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15 Jan 2003 : Column 720—continued

Mr. Burstow : This is far the largest group of new clauses and amendments with which we shall deal, and it enables us to explore quite a few of the issues we touched on in Committee. I hope we shall receive further clarification from the Government today, not least on issues raised by our amendments and those tabled by the hon. Member for Woodspring (Dr. Fox), which deal with some of Opposition Members' most fundamental criticisms of the Bill. We hope that even at this stage the Government will be minded to accept some of the amendments.

New clauses 3 and 9, and Government amendments Nos. 27, 30, 32, 39 and 40, address a number of concerns that I raised in Committee. As drafted, the Bill says nothing about the rights of carers. They are seen as innocent bystanders who are left to pick up the pieces resulting from the discharge process.

Research by Carers UK has repeatedly demonstrated poor hospital discharge practice. The new clauses are intended to ensure that carers do not bear the brunt of poor practice and are not victimised by over-zealous implementation of the Bill across the country. Research published about a year ago by Carers UK showed that anything between 70 and 77 per cent. of carers said that they had no choice about taking on caring responsibilities when the person for whom they cared left hospital. In other words, seven carers out of 10 were effectively dumped on and left to get on with it. That cannot be a satisfactory outcome of the way in which discharge is currently being handled in far too many hospitals across the country.

The guidance published by the Government over the years says that carers should be consulted about discharge planning and that they should play an integral role at each stage of a patient's progress. However, all too often that does not happen in practice. The new clauses deal with that lack of consultation and assessment of carers' needs.

Carers UK has followed up the research that it has done over the years and monitored how things have changed over time, so it is educational to look more closely at its research. For example, it has found that there has been a near doubling in the number of people being readmitted to hospital within two months of discharge—from 19 per cent. in 1999 to 43 per cent. in 2001. When the most recent survey by Carers UK asked why the rise had occurred, 45 per cent. of carers said that they felt that premature discharge was the cause of what might be considered a revolving door syndrome that meant that people returned to hospital as emergency readmissions.

The problem of premature discharge from hospital was highlighted by last year's Audit Commission report entitled XFully Equipped 2002—Assisting Independence". I referred to that report in Committee. The quotation that I shall read out now was referred to but the Minister did not then respond to the point that the Audit Commission was making. The report stated:


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In other words, the policy becomes self-defeating: ejecting people prematurely from the hospital only results in them returning for additional care.

I raised the matter with the Minister in Committee, but on checking the record I found that she did not deal with the point in that debate. I hope that she will be able to do so today. By introducing a system of fines to bear down on delayed discharge problems in the NHS, new perverse incentives will be created elsewhere in the system that will distort priorities. The district auditors and the Audit Commission have found that that is already happening: the delayed discharge targets are already causing hospitals to become the priority of social services departments at the expense of others.

There is nothing in the Bill to prevent that from happening. In fact the Bill promotes it. Many people wait in their homes for assessment by social services departments, and are often in desperate need of an appropriate package of care and support. It is bizarre to discover that the Bill means that the quickest way for them to get what they need will be to get themselves admitted to hospital. The fine will cause social services to focus on their need once they are occupying a hospital bed. However, because there is no fine attached to the fact that those people are not being assessed at home, that will not be prioritised.

That is the perverse incentive that the Bill will create.

2.45 pm

Mr. Nigel Waterson (Eastbourne): I am following the hon. Gentleman's argument closely. Does he accept the Alzheimer Society's contention that the point that he makes about carers applies even more strongly to those looking after people suffering from that disease? Almost by definition, such patients are unable to give any input about what should happen to them. Carers often feel under enormous pressure to allow an inappropriate discharge and subsequent placement.

Mr. Burstow: The hon. Gentleman makes a good point about mental incapacity, and the amendments in the name of the hon. Member for Woodspring in part deal with that. I shall return to matters connected with dementia later in my remarks.

I want to follow up an undertaking that the Minister gave in response to an amendment that I moved in Committee that dealt with the question of charging carers for services. I pursued this matter in the previous Parliament in connection with the Carers and Disabled Children Act 2000. It remains a concern for many carers.

In Committee, the Minister acknowledged that it would not be right for carers to end up footing the bill for equipment. She said that the Government would return to the matter on Report. It is not clear which of the Government amendments under consideration deals with that point. I should be grateful if the Minister will make clear which amendment deals with the question of charging carers.

In Committee, the Minister said that she would deal with matters to do with the regulations, several of which directly affect carers. It was useful that the Minister

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wrote to members of the Committee setting out in summary terms the issues that the Government indented to cover through regulation.

My first question is about clause 2(4)(a), which deals with


of likely need, and the manner in which they are to be given. The explanatory notes say:


However, I hope that the Minister will reassure the House about whether carers and relatives will be notified at that stage. Neither the notes nor the Bill makes that clear. Will they be part of the process? I hope that the Minister will confirm that the regulations will recognise and acknowledge the role that carers play.

