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NHS: Disability Equipment

5. 59 p.m.

Lord Ashley of Stoke rose to call attention to the recent Audit Commission report on the provision by the National Health Service of specialist disability equipment; and to move for Papers.

The noble Lord said: My Lords, the Audit Commission's report on equipment services for old and disabled people is a truly shocking indictment. It vividly demonstrates indifference, neglect and incompetence which have lasted for decades. The report examines five essential services provided to some 4 million people, including 700,000 wheelchair users, 400,000 users of orthopaedic shoes and callipers (orthotics), 65,000 users of artificial limbs (prosthetics), 2 million people using National Health Service hearing aids, and 1 million users of community equipment services who require basic but essential equipment.

The Audit Commission is in no doubt about the value of these services. Its report states:

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    or break the quality of the lives of many older or disabled people, and the lives of those 1.7 million people who provide informal care for more than 20 hours each week. Equipment services are central to the Government's drive to promote greater independence for older or disabled people".

I agree with the Audit Commission. The value of good equipment services is undeniable. But so, too, are the consequences of bad equipment services. What kind of life is it if a person is lost in a fog of misunderstanding because of a poor hearing aid; or cannot walk without pain and discomfort because orthopaedic shoes are faulty; or cannot cope with a heavy, unsuitable wheelchair; or, when confined to bed, develops painful bed sores because a special mattress is not available? It is an absolute disgrace that this equipment, which is so obviously needed, has not been routinely available to a universal high standard. The record is deplorable and disabled people are suffering as a result.

I mention some examples. Some noble Lords may have heard of the woman who lost her hands and legs. She said that she was given a poorly made hook for a hand, and artificial legs which did not fit and caused blisters. She said that she was in total desperation and that going to the prosthetics department of the hospital was like stepping into a time warp; nothing had changed in 50 years. She eventually obtained excellent prostheses privately, but only because of a wealthy philanthropist, which, of course, is simply not an option for millions of other disabled people.

What are we to make of the trust which had an explicit policy of not issuing pressure relieving mattresses until bed sores had developed? Sores are not only painful. They take a long time to heal and can also be life threatening. My only criticism of the Audit Commission is that it did not name and shame the trust.

The Audit Commission's report is comprehensively damning. It found that essential services get no priority. Waiting times are excessive. The patient often receives equipment that is unsuitable or painful. It is an incredible saga. The views of patients are not sought. Good practice is not copied. Research and development are inadequate. Specialist, multi-disciplinary centres are lacking. Referral systems are poor. So, too, are information systems. Management is weak and inadequate. There is no feedback or audit of services or failures. A conflict of interest can exist between the clinician and the salesman selling the equipment. That is an incredible saga of incompetence. Any one of those shortcomings would be a cause for concern. Added together, they are a cause for anger and condemnation.

This nation prides itself on progress. However, the report's findings regarding equipment services take us back to the early part of the previous century. All too often equipment turns out to be out of date. This is especially true of hearing aids. More than half of the hearing aids provided by the National Health Service are the cheapest and the most basic. Those are the official facts. It must be a major reason for one-third of the aids being infrequently or never used. The pilot digital programme initiated by the present Government is welcome, but I wonder why it was not

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introduced years ago. The substantial advances in digital technology in the private sector have existed for a long time.

In view of the enormous number of inadequacies it is no surprise to read not only of disabled people receiving poor equipment, but, as a result, of much financial waste with faulty equipment left unused. If people are forced into institutional care because of inadequate services, the cost escalates. Everyone loses--disabled people, the Treasury and society as a whole.

There are some bright spots, some good centres and some helpful local authority service providers. However, good practice is not copied. We hear a great deal today about the postcode lottery. The report reveals gross inequalities between regions and within them. It states bluntly that the standard of service is "unacceptable" in many parts of the country.

The report is a grave reflection on those who were responsible in the past. I welcome the present Prime Minister's response when he said,

    "We cannot have a situation where older and disabled people are let down in the way this report suggests".

I want to raise the question of how it has happened that millions of disabled people have suffered so much and so needlessly. Who is responsible? Very little, if any, of the material in the Audit Commission's report is new. All that the report has done is to find evidence, collate it and present it admirably, thus authenticating something we have known for years.

So, we must ask, did Ministers of the Tory government, in power for 18 years in the 1980s and 1990s, know about this state of affairs? If so, what did they do about it? A well informed report by the noble Lord, Lord McColl, in 1986 complained about the unhealthy lack of competition in the prosthetics market. But what happened next? Very little, it seems. The Audit Commission report states that few new suppliers have entered the market since. Overall we have to conclude that if effective action had been taken during those years on the issues dealt with by the Audit Commission, this sorry situation would never have arisen. The government of that time bear a heavy responsibility.

Today, fortunately, there is a new spirit in the air. The voluntary disability organisations have a new spring in their step. The vigorous organisation, emPOWER, a consortium of charities, has made a major contribution to these key issues by its conferences, charters and case studies. I pay tribute to it.

The welcome for the Audit Commission report by the Prime Minister, the statement by the Minister of State at the Department of Health, John Hutton, that work has already started to drive up standards in the main areas of the report, the setting up of a working group by the Department of Health to see how the orthotics service can be improved, and the establishment of the Disability Rights Commission before the end of this month--I think on the 28th--are all happy auguries for the future.

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But they are just that--auguries. Nothing more or less. We need now an absolute commitment at every level to make radical improvements, and to make them a high priority. We need to sustain the momentum rather than have a seven-day wonder.

The report makes some excellent and welcome recommendations which require changes in organisation. But the main change needed now is one of attitude. Unless we stop regarding equipment for older and disabled people as unimportant and dispensable, we shall make no substantial progress. We require now--I hope my noble friend can give the House such an assurance--a clear timetable of improvements that can be expected, and when, and an explanation of how they will be monitored by the Government. Nothing less will do. Those of us with a special interest in disability will carefully monitor progress.

If the Government follow the Prime Minister's constructive lead and vigorous action is taken to deal with the shortcomings outlined in the report, we shall at last provide older and disabled people with the quality of equipment services they deserve, undoubtedly enriching their lives. My Lords, I beg to move for Papers.

