................................................................................ ON THE RECORD RECORDED FROM TRANSMISSION BBC-1 DATE: 22.10.95
................................................................................ JOHN HUMPHRYS: Good afternoon. The debate is hotting up again over whether a Tory Government should edge away from offering us cradle to grave care. Should old people have to sell their homes to pay for the nursing they might need? I'll be asking the Health Secretary, Stephen Dorrell, On the Record ... after the news read by Moira Stuart. NEWS HUMPHRYS: - it didn't take long after the summer holidays for the first political crisis to blow up...approximately twenty minutes, in fact, before the Government was in deep trouble over the prison service. But it didn't take long for it to go away either.. a storming performance by Michael Howard in the House and that was that - for the moment anyway. But there is something on the agenda that can't be resolved with one quick knock-out on the floor of the Commons and that's because it has the potential to re-open old divisions within the party. Public spending - how much need the State do in a civilised society? The hot potato at the moment - how to meet the nursing bills for old people. Should the State pick up the cost? That was then first question I put to the Health Secretary, Stephen Dorrell, when I spoke to him earlier this morning. STEPHEN DORRELL MP: The State has picked up a dramatically larger share of looking after the care of elderly people over the last fifteen years. It was a waiting list position, when I first became an MP I used to have to spend large amounts of time every month looking for places in local authority homes for elderly people who were clearly incapable of looking after themselves at home. That's a waiting list that had been abolished because the government has provided huge sums of extra money for those who can't afford to pay nursing and residential care home fees for themselves, to ensure that they are properly looked after. HUMPHRYS: But you know what I'm talking about, the nursing fees of people who find themselves having to need a great deal of nursing and maybe because they can't afford it, have to sell their homes to meet the cost because of the rules that now apply. DORRELL: But it's well known that the government recognises there are special sensitivities that arise when people have to sell their homes and there's a feeling that this is a burden for which many families haven't prepared and perhaps in the future will need to prepare. The whole of that subject is something that the government is looking at and it's not something where ministers have yet reached conclusions. HUMPHRYS: But that's in the future, as you say, in the future they'll need to prepare, I'm talking about now rather than in the future and there are lots of people in this difficulty as you know. DORRELL: And that was why I started off answering your question by referring to now and reminding you that we pick up the tab for residential care for a far larger number of people than was ever the case before. HUMPHRYS: Inevitably because of demographics and because we're living longer and all the rest of it. DORRELL: No, no, not just because of demographics, because we meet that demand much more flexibly, much better now than we did fifteen years ago. As I said, when I first became an MP you went on a waiting list, these days there is no waiting list, the waiting list has been abolished because the system is more flexible, we have a vigorous private sector which meets that demand with State support for those who need it most. HUMPHRYS: Right, but once you find yourself in a home you have to pay the cost of nursing, somebody has to pay the cost of nursing, should it be the individual or should it be the State? DORRELL: Well the position we're in now is that those who can't afford to pay the State pays, those who can afford to pay are expected to make a contribution themselves. HUMPHRYS: Even if that means they have to sell their home for instance, to do it? DORRELL: That is the position now and that of course is precisely the reason why the government has indicated that it is looking at how we can ensure that families are properly prepared for this obligation which will..which there's a significant risk will come to all of us at the end of our lives. HUMPHRYS: Do you think the situation as it is at the moment is too tough on old people? DORRELL: Well there is a...we're obviously all aware that there are many families who are surprised by this obligation that they find late in life, that is the reason why the government has said that it's going to, that it is currently reviewing those arrangements in order to ensure that people are fully prepared for the obligations that there's an increasing risk that all of us will have to meet at the end of our lives. HUMPHRYS: The fact is you've made it more difficult, the government has made it more difficult because of the increasing pressure on hospitals not to keep old people in hospital beds that are used..needed for other things. So, you have an obligation here, the government...the State has an obligation and this isn't a Party Political issue particulary but does not the State have an obligation. DORRELL: You say we've made it more difficult, with great respect I don't accept that because the development over the 1980s of the system based on Social Security which later was transferred into Community Care, run by Local Authorities, has made it far easier for those who need residential assistance to find that residential assistance and if they are unable to pay for it themselves, to pick up...to secure State support to pay for it. That was something, whereas I said there were fifteen years ago repeated examples of elderly people, clearly in need of residential care, who weren't able to get it because the only residential care around was that which was available from the Local