system”.
As stated in our report, witnesses found it difficult to organise formal support for the person they care for.
Because of the difficulty of accessing care and support, social workers and local authorities are seen as gatekeepers, and there is little trust in the system’s ability or willingness to provide help. How sad, as my noble friend Lady Fraser said, that some unpaid carers told us that they live in fear of assessments which they see as a process designed to minimise their needs so as to deny them support.
I totally understand. My mother is suffering from brain cancer and has 24/7 care at home in Liverpool. We have experienced, and are experiencing, both some of the best and the worst that the system has to offer. On the positive side, the care and attention of the Marie Curie Hospice in Woolton, Liverpool, led by the deeply sensitive and professional palliative care doctor Dr Mark Mills and his team, has been exemplary. While mum is at home, the staff at the hospice have been an enormous comfort and help, not just to my mum but to my sister and brother too.
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Today’s realities are very different. Many of those who need care or support in order to care, particularly as unpaid carers, battle their way through a barrage of services, systems, agencies, tests and charging regimes that seem designed to deter demand until needs become extreme. The daily realities are set out in our report in the words of those who live that reality. We were extremely privileged to hear so many witnesses share their experiences and their lives with us—people who have lost jobs, homes and health in the process of caring. That co-production helped our report to reach a wider audience, and we owe them a huge debt of gratitude, as we do our superb committee staff—Megan Jones, Daphné Le Prince-Ringuet, Alasdair Love and Abdullah Ahmad—our wonderful special advisers, Jon Glasby and Anna Severin, herself an expert by experience, and every member of the committee who gave so much time and insight and shared their own experiences. I am sorry that the noble Lord, Lord Laming, could not be in his place today. He kicked this off through the Liaison Committee and helped us settle on a topic in a very well-worked field which has not had the attention it deserves—the plight of the unpaid carer.
Caring goes on day and night, without public acclaim, in private, behind closed doors, and with pitiful reward. Indeed, unpaid carers were described by no less than Jeremy Hunt, when chair of the Health and Social Care Committee, as the least visible aspect of a service which, overall, suffers from “entrenched” invisibility. Understanding what that means for adult social was a task we undertook, and trying to work out how to dismantle it consumed much of our inquiry, because invisibility takes many forms and has many impacts. Adult social care may be a nationally funded service, but it is locally delivered. It does not have a coherent national profile; it is fragmented across 18,000 organisations. While care homes are, tragically, more in the national spotlight because of Covid, the rest of the service is below the radar until you need it—when you cannot find it. At its most graphic, although it is the same size as the health service and of equal importance to the well-being of the nation, its budget is a fraction of the NHS’s: £17 billion compared with £153 billion. As we know—this statistic is all too familiar—a third of local government funding has been lost in the past decade. Compared with the NHS, adult social care is not the national treasure it should be.
This is not a remote failure. At the start of 2022, 2.6 million over 60s were living with some form of unmet need, such as the basics of washing and eating, and 2.2 million hours of care had been lost in the first three months of that year. Half a million people are now waiting for assessment. Care support, as it was described to us, even when it comes with the best of intentions and people, can still make people feel very grudging and guilty rather than supported.
The relative invisibility of the service is compounded by a lack of information. We were astonished by what we did not know. The number of unpaid carers is estimated at between 4.2 million and 6.5 million, but there may be many more who are not registered because of the problem of identification. We know that they save the country £132 billion a year, but less well known is that they receive the lowest of all benefits—£2 an hour, or £69.70 a week. To get that, you have to work for more than 35 hours a week and fulfil a means test. It is no wonder they are worried sick about heating and food bills, and that they do not manage to stay in work—and when they do, the support they get is significantly less than that offered by other countries. Put together with a paid workforce which is not valued for its exceptional skills and which works for less than the minimum wage, it is hardly surprising that they are driven out of a job they love or that it is so hard to find a personal assistant these days.
The reports provide all the evidence any Government would need as to why this is urgent, and they set out a plan for change. Both say unconditionally that there must be a radical shift in perception and investment in all parts of the service, so that adult social care can become the transformational life-enhancing service it could have been designed to be. We heard someone say to us informally, “The NHS saved my life. Adult social care has helped me to live it.” That was a graphic description.
The greatest failure has been the failure to plan strategically for an ageing society. The result is that we see longer life as something to be borne, a burden, a nuisance—and that cannot now just be fixed. That needs to be seen together with the repeated failures to cap residential care; to implement the Care Act 2014; to integrate social care into the health service, until recently; to prepare a realistic adult workforce plan based on skills, a full pay review, and a resilient service that people feel proud to be part of; and to challenge the false economy of underinvestment in adult social care year on year, at a time when the impact on the health service alone is immeasurably worse.
