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28 Nov 2002 : Column 521—continued
Dr. Andrew Murrison (Westbury): The hon. Lady makes a good point with which I agree. Does she also agree that readmission is not exclusively the fault of hospitals? She referred to the multidisciplinary teams responsible for discharge delays, but they may also be responsible for high readmission rates, so it would be wholly wrong to fine hospitals for those rates, for the same reason that it would be wrong to fine social services departments.
Glenda Jackson: I hesitate to agree entirely with the hon. Gentleman that it is wholly wrong to impose fines because there are examples of best practice, certainly in hospitals. I know that some hospitals—not, I hasten to add, in my constituency—are dilatory in tackling these issues, and I am perfectly prepared to accept that some councils are less than good and do not spend the entire amount earmarked for social care for the elderly. However, we delude ourselves if we believe that the integrated, high quality care that we all want our elderly people to receive will be delivered by proposals that, in targeting bad councils, have a deleterious effect on local authorities that are committed to, and doing their best to deliver, those services.
I am concerned about the time afforded by the Government for consultation. There is an opportunity to reconsider the model on which the proposals have been based. I am not for one moment saying that they will not be effective, but this may not be the best model for achieving the aim to which the Government are clearly committed. There should be an opportunity for local authorities that are delivering high quality services and want to improve their delivery to make representations to the Government about the model that they would introduce. There are also justifiable concerns about the additional costs to local authorities, which are inherent in the Bill.
There is no uniformity among the many agencies responsible for ensuring that elderly people, once discharged from hospital, receive the care that is best for them. There are variations in practices and disagreements about which produces the best care. I am fully prepared to accept that the Government's heart is in the right place, but the basis of implementing their proposals is partnership, which means that the constituent partners who will eventually deliver these high quality services have at least to agree on the basics. It would be nice if they all had similar information technology, but they do not, so any attempt to track down the best person to provide a service among a wide range of service providers is time consuming. As we know, time equals money, so additional burdens may be placed on local authorities.
As I said, I strongly believe that the Government's heart is in the right place. We all want to see the highest quality services delivered, but I urge the Secretary of State to consider the points that will undoubtedly be made because there are dangers in the Bill, even though I will, of course, vote for its Second Reading.
3.55 pm
Mr. Paul Burstow (Sutton and Cheam): The Secretary of State told us that there is no magic wand to deal with delayed discharges, and I agree. The Bill is not a solution to that problem; it will simply exacerbate it and cause further problems in the NHS and the whole care system. The right hon. Gentleman's announcement of a £100 million sweetener will do nothing to remove the bitter taste of the Bill. The fact that that money is to be taken from the NHS, given to social services and then returned to the NHS is an admission that the Bill is fundamentally flawed because it is based on a crude market mechanism that does not reflect the complexities of the situation.
The Secretary of State told us that the proposed penalty system is based on one that was introduced 10 years ago in Sweden, but the penalties introduced there were only part of a much wider set of reforms to that country's care system and they were arrived at after a good deal of consultation and debate. They aimed to shift the centre of gravity in the Swedish care system out of the acute sector and into community care systems. That is not the aim of this proposal, which is grafted on to a system that includes a large amount of private and independent provision, whereas care in Sweden is largely provided by the state, through local govt. By contrast, in the UK, we have seen the NHS withdraw from long-term care, and a fragmented, unplanned set of arrangements put in its place.
Reading the report of the Health Committee's inquiry into delayed discharges earlier this year, I found that some of the most interesting hearings were those with the Department's officials. Their ideas do not appear to have got through to the Ministers framing the policy and the measures in this Bill. For example, the chief inspector of social services told the Committee in February:
- XOur concern about the over-75s is that delayed discharges here are a symptom that we need to do something about the totality of the system for older people. Actually just homing in on the issue of delayed discharges is concealing that there is a systems issue."
Mr. Roger Williams (Brecon and Radnorshire): The Bill deals with England and Wales, but both health and social services are devolved responsibilities, so I hoped that this would be enabling legislation within the spirit of the devolution settlement. In Wales, the Assembly already provides free care for six weeks after discharge from hospital. It would like, if it had the power, to provide free long-term care for the elderly, which it believes would prevent unnecessary admission to hospital and promote prompt discharge.
