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28 Nov 2002 : Column 517continued
It is typical of the Government to believe that they know better than those on the front line who are already responsible for these services, and so like them to produce yet another one-size-fits-all blueprint designed in Whitehall against all the advice of those with hands-on experience.
Mr. Steinberg: I have some sympathy with what the hon. Gentleman says, although I do not necessarily agree with all his comments. What would he do to a social services department that receives money to use to unblock beds in hospitals but does not use that money accordingly? What sanctions would he use against authorities that do not use the money for the purpose for which it is given?
Under the proposals, local authorities will come under pressure as never before. The question we must ask is whether these changes will increase or decrease the probability of finding the most suitable care and type of placement for individual patients' needs. Alternatively, are the proposals likely to mean that, to avoid financial penalties, patients will be removed from hospital to the first available place, whether it is the right place or not? That is a major problem. Are we likely to see a repeat of some of the awful cases of inappropriate care being provided for elderly people? Elderly patients have a right to feel less secure under these changesfor the first time, they are being regarded in the system as a financial liability to be moved around for cost reasons.
The potential for perverse incentives as a result of the Bill is equally worrying. The hon. Member for Dartford (Dr. Stoate) raised the issue of the impact on general practitioners. Let me tell him one of the problems that the Bill will produce. GPs who are already finding it difficult to get their patients placed in a care home will come to understand something new: precedence will be given by local authorities to patients who are already in acute wards in a hospital. What will be the inevitable result? It will be the creation of a perverse incentive whereby GPs know that they are most likely to be able to get a patient into a care home by first getting them into an acute unit. That has the potential to cause more delayed discharges, by blocking more hospital beds, than we have at present. I am sure that that is not what the Government intend, but that will be the effect in the real world. It is the inevitable result of the Government not understanding how the system works in reality.
Mr. Roger Gale (North Thanet): As the Secretary of State was unable or unwilling to answer this point, perhaps my hon. Friend can touch on it. The logical extension of what he is saying is that a problem that is already bad will be made worse. One of the principal causes of bed blocking is that families will not accept the provision that is being offered and want choice. How will that dispute be resolved within a three-day time limit? Will not beds be even more blocked as a result of what my hon. Friend describes?
Dr. Fox: As I said, there is the great possibility that things will deteriorate rather than improve as a result of the Bill. I am sure that Ministers do not intend it to have that effect, but that is what will happen, and it is the Bill, not the intention, that we are discussing. We have to take into account what we judge to be its effect on real patients in the real world, not what we think Ministers might want to happen.
The Bill leaves far too many questions unanswered. Those who followed the sad affair of the Government's creation of the care home crisis will be aware that there was much consensus on the Care Standards Act 2000, and that the damage came not from the contents of the Act itself, but from the ministerial regulations that were applied later on, which were recently subjected to a U-turn. Indeed, the Government's standard approach is to produce the merest skeleton of a Bill only to flesh it out later with mile upon mile of red tape and regulation. It is usually a sign that they are making it up as they go along.
The Bill falls neatly into that category. Far too much of it depends on subsequent regulation to make it work and many of the important questions go unanswered. For example, who lays down the level of fines? The Secretary of State estimates that local authorities will be liable to pay a total of £100 million, but who sets the fine? How often will it be changed? Will there be an upper limit or will it be at the discretion of a future Secretary of State? Will fines apply if there is no appropriate bed, no other placement or no individual care available? Who will make those decisions? What will the Secretary of State do to determine who is, or is expected to become, a qualifying hospital patient? What procedures will be used and how does he justify such a ludicrous level of mismanagement when uses such achingly funny rhetoric about devolving power?
Then we have the problem of the dispute resolution mechanism. The disputes do not exist at the moment, but the Government admit that they will arise when the Bill is implemented. Three clauses out of 10 relate to the resolution of conflicts. Strategic health authorities are being established to steer the panels, which means that the NHS will be judge and jury in disputes between the NHS and local authorities. What sort of people will sit on the panels? What qualifications will they need? Most importantly, how much time and money will this nonsense divert from patient care into unnecessary, pointless and mindless bureaucratic squabbles?
Mr. Waterson: Is my hon. Friend aware of Age Concern's opinion that the Government's proposals may be in conflict with standard 2 of the national service framework for older people, which specifies that older people should be treated as individuals and enabled to make choices about their care?