6.12 p.m.

Baroness Greengross: My Lords, I congratulate the noble Lord, Lord Ashley, on securing this debate on such extremely important issues. As he said, the Audit Commission has produced an excellent report. It highlights particular services which are of great importance to many people. It will ensure that they are given at least a higher priority than they have been in the past.

The report demonstrated how poor and patchy the service often is; the long wait that people often have to endure to obtain what they need; that individual needs are frequently still not met; and that the equipment is often poorly fitted and arrives after individuals have waited for a very long time.

I also welcome the recommendation in the report to consult service users and their carers. In regard to carers, I am sure that the noble Baroness, Lady Pitkeathley, will undoubtedly address their specific needs. I should like to mention the needs of individual elderly, frail people who often care for chronically sick and disabled elderly partners, usually spouses. Such people need specialist equipment--hoists, stair lifts, baths and so on--to make life bearable and to ensure that the cared for person is able to stay at home--a big cost saving to public services. It would also alleviate much personal suffering and restore dignity to many people.

I want to stress the fact that two-thirds of disabled people are elderly. Their disabilities are often multiple, both in cause and in effect. They are often neglected by comparison with the more frequent acute tragedies which tend to affect the younger victims of accidents or injuries. The disabilities which affect older people are often associated with their age and often become more incapacitating over the years.

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Finally, I wish to mention rehabilitation. Last year my own organisation, Age Concern, produced a report entitled Rehabilitation discovered. It demonstrated that the medical profession is often more comfortable and better trained to deal with acute conditions. Staff and patient expectations are often very low. Good rehabilitation services can help many people with disabilities to regain their independence, but they require prior investment, particularly in community-based services.

In its report, the Audit Commission recommended the provision of integrated rehabilitation centres which would provide clinical and managerial leadership. For this a different culture is needed, as the noble Lord, Lord Ashley, said, in which users and professionals work in partnership to obtain the services that they need. We would like to see a new national service framework for disablement services established by the Government, to set national standards and to define service models which would significantly improve the independence and dignity of life for many older and disabled people.

6.15 p.m.

Lord Morris of Manchester: My Lords, my good and noble friend Lord Ashley has done the House an important service in securing this debate. Since it takes place in parliamentary time allocated to these Benches, disabled people will also be indebted--as I am--to Labour Peers generally for having agreed, within a week of its publication, to give the Audit Commission's report such priority.

The noble Earl, Lord Snowdon, expressing deep concern about the report in a speech he made last Thursday, called it "a real shocker". That was no exaggeration. The report describes in graphic detail the outdated and unusable equipment supplied to disabled people by the NHS and local authorities alike and the inhumanity of the treatment meted out to them. It cites the case of a woman who has waited 12 years for a hoist to help her to move her chronically sick husband in and out of bed. We are told as well of the 25 year-old woman, referred to so movingly by my noble friend, who lost both her hands and legs when she was hit by meningococcal septicaemia, a rare form of blood disease. Let me briefly remind the House of the extent of preventable suffering in this shocking case. She was given a poorly-made hook for a hand that did not work properly, and artificial legs that did not fit. The report quotes her as saying:

    "They had cut these two enormous holes in the front which caused terrible problems with blisters. I was in total desperation".

Last year she won a "Pride of Britain" award for outstanding bravery, and her life was transformed when publicity about her plight led to a benefactor paying the £27,000 bill for the new limbs she now wears. Memorably, she told the Audit Commission:

    "It was very important: children and young women need a limb that looks like a limb, not something cobbled together and covered with an orange stocking".

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Another case cited is that of a three year-old child who was born without a right foot. Her parents complained of long delays in obtaining an artificial one. When it finally arrived, the quality was poor. Of three prostheses made in nine months, one split, one was too small and the other was too large. She, too, eventually received private care.

A quarter of the people who have artificial limbs provided by the NHS cannot use them properly due to poor fitting that causes discomfort and pain. A fifth of amputees wait for more than six months for a first fitting of their artificial limbs. Nearly one in five wheelchair users has to wait more than two months for delivery and the Audit Commission's controller says that the policy of promoting independence for disabled people in the community is undermined by,

    "long waiting times, unclear eligibility criteria and poor-quality products".

What compounds the concern and anger of the disability organisations with which I have discussed the report is that it only confirms what they have been telling Whitehall and Westminster for years about the extent of avoidable hardship among disabled people who depend for their mobility and independence on equipment from the NHS and local authorities. The organisations claim that Whitehall's main preoccupation has been with initiatives such as the costly and now discredited and abandoned Benefit Integrity Project, not with improving disability equipment or increasing the take-up of disability benefits. They point out that not one case of proven fraud was revealed by the Benefit Integrity Project after over 40,000 visits to the homes of disabled people by DSS inspectors and that Ministers themselves have said that the amount unclaimed in disability living allowance alone may exceed £6 billion.

Of course, my noble friend who will be replying to this debate speaks as a health Minister and these other issues are the responsibility of the DSS; but disabled people and their organisations say that repetitive emphasis has been put by Ministers on "joined-up" government and that palpably it cannot happen when priorities are so ill chosen and the shortcomings of one department undermine the policies of others.

Let us take one example from this scathing report. It says that people are being forced unnecessarily into nursing homes, costing the NHS millions of pounds when, with proper help and equipment, they could live in their own homes. Millions more are being wasted, insists the report, because some local social services authorities lose up to 80 per cent of the disability equipment they supply, including items such as hoists and mattresses. The report examined equipment provided by the NHS and social services departments for 4 million people in England and Wales. It found that poor services are stripping disabled people of both their dignity and independence.

Commenting on this on 29th March, the author of the report says:

    "There are lots of people using these services and the quality of the help they get can make or break the quality of their lives, their families' and those who care for them. If people can live independently in the community it saves lots of money in the

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    health care system. If you give people access to the equipment they need, there is a much lower rate of hospital action, decline is much slower and they have a better quality of life".

He goes on:

    "The problem that we came across just about everywhere was that budgets are under very significant pressure and it is always easier to reduce expenditure on equipment than on staff. The quality you get depends on where you live. It is a real lottery by post code".

