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19 Mar 2003 : Column 983—continued
Mr. Burstow: I agree with many of the points that have just been made by the hon. Member for Hampstead and Highgate (Glenda Jackson), and she probably speaks for all Members when she says that we do not want people to be stuck in hospital unnecessarily. That is absolutely the case, and we would support any measures that facilitate appropriate discharges. Our fear and our belief is that the Bill does not facilitate appropriate discharges. Some of the Minister's comments gave me the strong impression that the anxiety of the Government is not so much to secure the appropriate discharge of an elderly person as to free up a bed so as to facilitate other NHS objectives.
Andy Burnham: What is wrong with that?
Mr. Burstow: It is wrong if someone is discharged prematurely. That is why we have seen a massive increase—
Andy Burnham: Will the hon. Gentleman give way?
Mr. Burstow: In a moment, when I have finished answering the hon. Gentleman's sedentary intervention. We have seen a massive increase in emergency readmissions. Indeed, the National Audit Office, in its report on delayed discharges, identified that as a serious risk. A focus on discharges may increase the number of emergency readmissions.
Andy Burnham: Neither the hon. Gentleman nor the Conservative Front-Bench spokesman appears to understand that the decision to discharge is a clinical decision, and nothing in the Bill will affect the clinical decision about when a patient may be safely discharged.
Mr. Burstow: The hon. Gentleman is a member of the Health Committee and took part in the evidence sessions. He will have heard the officials from the Department talk the Committee through the definition, and they made it clear that it was not just a clinical decision. They said that the decision to discharge was a multi-disciplinary one.
When the National Audit Office published its report in February, after we had finished our initial consideration of the Bill, it included some interesting findings that we must consider when deciding whether we should retain the Lords amendments. Those findings make a strong case for delay so that matters may be properly considered.
The first is the finding of the NAO about the accuracy of the measurement of delayed discharges. According to the report, the NHS finds it difficult to provide accurate and reliable figures. Indeed, a survey found that only 27 per cent. of NHS trusts provided figures based entirely on the definition issued by the Department. Some 22 per
cent. of trusts used only a vague approximation of the definition and 44 per cent. did not follow the definition at all and were, therefore, supplying incorrect and unreliable data to the Department. Those are the data being used by Ministers to frame their policy and to demonstrate a reduction in the number of delayed discharges. From the work of the NAO, we know that we cannot place confidence in those figures.
- "Continued inaccuracies in this data could affect the effective implementation of the Community Care (Delayed Discharges etc.) Bill, if it becomes law from April 2003, as the data will form the basis for calculating reimbursements payable by Councils to acute hospitals as part of the new arrangements".
The other issue that I hope the Minister will consider is the Coughlan judgment and continuing NHS care. In the light of the health service ombudsman's report last month, real anxiety still exists that the guidance issued by the Department of Health in 2001 is misleading, inaccurate and does not comply with the Coughlan judgment and is, therefore, not in accordance with the law. As a consequence, people are being passed from the NHS to social services departments, where they are means-tested for their care, when they should have continued to be the responsibility of the NHS.
I hope that the Minister will tell us more about what steps the Department will take to ensure that it issues proper guidance on delayed discharge and discharge planning to clinicians who take initial decisions about the appropriateness of discharge, so that they can make a proper assessment of any continuing health care needs. Clinicians judge not only whether the need is still acute but also whether the need is continuing. If it is, the NHS clearly has a responsibility to continue funding care whatever the patient's location after discharge. That is not clear in the present guidance or in the majority of the rules used by local health authorities to guide those who make the decisions.
3.15 pm
My final concern, which is picked up in the NAO report several times, relates to capacity, which has been a running theme since Second Reading. The report finds that many parts of the country—especially London and the south-east—now have occupancy rates of more than 90 per cent. in care homes. The lack of capacity means that the NHS cannot discharge patients. If the Bill were to be implemented from 1 April this year, the extra resources for social services—for which I voted—would not be available in time to bring extra capacity on stream. The issue is not only care home capacity, but home care capacity, as the NAO report confirms. There is a shortage of care home workers and new ones cannot be recruited overnight.
For those reasons, the Liberal Democrats believe that the Lords amendments should continue to stand part of the Bill. The Lords were right and wise to say that the sun should not rise over the Bill until we have got the detailed answers to the points made by the NAO, which we have raised time and again with Ministers without receiving proper answers. I hope that the Minister will
be able to reassure us, but I will encourage my colleagues to support the retention of the sunset and sunrise clauses in the Lobby this afternoon.
Mr. Hinchliffe: When the Bill was introduced, several Labour Members wished to consider whether it would be possible to improve it fundamentally. We had grave doubts that the mechanism in the Bill was the right one to adopt in the circumstances. The only common ground we could reach on what amendment could be made is reflected in Lords amendment No. 5, so I support it as all that could be done to improve what is not good legislation. I regret having to say that, but I made my views clear on Second and Third Reading.