Add to that the failure to honour the promises that have actually been made to unpaid carers: better leave, a better carer’s allowance, better respite. It is a catalogue of disappointment. There has been so much analysis and diagnosis, so much hand-wringing over failure and so little meaningful change.
But the future is catching up with us: we will have a population of about 2 million in 10 years’ time who will be ageing without care, with no family to look after them. Where are the plans for these people to get the support they need? At the same time, if we are smart, we have new technologies and new devices that can help reduce risk and plan for where the skill gaps are. I think of the wonderful Tribe Project we came across, which does outstanding work but which ought to be all across the country. We saw so much good practice in local authorities as different as Wigan and Somerset, and an appetite for innovation and for engagement with the community. There are tremendously creative ideas at local level, all waiting to be galvanised and shared.
The most challenging question of all is what needs to change before we care more sufficiently to make adult social care a national imperative. Four things are necessary: to raise adult social care’s voice, visibility and agency; to revisit and build on what already could work better; to build capacity through workforce skills and strategic investment; and to change the way we view it—as a unique social good in itself, not simply part of propping up the NHS.
First, and simply, adult social care has to have a louder, more coherent and challenging voice, so that it can be more powerfully championed inside and outside government. It has been too easy to get away with simply patching up adult social care in an emergency and parking the workforce strategy. It has not had the power to fight for priority, which is extraordinary when we think of the power it has to change lives, for better or worse.
We recommend what looks like an easy reach, but which could make a huge difference: a commissioner for care and support to lead that fight, to raise that voice, to hold Ministers’ feet to the fire, to do some shaming if necessary, but also to celebrate and mobilise the best. That champion will be a champion for unpaid carers as well, to make sure the Government cannot get away with any more delay and procrastination there.
Reducing invisibility means knowing more: to do better, we have to fill those information gaps. We have to have a national plan for data on adult social care, so that we actually know who is caring when and where; so we know where the gaps are, where the resources can be deployed best, and what we need to invest in most effectively. That could also be helped by creating an R&D network akin to that in the NHS, so that we could trap ideas, innovation and good practice. If we have increased visibility, we can have more and better opportunities to design more flexible services—more “choice and control”, as is described, whether through better access to better packages that work more effectively, more personal assistants with less bureaucracy, direct payments that actually get to where they are needed, or giving respect to enable unpaid carers to give their own expertise more effectively, as full partners in providing care.
I have been banging on about housing in this House for well over a decade. We need accessible and adapted housing, so that we do not have thousands of people stuck in hospitals. They should be able to go to a safe home and be looked after safely, not just at times when care is needed, but urgently, as a matter of sensible planning for an ageing society. The social care White Paper recognises the role of housing, so I very much hope we will see some funding come forward to actually meet that desire.
So much of what is in these reports is not new; so much was set out in the Care Act 2014—principles, processes, project design. It is tragic that it has been on the statute book but not implemented by local authorities, which have not been able to put the training plans in place; they have not been funded to do so. That leads to the inescapable reality that adult social care needs a national investment strategy.
Compared with the costs of failure and delay, adult social care is not expensive. Again, when the Chancellor was chair of the Health and Social Care Select Committee in 2017 he called for an annual increase of £7 billion between 2021 and 2023—this at a time when energy companies are scooping up hundreds of billions. This is the same Chancellor, though, who did not put any additional money for adult social care in the Budget. I ask the Minister what he thought of that.
In conclusion, so much of this is not about money at all; it is about moving away from the culture and perception of a service where the dominant language is not that of celebration but of “burden”, of “dependence”, of “failure” and of “crisis”, towards one which values and empowers the people it serves and those who do the caring, paid and unpaid. Among the assumptions which must change are the long-held assumptions that disabled adults and older people are not capable of living a life that is as rich and fulfilling as everyone else’s; that social care work is unskilled work; and that families will always be there to care.
Let me put it another way and quote Social Care Future:
“We all want to live in a place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us.”
It seems to be the most modest of ambitions—so many of the things that are asked for are so modest—but one that is well within reach if we choose to do it. The greatest risk, as our report says, is not to change, and the hardest question is, if not now, when? We have waited long enough to make adult social care a national treasure as well as a national imperative. I really hope the Minister agrees with me this afternoon. I beg to move.
The effect of all this on those needing social care, almost always urgently, is that they face a lack of comprehensible information even to get into the system. They then find, all too frequently, a shortage of provision, delays, confusion and unclear accountability. Our report contains wonderful examples of good practice and ingenious solutions to these problems, but also graphic evidence from people struggling to cope at the same time with grievous personal or family situations via a massively complicated system. Their courage, and that of those caring for them, is immense.
