Community Care (Delayed Discharges etc.) Bill

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Mr. Baron: I want to pick up on something that the hon. Member for Sutton and Cheam said. If the single assessment is not coming into place fully across the country until April 2004, and the Bill takes effect from April 2003, what measures will the Government implement to bridge the gap over those 12 months?

Jacqui Smith: The single assessment process should be seen in the context of section 47 of the 1990 Act, which contains the statutory duty to assess. There are milestones on the way to full implementation of the process. We have issued guidance on how the process should work, and plenty of work is going on at a local level to begin to develop the protocols and relationships important for it. As people introduce or continue with assessments and improve them in the light of the single assessment process, they will obviously bear the guidance in mind. The fact that full implementation is not until 2004 should not prevent us from saying that the principles should begin to be included in assessments, or that the principles of the Bill should be held up until then.

We are backing up the need for assessments to be proportionate and speedy, with a new target for assessments to begin within 48 hours and to be completed within four weeks. Most importantly, the reforms put the users' needs centre stage. In contrast, I fear that the amendment would promote the duplication that the single assessment process is designed to stamp out. It would also not be proportionate to the needs of the majority of individuals, which is a point that I think my hon. Friend the Member for Crawley was making. Last year, a district audit carried out a survey of 213 intermediate care schemes. Evidence from that survey showed that most intermediate care services lead to older people returning to or remaining at home. Between 65 and 90 per cent. returned to independent living after intermediate care.

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If an average of 75 per cent. of people across intermediate care schemes return home to enhance independence, a mandatory assessment for continuing NHS health care over and above what should have been given at the beginning of the assessment process—which is what the amendment appears to propose—would be wasted on most people. One of the

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major complaints of older people is the unco-ordinated and sometimes slow assessment that they receive. The amendment would add to those complaints, and for that I reason I believe that it should be rejected.

Mr. Baron: I am not convinced by the Minister's response. I am not happy with the fact that the single assessment process will not come into force until April 2004. There is a gap, and the Minister has not denied it. I am not convinced that the Government have put enough resources into ensuring that that gap is bridged. The Bill appears to be being rushed through and will take effect from April 2003.

Ms Munn: I could understand the hon. Gentleman's concerns if it were not for the fact that many authorities have operated single assessment processes effectively for a long time because it is, after all, good practice to do so. We are talking about getting the authorities that do not do so up to that level. As the Minister has fully explained, those authorities are well on their way. It is wrong to give the impression that some 150 local authorities are nowhere near implementing the single assessment process.

Mr. Baron: One is not suggesting that no authorities are moving forward—it is quite obvious that many are. By implication, however, a number of authorities are not. Therefore, if some authorities make little or no progress in 12 months, it is only right that we, as Members, fully consider those types of situations, and those patients who get very little attention when it comes to single assessment generally. Some authorities are moving forward, but many are not.

I turn to another reason why I have a slight reservation. One or two members of the Committee have perhaps not picked up on the fact that one of the main aims behind the amendment is to ensure not only that patients have some say in the big scheme of things, but that they are consulted when possible. There are clearly situations in which patients cannot be consulted and may not even be able to express a view. However, we should recognise that patients have a certain right in such decisions. The amendment attempts to put that in the Bill, as it is not there at present.

There may be a tonne of regulation coming up. The Bill is barely a skeleton—I will not use the analogy of a Christmas tree. Unless we include the amendment, we cannot guarantee that patients' views and concerns will be acknowledged, or that they will be consulted. For that reason, I would like to press for a Division.

Question put, That the amendment be made:—

The Committee divided: Ayes 7, Noes 8.

Division No. 15]

AYES
Baron, Mr. John Burns, Mr. Simon Burstow, Mr. Paul Calton, Mrs. Patsy
Gillan, Mrs. Cheryl Waterson, Mr. Nigel Young, Sir George

NOES
Blackman, Mrs. Liz Fitzpatrick, Jim Linton, Martin Love, Mr. Andrew
Moffatt, Laura Munn, Ms Meg Smith, Jacqui Starkey, Dr. Phyllis

Question accordingly negatived.

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Mr. Burstow: I beg to move amendment No. 91, in

    clause 12, page 7, line 29, after '(c)', insert 'and (f)'.

The Chairman: With this it will be convenient to take the following:

Amendment No. 92, in

    clause 12, page 7, line 31 , at end insert 'or

    (c) community equipment, including aids to daily living, mobility aids, adaptations to the home, equipment for home nursing, communication aids and other items listed in Schedule (Community Equipment); or

    (d) intermediate care as defined in Schedule (Intermediate care).'.

New schedule 2,

    'Community Equipment

    Community Equipment shall be taken to include—

    (a) equipment which may assist with daily living: special seating, shower chairs, bath-mats, raised toilet seats, teapot tippers and liquid level indicators;

    (b) minor adaptations to the home, such as grab rails, lever taps, improved domestic lighting, and improving the use of contrasting colours;

    (c) equipment for home nursing such as pressure relief mattresses and commodes;

    (d) mobility equipment such as walking sticks, zimmer frames and wheelchairs for non-permanent wheelchair users;

    (e) ancillary equipment for people with sensory impairments, such as flashing doorbells, low vision optical aids, textphones and assistive listening devices;

    (f) telecare equipment such as fall alarms, gas escape alarms, health state monitoring and ''wandering detectors'' for people who are vulnerable.'.