This does not suggest that he found much evidence of "joined-up" thinking--even perhaps of "joined-up" writing--let alone "joined-up" government. Very clearly what he has established is that present arrangements are inhumane; that if the right agency gives the right help at the right time and in the right place, a huge waste of resources can be avoided; that pressure on hospital beds, not least in the winter months, can be reduced by timely and appropriate help in the community; and that cost effectiveness is now at a discount among both NHS and local authority suppliers.

It is, of course, true that NHS budgets no less than those of local authorities have been under relentless pressure and that the perverse--and indeed bizarre--judgment in the case of Regina v Gloucestershire County Council and the Secretary of State for Health ex parte Barry has been widely interpreted as an invitation to local authorities to argue lack of resources for failure to provide the statutory entitlements that enable disabled people to live independently in the community.

It is plainly in straight defiance of Parliament's intention in enacting my Chronically Sick and Disabled Persons Bill in 1970 to deny housebound disabled people the right to a bath, now one of the most fundamental of human rights which, as I said earlier today, is well recognised in our prisons. Yet the recent Out of Service report, published by the Needs Must Coalition of disability organisations, shows that some disabled people have now been waiting five years without being able to bathe in their own homes. Here are brief extracts from the statements of two of those quoted in the Audit Commission's report. The first is from a woman in Staffordshire. She says:

    "My husband and I, both in our 80s, are taken to an old people's home twice a year for a bath. We asked the council to put in a bath but were told there is no money".

The second comes from a housebound person on the south coast, who says:

    "All care was withdrawn over the Christmas and New Year period. I went without food as there was no one to cook it for me. All baths stopped and my home help's hours were cut by two-thirds without letting me know".

A third case quoted is that of a 73 year-old man who was paralysed in an accident at the age of 28. He worked all his life until retiring a few years ago. He lives independently on industrial injuries benefit and the basic state pension and requires help in his home for up to 14 hours a week. He was charged £12 a week for this help. Now his local authority has put up the charge to £112 a week: a cripplingly punitive tenfold increase.

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In effect, statute law on home-care facilities for disabled people is now in abeyance in many parts of Britain and both the Audit Commission's report and Out of Service graphically document a crisis in community care that cannot be allowed to continue. Their withering criticisms of present arrangements can only be convincingly addressed if ministerial directives are now issued both to health and local authorities that take full and urgent account of the strikingly clear message of both reports. At the same time I urge Ministers to respond quickly and positively to the call of the 35-strong disability charity consortium, emPower, for a National Service Framework on Disablement Services and to let us know this evening--I speak as honorary parliamentary adviser over many years to the Royal British Legion--what consultation they have had or will be having with BLESMA and other ex-service organisations about the Audit Commission's report.

I heard the Prime Minister say with clarity and eloquence two days ago that a strong economy and social fairness are the two overriding objectives of his Government. Much to the credit of my right honourable friend, no one can doubt that our economy is stronger now than for many years and that social fairness is more achievable than before. But the Audit Commission's report and Out of Service show how long a road disabled people still have to travel to win anything like social fairness.

Where a person with a disabling condition cannot be cured, the supervening duty of parliamentarians is to do all they can to reduce the handicapping effects of her or his disability. Sadly, what both the Audit Commission report and Out of Service demonstrate is that, far from being reduced, the handicapping effects of disability are being gratuitously increased by health and local social services authorities all over the country, leaving disabled people disadvantaged twice over and doubly distressed. I strongly urge my noble friend to respond quickly and positively to both reports. I have every confidence that he will want to do so.

6.30 p.m.

Baroness Pitkeathley: My Lords, I, too, am grateful to my noble friend Lord Ashley for giving us the opportunity to debate this important issue. As ever, he and my noble friend Lord Morris of Manchester lead the way in these matters. Perhaps I may say also what a pleasure it is to have the noble Baroness, Lady Greengross, with us now to add her powerful voice and experience. The noble Baroness was right to predict that most of my remarks will be about the issue of carers.

As noble Lords have reminded us, the opening paragraphs of the Audit Commission's report recognise the effect that providing the right equipment has on the lives of carers. That comes as no surprise to those of us who have worked in this field. Complaints about delays in the supply of equipment, failure of the equipment itself, and unsuitability of the equipment

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for its purpose are among the most common problems that are brought to the Carers Help Line at the Carers National Association.

Some of my most vivid memories are of conversations with carers revolving around their stories about these problems. I remember in particular one small woman called Kathleen, disabled herself, who was caring for her even more disabled 14 stone husband. After a wait of almost six months following his stroke, a wheelchair was eventually supplied. Neither was given any instructions on its use. It was in any event too large for most of the doorways in their small flat. One of the things that they wanted to do was eat their meals together at their kitchen table. The wheelchair was so inadequate for the intended purpose that the husband had to eat his meals in the hallway with a tray across his knee because the wheelchair would not go through the door. His wife's existing disability was exacerbated by the weight of the wheelchair and she, like many carers, injured her back.

If there are problems with wheelchairs, problems with hoists are even worse. I remember one mother's astonishment when her heavily physically disabled son was admitted to hospital. No nurse would even attempt to lift him without another nurse and a hoist, while his mother lifted him several times a day from bed to chair, to lavatory, and back again, with no help at all and indeed was expected to do so. She had already been waiting 14 months for a hoist to be fitted.

A survey of carers' experiences of the NHS carried out by the Carers National Association in 1998 found that half of the carers who responded had sustained a physical injury since they had begun caring. Women, at 54 per cent, were more likely to incur an injury than men, at 43 per cent--largely because of their less robust physical condition. Many carers also reported exhaustion and there is no doubt that reducing the level of care that carers have to give by providing the right equipment is desirable.

Carers say that small but important pieces of equipment can make a difference to their lives by reducing the level of the caring tasks. Pressure-relieving mattresses are among those. It must be remembered that some carers have to turn patients not just once or twice a day, but constantly, and through the night too, in order to prevent pressure sores. The Audit Commission found, as my noble friend Lord Ashley reminded us, that one trust did not even think about providing pressure-relieving equipment until sores had actually developed. The commission also estimates that the cost of treating pressure sores is in excess of £35,000 per episode.

