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Lord McIntosh of Haringey: My Lords, I gather from that that the noble Lord, Lord Stoddart, feels resentment but, since his resentment is based on so many misconceptions about public finances in this countryin the south of England, the north of England and in Scotlandhis claim that there is resentment outside does not stand up very well.
Lord Barnett: My Lords, my noble friend seemed to argue that the reason for not scrapping the formula is because of all the various changes that have been made and the fact that there are a number of exclusions. Is he now saying that it is all right because it is only a little bit unfair?
Lord McIntosh of Haringey: My Lords, I did not say either of those things; I said that the formula works and is understandable, predictable and challengeable only on the grounds of different calculations of population. Those do not seem to be virtues that should be lightly thrown away.
Lord Berkeley: My Lords, I am grateful to my noble friend for that Answer. Is he aware that, apart from affecting seriously business confidence in the industry, it is estimated that cutting these grants is likely to put 5 million more lorries a year on the roads? How is that in line with the Government's 10-year plan to reduce congestion and transfer more freight from road to rail?
Lord McIntosh of Haringey: My Lords, I believe that we should put this issue in context. The budget of £40 million for freight facilities grant and track access grant has become exhausted for this year. The Strategic Rail Authority has said that, until about the end of this year, no more applications which have not been contractually committed will be entertained. The advantage of doing that, and the purpose of doing so in relation to the purposes under the Transport Act 2000, is to avoid wasted effort and expense by bidders and, at the same time, to honour existing contractual commitments. In the context of a £33 billion budget over the 10-year period and virtually a £12 billion budget over the period of the current spending review, that does not seem to me to bring about the kind of conclusions envisaged by my noble friend Lord Berkeley.
Lord Bradshaw: My Lords, does the Minister share my concern about conflict of interest where large sums of public money are expended on the railway, mostly in the interests of train services operated by Virgin Trains? Does he agree that the fact that the chairman of the Strategic Rail Authority, his deputy and the rail regulator were all involved in that deal raises questions, and what does that mean for the rest of the railway, which will get virtually nothing?
Lord McIntosh of Haringey: My Lords, I believe that if the noble Lord, Lord Bradshaw, is to make accusations of conflict of interest, he had better do so other than with the benefit of parliamentary privilege. This is not a matter for me to comment on. He will know that the balance between expenditure on passenger services, which is what I believe he is referring to, and expenditure on freight services has been greatly affected by the freight charging review introduced by the rail regulator, to whom he referred, in October 2001. That has already halved the access costs to freight operators. The £500 million extra cost has been paid for by the Strategic Rail Authority in its grant to Network Rail.
If the substance behind the noble Lord's question is the balance between passenger and freight expenditure rather than accusations of conflict of interest, then I do not believe that he has any grounds to go on.
Lord Lea of Crondall: My Lords, I return to the Minister's reply to the supplementary question of my noble friend Lord Berkeley concerning the relationship of this matter to the 10-year plan. Can we infer from the Minister's reply that the Government are still committed to the 10-year plan? In particular, can we infer that the figure of 80 per cent for growth in rail freight provided for within the 10-year plan is still government policy and that the Government are committed to achieving that?
Lord McIntosh of Haringey: My Lords, the Government are, indeed, committed to their 10-year plan. As I have already said to the House, a full review of that will take place within the next 18 months. As to the immediate future, it is a little difficult for me to comment because the Strategic Rail Authority will produce its strategic plan only this week, on Thursday, 30th January.
The Lord Bishop of Hereford: My Lords, if certainty and predictability are good arguments for maintaining the Barnett formula, can the Minister tell us why they are not equally good arguments for maintaining rail freight grant where the ability to plan ahead is essential if businesses want to make the transfer? Furthermore, if he is not persuaded that the legal or business arguments are decisive in this case, will he agree that the environmental arguments should be and that the transfer of freight from road to rail is of enormous environmental importance? It is a policy to which the Government are committed. Will they not make an exception in this case to enable the grants to continue? Can he also confirm that, even if the grants are not to be continued in England, they will be continued in Wales and Scotland?
Lord McIntosh of Haringey: My Lords, I believe that the thrust of the intellectual argument follows the same course in both Questions. Certainty and ability to plan are good things. That applies to the Barnett formula and to the action of the Strategic Rail Authority. The authority said that it has no money for new applications under the freight facilities grant or the track access grant this year. Therefore, it said that time and money should not be spent in producing anything now but that thought should be given to submitting applications towards the end of this year as money will be available next year.
However, that is against the situation where tonnage of rail freight has increased over the past 20 years or so from 17.6 billion tonne/kilometres in 1980 to 19.4 billion tonne/kilometres in 2003. The commitment to the extension of rail freightthis is the environmental argumentis still as strong as ever.
