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Lord Hunt of Kings Heath: My Lords, I am happy to endorse the remarks of my noble friend. I wish to make two points. Notwithstanding the serious pressures on the NHS, I believe that the service is better prepared for such pressures this winter than has ever been the case before. I refer to the point made by my noble friend as regards the use of NHS Direct. I believe that the service is well placed to respond to pressures such as a flu epidemic. Nurses taking a call can identify quickly those callers who might be at greater risk, such as those with respiratory problems, who may need professional help. In other cases, nurses have been able to give basic advice on the need to rest and to drink plenty of fluids, and on basic medication. We shall need carefully to evaluate how the service has worked at this time of pressure. However, I believe that the evidence we have seen so far will vindicate the service and show that it has been a source of enormous help.

Lord Geddes: My Lords, is the Minister able to answer the question of my noble friend Lord Howe regarding the difference, if any, in theory and practice, as to the availability of intensive care beds?

Lord Hunt of Kings Heath: My Lords, I believe that I mentioned the more than 1,500 intensive care beds which were available. As regards the whole country I do not have the information on whether at any time any could not be used for whatever reason, for example, staff shortages. The NHS has been careful to plan the most intensive possible use of those beds. We

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have had information on the daily bed numbers available. We have kept a close check on the availability of those beds. At the end of this period we shall evaluate the numbers that have been used and learn what lessons we can for future years.

Care Standards Bill [H.L.]

5.8 p.m.

House again in Committee.

Clause 3 [Care homes]:

Lord Clement-Jones moved Amendment No. 7:

    Page 2, line 42, after ("with") insert ("clinical,").

The noble Lord said: We now move to Clause 3 which sets out for the purposes of the Bill the definition of a "care home". That effectively brings together the definitions in previous legislation of a "residential home" and of a "nursing home". There is some concern--this is interesting in the light of our discussions on the Statement--that when considering care homes the whole issue of clinical governance will not be considered. For that reason, Amendment No. 7 proposes the insertion of the word "clinical" after "with" on line 42, page 2.

There is an increasing trend for nursing homes in particular to be used to treat NHS patients. When a hip is replaced in an NHS hospital as part of the treatment episode, the patient may be discharged from an NHS hospital to a private nursing home for rehabilitation. I am told that around the country winter pressure money is being used to purchase space in care facilities in order to release beds in the acute sector. That, of course, is of great relevance to what we have been discussing. If the word "clinical" is not inserted in the clause, can the Minister say what procedures would be in place to assess the clinical care delivered to individuals transferred to care homes from hospital as part of their treatment episode? Can he also explain what plans there are to implement clinical governance procedures in the social care setting when doctors and nurses carry out clinical procedures in such care homes? That is precisely what the amendment seeks to elicit.

A further concern has been brought to my attention: the bringing together of the definition of a residential home and a nursing home may well allow, in some back-door way, means testing to be applied across the board. At the moment, nursing homes are means tested but residential homes are not. Can the Minister give a specific assurance--I am not sure that this was delivered on Second Reading--that there will not be any effect on means testing pending the outcome of enquiries such as the Royal Commission on Long-Term Care? I beg to move.

Baroness Pitkeathley: I would be concerned about the inclusion of the word "clinical" in the clause for fear that it would further narrow the definition. It seems to me that in the Bill we are attempting to apply standards, in so far as we possibly can, across the board as regards care in all settings. I would be

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concerned that the use of the word "clinical"--which has a medical connotation, a medical connection--would too much narrow the definition.

Baroness McFarlane of Llandaff: I am grateful for the letter from the Minister following Second Reading which clarified for me some of my anxieties about this part of the Bill. I welcome the single registration system for nursing and residential homes. It should lead to a much more flexible system which is better able to provide care tailored to the patient's needs.

However, I ask the Minister for some clarification about the financial implications of this provision for patients. As we know, at present nursing care provided in nursing homes is means tested, whereas all other health care, such as that provided in residential homes, acute and community hospitals and people's own homes, is provided free by the NHS. We seek some clarification and ministerial assurances that this change in the Bill will not be used to extend means testing of nursing care by the back door.

Lord Hunt of Kings Heath: The amendment of the noble Lord, Lord Clement-Jones, seeks to bring an establishment which provides only clinical care and accommodation within the definition of a "care home". Clause 3(3) excepts hospitals and independent clinics from the definition of "care home" as they are defined elsewhere.

This does not mean that other key services for vulnerable people will fall in a gap between the definitions of care home and of independent hospital or clinic. For example, a hospice which provides palliative care would be covered within the definition of an independent hospital under Clause 2(6) as providing a listed service. Independent clinics and hospitals, as they are defined in Clause 2, are distinct services from care homes, and the Bill is drafted to allow different regulatory provisions to be made in respect of such services.

Regulations and standards will be needed for independent hospitals and clinics which relate to the provision of their particular services--for instance, the staffing required in terms of doctors and nurses in establishments carrying out surgical procedures under general anaesthesia.

Care homes will often provide a permanent home for their residents and so regulations will be needed to ensure that facilities and services are provided that would ordinarily be available to residents if they were in their own homes--clothes laundering, for instance.

So far as concerns the question about means testing and definitions, I do not believe that these provisions will have any impact on those issues. The registration process and the registration certificate that will be given to particular homes will specify the kind of home as which they are registered. If a home was a nursing home, it would continue to be registered as a nursing home. Therefore, the application of means testing would continue as heretofore.

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5.15 p.m.

Lord Clement-Jones: I suspect that the Minister has moved on from the previous point about the clinical care carried out within a care home but, unless I misheard, I do not think that he said what system of regulation there will be with regard to clinical care carried out within a care home--for instance, the kind of rehabilitation and transitional care I described earlier. What regulation applies in those circumstances? That is what the amendment seeks to elicit.

Lord Hunt of Kings Heath: That will very much relate to the regulations and the national minimum standards that will follow from them, and the role of the care commission in inspecting those homes. The definition of a "care home" in Clause 3 is that an establishment is a "care home" if it provides accommodation, together with nursing or personal care, for the persons listed. If in such a home clinical provision was being carried out, as I mentioned in relation to a hospice, it is most likely that that particular institution would be registered as a hospital. But clearly there are judgments to be formed, on the basis of both the regulations and the national minimum standards, in relation to whether an establishment is a care home as defined or an independent hospital.

Baroness Masham of Ilton: Before we move on, perhaps I may further press the Minister about the definition of residential homes. Do residential drug and alcohol rehabilitation facilities come under this clause?

Lord Hunt of Kings Heath: Clause 3 of the Bill specifies that,

    "an establishment is a care home if it provides accommodation, together with nursing or personal care, for any of the following persons".

That includes,

    "persons who are or have been suffering from dependence on alcohol or drugs".

Lord Clement-Jones: I thank the Minister for his reply. I welcome his assurance about the means testing status quo, so to speak. I am no nearer feeling that I have had an answer about the clinical governance aspect. I recognise that the noble Baroness, Lady Pitkeathley, may have reservations about the particular expression in the amendment.

The amendment seeks to elicit an answer from the Minister about the kind of clinical governance regime that will apply to clinical care when it is provided within a care home. Following the Minister's reply, I am no nearer feeling that there is an answer than I was earlier. The Minister seemed to say that such a home has to be defined as an independent hospital before the clinical governance regime can take place. In this amendment we are talking about situations which may be thought of as half-way houses. That brings us back

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to the old chestnut we discussed earlier; that is, the question of seamless clinical governance between all sectors.

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