Health and Social Care Bill

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Mr. Stewart: Let us have it out in Committee. Is the hon. Gentleman advocating the introduction of insurance to cover that provision?

Mr. Hammond: Not necessarily. Insurance products are available for people who wish to protect themselves against long-term care costs, but the evidence suggests that they have not been successful. Take-up has been poor.

Mr. Ben Bradshaw (Exeter): Exactly.

Mr. Hammond: There is no point in the hon. Gentleman sitting there, saying ``exactly'' and nodding his head.

I hope that the Government would acknowledge that there is a need to consider the long term and to consider what message we want to send to people who are in their 30s and 40s about how they should prepare themselves for their long-term care. In 20, 30 or 40 years time, the retiring population will include a much higher percentage of property owners, so it is possible that, under the proposed arrangements, the state's share of the burden of long-term care will fall. More and more people will be subject to the means test by virtue of being property owners—which is a good thing that we all support. Whether or not using property is the best way of arranging for people to make an affordable contribution to their care costs, and whether or not the current means test is the best way forward are legitimate questions that we expect the Government to address, along with the proposals in clause 48.

The Opposition are considering issues such as the appropriate roles of the individual and the state, and are debating those issues with people and bodies outside the House. We aim to create a situation that encourages those who are able to do so to make proper provision for themselves, and to do so in a way that does not present them with unpleasant decisions, such as selling a family property, at an awkward moment in their life, when that might not be the best way to meet the requirement to contribute to their own care. We also aim to define the proper role of the state in ensuring that everybody has access to the care that they need and that people do not face long periods of care and open-ended bills just because they have been prudent during their lifetime and saved, when their neighbours have not.

Mr. Stewart: Can the hon. Gentleman give us an example of how that could be achieved other than through the insurance provision that he has rejected as unsatisfactory?

Mr. Hammond: I do not want to outline our innermost discussions at the moment, but I will give the hon. Gentleman some ideas, because they are not rocket science, and they are not secrets. We have not heard anything from the Government about equity release arrangements for property, other than those that they are putting in place under clause 54. Perhaps we shall discuss how those will work when we reach that clause. There is scope to use the saving schemes that the Government and previous Governments have promoted to orientate people to think about the need to contribute to their long-term care needs.

More and more people who reach retirement, even though they do not consider themselves especially wealthy, will find in the context of our means-tested system that they are considered wealthy enough to contribute to their care needs. It is essential that people who will be asked to contribute to their care needs are fully aware of that eventuality and are assisted in every practical way during their working lives to prepare for it, rather than having to deal with it on the hoof in adverse and emotional circumstances, perhaps having had to give up their homes to go into residential care.

Mr. Burns: The hon. Member for Eccles (Mr. Stewart) is oblivious to the previous Government's proposals for an alternative to current insurance policies. Before my hon. Friend takes another intervention from the hon. Gentleman, does he think that the hon. Gentleman should read the proposals, as they are a viable alternative?

Mr. Hammond: My right hon. Friend the Member for Charnwood (Mr. Dorrell) made those proposals. I have already said that they have often been derided, but in my view have not been bettered. They are a contribution to the debate.

I strongly believe that one size does not fit all. We should seek to create a sense of personal responsibility in individual members of society, in relation to long-term care, so that there is a partnership with Government. The sooner individuals understand that role, the better, rather than their finding out as a nasty shock after retirement that the state will not provide them with the level of support that they had expected. That comes as a rude awakening to many people. I hope that the Government will actively pursue such an approach in parallel with the arrangements.

I have talked around the principle of the Government's proposal, but amendment No. 306 and related amendments tackle a practical issue. I hope that the Opposition can all agree on that issue, as that would realign the division in the Committee. The Government's decision is that nursing care will be provided. Many Members from all parties believe that it would be artificial to assess nursing care and personal care separately. However, if we accept the Government's proposition, we have to define nursing care. The Government propose, as a definition, only services provided by a registered nurse that cannot be provided by others. That is an extremely narrow definition.