We must not forget, too, the cost of treating carers for the injuries that they suffer. As one carer put it, "I strained every muscle in my body". The survey that I have quoted, Ignored and Invisible, mentioned also that occupational therapists were second only to general practitioners and district nurses in providing practical help to carers and that they were very much valued for that.

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Incontinence services are mentioned only briefly in the report, but we should not forget them either. I always remember the particular problems that carers have had with those services, when lack of information and clarity was coupled with embarrassment about dealing with the subject, and that led to many horror stories. I was always struck not only by the physical problems of disabled people and their carers but the emotional anguish which resulted from the fighting and the chivvying. "You get weary", said one carer. "You shouldn't have to fight for equipment. You get passed from pillar to post as they argue about whether you are entitled to this or that. I felt just like giving up many times and just managing alone".

The report confirms that there is confusion over people's eligibility for help, which then results in arguments between departments and in even more delay. In that area, as in so many others, co-operation must exist between departments. If things worked better, the health benefits for carers and those for whom they care could be significant.

The Audit Commission suggests that local authorities and health authorities could use the powers in the Health Act 1999 which allow integrated services, pooled budgets and lead commissioning where there is a health benefit. Carers often find a lack of integration between health and local authority services and the report highlights that. Along with increased funding of the NHS, the survey of carers' experiences that I have quoted mentioned better integration as a key priority. That could help reduce delays. Carers often experience a threefold delay. They experience delay in having a carer's assessment, a further delay in having an occupational therapy assessment, and yet another delay in having the equipment delivered and fitted.

The report gives a sobering account of how lack of co-ordination blighted the early life of a baby born with disabilities in both legs and the distress of the parent carers. One of the baby's legs was amputated and a full-length splint was prescribed for the other. But the consultant responsible for fitting an artificial limb decided that the splint--the responsibility of a different clinician--needed to be modified. As the report puts it, a "debate" ensued. Even when that issue was resolved, the modified splint,

    "sat on a shelf for several weeks",

as the supplier and the hospital argued over outstanding invoices. Meanwhile, a separate argument was taking place among the wheelchair service, social services and the regional centre for disabilities about a special buggy for the baby and a chair. In the end, all three units did their own assessments.

The story in the report concludes:

    "The package of care eventually provided was considered inadequate by the specialists at the regional centre".

Yet that inadequate process, with its inadequate result, took over a year to complete. And who was providing the care for the baby during that time? The parents of course--with very little help.

I do not really see how anyone who is familiar with this field could disagree with the recommendations in the report on greater integration, better leadership,

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improved quality and cost-effectiveness. Like the noble Baroness, Lady Greengross, I am delighted that there is emphasis on user involvement in developing and improving the services.

The commission recommends that the Government include key monitoring, performance and practice issues into key areas such as the national priorities guidance and national service frameworks. It also highlights a further couple of helpful suggestions. It says that hospital discharge procedures could be improved and that this would be an ideal time properly to consult and assess the needs of carers. The assessment could include assessments which have regard to a carer's need for equipment. New guidance on hospital discharge is being developed at present and would be an ideal place to reflect on these issues. I hope that my noble friend will be able to reassure us on that point.

The second helpful point that I should like to draw to your Lordships' attention is that professionals need to have more reasonable views about what are acceptable levels of care for a carer to provide. Carers are left in situations where they have to lift a person alone and without appropriate assistance. If the carer was employed it would be a clear breach of health and safety lifting and handling regulations. Given the additional stress and injury suffered by a carer, it suggests that early intervention and the provision of the right equipment can deliver health savings as well as make carers' lives more tolerable.

I remind the House that the Carers and Disabled Children Bill awaits its Report stage in another place. That Bill is expected to come before your Lordships' House after Easter. If that Bill becomes law it will open up new possibilities in terms of carers' rights and updating guidance on carers' assessments. The Bill makes provision for carers' assessments and services to help carers to care. While the services are not defined, the Bill excludes those services which would be considered to be of an intimate or personal nature to the disabled person. Equipment, such as pressure-relieving facilities, could therefore be defined as a carer's service. I hope that that will be borne in mind when the Bill comes before your Lordships' House.

Finally, as other noble Lords have said, it makes sound economic, as well as moral, sense to give disabled people as much independence as possible and to support carers. We should never forget that carers save our nation billions of pounds by the care that they give willingly and with love. We must provide the equipment to help them.

6.41 p.m.

Lord Addington: My Lords, to put it bluntly, this report reads like a Kafkaesque bureaucratic nightmare. It says that good service is provided but that it is patchy and one may spend hours trying to find it. If one is the right person in the right place, something will be done; if not, one has a struggle. The essence of the report is that one may never find the right service; or one may find it having wasted a vast amount of time and money. The technology is

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available to do much of what is described in the report. I do not believe that the report suggests that anything should be provided which is not a developed product. However, the report suggests that increasingly the services do not reach the right people and that the structures currently in place tend to work against and not with each other.

People do not talk to each other. It appears that "doctor knows best" has now turned into "the specialist knows best" or "the department knows best"; in other words, one department cannot possibly do something if another department knows best. The noble Baroness, Lady Pitkeathley, said that carers are now being treated for slipped discs. They have had to lift perhaps twice their body weight a number of times in the absence of a comparatively inexpensive piece of equipment to help somebody in and out of the bath.

At Question Time noble Lords drew attention to the problems arising from the judgments in the cases in Gloucestershire which mean that local authorities do not have to provide certain kinds of care. I tried to draw the attention of the noble Lord on the Government Front Bench to the fact that, as a result, in acute cases often the health service will have to pick up the bill later. The Government then have to fork out more money and the lives of the people concerned are damaged and wasted. Nobody wins. Often the only person who benefits is a professional paper-pusher in a low-grade job. I am sure that the same person could be employed to ensure that people talked to each other. One of the few bright spots in the report is its assertion that many of the current government initiatives could, if used correctly, solve a number of problems. Was it not ever thus? When have we not had the capacity to do it? However, without the necessary will to do something, it will not happen.

