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28 Nov 2002 : Column 551continued
Dr. Andrew Murrison (Westbury): The Labour Front Bench is struggling somewhat for support, even from its own Back Benchers. Far be it from me to offer any comfort, but may I point out that in February this year I introduced a ten-minute Bill? I wanted to call it the bed block Bill because I thought it sounded rather catchy. Unfortunately, the private Bills office had other ideas and it was downgraded to the Waiting Time for Discharge from Hospital Bill, which did not convey quite the meaning that I wanted. As is the way with ten-minute Bills, it ran into the sand, but in April, Ministers and Mr. Wanless appeared to be thinking along somewhat similar lines and subsequently produced the Bill before us.
I would not like to be considered a professional whinger, in the words of the hon. Member for Doncaster, North (Mr. Hughes) and although I would like to be fairly positive about some of the ideas that the Government are putting forward, I will explain why I think that the devil is in the detail, why the measure is doomed to fail and why it will not be attracting my support.
I note that the Government have consulted very widely on the Bill, which is good, and have had 270 responses. The Department of Health tells us that there was a wide spectrum of responses but did not say that there was much in the way of support for the measure from those 270 respondees. It would be interesting to hear in the winding-up speech who, among those 270, were positive about the measure. The soundings that I have taken in my constituency have been uniformly hostile.
There has been some recent improvement in the bed-blocking figures, and we need to give due credit to all who have worked hard to achieve that, but problems remain and winter is upon us. A London consultant recently told me that patients in his ward regularly have to spend the night on a mattress on the floor. That is a damning indictment of our health service in the 21st century. Those of us with first-hand experience as patients know full well that being on a hospital ward is an unsettling experience, whether or not we have a bed. For elderly or vulnerable people, that would be a gross understatement, and the experience would not be therapeutic.
We also know that the longer people are in hospital, the greater their chance of succumbing to hospital-acquired illness. Long stays mean unnecessary medicalisation of people's problems and the demotivation of valuable NHS staff. It is a classic lose-lose situation.
Despite the small measures to resolve the imbalance between the social services and the NHS announced today, I believe that there is a deficit between the two sectors. That is historic and I believe that we should be supporting what might be described as the less ritzy part of care. Traditionally we support those medical specialties that produce obliging targets and outputs. They focus strongly on cardiology and surgery in general, when we should perhaps be looking more closely at areas of care that could arguably produce more in terms of health care and outcome for people for every pound spent. To that extent, I welcome the Secretary of State's announcement that he is
Much of the devil in the detail to which I referred is contained in the explanatory notes accompanying the Bill. I was left rather puzzled as to what qualified as a qualifying hospital under the definitions in the Bill. I am not entirely sure whether Ministers know either. For example, I have previously asked Ministers what they mean by Xintermediate care" because they are often less precise than they should be. I am certainly confused about what it means in the Bill. Will an elderly person in a community hospital who is under the care of a consultant be a qualifying patient in a qualifying hospital for the purposes of the legislation?
Although there is little mention of primary care trusts, community hospitals and GPs in the Bill, the explanatory notes on clause 4 come close to that in the reference to care of an Xinterim nature" pending fuller social services assessment. That worries me as it could mean that a patient is discharged before a fully comprehensive package is in place. A fully comprehensive package involves primary care and I am amazed that a community care Bill can so obviously neglect primary care trusts.
Cross-charging rates are to be set by regulation. The consultation document suggested £100 a day except in London and the south-east, where the rate will be £120. That is a substantial differential and it implies that social care in the south-west is substantially less expensive than it is in the south-east. As I represent a Wiltshire constituency where we constantly make comparisons with the largesse that is heaped across the border on Hampshire, I shall be interested in any evidence that the Minister can provide to back up the assertion that social care in Wiltshire is less expensive than it is in Hampshire.
The measure's most obvious perverse incentive hardly needs restating. As a GP, I should be far more inclined to seek admission to an acute unit if I thought that it was the best, or only, way to obtain the social care that my patient needed. That would both encourage bed blocking and make it difficult for people who were not admitted to hospitalthey would be for ever at the bottom of the pile.
A more subtle perversity occurs to me, as it may have done to other hon. Members: the relative disadvantage that would be introduced for emergency surgical and medical patients compared with those whose admission is anticipated in advance. Those potentially disadvantaged patients tend to be older and frailer than those considered well enough for elective surgery. Those who are less well would thus be disadvantaged by the Bill, because those who are well enough for elective surgery would, by definition, be relatively fit. I should be grateful if the Minister could consider that point.
Clause 2 restates Ministers' obsession with cold surgery. In his opening remarks, the Secretary of State said that Opposition Members had an obsession with the acute sector, which seems to be the pot calling the kettle black. There is no doubt that Ministers are obsessed with cold surgerypatients undergoing elective procedures. Such patients can expect their package to be arranged well in advance of those admitted as emergencies, yet it is arguable that prompt
Readmission rates are rising, and hasty discharge may be one of the causes. However, it is a fallacy to suppose that that is the province of one sector or another. It is not only the shortcomings of hospitals that cause increases in readmission rates. The problems lie also in primary care and social care, so fining hospitals is plain daft. Furthermore, health care staff will resent the implication that their actions should be dictated by the possibility that their hospital might be fined.