New schedule 3,

    'Intermediate Care

    Intermediate care should be regarded as describing services that meet the following criteria—

    (1) community care services targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care;

    (2) services provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery;

    (3) have a planned outcome of maximising independence and typically enabling patients to resume living at home, typically within a time limit of up to six weeks or more;

    (4) involve cross-professional working, with a single assessment framework, single professional records and shared protocols;

    (5) short-term programmes of therapy and enablement in a residential setting (such as a community hospital, rehabilitation centre, nursing home, or residential care home) for people who are medically stable but need a short period of rehabilitation to enable them to regain sufficient physical functioning and confidence to return safely to their own home;

    (6) services covering a short-term period of nursing or therapeutic support (or both) in a patient's home, typically with a contributory package of home care support and sometimes supported by community equipment and/or housing-based support services, to enable earlier transfer of care from an acute hospital and to allow a patient to complete his rehabilitation and recovery at home.'.

Mr. Burstow: I hope to explore with the Minister some of the details of the proposals to provide equipment free, and some of the issues surrounding intermediate care. The clause is about designating

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community care services as free. The amendments would introduce a more detailed list of equipment that would ordinarily be deemed to be available on the basis of need rather than means. The amendments probe the Government's thinking. Paragraph 46 of the explanatory notes states:

    ''Community equipment (also known as aids and minor adaptations) is aids to daily living to promote independence in the home, ranging from walking sticks to grab rails and shower mats, predominantly provided to older people and disabled people.''

That is a very brief description. Can the Minister give a clearer indication of what sort of equipment older people should expect to receive? What latitude is to be given—can we be sure that when the legislation is rolled out there will not be wide variations in practice around the country? We should like to have the aims of the policy and the Minister's expectations clearly on the record.

Will the Minister confirm that the clause will be used to extend the provision of free equipment to all care settings, not just as an aid to speedy discharge? If it is the latter, it will be useful to know how the distinction will be drawn. If it is not, that will be very welcome. Has the Minister considered the findings of the Audit Commission's report ''Fully Equipped 2002—Assisting Independence'', which was published in June? It says:

    ''In the case of community equipment services in particular, social services departments were finding themselves under increasing pressure to cope with the demands of people being discharged earlier from acute hospitals. The policy to support the immediate needs of the NHS was putting pressure on other parts of social services home-care budgets, and driving up eligibility criteria for those who needed less intensive support to help them to stay at home—risking unnecessary hospital admissions and increasing demands on the NHS.''

We have been telling the Minister that that is a concern. What safeguards will be put in place to ensure that the fines system in part 1 does not exacerbate that trend, which auditors across the country were already observing when they compiled that update on equipment?

Will the Minister also take the opportunity to give us some much needed clarification about the provision of equipment in respect of residential and nursing homes? The Audit Commission describes that as a grey area. It says:

    ''Some nursing and residential homes provide equipment as part and parcel of the package of care that they provide, some rely on the NHS to provide the equipment and others require residents or their relatives to pay for it. As the policy of continuing care develops, residential and nursing homes will become responsible for residents who are more dependent. This will increasingly force the issue, and many commissioners will need to clarify their policies for providing more expensive specialised equipment, such as pressure-relieving mattresses or hoists.''

Can the Minister tell us whether pressure-relieving mattresses and hoists will be free under the Bill's provisions? Will they now be available under the provision for free equipment, or will lines be drawn? If lines are to be drawn, will the Minister tell the Committee where?

In an earlier exchange, the Minister referred to the additional 500,000 pieces of equipment that will be issued as a consequence of new investment. Will she elaborate on what assumptions were made about

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increases in demand arising from that measure, and will she give us some idea of what assumptions were made on the types of equipment that would be issued in order to reach that number? Are we talking about basic items such as grab rails, or about more expensive, specialised equipment?

The other amendments concern intermediate care. The Bill introduces a strict time limit on free intermediate care of six weeks. New schedule 3 would include the definition of intermediate care in the Government's current guidance. The guidance—and the Bill, should the amendment be accepted—says that intermediate care could be free for longer. It does not have to be confined to a six-week period. Surely it is appropriate to consider the need for intermediate care case by case. Some people, particularly those who have dementia as one their conditions may find that they can be rehabilitated into the community but may nevertheless require a longer period for rehabilitation. Will the Minister tell us the Government's thinking on that? Will it be a strict rule that people will have to pay after six weeks?

I draw the Committee's attention to another passage from the 2002 update report that raised a serious question about the capacity to deliver intermediate care. It said that there are serious staffing problems for occupational therapists. It stated:

    ''auditors were concerned that the staffing levels of some equipment services prevented proper investment in rehabilitation and community care. In particular, the shortage of OTs was identified as being a major problem. Community OTs spent, on average, a small proportion of their time on rehabilitative advice and continuing care management, and were having to concentrate instead on their role as equipment providers.''

That is a major obstacle to realising the Government's policy intention of speeding up delayed discharges, getting people into more appropriate care settings sooner, and ensuring that they receive the care, as the Minister put it, in the right place at the right time. What assessment has she made of the Audit Commission report on the staffing bottleneck? Although there is the potential for more people to train for occupational therapy, still not enough are coming out at the other end.

Earlier this year, I surveyed intermediate care co-ordinators and I found grave misgivings among them about the overly rigid six-week rule that they perceived in the guidance. I accept that the guidance is flexible on that point. My concern is that the Bill is not flexible. I hope that the Minister can answer my questions on the six-week rule and on intermediate care and, more particularly, my questions on equipment.

 
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Prepared 12 December 2002