Having got the main criticisms out of my system as quickly as possible, I believe that we should seek to make people's lives as full and independent as possible. In many cases people's lives can be improved comparatively easily, quickly and cheaply if the structures and cultures are in place. At the moment, in the majority of cases, that is not so. If the structures are in place, one has artificial limbs that work properly, wheelchairs in which people can sit for long periods of time, and supportive shoes in which people can walk comfortably. It appears that one of the greatest enhancements of personal lifestyle at home or in public is independence of movement.

Technological initiatives have already been taken. The RNID suggested in its briefing that one-third of people did not use their hearing aids because they were simply not worth using. It also suggested that one could double the number of users of hearing aids and improve their quality of life by using currently available technology; in other words, social exclusion can be dramatically reduced if we make the best use of what is available and stop wasting money on out-of-date equipment which cannot be used and which the public do not tolerate.

I thought for a minute that I had got rid of all the bad bits of the report. The report does not contain very much good news, other than possibly the suggestion

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that one day we may be able to do something slightly better. We cannot do much worse than we are doing, unless we seek to make people's lives unpleasant. But we can ask the Government to address one problem; namely, to state what should be available according to best practice and then let users know. For the foreseeable future, people will still have to struggle through the machinery to access the right services. I am aware that in the field of special needs education, for example, if people have the information, they are usually much better able to obtain what is needed. Usually they have a struggle to find it, but once they have the information that they need, it is much easier to ensure that something is done. I believe that recently one of the Minister's colleagues told a meeting of emPOWER just down the corridor that there was a problem here.

The first step that the Government can take is to inform people of best practice within current levels of resource. We are talking primarily about resources. Reference is made to back-up services but not carers. We are talking here about a cheaper form of assistance. People are expensive. The main thrust of the report is that the Government have the opportunity to introduce the right people in order to retrieve acute situations by means of the correct assistance. We have to get the bureaucratic system right to give people the necessary expertise without too many forms to fill in and too long a wait. Invariably, an acute condition which is treated early is easier and cheaper to deal with. If these services can be provided quickly, we shall improve everybody's quality of life.

If the culture of buck-passing, departmentalisation and Chinese walls is not attacked soon--since I do not know how far back this problem goes, I do not attack those on the Benches to my left--we shall merely create a new situation where the barriers are shifted slightly sideways. A new department which is set up to deal with the matter will say, "But this is our department to deal with a new initiative". Unless joined-up government is pursued with real vigour we are in danger of creating new blocks. I know that that happens. Therefore, another challenge faced by the Government is the need to look sideways.

Much of what I was going to say regarding cases has already been used by other noble Lords. Therefore, I shall conclude my remarks by saying that unless the Government are prepared to use their resources to the best of their ability--or rather, at least to make an improvement in the use of the resources they already have--they might as well give up. They must put energy and time into the problem; not just money. I have come to the conclusion that those are probably more difficult than money to get out of establishments, particularly establishments within government.

6.50 p.m.

Earl Howe: My Lords, I, too, thank the noble Lord, Lord Ashley, for giving us the opportunity to discuss this disquieting report. I am proud to declare an interest

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as a patron of DEMAND, a registered charity founded by the late wife of my noble friend Lord Renton which makes special bespoke equipment for disabled people.

The saga began a long time ago. The McColl report of 1986 revealed a service for disabled people which was inadequate and inefficient, largely due to the actions of officials who unwittingly distorted the market-place. They did so by giving the manufacturers design specifications instead of performance specifications. That resulted in uncomfortable and unattractive wheelchairs with profit margins so low that many of the companies went out of business. The limb fitting service was in the hands of a monopoly which supplied 75 per cent of the UK market on the back of a poor service from a workforce much of which was complacent and sloppy.

Happily, almost all the recommendations of the 1986 report were implemented. Great credit is due to the distinguished team behind it. That included the noble Lord, Lord Hussey of North Bradley--who has asked me to say how sorry he is that he cannot be present for the debate--and my noble friend Lord Griffiths of Fforestfach. A special health authority was established to effect the necessary changes under the chairmanship of my noble friend Lord Holderness, himself a bilateral amputee from the last war. My noble friend Lord McColl was the distinguished vice-chairman.

I can say to the noble Lord, Lord Ashley, that considerable improvements ensued. The artificial limb providers' monopoly was broken with the help of the Monopolies and Mergers Commission and the trade opened up to allow more competitors. There was better training of prosthetists and orthotists. Modern techniques were made more readily available throughout the country. Later, indoor and outdoor powered wheelchairs were supplied to those severely disabled people able to make use of that provision. Unfortunately, it is abundantly clear from the Audit Commission's report that the situation has deteriorated over the past few years. The task of the commission is, of course, to examine the economy, efficiency and effectiveness of the use of resources, with the aim of the best possible delivery of services within the money available for the 7 million disabled people in the UK.

I turn first to orthotic services. There are 400,000 people who use orthotic footwear, callipers, splints, surgical collars, spinal braces and so forth. Improvements have undoubtedly occurred during the past eight years, but, as the report identifies, they have been uneven. The criteria for supplying orthotics have not only varied between trusts, but have varied also at different times of year depending on the available budget. The service itself is fragmented. Will the Minister take steps to correct those unacceptable anomalies and to implement the report's recommendations to ensure that each service receives complete medical records, is subject to clinical audit and has sufficient throughput to ensure high quality? Will the Minister implement also the recommendation that those orthotic services which currently supply breast prostheses, wigs and support stockings should

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be located in clinical directorates alongside breast care specialists, physiotherapists and vascular nurse specialists?

I turn now to prosthetic services. As we have heard, there are approximately 60,000 amputees in the UK served by the NHS, some of whom are content and some of whom are not, especially young people who lost their limbs through accidents rather than disease. The curious thing about the report is that I can find no reference in it to the 5,000 surviving ex-servicemen and women who risked their lives and gave their limbs in the service of their country and who traditionally rarely complain about anything. The organisation which represents more such limbless people than any other is, of course, BLESMA. It is extraordinary that no one seems to have talked to its representatives. Had the noble Lord, Lord Hussey, been present, I know that he would have expressed his firm and authoritative view that--as he put it to me--there is far too much whingeing on the part of some service users and that many are perfectly satisfied with the service that they receive.