Mr. Burstow: My hon. Friend has made an important point about whether the Bill should apply equally to England and Wales. It is one thing for English Health Ministers to want to put the proposal into practice, but it is entirely different for it to apply automatically to Wales. I hope that as the Bill proceeds through the House, we will find a way for Wales to have discretion. Given the Government's commitment to devolution, I hope that the Bill will include powers to enable the Welsh Assembly to go as far as it wants in providing long-term care and making personal care free on the basis of an assessment of need.
Mr. Tom Clarke (Coatbridge and Chryston): My interest in these matters derives from the fact that I introduced a measure as far back as 1986 covering the whole UK, so I am interested in seeing how the Bill progresses. Does the hon. Gentleman agree with the Secretary of State, who made an important point—not mentioned by the Opposition spokesman—when he said that of course we want to consult patients, their families and their advocates?
Mr. Gale: How do you do that in three days?
Mr. Burstow: The Bill does not stipulate the patient's right of consent to discharge arrangements. Nothing in the Bill stipulates the carer's right to be consulted about whether or not they wish to continue to take on a caring duty or, indeed, take it on in the first place. There have been representations from many organisations about the absence of those issues from the Bill. I hope that in Committee we can move beyond the vague promises that that will be dealt with in regulations to cast-iron commitments that it will be dealt with in the Bill.
The hon. Member for North Thanet (Mr. Gale) asked how consultation could be completed in three days. We have been told that the Government are satisfied that we
will have a partial assessment of someone's needs while they are in hospital. What on earth is that? How does it relate to the single assessment that the Government said would be in place from April this year? We now have the spectacle of the Government wanting to rush through discharges and implement an assessment procedure that does not include everyone who ought to be part of the process, shunting patients into an unsatisfactory interim provision and leaving them there too long.
Dr. Starkey: Does the hon. Gentleman accept that many local authorities, including my own, have already attempted to solve that problem by providing heavily supported, if I can so describe it, accommodation for patients who have been discharged—in my local authority's case, for up to six weeks—to give them time to decide whether they need to go into full-time residential care or go back home? Is that not better than leaving those patients in a hospital bed, which is unsuitable for elderly patients?
Mr. Burstow: It is better, but there will be a short decision-making process of three days to get someone out of hospital, which does not address their long-term care. We need a process that ensures that appropriate judgments are made. The hon. Lady must address the fact that the provision that her local authority has been able to make does not exist universally across the country, and is unlikely to come on-stream when the Bill is enacted. I want to try to explain why that is the case.
The Bill is all about treating symptoms, and does not tackle causes such as lack or loss of capacity upstream and downstream in our care system. Budget pressures have forced social services departments in the past 10, 15 or 20 years increasingly to ration access to care. Eligibility criteria have been drawn ever tighter as a result. Indeed, the Local Government Association says that two thirds of local authorities have narrowed their criteria still further in the past two years. They have done so by denying help to people with moderate needs or carers; by making people with high needs wait, often in their own home; and by setting limits on price, quantity and quality of care. In the past 20 years, social services departments have withdrawn home help services that offer domestic help and have concentrated care on the most disabled and dependent, in stark contrast to what is done in Sweden—the exemplar that the Government have chosen to use for the Bill. In Sweden, people still have home help services, which cover such activities as cleaning, shopping, outings, social contact and so on. The penalty system to be introduced by the Bill will undermine efforts to develop the preventive services that the hon. Member for Milton Keynes, South-West (Dr. Starkey) and many other Members believe should be widely available. Investment in prevention can postpone the onset of disablement, disability, illness and dependency, and has the biggest long-term impact on the problem of inappropriate admissions to hospital that result in delays in discharge.
It is not only upstream that there are capacity problems—there are serious capacity constraints downstream as well. We have serious staffing problems in the care system across the country, including a 15 per cent. vacancy rate for occupational therapists. Indeed, 40 per cent. of local authorities report severe difficulties in recruiting occupational therapists, who are key
players in facilitating a speedy discharge from hospital, enabling adaptations and changes in someone's property to be made quickly. If the OT is not there, who will do the assessments? That issue was considered by the Select Committee, but I do not think that it reached a final conclusion on how to progress the matter.
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