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28 Nov 2002 : Column 535—continued
4.40 pm
Mrs. Joan Humble (Blackpool, North and Fleetwood): I agree with the many Members who have said that we can all applaud the aims of the Bill. No one wants to see elderly people unnecessarily delayed in hospital. Elderly people deserve to be cared for in the most appropriate setting, and we need to examine ways of ensuring that that is provided.
One of the other aims of the Bill is to establish better communication between health and social services departments. Of course that should happen; these are the two agencies that have responsibility for looking after the very vulnerable people in our communities. If I have a concern, however, it is about the manner in which the Bill sets about achieving those two aims. I am raising my concerns not from the point of view of the social services departments in my constituency, which could be subjected to substantial fines; in fact, quite the opposite. I cross my fingers when I say this, but my local hospital does not have a problem with delayed discharges.
I am always extremely sceptical about statistics, especially those relating to health and social services. I was shocked and amazed, last year, to see that my hon. Friend the Minister had said, in response to a written answer, that north-west Lancashire had a 10.6 per cent. delayed discharge rate, and that that compared with 4.2 per cent. in south Lancashire and 0.2 per cent. in east Lancashire. I wrote to the then chair of North West Lancashire health authority and received a reply that can be described only as a confusing analysis of how the statistics are arrived at. She wrote:
- XThe figure of 10.6 % is a plan figure which is provided by the Authority's 2000/2001 Service and Financial Framework."
- XI am pleased to be able to reassure you that actual performance during the first two quarters of the 2000/2001 financial year is considerably below the plan figure in the Service and Financial Framework. Quarter One showed delayed discharges running at 8.9 %, whilst in Quarter Two this number fell to 4.6 %."
As well as writing to the health authority, I wrote to Lancashire county council's social services department and to Blackpool social services. They both wrote back to say that they did not have a problem, and that they were working well with the health authority and with the hospital. They commented, however, that the picture behind the delays that did occur was not a simple one. The reasons for delayed discharges included non-availability of a specialist service at a particular time—for example, assessments or continuing therapy from
health staff such as occupational therapists, who are employed by the health authority in Lancashire, or physiotherapists. In some instances, delayed discharges were also caused by a place not being immediately available in a patient's choice of residential or nursing home.An analysis of the figures for delayed discharges shows that about 50 per cent. of them were due to a patient's choice of residential or nursing home not having a vacancy. I say that in the context of there not being a problem of availability of nursing home and care home beds in Lancashire; we have an over-provision. Patients are therefore waiting in hospital until a vacancy arises in their preferred home. That raises concerns for me about the choice directive. What will happen to patients in hospital who are saying, XI am ready to move, but I want to go to that home down the road, and no other." How will the choice directive be applied? How will that bed become unblocked? How will the person be moved? I hope that my hon. Friend the Minister will address the issue of consultation with patients and carers in this context. For example, if an individual had to make an interim move, they should be fully consulted and offered a reassurance that, should a vacancy arise in the home of their choice, they would be considered for it.
I carried out my inquiries a year ago, so I thought that I should also look at some more up-to-date figures to find out what is happening now. I contacted Blackpool primary care trust to find out the current position. Of the 163 delays recorded between 5 August and 17 November 2002, only 16—9.8 per cent.—were attributable to social services departments. If those delays attributable to patient or carer choice are removed from the statistics, the actual figure falls to 5.5 per cent. So social services cannot be blamed for the number of delayed discharges. The blame—if blame can be ascribed—lies either with the health authority or with the patients and their carers. In Lancashire last week, there were 27 cases of delayed discharge. Of those, 17 people were awaiting practical or other arrangements beyond the control of Lancashire social services. Those 17 people included five who were awaiting arrangements to be made by families, and, for three others, discharge from hospital was imminent at the time that the statistics were being collected. I am concerned, therefore, that social services are being blamed for this situation when, certainly in my own locality, they are not to blame.
