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Lord Williamson of Horton: I heard the words of the noble Lord, Lord Lipsey, and I made the simple resolution that my own intervention would be shorter than his. The grouping of the proposed purpose clause, the amendment of the noble Lord, Lord Morris of Manchester, and the proposed new clause in Amendment No. 260 brings us to the difficult but important issue of the definition of nursing care and what we do about other forms of personal care. We greatly welcome the Government's commitment to fund free NHS nursing care for all who need it. If we were wholly satisfied with the definition in the Bill as it stands, we could say thank you. I advise the Minister that I sometimes do say thank you to the Government; it is not very common, but I sometimes do it.

Clause 56, to which we are coming, refers only to nursing care by a registered nurse covering the provision of care itself and the planning, supervision and delegation of the provision of care but excluding services which do not need to be provided by a registered nurse. This would exclude services provided by health care assistants who carry out a lot of essential tasks. On the other hand, Amendment No. 1 refers much more widely to free personal care which is evidently wider than services provided by a registered nurse. Amendment No. 260 is even more specific with a list of seven types of personal care services.

Experience in your Lordships' House has taught me that although many parliamentarians like purpose clauses, legal eagles do not and they are unlikely to be converted on the road to Damascus or Westminster. Therefore, in relation to personal care and assessment of need, we are dealing with a paving amendment. I do not think that we shall get anything more than that. I like to treat my intervention in the same way as a paving intervention, if there is such a thing. While there is a huge difficulty about definition and the risk of putting into legislation lists of services that may become outdated if there was a policy decision, it is none the less true that the current definition of nursing care in Clause 56 should be looked at again. That would be the consequence of the amendments; there would be a change. We need to recognise that we should include some other services which most people would consider to be an integral part of personal and nursing care. They would think it was one sole type of care and would not make a great distinction between them.

Baroness Masham of Ilton: It is very difficult to separate personal and nursing care. If a person is turned at night to prevent pressure sores, is that considered to be personal care or nursing care? If a person develops pressure sores, nursing care becomes necessary, and that can cost an immense amount. In the end, the patient can land up in hospital. The turning of a patient can be undertaken by an assistant or a nurse. This is vitally important because pressure sores are costing the country millions of pounds.

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6.15 p.m.

Baroness Ashton of Upholland: I am conscious of the comments made about procedure so I am not sure whether I should be speaking. I remind the House that I am chair of a health authority. I want to make an administrative point, and a moral one from a personal view. The administrative point is that I have asked my health authority, if we were implementing this legislation today, how we might go about it. I recognise that we will receive fantastic guidance from the department--as always; and, as always, the department is glad to have views fed back to it in advance. I shall take the liberty of doing that via this statement.

From our point of view, it is simple. At present when persons are assessed to go into residential nursing care, we have an inspection registration unit responsible for ensuring that the appropriate standards of nursing and care are available for those patients. A typical percentage ratio would be 65 per cent of services provided by carers and 35 per cent provided by registered nurses. We do not investigate precisely what the registered nurses do; I do not believe that that is our job. They may decide to brush a patient's hair as a beneficial treatment for the scalp or because they are trying to develop a relationship with that patient. Were this Bill enacted now, we would pick up the bill for the 35 per cent that is currently paid by the residents of that nursing home. We have a clear administrative way of dealing with this that does not get us into the list of what is personal care. We should be cautious of doing anything other than leaving that in the hands of nurses who know perfectly well what they are doing and when they need to intervene with particular patients and not others.

We reassess patients every three months. We look carefully at patients who become more ill with regard to whether to move them. Currently, we have eight patients in my health authority who would have gone into NHS continuing care, but we feel that it is wrong to move them and we have paid for the additional nursing care.

On the ground this feels a lot easier from a health authority perspective than it feels in your Lordships' House. I would argue strongly that we should not include in this legislation lists which would tie the hands of nurses with regard to what they can do and which would create a division in the seamless care we wish to see in our nursing homes.