Authorities. Incidentially, residential care that is increasingly now being found to be below the standards that we require from the private sector and which we are requiring Local Authorities to improve to match private sector standards. HUMPHRYS: But the problem is that there are many people who have to sell their homes in order to afford the kind of accommodation AND - and this is the thing that I'm talking about at the moment - the nursing costs that they need and what you seem a bit reluctant to deal with is whether the State has an obligation to pick up those costs. Notwithstanding whether they've got eight thousand pounds or more. DORRELL: I've answered your question very directly. HUMPHRYS: Well I've missed the answer somewhere along the line in that case. DORRELL: Well the answer is that I think that individuals should pick up...should accept responsibility for caring for themselves at the end of their lives. I also think the State should support those who are unable to pay that bill for themselves, I think that there should be proper arrangements to encourage individuals to plan to meet that cost and the government is reviewing those arrangements at this moment and that's why I'm not giving you a precise answer to every question that you ask because I actually think it's a good idea for ministers to reach their conclusions before talking about them. HUMPHRYS: Well let me just pursue the bit about which you were quite clear then, you said in the first part of that answer, if I understand you correctly, if you have the money, the wherewithal to pay for your own nursing, when you get older, you should do it. And if that means, if that means you have to sell your house in order to meet those bills so be it. That's okay. DORRELL: And what's obviously better for everyone is if the arrangements are made earlier in life... HUMPHRYS: Of course I accept that.. DORRELL: In order that it doesn't come as a surprise. HUMPHRYS: Absolutely, but we're not looking at ten or fifteen years down the road, we're looking at today where many people felt when they were youngsters and as they grew up that the State would look after them because we have a cradle to grave system, at least that's what they thought. Now you're quite happy to sit there and say "no, no, that isn't right they have to pay their own nursing costs and if that means selling their house so be it." DORRELL: Well if you want to compare the position now with the position fifteen years ago I simply ask you to compare.. HUMPHRYS: I don't particularly, I'm looking at the situation...as it is today.. DORRELL: That was the underlying theme of your question. I simply ask you to compare the totality. It's certainly true that the NHS used to run more geriatric hospitals, that's what they were called, we don't actually like the title any more, but the label geriatric hospital applied to a very specific... HUMPHRYS: ....geriatric wards in hospitals, many of which no longer exist for very obvious reasons. DORRELL: And the geriatric hospitals and very often the geriatric wards in the larger hospitals were a standard of care that very few people would want either for themselves or for their families these days. Furthermore, there were many many people who didn't get into hospitals because the consultants quite rightly said they didn't need clinical care, they simply needed residential support and for those people, in the old system, the only option was local authority part-three accommodation which was an extremely scarce source and which MPs used to have to spend large amounts of their time trying to find people ways into that kind of care. Both of those I think have been improved. We don't provide sub-standard geriatric care in the NHS any more, when people need hospital care, whether they are old or young we set higher standards for that kind of care. Where people need social care, we provide, as we always have done, support for those who can't afford to pay for themselves, and we do expect people to meet their own social costs if they can afford to at the end of their lives. HUMPHRYS: I note you use the phrase social costs not nursing care. Do the two mean the same, is that what you're saying? DORRELL: It's very difficult, isn't it? When you look at the needs of a specific elderly person to determine where the boundary is between health and social costs. HUMPHRYS: Well alright let's be specific then. Let's try and make it easier then. There is an old lady who has been - I don't know - she's reached the age of seventy-five, she doesn't desperately need clinical help but she needs nursing care, she can't look after herself properly. She needs a nurse to help her with injections, or whatever it may be. DORRELL: With great respect a nurse is a clinician. HUMPHRYS: Ok. Alright. Well, let's not quarrel about the words. She needs nursing care. She has relatively little money in the bank but she does have a rather nice house which she was hoping - or not a very nice house - which she was hoping to pass on to her children. Now, I'm still looking for some sort of answer as to whether you believe it is right that she should have to sell that house, rather than relying upon the State to provide what she believes is a part of the National Health Service and if not ought to be. DORRELL: No, it's never been part of the National Health Service obligation to provide residential care for those who need support with their shopping, who can't do their own cooking. HUMPHRYS: No, no. I'm not talking about that. DORRELL: Well, you are, actually - you are. If she can live at home and all she needs is a bit of nursing support to allow her to continue to live at home the NHS provides that. That's what the Community Nursing Service does. HUMPHRYS: Right. She's in a home, she's in a residential home. DORRELL: Indeed. HUMPHRYS: And she needs nursing care. DORRELL: Well when she's in a residential home, other people are meeting her cooking costs - they're doing the cooking for her,