Dr. Fox: I am sure that that is the correct approach. To be fair, I am not saying that the Government intend to do otherwise. Regardless of their intentions, however, the Bill could become another Dangerous Dogs Act 1991 and have the opposite effect of that intended. The Bill is a bad piece of legislation. Although it includes some good things that could command support on both sides of the House, they are totally outweighed by the dreadful provisions that I have outlined.
The Bill will not achieve its aims. It may well result in exactly the opposite. It is unfair to local government; it will divert time and effort away from patient care into bureaucratic games; it will create perverse incentives; and it will increase the risk of inappropriate care, especially for the elderly. It is part of the paperchase NHS created by the Government. It is about throughput not outcomes. It is about a XNever mind the quality, feel the width" health service. It punishes one group for the
Glenda Jackson (Hampstead and Highgate): Setting aside the somewhat hysterical contribution of the hon. Member for Woodspring (Dr. Fox), I think it would be impossible to find anyone in the House or the country who would argue against the basis of the Government's proposal to have a national and properly integrated, multifaceted, high-quality service for older people. I do not think that anyone would argue with the Government's attempts to ensure that taxpayers' money earmarked for the provision of integrated social services for the elderly is spent. There can be no possible argument with the fact that the Government have their heart in the right place. They are clearly committed to ensuring that care for the elderly is not limited exclusively to residential care or nursing care, or to the practice of keeping elderly people in hospital long after their medical condition warrants a discharge.
Local authorities have been criticised for failing to spend the taxpayers' money that is accorded to them. That criticism could not, by the widest stretch of the imagination, be levelled against my local authority, Camden. It is not only council of the year, but a beacon authority for the care that it provides to elderly people. It has also more than spent the money that was earmarked by the Government for the provision of social services. It has exceeded the £30,876,000 given to it by more than £2 million. There is no doubt that the authority takes on board the thrust of the Government's policies, and not only in the provision of integrated services for the elderly. It is the first local authority to create an integrated mental health and social services trust. I pay tribute to the Government and my right hon. Friend the Secretary of State for ensuring that that was created.
Having been as polite as it is possible to be, I come to the difficult bit, which is to be critical of the Government. I would be less than honest if I did not say that it is my bounden duty to criticise aspects of their proposals. I am most critical of the idea that social services are exclusively responsible for ensuring that an elderly person does not remain in hospital longer than necessary. My constituency is part of an inner-London borough. Like other such boroughs, we have a suppliers' market for residential nursing home places. The homes charge and obtain higher fees for clients from the private sector. My local authority has received additional funding for the building care component, but there is still a desperate shortage of places, not least because patients in the two main teaching hospitals in the borough of Camden are not exclusively Camden residents. Social services departments outside Camden find places for their residents within my borough's boundaries because the treatment there is best suited to their needs.
There is another problem. It arises, curiously, from the fact that the Government have been hoisted on the petard of their own success. They listened to what hon. Members said about providing individuals with the ability and, indeed, the money to arrange their own domiciliary care. That has had an impact on local authorities, especially ones like Camden, because it removes the ability for authorities to block buy domiciliary care when elderly individuals return home.
Difficulties also arise in hospitals and medical teams when they have to determine whether an individual is ready to leave hospital. If they agree that someone can leave, the next problem is ensuring that that person can return to an independent and healthy life.
As I said, Camden has spent more than central Government gave it to provide integrated services for elderly people. It has increased the numbers of step-down beds and domiciliary beds and transformed some of its housing stock so that it can take people in wheelchairs, but there is still an element of bed blocking.
In some cases the failure to remove an elderly person from hospital has to do with limited capacity in occupational therapy. That point is anecdotal and I do not have figures to support it. As a Conservative Back Bencher said, there may be difficulties because the family disagree with what is proposed for their relative. It is not unusual for an elderly person to have no family or for the only person capable of caring for them to be as old and, in some instances, as frail as they are, so a return to home, even with a properly integrated programme of domiciliary care, may not be the best solution for that individual.
There seems to me to be gross inequity in the Government's proposals. I listened with interest to what the Secretary of State said about setting a ceiling of £100 million on the fines that may be imposed on local authorities and about taking that money out of the NHS. The fact remains, however, that local authority social services are not exclusively responsible for delayed discharges.