---

19 Mar 2003 : Column 1032—continued

6 pm

Similarly, in the rush to avoid a fine, patients could be discharged into inappropriate care, or into the least appropriate care. No one wants that to happen, but it may be an unfortunate consequence of the possibility that local authorities could be fined. Alternatively, patients could be discharged to their own homes without adequate support services from either the NHS or the local authority social services department. Carers could suffer because undue burdens are placed on them when patients are discharged—by local authorities wishing to avoid being fined—without the support of a proper and comprehensive care package.

Amendment No. 24 would alleviate those potential problems. It would allow the situation to be monitored, as reports would be made to local authorities and the NHS. In that way, the problems that could arise would be minimised. For that reason, the Minister got it wrong when she criticised the amendment in her opening comments. She should think again.

Amendment No. 25 is eminently sensible. It would straightforwardly require the Secretary of State to report annually to Parliament on the outcomes of patients affected by the provisions in the Bill. I should have thought that the Government would warmly welcome that. Certainly, in opposition, they were strong proponents of open government. We have heard the rhetoric—they have talked the talk, but they do not often walk the walk—that people should be empowered with information and knowledge. The amendment represents a classic example of that. It is justifiable that Parliament—which will, if the Government get their way, pass this unpleasant Bill—should be made aware of the outcome of the legislation that it passes. That is not an unreasonable requirement, and I should have thought that the Government, in the spirit of open government and empowering people with information, would be prepared to accept it.

There may be an overriding reason why the Government do not want the Secretary of State to be required to report annually to Parliament on the outcomes of patients affected by the legislation.

19 Mar 2003 : Column 1033

Perhaps, in their heart of hearts, they accept the arguments that my right hon. and hon. Friends and I, as well as the Liberal Democrats, have been making for many months—that the Bill is counterproductive and highly damaging, that it will destroy partnership working between the health service and local authorities, and that it will have an adverse impact on patients because it will increase pressures on the early discharge of patients, especially elderly patients over the age of 75. As is shown by the statistics that the Government have produced in recent months, those pressures have led to a rising level of emergency readmissions. In fact, it is probably the case that the Government do not oppose the principle of amendment No. 25, but fear its consequences, in that it would annually reveal to Parliament the failings of the legislation. Moreover, it would show how right the Opposition have been to oppose the Bill root and branch and how misguided Ministers and their followers on the Back Benches have been to press ahead with it in defiance of all the evidence that it is not a good piece of legislation.

Mr. Greg Knight: Is not there another argument that the Minister might find more attractive—that is, that if the legislation works well, members of the Government would have an annual opportunity to come to this House to say so?

Mr. Burns: My right hon. Friend makes an interesting point. He knows as well as I do that some members of the Government are not as keen on coming to this place as others. In some cases, the amendment could represent an opportunity to ensure that they are here, and it could become an annual visit, so it has that extra potential benefit.

I hope that the Minister will, in the spirit of maintaining the highest possible standards and of open government, be minded to think again. I am not confident about that, but perhaps I can encourage her by saying that I will ask at the appropriate moment to divide the House on amendments Nos. 24 and 25.

Mr. Burstow: I support the amendments because it is appropriate to ask the various inspection agencies covering health and social care now and in future to monitor the implementation of the legislation, and, not least, because the Minister has been unable to answer several questions in the course of the debate, and by monitoring the situation closely we might begin to get some of those answers. Earlier, I referred to the National Audit Office report—and specifically to the accuracy of data that were being supplied on the numbers of people who are suffering delays in their discharge. I was a little disappointed that the Minister was unable to cast any light on Government actions in response to the NAO's findings and was unable to say whether the Government accepted the NAO's conclusion that there were difficulties that would impact on the Government's ability to implement the system of fines that the Bill would introduce. More than four out of every 10 NHS bodies that are responsible for submitting data on the numbers of people who are experiencing delays appear not to be following the Government's definitions. That is a problem.