doing the shopping, doing the cleaning and that is what I mean by the phrase 'social costs'. HUMPHRYS: Right. DORRELL: ..and that, indeed, has always been a means-tested benefit. We provide support - much more generously now - than has ever been done before for those who need that kind of support. In order to allow them to have a decent standard of living. HUMPHRYS: But that's not in dispute. It's nursing, on top of that, that I'm talking about. DORRELL: Indeed and nursing where it's necessary to have nursing in addition to that residential care but not...the individual doesn't require hospital care, in the opinion of the hospital-based clinician. That has always been regarded as nursing residential care and has been regarded as, therefore, social care. HUMPHRYS: And you don't believe that the State should pay that cost. DORRELL: That's the....the position has been ever since the foundation of the Health Service and the development of Social Service Departments in the Sixties, that residential nursing care has been regarded as part of nursing...of social care. HUMPHRYS: See there's a...and the reason I raised this specifically and have spent so much time on it, there seem to be - there are - fundamentally different views in British politics in the Conservative Party. Those who want to get away from universal benefits, who would say the sort of thing that you've said this morning, interestingly enough - that we ought to make provision for our old age - tax breaks or whatever it happens to be. The State will encourage it but nonetheless we've got to make our own provision so we move away from the cradle to grave care into which category I would put nursing care and I think many other people would as well, towards more private provision. DORRELL: Well, I don't actually think you'll find any distinction between different Conservatives. Or come to that, across many people outside the Conservative Party as well, any difference on the principle that people should be encouraged in a modern world to provide for themselves, rather than relying on the State. For example, on the development of pensions, I regard it as one of the great successes of the last thirty years that we have in this country, one of the best funded pension systems to be found anywhere in the developed world. People do now have - the huge majority of people do have second pensions based either on their own personal pension provision or on their Occupational Pension provision. That's an example of people providing for themselves. Where we also have - what we've also done in this country is to maintain a commitment to universal benefits, specifically in the field of Health and of Education. Those two aspects of the Welfare State, are not safety net services. They're services that set out to provide the highest quality of Education and Health care that a modern society can afford and provide for the whole of the population, not just for those who don't provide for themselves. HUMPHRYS: Ah well, because what you seem to be telling me is that you're encouraging to use that word, to use your own word - people to provide some basic health services for themselves. Because that, after all - to return to it - is what nursing is all about. DORRELL: Well, the position as regards nursing care in a hospital or in your own home is that that is an NHS obligation. We have always in this country regarded a nursing home as part of social care. But what I - the point I am making to you very strongly - is that we maintain in this country a universal Health Service. Health care available on the basis of need - not ability to pay - available to the whole population, not as a safety net. Similarly, in the Education Service, we maintain a State service for Education, designed to deliver the best quality education that we can, available to everybody, to put the starting blocks in line for all children at the beginning of life. Those are two universal services within the Welfare State. They're different from the system...the support available from the Welfare State for housing, where we provide a minimum, for pensions, where we provide a minimum through means tested support and encourage people to improve upon that minimum to make the best of their lives. HUMPHRYS: You say there's no great debate about this. There are no great debates about universal provision. But, there have to be. There are because there are those who say the State must spend less of our money. If the State is to spend less of our money and the State spends a vast amount on Health and Education it follows - you don't need to be a great mathematician to work this out - there has to be rather less spent in order for us to compete effectively on the world stage on things like Health and Education. Now, if we're going to provide the first class service that you talk about and it not just being a safety net, to use your other phrase that follows, doesn't it? DORRELL: No, it doesn't follow, at all. I followed your argument when you were saying: if we're going to provide high quality health, high quality education and reduce the total size of the public sector, there is a consequence, of course for other aspects of the public sector. I, certainly, agree with that. But, the kind of public sector I want to see is one that continues to deliver its obligation for a universal Health Service, a universal Education service but, then, recognises that if we're going to do that and have an acceptable tax burden that allows Britain to compete in the increasingly competitive markets of the early part of the next century, there is a necessary consequence for the other things the State can afford to do. And, that is precisely why I'm strongly in favour of ensuring that people develop their own pension provision, people develop their own independence of the safety net services, which the Welfare State still spends actually rather more on than it does on either Health or Education. HUMPHRYS: Indeed. But, Health and Education