The effect on the NHS of neglecting social care must also be tackled. We all know the NHS is experiencing unprecedented problems, some resulting from the pandemic, of growing demand and staffing and funding difficulties. How acceptable is it that every single day 10% of hospital beds are occupied by patients who do not need them but cannot be discharged because social care is not available, and that preventative social care is not available to avert many hospital admissions in the first place? The NHS has got to be fixed, but it cannot be fixed without first fixing social care.
The Government know this, and, to their credit, they do have solutions, not least from reports that they themselves have commissioned, such as the Dilnot report of 2011; from legislation they have passed, such as the 2014 Care Act; and White Papers they have published, such as People at the Heart of Care in 2021. For the one in five of us, and for the health of the nation, it is now time to see some implementation.
The second recommendation is that we need, as a matter of urgency, the development of legislation, policy and protocols that governing the use of, and access to, data of health and social care users. Currently, we have a system in which the sharing of information just between the departments of an acute hospital is utterly random, and between the different parts of the health and social care system, between acute and community health, and social care and local authorities, is non-existent. We talk about care pathways, but they are rapidly becoming a fictional idea. I defy anybody—a professional, a user or a carer—to know what a care pathway is and how to get from one place to another. Unless and until we sort this, we will have an ineffective, expensive mess: duplication of services on the one hand and lack of access to basic services on the other.
My third point is that, as regulators of health and social care—particularly the CQC as it goes into the new single assessment framework—look at these new integrated care systems, they need to specify who is responsible not just for a single episode of care but for care pathways. We have not begun to see that yet, and it is fundamental to our ability to build a system which works in the long term.
I suspect, in the run-up to the election, there will be calls from some people to say that we ought to take care away from local authorities; that for the sake of efficiency, we either put everything under the NHS, or outsource much more to the voluntary sector, charities and faith groups because they will make better use of limited resources. I would caution against that. Local authorities have a public equality duty and access to population data, and to data about individuals within their areas. I think it is crucial that we stick with them.
Finally, as president of the National Association of Care Catering, I want to make a plug for meals on wheels: old-fashioned, much denigrated, but an absolute lifeline to people. I had the privilege of being an undercover meals-on-wheels volunteer a couple of years ago—I said I was a trainee; I do not think most of them would have given me the job. The immense value of low-tech services to older people cannot be overestimated. We really should make sure that those services which give great value are maintained for older people.
Funding matters. If it is our starting point, we will fail. Once we know what kind of care system we are aiming for, we can begin to see how it could progressively be paid for. Much as I admire His Majesty’s Treasury, if we start with it, we will be pragmatic but are unlikely to be imaginative.
The revolutionary value that should be at the heart of our social care system is interdependence. In the report, it replaces the myth of autonomy for each person. No one is autonomous; we all rely on others at every point of life and death. We must recognise that reality, with its beauty and dignity. Interdependence builds community; autonomy creates atomisation. Atomisation is painfully described in a book with that name as the title in the English translation but which in French is called Les Particules Élémentaires, by Michel Houellebecq. Autonomy takes us to Huxley’s Brave New World; interdependence overcomes differentials of class and power and offers the prospect of robust compassion. Autonomy ends up with dependence on the state, because we all need support. It is a myth, and the truth is found in the prayerbook phrase
“whose service is perfect freedom”.
Interdependence takes us away from a narrow argument about who should provide care and instead says that responsibility lies with all of us to different degrees: with families and communities; with government, with regard to funding and implementation; and with NGOs, the voluntary sector and community actors such as churches, with regard to participation.
So I ask the Government and the Minister: will they begin, as we move forward, to reimagine the care system and to look at setting out clearly through a national care covenant the mutual responsibilities we all have?
For many of working age, what they want and need are good PAs, personal assistants. These are professional enablers who help you do what you want, whether it is getting to work, feeding you, taking you to the pub or, in a case highlighted to us during the course of our inquiry, enabling someone to pay their respects to Her Majesty Queen Elizabeth II at the gates of Balmoral—something that could never be assessed as an outcome by a local authority care package.
Yet there are not enough PAs. You are really stuck if your PA is ill or does not turn up, and the challenges of becoming an employer and dealing with recruitment, PAYE and pensions too often just puts people off. We heard evidence in our committee from Enable Scotland, a charity which works with local authorities across Scotland delivering their PA model of care, where the charity deals with all of those employer issues and provides a personalised service to people who want it. I encourage the Minister to look at this model.
For too many, as we have heard, contact with social care services is forged in crisis and fraught with difficulty. The providers of last resort are family and friends, who are thrust into roles they neither sought nor are supported to fulfil as unpaid carers. I believe the Minister himself has been a carer and appreciates the challenges. He has called unpaid carers
“the backbone of the system”—[Official Report, 20/2/23; col. 1434.],
but I am afraid that, despite warm words, unpaid carers continue to be taken for granted.