The Government have taken many steps to address is a major problem in the NHS and they have done much to improve the working relationship between the NHS and social services. The Government have produced a definition of a delayed discharge—on that point, I disagree with the hon. Member for West Chelmsford (Mr. Burns), because I recall asking the previous Government about delayed discharges, but they did not even have a definition for them. It is commendable to try to establish what we mean by delayed discharge, because it is useful to know exactly what the problem is before addressing it. However, I take the point—picked up in the Health Committee's inquiry into delayed discharges—that several different approaches have been taken to the definition, which will cause problems when trying to apply a common system such as that in the Bill.
I agreed with some of what the hon. Member for Sutton and Cheam (Mr. Burstow) said a moment ago, and with virtually everything that my hon. Friend the Member for Hampstead and Highgate (Glenda Jackson) said a little earlier. I object to the common thread that appears in debates such as this—that our problems in this country could be solved by making more institutional care available. The lack of care home capacity is mentioned time and again. It saddens me that that is repeated as though it is factually correct. In this country, the problem is that far too often we have gone down the road of providing institutional care for elderly people. We have not examined how we could take concrete steps to develop alternatives.
To be fair to the Government, they accept that. It frustrates me that other European countries not very far away provide no care homes or nursing homes at all. People in their old age are afforded much more in the way of independence and rights than elderly people in this country are offered. It is about time that we kicked into touch the nonsensical proposition that we should have more and more institutional care for old people. It is simply untrue.
Mr. Dawson: Does my hon. Friend agree that a good example of what he describes can be found much closer to home than Denmark? The hon. Member for West Chelmsford (Mr. Burns) completely undermined his argument about care home places when he told us how successful the Government have been in introducing partnerships and in forging partnerships between health and social care services. The public, private and voluntary sectors work really well together.
Mr. Hinchliffe: Yes. It is also about time we recognised that a reduction in the number of care home
places is a success, providing that we are assured that the alternatives to that form of care are being developed. Far too often, colleagues in other parties assume that the way to make progress on these matters is to provide more and more institutional care in the private sector. I profoundly disagree with that.My hon. Friend the Minister said that there were 6,000 inappropriately delayed people in NHS beds. The Health Committee did some costings on the matter, which were very worrying. Money is being wasted that could be invested in treating the people in those beds who need treatment.
However, as I and one or two others noted on Second Reading, it is worrying that so much emphasis is being given to delayed discharges. As I know from my own local hospital, inappropriate admissions are another significant problem. If we are applying one approach to delayed discharges, it would be inconsistent not to apply a similar approach to inappropriate admissions. I would be more convinced that the proposed mechanism was going to work if it was being applied in an even-handed way, and if it was proposed to establish a mechanism that would push costs back to the people who are making the inappropriate admissions in the first place. Why are they doing that? We need to find out.
I want to refer to what the Health Committee has said in connection with the amendment. I hope that, on the many issues that we investigate, the Committee's comments are seen to be constructive and helpful. They are made on the basis of the evidence that we take, and on the basis of the cross-party consideration of matters. Committee members belong to different parties, and those that belong to the same party often have different views. Even so, we came to some clear conclusions on the matter, and I should like to refer to a couple of them now.
At paragraph 162, the Select Committee states:
- "While there was some cautious support for the model"—
- "the predominant reaction was that the proposals constituted a blunt instrument that, rather than improving partnership, would be likely to reinforce a negative blame culture. We are especially concerned that the underlying assumptions behind the charging proposals is that most delays in the system are the fault of social services. As we have emphasised throughout this report, the causes of delay are complex and multi-factoral. It is far from clear that the issue can be resolved by such a crude solution."
- "that appropriate incentives have a role to play, but we would also urge the development of positive incentives that reward good practice, rather than any precipitate and over-zealous emphasis on penalties. We recommend that any new schemes should be subject to piloting."
Finally, these problems come up time and again, in all sorts of bits of legislation. We have a go at them around the edges, but we never address the fundamental problem—the organisational division between health and social services. In the previous Parliament, the Committee, which had a completely different
membership, came to the key conclusion that the only real solution is to integrate our health and social care systems. That requires common budgets. The Health Committee's most important conclusion in respect of delayed discharges is that we should integrate health and social services.I shall say no more this afternoon. I shall go and lie down now that I have made my contribution. I hope that, at some point, the Government will adopt what is increasingly the consensual opinion among people in the voluntary sector and in pressure groups—that there is a need to examine the matter radically. Once and for all, we must end the nonsensical division between these two key areas of policy.
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