The briefing sent to members of the Committee by the Royal College of Nursing states:

    ``In practice, much of the nursing care received by frail older people in nursing homes is delivered by health care assistants, working under the supervision and delegation of a registered nurse.''

Dr. Brand: Does the hon. Gentleman recognise that the same holds true for nursing care given in NHS hospitals?

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Mr. Hammond: The hon. Gentleman is right.

I have two worries about the Government's proposal at a practical level. First, it will constrain the total supply of NHS-funded care that can be made available. As the Minister knows, nursing manpower is a constraining factor. If he says that only the care that is provided by the registered nurse is eligible, he will be rationing the amount of NHS-funded care that can be on offer in areas where registered nurses who are available for work are more rare than hen's teeth—a matter that I shall explore with him.

Secondly, the proposal will create a sub-optimal division of labour. Nurses, when deciding whether to delegate tasks to a health care assistant, will have regard not only to the competence of the person and the efficiency that that will create in the care setting, but to the implications that any such decision would have on charging. That conflicts with the Government's avowed intention—which we support—to ensure that, within our health care establishment, all professionals work to the maximum of their capabilities. Surely it would be a retrograde step if a perverse and unintended consequence of the Government's proposal was that work that could safely be delegated to health care assistants and, as the hon. Gentleman says, is delegated to heath care assistants in hospitals, in a nursing home setting had to be carried out by a registered nurse.

Amendments Nos. 306, 307, 308 and 309 recognise the Government's decision on nursing care, but would define it in a way that avoids the worst difficulties of demarcation and the most perverse resource misallocations. The test would be whether the care was of a type routinely or usually provided by nurses. Nursing care would be defined according to the type of care, not the person who delivers it. That would optimise the use of the total care work force, reduce costs and overcome the labour cap that is otherwise being applied. That is not so much a cash limit as, in areas in the south-east where nurses are difficult to come by, a human resource cap, which is being applied to the total amount of care that might be provided under such arrangements. It will allow nurses to continue to delegate their responsibilities when it is clinically appropriate to do so, without having to have regard to the financial consequences of such action for the people in their care.

The Government have not been clear about the assessment process in relation to nursing and personal care. Can the Minister confirm that the assessments will be carried out by nurses, not other NHS personnel? What impact do the Government expect the assessments to have on manpower resources? How many nurses will be diverted from patient care activities to undertake those assessments? Will the global amount of available NHS-funded nursing care be limited? In other words, will the assessments be competitive? In practice, social services assessments often are. A limited pot of resources is available and it is a matter of who demonstrates the need for it, as a result of the assessment process. Or will the services be available as of entitlement, without there being a strict cash limit being placed on the amount of resources that can go into NHS-funded nursing care? I look forward to receiving the Minister's response to such a large group of amendments.

Dr. Brand: The hour is quite late. I do not want to repeat yesterday's excellent debate other than to express my disappointment that the Government and the Conservative Opposition have not taken on board properly the message from the Sutherland report. They also failed to take on board three reports from the Select Committee on Health, which set out the difficulties involved in charging regimes that got in the way of team working and patient or client access to services. I pay tribute to my hon. Friend the Member for Sutton and Cheam, who set out the case clearly, and to my hon. Friend the Member for North Devon (Mr. Harvey), who made it clear how an extended scheme could be funded. [Interruption.] The Minister is not happy and says that it was not clear.

I must say that I was not clear myself about the motivation behind the Government's position. In his opening speech yesterday, the Minister bravely talked about the difficult choices that had to be made, and said that resources had to be allocated. He almost seemed to regret that the Government could not, at this stage, accept the majority recommendations of the Sutherland report. The winding-up speech from the Under-Secretary, the hon. Member for Birmingham, Edgbaston (Ms Stuart) implied that the Government's adoption of the majority recommendations would, in some way, impede better patient care.

I find that difficult to accept. In the modern health service, care is delivered by teams, which may be headed by nurses, doctors, social workers, psychologists or physiotherapist, depending on the task involved. One may also define the tasks as being predominantly medical, nursing or social work. However, it is less clear how one defines that activity by the team member who carries it out.