Exciting initiatives are being introduced locally. Lancashire social services, for example, has introduced a new scheme involving named social workers. One of the problems is that it can be difficult to manage and link the social work team in the hospital, which does the discharge assessment as part of the multi-disciplinary team, with social workers in the community. So Lancashire has introduced a system in which, if someone known to social services goes into hospital, a named social worker who knows that individual and knows their care needs follows them through the hospital process and arranges their discharge into the community—an excellent initiative that could, and should, be replicated elsewhere.
I recognise, however, that not every part of the country is as fortunate as the Fylde coast. We have not only excellent collaboration between social services and
the health service but some very good health service units, including two new NHS rehabilitation units at Rossall in Fleetwood and Kincraig in Blackpool. The Minister of State, Department of Health, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), opened the Kincraig unit, and he will have seen the excellent work that the health staff do to help to rehabilitate elderly people and to provide the interim care to ensure that they can safely be discharged from hospital and settled in the community.When I speak to some of my hon. Friends, however, they tell me that the situation is not the same elsewhere. I want to make one supportive comment to my hon. Friend the Minister. I understand the importance of standardising some of the procedures, learning from good practice and ensuring that examples of good practice in discharge procedures are replicated around the country, but I ask her to allow time for that good practice to be developed. I also urge her to defer the introduction of fines, which will be counter-productive in this context and will undermine the good practice that I have seen and that I would like to see developed elsewhere.
4.50 pm
Mr. Andrew Lansley (South Cambridgeshire): I am glad to follow the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble). I recall that, only recently, we lost the chief executive of Addenbrooke's NHS trust in my constituency to the Blackpool NHS trust—our loss is her gain. No doubt if she discusses the matter with him, he will describe circumstances in South Cambridgeshire regarding the availability of nursing and care home places very distinct from those that she described on the Fylde coast.
None the less, some of the arguments continue to apply, and they speak of the necessity for the Government not to attempt to construct a theoretical national argument, but to consider practical issues as they affect localities. As my right hon. Friend the Member for North-West Hampshire (Sir George Young) so eloquently spelled out, they must not address issues by attacking one point in the system instead of understanding the whole system.
Essentially, I have four points to make. The first, which my hon. Friend the Member for Woodspring (Dr. Fox) referred to from the Front Bench, is about partnerships and it has been echoed across the House. In 1997–98, the hon. Member for Wakefield (Mr. Hinchliffe) and I, as members of the Health Committee, considered the relationships between health and social services. We could see then the necessity of taking down the Berlin wall between the two and of building partnerships. That began to happen, particularly over winter pressures, and it has extended to become more effective. Although it has become much more effective in my constituency, the Bill is designed not only to recreate that Berlin wall, but to give those on one side of the wall the ammunition to fire at those on the other. That is wholly misplaced and the Government should simply consider the response of the social services directors, the Local Government Association, the NHS Confederation and all those who gave evidence
to the Health Committee. It will become obvious that those who are managing such partnerships do not regard the proposal as at all helpful in that process.Secondly, on the question of uniformity, I want to make a distinctive point that I have not heard set out in detail. We might bandy around national figures on the loss of care home places, but, in practice, that loss occurs for different reasons and to a different extent in different parts of the country. The Government are fond of saying—indeed, I have heard the Prime Minister say it—that places such as South Cambridgeshire are losing some nursing and care home places because of the rise in property prices. If there is a rise in property prices that is leading to such a loss, it is happening in South Cambridgeshire as much as anywhere else in the country.
However, we are also losing nursing home places in South Cambridgeshire because they are being converted, for example, to provide mental health places, as more money can be earned from those. We are losing availability in nursing and care home places because of the change in care standards. I shall not rerun that argument from a previous Session, but it has had an impact and it has driven care home providers out of business. It would not have done so if Cambridgeshire's authority had been in a position to provide the fees necessary to meet their costs, but, as things stand, Cambridgeshire cannot meet those costs.