However, it is clear that there are too many quite unacceptable delays in supplying legs for recent amputees. My medical friends tell me that that should occur as soon as the stump has healed--usually within four weeks--but two-thirds of patients have to wait much longer for no good clinical reason. Prosthetists are skilled and dedicated people. However, each of the 42 centres in the UK has on average only two or three new amputees per week; a workload which could hardly be described as excessive. What is even more unacceptable is the time taken to repair prostheses. Only 54 per cent of repairs are carried out within 24 hours. Ten per cent take up to 48 hours, 15 per cent take two to five days and 21 per cent take over five days.

Equally worrying are the 25 per cent of people who do not use their artificial limbs once they have received them. The reasons include: too much pain--which accounts for 25 per cent of those people; too heavy--18 per cent; too uncomfortable and "doesn't fit"-- 12 per cent. Those are shameful statistics. As a result of the McColl report the number of companies fitting limbs increased significantly, but in the past few years the number has been reduced to three, which is even more of a monopoly than there used to be. I hope that the Government view that situation with as much dismay as I do. Will the Minister take appropriate steps to reverse that trend and to encourage excellent firms such as Dorset Orthopaedic Services to tender again?

I should like to ask the Minister also about the present policy of the NHS Supplies Authority, which seems to take the cheapest tender even if the quality of the service offered is poor. Does not the Minister agree that a poor service means that the cost of correcting the damage is usually more expensive in the long run, to say nothing of the unnecessary distress caused to patients? We desperately need more companies to come into that area.

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Continuity of care is too often lacking. As that is an essential component of proper care, will the Minister implement the recommendation that trusts should allocate a named prosthetist for each patient to manage treatment on a long-term basis and should arrange appointments in such a way that patients are able to see their own named prosthetist?

I turn to wheelchair services. As we have heard, there are at least 640,000 wheelchair users in the UK, about 70 per cent of whom are more than 60 years old. The provision is described in the report as a lottery that is dependent on postcode. It states that services could be improved by being more responsive to the views of the users and by better practice in procurement, stock management and recycling. Waiting times presented serious problems, with 25 per cent waiting over a month for an assessment and 10 per cent waiting more than two months to get an outpatient appointment. Waiting times for receiving chairs were lengthy; 17 per cent waiting four to eight weeks and a further 16 per cent waiting more than eight weeks. Will the Minister implement the three main recommendations here: first, that most users be assessed close to home; secondly, that proposals be introduced to deliver incremental quality improvement programmes; and, thirdly, that systematic re-assessment programmes be introduced for all users?

Equipment that enables a million people to live independently in the community is supplied by local authority social services and NHS community trusts. I am, of course, referring to community equipment services. Unfortunately, the hapless patient may find, through no fault of his own, that he falls between these two stools. The noble Lord, Lord Morris, mentioned the case of Eleanor Jones, who had to wait for 12 years before she could get the electric hoist that she needed to move her husband who had been left paralysed by a stroke almost two decades ago.

Effective working relationships must be established throughout the country not only to provide co-ordinated and caring service, but to avoid the waste of resources. For example, walking sticks, zimmer frames, bath benches and simple home adaptations not only preserve the independence of older people and improve their quality of life, but also cut healthcare costs in half. In a recent trial quoted in the report of those who had unlimited help according to need, which amounted on average to 14 devices each, cost 14,000 dollars per person in total healthcare costs over the following 18 months. In marked contrast, users given standard care, which amounted to two devices each, cost over 30,000 dollars in total healthcare costs per person during the same period.

Lastly, I should like to mention the very important field of audiology services. Although there are 5 million or 6 million people in the UK who could benefit from a hearing aid, fewer than 2 million people actually have one. As the report states, millions of people could benefit from reduced waiting times and the provision of more modern hearing aids and from the integration of NHS hearing aid services with local

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authority assistive listening services which provide such devices as telephone and doorbell aids. I was very much struck by one sentence in the report which says:

    "Nowhere is the cost versus quality debate in public service provision better exemplified than in the provision of hearing aids".

In order to correct the present deficiencies in the audiology services, can the Minister tell the House which of the recommendations he intends to implement?

In summary, this excellent report describes the unsatisfactory state of all of these services, which are plagued, first, by the lack of involvement of the users at all levels of service planning and delivery; by the low priority given by managers to the service; by under-investment on the part of the public sector and supporting industry and, lastly, by geographic variations in the quantity and quality of the service.

It is abundantly clear that urgent action is needed to implement the recommendations. Will the Minister give the House an assurance that this is one area where a decision need not be put off by the setting up of yet another taskforce; but rather that he will follow the wartime example of Mr Churchill and place the recommendations in a box clearly marked "Action this day"?

7. 3 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, this has been an important, uplifting and, I believe, instructive debate. I begin by expressing my gratitude to my noble friend Lord Ashley and other noble Lords for drawing to the attention of the Government what all noble Lords consider to be a very important report published by the Audit Commission. I know that a number of other noble Lords would have wished to take part in the debate. I am grateful to my noble friend Lord Morris for informing me of the regret of the noble Baroness, Lady Masham, that she is unable to attend your Lordships' House tonight.

We are all aware of the importance to disabled and older people and their carers of the services examined in this report. I do not believe that there can be any doubt at all that these services have not had either the profile, the attention or the leadership that they deserve within the National Health Service and local agencies. My noble friend Lord Ashley and other noble Lords have rightly drawn attention to many of the shortcomings identified in the report--the consequences of poor equipment services which have proved to be painful and unsuitable.

My noble friend Lord Ashley referred to the trust which, quite extraordinarily, was not issuing pressure-relieving mattresses until patients developed sores. We have heard also of inadequate local authority services, of inadequate research and information systems, and of out-of-date equipment. The noble Baroness, Lady Greengross, referred to long waits and to the need, a view I very much share, to consult users. She referred to the particular problems faced by older people caring

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for frail spouses in the context of multiple disabilities. I say to her that I fully accept that we need to do much better as regards services generally for older people. That is one reason why we shall be developing a national service framework for older people.