The hon. Member for Macclesfield (Mr. Winterton) made a good intervention about physiotherapists and chiropodists—a subject that has not otherwise been mentioned and may not be relevant to the Bill. However, it is a clear example of what I mean. Most physiotherapy for people who have had strokes is delivered by care assistants under the supervision of a physiotherapist. Would that care be defined as a nursing-type intervention, or as personal care for which people will have to pay?

The definition adopted by the Government, although administratively simple, contradicts the ethos of team membership that we have all tried to encourage. Successive Governments have encouraged that ethos, as have the caring, medical and nursing professions; all agree that people should be trained for a relevant task irrespective of their specific qualification. To base the entitlement on qualification is extraordinarily negative and may have dangerous consequences for the way in which care is delivered, especially in the home.

As the hon. Member for Wakefield (Mr. Hinchliffe) said last night, preventative work done in the home could make a tremendous contribution to keeping people out of institutions. That is clearly what we all want to happen. However, preventative work is carried out by teams—not necessarily with a registered nurse—and the task may be difficult to define as a nursing or personal care task. When the Select Committee asked the previous Secretary of State to define the difference between a medical bath and a social bath, he could not. Nobody can define it, other than those who carry out those functions.

It is important that that issue is addressed. We shall not try to force the Government into reversing their decision about whether the full recommendation of the Sutherland report, or the minority recommendation, is accepted. That is for Government. However, I am worried that the Government are specifying the boundaries through primary legislation. Should the Scottish experiment work out well, and be seen to be cost-effective and clinically effective, it would be a nonsense for the Government to have to return to primary legislation to extend the role of the NHS team beyond work carried out, for instance, by a registered nurse.

I urge the Government to consider redrafting the Bill to meet current requirements, in order to allow flexibility to extend the non-means-tested provision if they find that they have made a mistake. I think that they are making a mistake, which is why my hon. Friend the Member for Sutton and Cheam and I tabled the amendments. They were difficult to table because of the curious nature of the Bill—it does not impose a duty on the NHS and health authorities to provide a service, it merely forbids a local authority to provide a service. That is a strange way of trying to create a care package. I listened with amusement to the Minister pointing out the deficiencies of our new clause in relation to Wales. That is a consequence of the way in which the Bill has been drafted. I want the Government to suggest an amendment to ensure that, once the Bill is enacted, there is not a fixed position. The Government should not have to return to primary legislation to provide a greater service. Clearly, they should not be able to provide a lesser service, but we should provide them with the flexibility to do more if they wish, if the nation can afford it, and if it is seen to be cost-effective.

The other issue, which is reflected in all the amendments—and especially well expressed in amendment No. 306—is that the Government should revisit the issue of how to define nursing care. I have given examples of how extraordinarily difficult that will be. We should consider the institutional setting in which there are no longer specific nursing homes as opposed to residential homes. A residential home that happened to be owned by a state registered nurse might put in all sorts of claims because the proprietor has performed a caring role as opposed to that of an ordinary care assistant. Clearly, that is nonsense. Who determines the kind of nursing, even when carried out by a registered nurse, that qualifies for NHS funding? Is it only nursing care that is provided by an NHS nurse? Will district nurses be introduced to homes? Alternatively, will NHS nurse managers try to run nursing homes, to determine which bit of the nursing can be claimed for, and which cannot? The fact that there are no boundaries to be drawn makes it look administratively easy, but the Government's proposals will, in practice, create an administrative nightmare, which was well described by my hon. Friend yesterday. The bar coding system for community nurses was tried 10 years ago on the Isle of Wight and it failed absolutely, mainly because the software was so useless. I do not want matters to move in that direction.

Our debate probably cuts in three directions. We are disappointed that the Government have not accepted the strong argument put forward in the Sutherland report. We shall not overturn such a decision this evening, but I urge them to create more flexibility under the Bill so that they can accept the majority recommendation if it comes to be regarded as a sensible move. Will they reconsider how they define nursing care, because the definition is not workable as it stands at the moment?

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Prepared 6 February 2001