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Baroness Thomas of Walliswood: My Lords, I rise briefly to support the noble Baroness, Lady Pitkeathley, in this new version of her former amendment. As she has just explained to us, she has removed one of the major objections to the original amendment which the noble Lord, Lord Hunt of Kings Heath, brought forward on the second day of the Committee stage. The sooner the health service in general is brought into the process of assessing a client's need--someone who is receiving social services help is called a client--the better.

If we are to go down the road foreseen by the report of the Royal Commission on long-term care the health service has to begin to understand that what it does at the earlier stages of the deterioration in, say, the health of an elderly person will have a great deal of bearing on the costs of that care if the elderly person becomes more disabled than might otherwise be the case. The earlier

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the health service is brought into the care of elderly people the better it will be not only for the elderly person but for the health service. For that reason, I shall be extremely interested in what the Minister has to say in response to the amendment.

Lord Laming: My Lords, I also support the thrust of the amendment. I am sure that your Lordships will agree that in recent years many demands have been placed on local authorities to respond to the requests from health authorities to meet the needs of a wide range of patients, clients or users of services, however they are described. These requests have been not only to respond to need but to respond very speedily. That must be a two-way process. Local authorities and health authorities are separate corporate bodies and the amendment seems to go with the grain of the Government's commitment to a duty of partnership, which is to be welcomed. Good health care can be undermined by poor social care, but good social care can also be undermined by poor health care. In this context, "poor" generally means delay and failure to respond. I hope that the Minister will consider carefully the thrust of the amendment.

Baroness Masham of Ilton: My Lords, I heard on Radio 4 this morning that 3,000 elderly people's beds have been closed. Rehabilitation beds are also being closed. Professor Millard said in his report that there was a Berlin wall between health and social service. There needs to be a smooth transition between hospital and home for seriously ill patients. It should always be the aim to get patients back to their own homes, but if they are elderly, frail or seriously disabled good quality care with adequate support in the community is vital. After anaesthetics, elderly people can become disorientated. They often take longer to get better than younger people and there is such pressure on hospitals that they are put out into the community rather too quickly. Health and social services should work together for the common good of patients; they should build common teams. But it is difficult. They have different budgets, different ways of working and even a different language.

There was an occasion when there was an argument between health and social services about who should wash a patient. It was decided that the upper end of the patient was the responsibility of social services and the bottom half of the patient was the responsibility of the health service. That is totally ridiculous. If there were co-operation with assessments there might be co-operation over care. I support the amendment.

Lord Hunt of Kings Heath: My Lords, we return to a very important issue which was raised by my noble friend at Committee stage. I have listened with great interest to the contributions of noble Lords who have spoken in the debate. I very much agree that the spirit of partnership that is required between the NHS and local government is essential to developing services in the way we wish and for avoiding some of the points and issues that the noble Baroness, Lady Masham, has brought to our attention. I do not think that there is anything between us when it comes to the need to tackle those issues. The question is how best to do it.

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Since your Lordships discussed this matter in Committee we have given the issue further consideration. We have taken on board the concerns that were expressed that, where an individual is identified as requiring a health assessment during his community care assessment that assessment, in a minority of cases, is not taking place. That is a genuine concern which we believe has to be addressed.

We have already taken some action to deal with the problem. Last year the Social Services Inspectorate carried out a special study of multi-disciplinary assessments and we have now commissioned work to follow this up to develop a self-audit tool for authorities. We believe this will help authorities to address local problems in partnership at the local level.

I mentioned at the Committee stage that our Better Services for Vulnerable People initiative set out the requirement for health and local authorities to develop a framework for multi-disciplinary assessment. The first joint investment plans developed under this initiative will address the needs of older people. From April 2000 joint investment plans will cover the full range of client groups. We will issue guidance on the development of joint investment plans to help authorities work up their plans for services from April 2000. I am pleased to confirm that we will, in this guidance, require health and local authorities to set out how they will work together to ensure that all the assessment needs of individuals are met.

My noble friend will appreciate that we welcome the spirit of the amendment but we believe that it would not solve the problem which it seeks to address. These are local problems which require local solutions. We must ensure that local partners deal with the underlying causes of the problems. We will make sure that this happens through our work on the better services for vulnerable people initiative. We are committing ourselves to ensuring, through guidance, that health and local authorities work together to address these issues as they develop their joint investment plans for April 2000.

Finally, I wish to refer back to the point I raised in Committee that the Secretary of State has a power under Section 17 of the 1977 Act--inserted by Clause 7 of the Bill--to direct health authorities, NHS trusts and primary care trusts to provide services. Where NHS bodies have failed to act in partnership as required by the provisions in this clause of the Bill; where they have failed to follow guidance on developing joint investment plans; and where NHS bodies appear to be acting unreasonably in failing to provide an assessment when required to do so by a local authority, we will have no hesitation in using this power.