As the noble Baroness, Lady Andrews, pointed out, carer’s allowance is the least generous benefit and considerably less than the minimum wage. There is little respite, little support and severe financial implications, but too many families feel they have no other options.
If we do nothing else in the Government’s forthcoming social care plan and future work, I urge the Minister to improve identification of unpaid carers, including children who care. Self-identification is not working and neither are the formal systems set out in the Care Act. There are still so many gaps. We heard about the No Wrong Door initiative successfully employed in Liverpool. How can the Minister ensure initiatives such as this are more widely adopted?
As others, particularly my noble friend Lady Shepherd, have said, over the years, Ministers have been given a veritable shopping list of solutions. I hope these two reports and our debate today can add to the impetus the Minister needs within government, because the last thing people who rely on care want is yet another plan that fails to be backed up with action.
So access to carer’s allowance must immediately be made easier by lowering the threshold of carers’ hours and ensuring that the earnings limit is uprated in line with the national living wage and in law. Further, the DWP should fundamentally review the carer’s allowance and report back to Parliament within one year to give some hope of financial support for this army of unpaid carers—I would be very grateful for the Government’s views on that today.
Touching very briefly on workforce, we wait expectantly for the Government’s social care plan and the workforce proposals within it. The current situation of low pay, limited career opportunity and thousands of vacancies in the sector is an utter disgrace. The committee’s recommendation that the Government must produce, with people who work in and draw on adult social care, a comprehensive, long-term, national workforce and skills plan, is an absolute priority.
Finally, it is essential that a laser focus is maintained on adult social care, and particularly on the incredible work and dedication of unpaid carers. To this end, the committee strongly believes in the establishment in the next 12 months of a commissioner for care and support to act as a champion for older adults, disabled people and unpaid carers. Critical early priorities for such a commissioner would be to include oversight of a government-commissioned, independent public review of the Care Act 2014, working with local authorities to ensure that the Act is fully implemented, and also to set up, as we have heard, the identification of the millions of invisible unpaid carers, perhaps through NHS patient records—with their permission—to ensure a mechanism to provide carers with information, self-care and digital resources to support them. They deserve nothing less.
This is an urgent problem. In a survey of 1,000 people by the LGA last year, 77% found it more difficult to recruit a PA—that has been my own experience. Not enough is known about the role of PAs. One witness told us that if it were recognised as a valuable and skilled role, “many will intuitively see that as a vocation—as a career”. Raising its profile would attract more people to the profession. The report recommends that a government-led workforce revaluate the pay and working conditions of PAs, and appropriate training.
To conclude, our committee endorsed Social Care Future’s simple challenge for social care: to make possible the ambition of people who “want to live in the place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us”. Indeed, our report is titled A Gloriously Ordinary Life—that was how one witness described their aspiration. The Government have the power to ensure that this is not a pipe-dream.
On the other hand, the experience we have had with the local authority assessors has been woeful. On 9 February, my mother was assessed by a nurse via Zoom. The nurse was in Kent and my mother was over 200 miles away, unable to communicate, in her bed in Liverpool. The assessment was to decide what the immediate next step for her care plan should be. The report, compiled by a nurse who has never met my mother, was then to be sent to an unknown panel of people who also have never met her to decide the best course of treatment and care. This absurd assessment was executed over a three-hour Zoom call seven weeks ago, and as I stand here today, we have heard nothing. The system is sadly broken. As we speak, we should consider that people up and down the country are battling to understand an incomprehensible system at the same time as trying to care for their loved ones as best they can.
During the committee’s deliberations, we understood that we were not going to be able to change a system that desperately needs an overhaul, but we were attempting to move the dial a little to bring some clarity to people doing their utmost to care. Our committee has made 36 recommendations, and that only scratches the surface. Each one is important. My own experiences have made me think more carefully, for example, about the point forcefully and powerfully made by the noble Baroness, Lady Barker, about people without children ageing. Like the noble Baroness, Lady Andrews, and the noble Lord, Lord Bradley, I urge my noble friend the Minister to look carefully at recommendation 9, where we ask the Government to establish a commissioner for care to bring about a more accessible adult social care system. I concur with the suggested actions on page 45 of the Archbishops’ report that assessment and budget planning should be simple and consistent, and that care planning services should be focused on what matters to people.
I appeal across this House to all parties and to none to help that commissioner to take the politics out of care. We must come together to find and implement an urgent solution so that people up and down the country can fulfil with dignity what the late Lord Sacks wrote in his book Celebrating Life—that the supreme act of caring is to make a difference to someone else’s life. In his book the Dignity of Difference, he said, “To care is to look into the face of the other and see their uniqueness, their vulnerability and their pain”.