19 Mar 2003 : Column 1034

However, it is not only what the NAO is saying that causes concern. Not surprisingly, local authorities, in partnership with their local NHS, are trying to test how the system would work. A colleague of mine from a metropolitan authority in the midlands told me:

"There is also a problem over definitions (there almost always has been but local work had, we thought, given . . . agreed definitions). A recent batch of 9 discharges from a local hospital went through a trial run to see what the results of the delayed discharge scheme would be, and the social services department thought they had agreement that only one of the discharges would count"

for the purposes of the fine system. However, when the department went back to the NHS trust, the trust declared that nine would be counted as delayed under the legislation. That was clearly a trial exercise to see what would happen, but it bears on the issue of clarity of definition. That clarity is still not in the Bill. The NAO has raised concerns about that.

Another issue that I hope will be contained in an annual report to Parliament, and that certainly ought to be subject to monitoring by the Commission for Health Improvement and the Commission for Social Care Inspection, is the interface between health and housing and social care. From 1 April, the supporting people programme will be rolled out across the country. Large amounts of money will be reorganised and distributed by local authorities to pay for supporting people in their own homes and in settings such as sheltered accommodation. However, I was surprised to learn recently that guidance on how the supporting people programme fits with the single assessment process—guidance that one would have thought should have been provided by now to local authorities—has not even begun to be written. The group that will do that work has not even been called together. It would therefore seem appropriate to have in the Bill a measure to enable agencies such as the Commission for Social Care Inspection to consider how the intersection between the single assessment process and the supporting people programme works.

One cause of dispute in the Chamber and in Committee, relating to whether this Bill can be implemented effectively, can be examined. It is the shortage of specialist staff. The NAO report found that two groups in particular—social workers and therapists—are in short supply. It was not only social services departments that foresaw a problem; it was the overwhelming view of primary care trusts that such shortages would continue to hamper dealing with issues of delayed discharge.

I have one final question for the Minister, and I feel that this amendment could allow this issue to be monitored. It concerns the dividing line between what is NHS-funded continuing long-term care and what are NHS part-funded registered nursing care contributions—also called free nursing care. I have raised a concern with the Minister and others on a number of occasions. The criteria for the highest band of registered nurse contributions are setting a threshold that requires a higher and more complex level of need than the eligibility criteria for fully funded NHS continuing care. It would be useful for that to be looked at.

19 Mar 2003 : Column 1035

The nursing care practice guide and workbook states:

"People with high needs for registered nursing care will have complex needs that require frequent medical, technical and/or therapeutic intervention. They will need frequent intervention and re-assessment by a registered nurse throughout a 24 hour period and their physical/mental health state will be unpredictable."

That is the definition used to enable a nurse to determine whether someone is in the top band and will receive a contribution of £110 towards their nursing care in a nursing home.

6.15 pm

The case studies in the workbook are examples that help nurses to apply the guidance meaningfully. However, it is interesting to compare them with the health ombudsman's report, which deals with real cases. The workbook stated that a woman who had suffered a cerebrovascular accident—CVA—would be placed in the highest band of nursing because she had suffered

"loss of speech and was unable to swallow; partial paralysis and poor balance and co-ordination, doubly incontinent, pressure sore and tearful and distressed. She requires peg feeding and enemas to maintain bowel function, the use of a hoist to ensure safe transfer, and monitoring of the pressure sore, teaching to improve sitting balance, review of need for anti-depressant therapy and work to maintain social interaction."

The amendment should include provision for the inspectorate to examine such cases because the health service ombudsman found that peg feeding was a criterion for continuing NHS care in one authority but not in another. In one case, the ombudsman's report helpfully listed Mrs. N's needs. They were

"a hoist to help with transfers, a . . . catheter in place to deal with her incontinence of urine and assistance with her bowel function every three to four days; changing position to maintain skin viability, help with washing and oral care, and peg feeding. She did not appear to be depressed but smiled in response to other people."

Those cases are similar, yet in one, used as an example, the person was entitled only to a contribution of £110 towards their nursing while in the other—a real case cited in the health service ombudsman's report—the person was entitled to have all their care met and paid for by the national health service. The Department's case study guidance is issued to nurses whose job is to make those systems work and it ought to lead to the conclusion that people are entitled to continuing NHS care funding.

Will the Minister comment on that? More important, I hope that we do not have to rely only on the health service ombudsman to resolve, on a case-by-case basis, the problem of the dividing line between free continuing NHS care and nursing contributions. The Government should take the opportunity provided by the health service ombudsman's report to clarify the situation so that we stop the injustice that is undoubtedly being done to thousands of people who are being denied their rights.

---