The second point I make relates to costs. I am conducting a review of elderly care in Hertfordshire. If I had the money that I believe is quoted in the documents and by the Royal Commission, I would not spend it in the way proposed in this amendment. That is because I have looked at all our care for the elderly. I would spend the money first on ensuring that elderly people at home who fall do not end up on trolleys in A & E departments. Currently, that is what happens because we do not have the capacity for teams of doctors and nurses to go out from intermediate or continuing care facilities to help them at home or to take them directly into a facility that would give them

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respite care. Secondly, I would look carefully at intermediate care where we have very little, if any, physiotherapy or occupational therapy--and I would invest in that. Thirdly, I would invest in ripping down some of the buildings we laughingly call NHS continuing care facilities and build purpose-built ones appropriate to the needs of our elderly population.

This does not mean that in an ideal world I would not want personal care; but I ask that we think carefully about the moneys we have available and could have available. This is not where I would put the money. There is a lot more to be done for elderly people. There are priorities that must come ahead of this.

Baroness Barker: Some months ago the noble Lord, Lord Lipsey, wrote an article in one of the broadsheet newspapers in which he gave six reasons why he was not a Liberal. I read that article and agreed with him on all six counts. I want to make it clear that, having listened to the arguments of the noble Lord on these matters over the past few months and watched him bravely go into the lion's den at pensioners' meetings, I am convinced that he is as passionate about the needs of older people as I am. We have different conclusions and priorities, but I do not doubt his sincerity.

The noble Lord referred to previous discussions on the subject in the House. I had hoped that he would rehearse some of the arguments which are germane to this issue. One of his most powerful arguments is that if something is free demand for it will inevitably increase. That argument was put forward by those who opposed the creation of the NHS in 1948. It was resisted at that time and the NHS was created. On the morning that the NHS came into being, healthcare workers in Birmingham went to work early, barricaded themselves in their offices and waited for the hordes to descend. At nine o'clock a short and orderly British queue formed.

It was right to resist such an argument in 1948; it is right to resist it today. From my experience, the idea that older people will ask for help to go to the toilet or to eat when they do not need it does not ring true. Older people value highly their personal independence.

The noble Baroness, Lady Carnegy of Lour, asked a valid question: why are we discussing this issue now? One reason is that the Government have put forward a number of different proposals emanating from the NHS Plan but without sufficient transparency to enable us to understand the future of healthcare. I refer in particular to the intermediate care guidance. The noble Lord, Lord Lipsey, states that £1.2 billion is too much to spend on personal care. We know--the Government have told us several times over--that £900 million will be made available for intermediate care. But we do not know how that will be made available. Because of the lack of transparency on the definition of nursing care we must now concentrate our minds on personal care.

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Opponents of the measure argue that 70 per cent of people already in residential care have all their personal care paid for and that the measure will subsidise those who are well off. Many people in nursing residential care already have to pay a considerable amount for their personal care. An individual with an income of approximately £185 per week may spend a third of his income on personal care.

The Government will say that things will change in the future because people will not have to sell their house. Those people may not have to sell their house immediately but the proceeds from the eventual sale will go towards the cost of their care. Although at a deferred stage, people with low incomes will still have to sell their house.

The noble Baroness, Lady Ashton of Upholland, argued for priorities. We shall discuss those in depth. Some of us cannot yet see the funding priorities in the detail of the Bill: we do not know from where the new money, as opposed to the recycled money, will come. We are told that there will be regulation and guidance. Until they are in place we must ensure that those who are in greatest need have those needs met.

The creation of the welfare state in 1948 was referred to as a settlement with the British people. At the heart of that settlement was an understanding that those most in need would have those needs provided for through taxation. The noble Lord, Lord Lipsey, may agree that the heart of the issue relates to taxation and priorities. On these Benches, we are not satisfied that the Government have made clear with sufficient transparency and clarity which needs of older people will be met. The measure appears to be a tax on age and vulnerability. That is not acceptable to Members on these Benches.

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