The notes also stated:


The phrase Xshared database" reminded of last year's Audit Commission report entitled XForget Me Not", which stated:


No one would disagree. The report continued:


When one goes on reading the report to see what that meant in practice, one realises that in 89 per cent. of the areas surveyed by the Audit Commission there was no compatibility between the systems—yet the Government are planning to predicate regulations on such an ability. I hope that the Minister will say a little more about that, too. How will the proposal work in practice given that the systems will hamper the sharing of information?

We on the Liberal Democrat Benches welcome amendments Nos. 27, 30, 32, 39 and 40 because they make provision for some of the concerns that Carers UK, my hon. Friend the Member for Cheadle (Mrs. Calton) and I have been raising. However, the amendments seem to fall short of placing a duty on social services departments to inform carers of their entitlement to an assessment. Indeed, Government amendment No. 27 states that the carer must ask for the assessment. In other words, the onus is placed on the carer. Surely during the stressful time in hospital associated with the planning of discharge it would not be unreasonable to place a duty on social services departments to give the carer notice of the fact that they are entitled to such an assessment if they want one.

I look forward to the debate on the Opposition amendments on consent. The Liberal Democrats strongly support their purpose. The Bill is silent not only

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on carers but on patients; there is absolutely no mention of patients. The provisions reflect an obsession with getting patients out of their beds as quickly as possible—and not necessarily in their best interests. The amendments are about ensuring that the interests of the patient are brought back into play. Under the Bill, the patient is seen as a passive recipient of whatever care or services the NHS or social services departments choose to supply.

The issue of consent is particularly relevant to patients with dementia, to which the hon. Member for Eastbourne (Mr. Waterson) referred. Indeed, when giving evidence last year during the Health Committee's excellent inquiry into delayed discharge, Professor Ian Philp, the national director of older people's services, made the following relevant point:


He went on to make the point that 70 per cent. of occupants of ordinary nursing homes are elderly mentally infirm patients—people with dementia and other problems. There are serious pressures on services currently available to provide support for people with dementia and for their carers.

We know that from the Audit Commission report, XForget Me Not", in which there are some important findings on home care services, to which the hon. Gentleman also referred. Last year's report said:


Only one in seven areas have people who are equipped with the skills to provide the services necessary to promote confidence in the fact that those with dementia will be safely discharged from hospital and will receive the support at home that they need. Surely that ought to concern the Government, although it does not appear to have been factored into the time scale for implementation of the Bill. Indeed, the Government have been hasty in introducing the legislation.

Is the Minister confident that matters have been remedied since the Audit Commission's finding just last year? Surely the patchiness of provision of services for people with dementia ought to be addressed. Even the extra resources, which are welcome and for which I and my hon. Friends voted, will not deliver from day one the extra EMI-trained staff to provide such home care and other much needed support.

Amendment No. 5, which was tabled by the hon. Member for Woodspring, would rightly ensure that patients and carers are informed about the costs of the proposed care. That raises some questions for the Minister. First, clause 3 sets up the process of partial assessments—what package of community care services ought to be provided for the carer. The assessment is not of the carer's financial circumstances, so how on earth can social services departments complete a financial assessment in the time scales proposed, especially given the intrusive nature of such assessments?

My second question is about consistency in NHS continuing care. As the Audit Commission found, there are wide variations in how the Government's guidance

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on continuing NHS care provision is implemented. Over the past months there have been some very damning health ombudsman inquiry findings against strategic health authorities that have acted unlawfully in saying that someone is not entitled to free NHS continuing care and therefore must instead be means-tested by social services departments. As a result people have given up resources to which they are entitled, whether by selling their home or running down their bank balance. Given such evidence, will the Minister ensure, if and when the Bill is enacted, that we can be confident that there will be an assessment of a person's entitlement to such care from the outset?

In Berkshire, the strategic health authority has been told as a result of the health ombudsman inquiries to trawl through records of the past few years to find when people have been wrongly pushed down the social services route and subjected to means-testing rather than receiving free continuing NHS care. That is the case not just in Berkshire but in Dorset, Wigan and Cambridgeshire. Will the Minister ensure that strategic health authorities will conduct those trawls, which have been requested by the health ombudsman; otherwise many people will feel that the guidance issued by the Department and the way in which it has been interpreted by health authorities run contrary to the decisions of the courts and rob people of money? People are having to pay for what is fundamentally NHS care.

Clause 3(8) deals with the circumstances for the withdrawal or cessation of the effect of a notice, where someone is awaiting discharge from hospital. If that person is told that they are not entitled to free continuing NHS care and they appeal, will the Minister confirm that the clock-on fines imposed on the local authority will stop?

We hope that the Government will be able to offer answers to some of the issues raised by the amendments that I have highlighted. I hope that my hon. Friend the Member for Cheadle will be able briefly to address Government amendment No. 37 to which I have not spoken. Unless both carers and patients are covered by the Bill and their rights are properly protected, the measure will not be satisfactory and should not pass through this House.


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