I hope that your Lordships will understand that therefore the right way to deal with this problem is to address its causes at ground level. I believe that I have set out today our commitment to a clear programme of work to deal with this problem. On that basis, I hope that my noble friend will consider withdrawing her amendment.

Baroness Pitkeathley: My Lords, I am most grateful to my noble friend both for his reply and for the extra

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consideration he has given to this important amendment. I am grateful also for the support of other noble Lords from around the House. I thank him for his commitment to putting a requirement for this co-operation in the guidance which will be issued. I am confident that that, together with the willingness to work together with local authorities, will address this issue. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 21 [Plans for improving health etc.]:

Baroness Thomas of Walliswood moved Amendment No. 51:

Page 16, line 10, at end insert--
("( ) Health Authorities shall, before drawing up any plan under this section, consult key partners in the delivery of NHS healthcare and the promotion of health.").

The noble Baroness said: My Lords, this amendment is very similar to Amendment No. 138 which was moved at the Committee stage. At that time the amendment was criticised by a number of noble Lords for what one might call its "shopping list" aspect. We withdrew it and said that we would think again. On the other hand, a number of noble Lords felt that it was a useful requirement to place on the face of the Bill; that is to say, that it would be desirable to require health authorities to consult "key partners" prior to drafting health improvement plans.

There have been objections to the expression "key partners" in the context of other amendments during the course of this Report stage. It is used in an attempt to describe in the most general of terms those bodies of all kinds which in any local circumstances should be regarded as the most important people to consult. It is very difficult to find a phrase that does that and so we have stayed with "key partners". As those key partners may not be exactly the same consultee organisations in every geographical area (or, for that matter, for every part of the health improvement plan), we believe that such a requirement should be on the face of the Bill.

The noble Lord, Lord Hunt of Kings Heath, in responding to my noble friend Lady Sharp, said, as many of us know from our own personal experience, that the health service has not been notable for the skill and depth of its consultation processes in the past. It is for that reason that we would like a general requirement of this kind on the face of the Bill, which is such an important Bill for the health service.

5 p.m.

Lord Hunt of Kings Heath: My Lords, again the noble Baroness has raised a very interesting point. I shall start by acknowledging what she said in repeating my words about the track record of the NHS in consultation in the past. One can look back--probably to 1974--to when governments of various shades issued instructions, circulars and guidance to the health service, which made it pretty clear that it needed to consult with all and sundry about any significant changes in services. Indeed, I go further and say that the health service can show that it consults with many organisations whenever it is faced with a difficult issue. The problem is that it has adopted a "tick box"

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mentality. The general approach has often been first to decide what it wants to do, then consult and then make marginal changes.

We return to the point about health improvement programmes. I believe that they do not have any hope of succeeding in the way we want them to succeed unless they engage in real consultation and partnership with organisations and the local community. Noble Lords will realise that I very much take the message of the noble Baroness. We want to see not merely consultation but active engagement and participation by local stakeholders in the health improvement programme process and we want to see them as real partners with the health service.

Having said that, I am not convinced of the case forputting this provision on the face of the Bill. I acknowledge that the amendment before us avoids the dangers of shopping lists which we referred to in Committee, but it still leaves us with the problem of how key partners should be defined and by whom. There may be uncertainty about whether the definition of the clause is broad enough to cover all those we envisage being part of the process. Is it broad enough, for instance, to cover the recipients of health care, partners in the delivery of social care, partners in research and development, partners in education, training and in workforce planning?

We certainly know what we mean by way of partner involvement in the health improvement programme process. That is common ground between us. Let me stress again that we are committed to ensuring that this develops in practice. We are requiring that each health improvement programme includes a statement of who has been involved, how they have been involved and plans to develop the arrangements for the future. We shall expect NHS regional offices to pool that information on the first round. That will enable us to identify problems in development needs and ensure that they are addressed in future rounds.

We also have it in mind to pursue the theme of involvement in the research we mean to commission on implementation of the health improvement programme process to help identify and disseminate good practice. We have already challenged the health action zones to make good progress on widening and deepening local partnerships. We will be looking to draw early lessons about their experience. I believe that action of that sort will be more productive in securing full involvement of all the key players, including the appropriate consultation, than attempting to write a general requirement on the face of the Bill.

I would say to the noble Baroness, as we discussed in Committee, that Clause 21 includes a power of direction which we can use if we need to target particular issues of involvement. I believe that that combination of clear policy and intention, active monitoring, development and dissemination of good practice, backed by a power of direction which is available to us to target any

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particular difficulty, offers a comprehensive package. On that basis, I ask the noble Baroness to withdraw her amendment.

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