The regulatory impact assessment glosses over the burden that the measure is likely to place on carerseither by design or default. We must recognise that social service providers lean heavily on informal carers. Without them, our system would crumble.
There are several cracks in the RIA. The major costs in our health care system are up front, so if capacity is increased, as the Bill is presumably designed to do, which is welcome, there will be a great increase in costs as more surgical operations are carried out. There is no indication that Ministers have fully grasped that point. I shall be interested in their comments on the greater up-front costs that will undoubtedly result from the Bill.
Mr. Paul Truswell (Pudsey): Before I join my hon. Friend the Member for Wakefield (Mr. Hinchliffe) in the Labour Back-Bench naughty corner by incurring the wrath of my equally hon. Friend the Member for Doncaster, North (Mr. Hughes), I want to say two things. First, no one doubts the commitment of the Government Front-Bench team to addressing this often difficult and deep-seated problem. Secondly, the Government's record on investment in the NHS and social services knocks that of their predecessor into a cocked hat.
The current situation is not, as Opposition Members try to suggest, the fault of the Labour Government. The roots of the problem go back not a few years but at least a decade. Opposition Members show their customary collective amnesia. Their hand-wringing makes me think that they must belong to the Uriah Heep appreciation society.
I shall remind the House of the background. In the late 1980s and in the 1990s, the Conservative Government's mantra was clear: public provision bad, private provision good. We all remember how funding was skewed so that people going into independent sector accommodation commanded more resources from the then Department of Health and Social Security than those going into local authority homes. We all remember the explosion in the number of private sector residential and nursing homes. We all remember the massive loss of care beds in the NHS and the closure of local authority homes, or their transfer to trusts, voluntary sector organisations or similar creative arrangements.
As a solution, however, the Bill is at best premature and at worst could destabilise the care system for older people, as some Members have already pointed out. There are several key points in the case against the Bill and I base them on my observations over many years as a councillor, a chair of social services, an MP and someone whose parents will undoubtedly require care in the near future.
The issue of choice has been referred to over and over again. Older people, or their friends, relatives or advocates, want a place in a particular home and they are reluctant to leave hospital until it is secure.
There are funding problems. Leeds spends over £18 million more than its standard spending assessment on social services, a situation that is unlikely to change as a result of the local government finance review. The authority has not been able to pay nursing homes as much as they say they need to stay in business. About 200 beds have been lost during the past couple of years. However, following an independent report commissioned from PricewaterhouseCoopers, Leeds has increased payments by about 10 per cent. or more, which will, hopefully, check that loss of beds. Only time will tell. The 6 per cent. growth in real terms plus any further funding from the Government will not achieve an immediate improvement in that long-term funding problem. It cannot instantly ensure that a build-up to appropriate levels of community care services is achieved.
Other Members have referred to key issues such as the recruitment of specialist staff and said that blame is shared equally among various agencies. I am not sure that blame is the right word, although we seem to have used it a lot in the debate. The Bill is premature and unhelpful.
My fear is that, as many hon. Members have rightly said, the Bill will lead older people to be pressured, albeit subtly, to leave hospital prematurely. They may have to undergo unnecessary extra moves between hospital and their eventual place of residence. For some people, those additional moves will require the commissioning of step-down facilities in the independent sector. In Leeds, as in so many other places, there is already little surplus capacity in nursing homes, and further use of spare capacity for step-down or interim placements may exacerbate the situation.
Leeds is trying to resolve the issue by creating the spare capacity in hospital wards that would then be transferred to a primary care trust. That capacity would not be designated as acute and, I hope, not counted against the measurements that would fall foul of the Bill. In the longer run, that resource could be decommissioned as better alternative community-based facilities were created, but that needs time, and the Bill is premature and unhelpful in that respect as well.
The Association of Directors of Social Services has understandably expressed concern that some independent sector providers may seek to take advantage of the pressure on social services departments imposed by the Bill to increase charges.
The penalty payments will, I understand, go to the hospital trust. As far as I am aware, there is no requirement to ring-fence that money for older people's services. The resources available for the care of older people will be absorbed into the general acute sector, thereby reversing a trend that everyone is trying to achieve. At the very least, if the Bill comes into effect, the Minister should consider ensuring that any penalties go to the PCTs, so that they can be recycled into the care of older people.
As other hon. Members have said, hospitals may accelerate discharge procedures to put pressure on social services or reap the benefits of the Bill. Many hospital trustsLeeds is no exceptionrun considerable deficits, and there is a danger that they will take advantage of any possible income flows and view them as very welcome news. Any use of interim step-down facilities will require proper medical cover and GPs may be reluctant to take on such work. I am not aware that any guidance or funding has been offered to PCTs to cover that issue.
In Leeds, there is a very good working partnershipother hon. Members have referred to similar circumstancesand a will to ensure that patients are not detained unnecessarily in hospital. Delayed discharges run at about 2 to 4 per cent. per annum, mostly because of considerations involving choice, and I understand that that percentage compares favourably with national figures. That percentage represents 50 to 75 older people.
There is a huge problem, and it needs big answers. The Government are already beginning to provide those answers through the extra funding that they have made available, but I hope that the Minister will not reply by saying that we are at our best when we are at our boldest, because those words were no doubt uttered by George Armstrong Custer immediately before the battle of the Little Bighorn. I cannot help but fear that the Billwell intentioned though it isrepresents perhaps the wrong battle in the wrong place at the wrong time.