takes up a huge amount of money. So, therefore, there must be enormous amounts saved on these other things, mustn't there? Great, slashing cuts have to be made. DORRELL: Health and education are very major spending programmes but I.... HUMPHRYS: Health second only in the list. DORRELL: Health and Education are two that are running roughly neck and neck. Both of them in roughly crude 'back of the envelope' terms half of what we spend on Social Security. And, what we're looking to do - not just in the Social Security budget - but right through other things that we do on agricultural support, on industrial support, on a range of other activities that the Government does, is to question whether they still represent the best use of taxpayers' money and to look for ways of delivering the proper obligations of the State more efficiently in order to be able to cut the share of national income, taken by public expenditure. That is a process that the Treasury has engaged on every year, engaged on, perhaps, with particular...attaching particularly high priorities. HUMPHRYS: Do you believe that the share, the slice the State takes is about right now, at the moment? Or, should it come down substantially? DORRELL: It's something that's been on a declining trend ever since 1970...since '81. HUMPHRYS: Well, I raise my eyebrows at that because that's not the figure shown me, but anyway. DORRELL: Well, I will tell you why I say that. Everbody knows that the figure, the proportion of National Income taken by the State will oscillate through the trade cycle. When there's a booming time more Tax. HUMPHRYS: Since 1979 we've seen what's happened. The share at the moment is higher than it was it in 1979. DORRELL: No, that's not true of Public Expenditure. Public Expenditure is not taking a higher share. HUMPHRYS: As a proportion of our total income it is true. DORRELL: No, it is not true with respect. What is true is that we're financing the Public Expenditure that we're doing now without incurring the kind of borrowing that allowed the Tax levels in 1979 to be abnormally low. What we've seen from 1981 onwards is that the peak share of expenditure of National Income in 1981 was not repeated in the recent recession- HUMPHRYS: Right. DORRELL: - and there is a downward trend. HUMPHRYS: And you want that downward trend to continue? DORRELL: And I think that downward trend should continue. Let me tell you why. There are two reasons. First it's a political choice, I want to have people spending more of their own money in their own way. But, secondly, and perhaps even more importantly I think if you look forward to the next ten or fifteen years, we're going into a world where competition from the Far East, from Eastern Europe, from other parts of the world, is going to put stresses on the Western European economy including our own which is going to require us to be flexible in a way we've never been flexible before and that compels us to make choices that deliver low Tax burdens as well as freer Labour markets and all the other things the Prime Minister talks about. HUMPHRYS: A pretty difficult trick to pull off that one, isn't it? So, what kind of levels ought we to deliver? You say it's on a downward trend at the moment. Some people might say: well, maybe, maybe not. But, are we looking at what - twenty-five per cent? Instead of the forty-one per cent we've got, at the moment? DORRELL: Wonderful if we can get there, but let's go one step at a time. I- HUMPHRYS: I'm trying to take - because we don't have terribly long left of this discussion - DORRELL: Yes, and I'm- HUMPHRYS: I'm trying to look into the future, really, and be a little philosophical about this. DORRELL: I'm not adopting your figure of twenty-five per cent. What I am adopting is a downward trend that takes us below forty. HUMPHRYS: Below forty. But, the reason I offered you the twnety-five per cent is because people like Mr Portillo - who said there is no difference within the Party over these matters - to people like Mr Portillo have said that that's the kind of thing that serves other countries terribly well and we must take that into account.... DORRELL: And I said it would be wonderful if we can get there but I think we-nobody has accused Mrs Thatcher's government of having been a slouch on the subject of reducing the subject of reducing the share of National Income... HUMPHRYS: Except you haven't been very good at it, that's the trouble. DORRELL: Over fifteen years we have established a downward trend and that trend must continue. HUMPHRYS: Our highest goal is to minimise the size of the State. Do you agree with that as a proposition? DORRELL: No I don't. Well Michael Portillo says that. No difference you say but that's his view - October '93. HUMPHRYS: Our highest goal is to ensure that in the next century Britain is able to compete in an increasingly competitive international marketplace. If we don't do that then all this argument frankly is purely academic because if we don't-if our economy is hidebound by social chapters, minimum wages, high marginal rates of tax, then Britain will lose in international competition. We shan't be able to afford either personal living standards or Health Service or Education that all of us want to see, so the highest goal is to make certain this country is able to take on international competitors, and win. HUMPHRYS: And in order to do that you cannot sacrifice any spending at all, on Health and Education? DORRELL: Well, every year - year by year -
difficult choices to be made. Nobody asks - nobody can expect to be emancipated from that - but there's no point in putting anything else in first priority. If - it has to be the British economy's capacity to pay for all of these things that is our first priority because if the British economy can't afford to pay for it, the rest of it is, frankly - the discussion is pure self-indulgence. HUMPHRYS: Thank you very much indeed Stephen Dorrell. DORRELL: Thank you. ..OOOOOO..