My noble friend Lord Morris, who has always been a doughty fighter for disabled people, spoke about the problem of long waits to be fitted and to receive equipment. Much of that equipment can be poor and, as he said, has been poor for many years. I accept fully the comments of my noble friend Lady Pitkeathley, as regards carers and the problem of unsuitable wheelchairs arriving too late and being the wrong size. She is right to draw our attention to the exhaustion felt by many carers having to cope in such circumstances. I was particularly struck by her comments on the problem of lifting. That is something we face in the National Health Service. There is a high incidence of back problems among nursing staff as a result of lifting accidents. How much more is the pressure on vulnerable carers having to deal with that kind of situation in their own homes.

I accept the strictures of the noble Lord, Lord Addington, when he spoke about a bureaucratic nightmare illustrating the problem of structures in place at local level which can often seem to fight against each other rather than provide a cohesive service. There can be little doubt that these services have been neglected for many years and that insufficient attention has been given to management, leadership, performance and development. I agree with my noble friend Lord Ashley and understand the anger felt by so many people over the poor quality of service that is often available.

However, there is a brighter side. I believe that the noble Lord, Lord Addington, was unduly pessimistic. Within the report there are excellent examples of good service and clear clinical leadership, with doctors, nurses and technicians working together and health authorities and local authorities also working together. It is these examples of good practice on which we have to build in order to get the services up to scratch. I could not agree more with my noble friend Lord Ashley when he said that because many of the services have a make or break impact on so many people, we have to do better.

My right honourable friend the Prime Minister and my right honourable friend the Secretary of State for Health have acknowledged the shortcomings. Some are already being tackled. We have promised that further action will be taken to improve services where it is clear that there is scope for doing so.

As made clear in today's debate, the report looks at five key areas of service of particular importance to disabled and older people. These services can make all the difference between isolation and dependence, being able to get out and about, and living lives with a minimum of support from other people. As the report says, they are the gateway to independence, dignity and self-esteem for many older or disabled people. For carers, equipment such as lifting devices and

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adjustable beds are often critical in enabling them to cope without risk to their own health, as my noble friend Lady Pitkeathley so vividly pointed out.

These services can provide a critical component of rehabilitation after illness and can reduce the need for more costly forms of healthcare such as delayed hospital discharge or premature admission to residential care.

We are not talking about a handful of people with special needs. There are a very large number whose needs vary from simple pieces of equipment to complex artificial limbs or electrically powered wheelchairs. The cost of providing these services is estimated at around £400 million a year. It is therefore important not only that we provide the services but that those services are of high quality and provide value for money.

The Audit Commission's report is hard hitting. It highlights an unacceptable variation in the availability and quality of service across the country. Procedures, it says, follow tradition rather than reflect local need. Staff as well as users are often unclear about eligibility criteria. Services are fragmented and there is a lack of clinical leadership. Equipment is not always of the best quality.

The report makes several recommendations as to how standards can be improved and a fairer service provided. For example--it is an important recommendation--it proposes the development of a "hub and spoke" arrangement across regions with specialist services at the centre supporting local services. There are proposals for joint health and social service arrangements for community equipment stores; the raising of the profile of those services and engaging the attention of senior managers, which I suggest is crucially important; and the better tracking of equipment to improve quality and save money by increased recycling.

From the tenor of my remarks, noble Lords will understand that the Government welcome the report. We believe it to be fully in line with our aim of tackling variations in the availability and quality of health and social services across the country for which the increase in NHS spending announced by the Chancellor in the Budget provides an important launchpad.

We are already working on improving equipment services. The measures we are taking will deal with many of the shortcomings identified by the commission. Even before considering the recommendations of the report, we are committed to significant improvements. We are investing £4 million this year in modernising the NHS hearing aid service. We have set up a working group to consider the introducing of silicone cosmesis in artificial limb services. We have funded the Disabled Living Centres Council to publish guidance on community equipment services. This has been promoted through national conferences. We are also funding the DLCC to promote the continued exchange of good practice on an Internet website.

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NHS purchasing and supplies has set up a number of working groups to bring together service commissioners, providers, representatives of the disability equipment industry and disabled people themselves to advise the authority on the services it provides. We shall be discussing specific recommendations from the report with them. Perhaps I may say to the noble Earl, Lord Howe, that of course we want to ensure that the best equipment is provided in the most effective way. We shall consider the points he made in the context of those discussions within NHS supplies which will embrace the views of users. I also understand the noble Earl's point about the number of manufacturers in the market. I understand that the NHS Supplies Authority operates an open tendering process. There is no limit on the number of manufacturers during that process. But we will reflect on the specific point he makes in the context of considering the role of NHS supplies in this area.

We have also commissioned the Oxford Brooke's University to develop a national training framework for all providers of wheelchair services. We are making £14 million recurrent with effect from 1st April for the provision of powered wheelchairs and for the continuation of the wheelchair voucher scheme which gives users the opportunity of contributing to a higher performance wheelchair of their choice. The recently published report on the evaluation of these two schemes has confirmed the success of the powered wheelchair initiative and the real contribution that it is making to the quality of life of severely disabled people. It has, however, made it clear to us that local services have found it difficult to supply the number of powered wheelchairs needed. The wheelchair voucher scheme has been slower to pick up than we had expected but there is now a steady increase in the number of people taking advantage of it.

I have made clear that we welcome the Audit Commission's report. We are already tackling many of the issues raised and we shall be looking carefully at the recommendations for change in areas that we have not so far scrutinised. But it may be helpful if I summarise the Government's response under the headings of the five services on which the commission reports.

First, I turn to orthotic services. The Department of Health issued guidance on contracting for orthotics services as long ago as 1995. Although the guidance dealt with many of the points raised by the commission, I accept that our advice has not been taken fully into account, although the Audit Commission report reveals that 53 per cent of trusts have complied with the key aspects of that guidance.

Following a conference last year put on by the disability organisation, emPOWER, my honourable friend Mr John Hutton has given a commitment that we will take action about improving the quality of orthotics services. He has asked that an NHS supplies orthotics group look at how individual users' views can be taken into account and more attention paid to the design and appearance of orthotic footwear. The

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Department of Health, in conjunction with NHS supplies, has set up a small steering group to monitor progress on this front.

The noble Earl, Lord Howe, asked some specific questions in relation to the recommendations in this area. These are early days. However, I assure the noble Earl that we shall take a careful look at the recommendations. Some fall to local decision because it is right that local services are able to come to a view. On others we shall have to take a national view; and we shall come to that view as soon as we can.