Cambridgeshire cannot even compete with authorities such as Hertfordshire. They receive the area cost adjustment, which is meant to reflect the additional cost of providing services in their area, but, in practice, those costs are exactly the same. If anything, they are, in some respects, less than those around Cambridge. Hertfordshire's response to its problems is to buy care home places in Cambridgeshire, which crowds out that possibility for Cambridgeshire social services.
In parenthesis, I am struck by how the Government are trying to rectify some difficulties associated with social services funding. Going back three or four years, they were, for political reasons, badging money as NHS money, which then had to be given to a health authority or an NHS trust to buy nursing and care home places and bail out a social services department that could not solve the problem. That is still happening in Cambridgeshire.
The Government have given us £2.3 million and the implication, of course, is that it can immediately purchase additional capacity. However, anybody who looks at markets will recognise that, as is true around Cambridgeshire, additional capacity simply cannot be bought if the price is below the cost of providing the service. Who will come into such a market and offer such a service?
So, £2 million of the £2.3 million provided has enabled Cambridgeshire to raise fees and to maintain provision rather than see it decline. The money has not added capacity so much as sustained it, even at current levels. If the Government are serious about building capacity, they must think hard about how much money is required to enable that to happen in parts of the country such as Cambridgeshire. Judging from what I have seen, I am not sure that £100 million is sufficient to make a substantial difference in building capacity in all those places across the country where the fees being paid are below the cost of provision.
If the Government are to go down that path, they must think hard about differentiating between impacts across the country. I shall not stand here and say that no local authorities are failing to meet their responsibilities. Some will be failing. Equally, however, others are performing well within the resources available to them. They are spending more than the social services standard spending assessment—that applies to almost all of them, including Cambridgeshire—and they are performing well in terms of the provision of home care packages.
The problems of delayed discharge involve, pre-eminently, the availability of care home places and, to an extent, the exercise of patient choice. In such circumstances, it is iniquitous to impose on an authority such as Cambridgeshire an additional fine that will drive the service further and further down.
My third point is that there is an alternative. As my right hon. Friend the Member for North-West Hampshire said, we need a more integrated system with incentives rather than penalties, which is what Cambridgeshire is setting out to achieve. A discharge planning team is being established, which will integrate health and social services and be managed by the primary care trust.
I like to think that we can be constructive whenever possible, so I point out that an option for the Government is to take out of the hands of the social services departments alone the question whether patients should be discharged to care homes. That should be put in the hands of a discharge planning team that is independent of social services to the extent that it can buy the place and pass the cost to the local authority if one is available. That would take from any given local authority the excuse that it cannot find a place when, in reality, one is available. Of course, that would follow evaluation.
As I said to the Secretary of State, I am worried that a consequence of the proposal will be the undermining of patient choice. In particular, and as the Health Committee heard from Essex, local authorities are required to make urgent placements and interim placements that are far from the choice of the patients and even not necessarily what is clinically best for them.
Patients will be damaged. I have seen that, especially when those with Alzheimer's or dementia are moved from one place to another. The physical process of transferring such patients from one set of circumstances to another and from one environment to another can do immense damage. I recall that, in some cases, patients who were moved from a ward to a nursing or care home died. The home was of perfectly good quality, but it was not in the patient's interest to be transferred.
There is an alternative, and it involves providing some independence so that a local authority that is failing to deliver on its tasks cannot escape any financial responsibility for meeting patients' needs. If a team is working on those matters and if the NHS trust concerned and the PCT are part of that team, they have an incentive to ensure that patients are not taking up beds when they should be out of hospital. Those bodies can push, through the discharge planning team, for the transfer of patients.
On adding to perverse incentives, due to Cambridgeshire's circumstances and the nature of my area, we know that many care home providers, good as
they are and as much as they want to work with local authorities, will raise their fees if they think that my social services department will lose money—
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