I refer next to artificial limbs services. Although in many respects those services are of a high order, it is nevertheless disappointing that some centres are not achieving the standards of practice we would expect. I pay tribute to the work over a considerable number of years by the noble Lord, Lord McColl, in recommending action to be taken in relation to the old artificial limb and appliance centres. It undoubtedly had a positive impact. However, it is clear that we need to build on those improvements.

Reasons for the reported under-use of limbs supplied are complex. They may be related to patients' general health, the quality of rehabilitation in getting them mobile again, or environmental barriers which affect their confidence. That is something we need to consider more closely. The delay in getting a first fitting may be for sound clinical reasons. But where that is the case it is important that clinicians give patients a full explanation of how their care will be managed.

The Government have given their broad support to emPOWER's users' charter for prosthetic and orthotics services. We look to health authorities and primary care groups to work with service providers and users to improve those services. As I said, the NHS Supplies Authority has set up a strategic commissioning group. I expect that group to consider carefully how it can respond to the report's findings and recommendations.

Perhaps I may say this to my noble friend Lord Morris and the noble Earl, Lord Howe. Of course we would very much wish to engage with ex-servicemen's organisations to gain their views and opinions about the report and the developments in services that need to take place.

I referred earlier to the measures being taken to improve the wheelchair service. The sum of £50 million of added investment has been made since 1996 to allow NHS wheelchair services to provide indoor and outdoor powered wheelchairs and to introduce voucher schemes. In recognition of unacceptable variations in eligibility criteria and speed of assessment around the country, we endorse the report's recommendation that health authorities and trusts need to establish clear targets to improve performance. We agree totally that disabled and older people should not be unnecessarily confined to their homes because they are unable to get a wheelchair when they need it.

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I turn to audiology services. My noble friend Lord Ashley and the noble Lord, Lord Addington, referred to issues of cost versus quality, as they described them. We recently announced a £4 million investment in 2000/2001 to modernise NHS hearing aid services. All NHS trusts are being invited to put forward proposals to take part in the scheme. The scheme will evaluate the benefits and costs of digital hearing aids for the NHS. It will evaluate efficient and effective ways of supplying hearing aids and examine the delivery of a modern hearing aid service for NHS patients.

The Department of Health will be working in partnership with the RNID, the NHS Supplies Authority and the Institute of Hearing Research to deliver the project and to ensure that it is properly evaluated. We know that this initiative has struck a chord. By the time the deadline for applications for pilot status was reached, we had received more than 80 expressions of interest from audiology departments.

I turn to community equipment services. It is clear that these services can be the key in helping people to live independently in the community. However, we also know of the historic confusion around the respective responsibilities of health and social services.

I agree with my noble friend Lady Pitkeathley that there is a compelling need to achieve a joint approach. That is reflected in the good practice guidance from the Disabled Living Centres Council, which I mentioned earlier. We want health and social services to take advantage of the new flexibilities--that is, lead commissioning, integrated provision and pooled budgets--which will enable them to work jointly in getting better co-ordination and efficiency.

Much mention has been made of the problem of getting health and local authorities to work across boundaries. I believe that the situation has drastically improved during the past two years. There is plenty of evidence of health and local authorities being prepared to sit around a table and reach good agreements on how they will work together. I accept that we need to go further and monitor their performance. However, we should be prepared to acknowledge the good work that has recently taken place. As regards the emergency planning of services for winter pressures in the NHS, the NHS was enormously gratified by the willingness of local authorities to work with it. There is a new and constructive relationship which we need to encourage. The flexibilities as regards finance between the two agencies will enable that to happen.

There is clearly considerable scope for improved efficiency and effectiveness across the whole range of disability services. I understand and accept the proposition put forward by a number of noble Lords that investment in services and support for carers can have an impact on lessening demands on other services because people will be able to live independently. I accept also the risks of authorities believing that equipment is an easy hit when budgets come under pressure. We cannot allow that to continue.

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My noble friend Lord Ashley asked for a clear timetable. We are studying the recommendations in the report and are working on the modernisation plan for the NHS. Any timetable will have to await the outcome of those exercises. Similarly, monitoring arrangements will have to be put in place in this context and in the context of overall changes in developments in services. However, I listened carefully to the comments made tonight and I will ensure that they are fully considered in the discussions that we need to take forward.

My noble friend Lord Ashley said that the main change that is needed is in attitude. Perhaps I may say how much I agree with him. I assure him and other noble Lords that the Government accept that change is needed. It is accepted that we need to monitor the performance of management and we will ensure that improvements take place.

7.24 p.m.

Lord Ashley of Stoke: My Lords, I do not intend to detain the House, but I want to thank all noble Lords who have taken part in what I regard as having been a splendid debate. All the contributions were well informed. We differed in emphasis, but we had the same objective of helping disabled people.

However, I am afraid that the noble Earl, Lord Howe, and I must disagree about what follows the splendid report of the noble Lord, Lord McColl. I was quoting from the report of the commission, but, like the noble Earl, I was surprised by the omission of BLESMA. It is possible that the commission discussed issues with BLESMA, but did not mention that in its report. Until we discover whether discussions took place, the thrust of what the noble Earl said was right. It is a pity that ex-servicemen and BLESMA were not mentioned, but we shall have to see what can be done about that.

I was heartened by my noble friend's response. I liked its tone and welcome the significant amount that is being done. However, I am not too happy about his comment on the timetable. Although I recognise that he wants to set things in order and in motion to create a timetable, such things have a habit of drifting on. I can only ask my noble friend to ensure that the question of a timetable does not drag on. We strongly believe that without a timetable we shall get nowhere.

The same comments apply to monitoring, which my noble friend said will also come. But, like Christmas, it can be a long time coming. If it is continually deferred by the pressures of other events, we might not get monitoring. Therefore, I press my noble friend to see what can be done about the timetable and the monitoring.

I am grateful for my noble friend's response and I appreciate what the Government are doing. I thank him and all noble Lords who took part in what I regard to have been a most constructive debate. It has taken the issues forward most strongly and vigorously for disabled people. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.

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