Lord Faulkner of Worcester: My Lords, is it not the case that, when Mr Bowker took over as chairman of the Strategic Rail Authority, the West Coast Main Line modernisation plan was in such disarray that there was no prospect of that line carrying even existing levels of freight in the future? It is only because
Lord McIntosh of Haringey: My Lords, Mr Bowker and the Strategic Rail Authority inherited from their predecessors and from Railtrack not only a bow wave of renewals, which was inevitably necessary after Hatfield, but, as my noble friend Lord Faulkner said, also a whole series of projects with unclear specifications and poor project management. The West Coast Main Line was a very good example of that. Happily, not all projects are like that. I refer noble Lords, for example, to the Channel Tunnel Rail Link.
Lord Berkeley: My Lords, I beg to introduce a Bill to amend the procedure for dealing with applications for orders under Sections 14 or 16 of the Harbours Act 1964 and for making orders under Section 15 of that Act, and for connected purposes. I beg to move that this Bill be now read a first time.
We are here today to debate a Bill that aims to bring an end to widespread delayed discharge, bring increased clarity to the roles and responsibilities of health and social care agencies, and increase the choice available to older people. On any given day in England, on average, 5,000 mainly older people are delayed in acute hospital beds across England. For each of those 5,000 people, something has gone wrong. Each of those individuals remains in a hospital bed unnecessarily when he or she can no longer benefit from acute treatment. First and foremost, that is bad for individuals who are delayed because, with each day that they remain on an acute ward, they are at risk of losing their independence and of becoming institutionalised.
I know there are those who argue that the Bill is unnecessary and suggest that as good progress has already been made on delayed discharges the issue can be tackled in other ways, such as through partnership and central performance management. I am the first to acknowledge the progress that has been made. I do not believe that the current level of heavy central intervention and top-down performance management that has brought about that reduction is consistent with the devolution and earned autonomy that we want to introduce across the health and social care system. It is also true that, even with the recent successes that we have achieved, the level of delay remains unacceptable. I do not believe that any older person should be delayed in an acute bed when he or she is ready to go home.
At Second Reading in another place my right honourable friend the Secretary of State announced that an extra £100 million per full year on top of the allocations already announced would be transferred from central NHS budgets to local authorities in order to meet the estimated costs to local authorities of the scheme. That means that lack of funding can no longer be used as an excuse for under-investment in delayed discharges.
Of course, there are issues around care home capacity in some parts of the country but we have a problem if we think that the only way to care for the older people in our society is to place them in care homes in ever increasing numbers. The National Service Framework for Older People makes clear that local authorities need to reduce their reliance on institutional care and instead invest in a wide range of alternate provision, including interim care, intermediate care, extra sheltered housing and intensive support at home. In other words, that means increasing our capacity so that services can be used flexibly to respond to an individual's needs rather than using capacity problems as an excuse for local authorities not having met their responsibilities.
I make clear that the Bill does not place any new responsibility upon local authorities. It does not require them to do anything other than what the best local authorities already do. Put simply, we expect local authorities to meet their existing responsibilities rather than, intentionally or unintentionally, passing the financial burden for some of those responsibilities on to the NHS. The Bill places a strong financial incentive upon local authorities to ensure that all individuals ready to leave acute hospital care are provided with the right care in the right place at the right time. It also places new duties upon the NHS that will ensure that robust discharge procedures are in place. I stress that the robustness of the new arrangements will be just as thorough on the NHS as on personal social services.
I shall explain the main provisions of the Bill in more detail. Clause 1 sets out its scope: that is, those patients to whom its provisions will apply. Under the Bill a qualifying hospital patient will be someone who is accommodated in an NHS hospital (or in an independent hospital following arrangements made by the NHS) receiving care of a description that will appear in regulations. In the first instance, the Bill will apply only to patients receiving acute care, but it is our intention that its scope should be gradually extended to other sectors as appropriate.
Clause 2 places a new duty upon the NHS formally to notify a local authority in cases where it looks likely that an individual will not be able to be safely discharged from hospital unless community care services are provided to him or her. We know that the earlier discharge planning begins the more successful the discharge will be, so we shall be stating in official guidance that that notification should take place as soon as the patient is admitted to hospital for emergency admissions and prior to admission for elective admissions.
Under Clause 3, once the local authority has been notified of a patient's case by the NHS, it will, in consultation with the NHS, carry out an assessment of the patient's needs and determine what community care services the patient will need in order to be safely discharged. As I said, the duty to assess the patient's needs is not new. The aim is to improve information flows and assessment procedures so that the NHS informs the local authority as early as possible that an individual may need services upon discharge and the local authority immediately acts upon that notification. That is vital. At the moment around a fifth of delays are due to patients waiting for the completion of an assessment of their future care. At the moment, in some cases the hospital may not even tell the local authority that it has a patient who may need community care services until just a few hours before the proposed time of discharge.
We have also taken the opportunity in Clause 3 to place a new, reciprocal duty upon the NHS to carry out its assessment of the patient's needs in consultation with the local authority. That will benefit the patient because it will ensure that he or she has the complete package of care that he or she needs without any gaps in services. It will benefit the local authority and the NHS because it will lead to improved communication and greater partnership as they work together to determine what is best in the interests of the patient. Under the clause the NHS must also provide the local authority with a formal notice of the proposed day of the patient's discharge. We shall use regulations to state that that must be given at least 24 hours before 9 a.m. on the proposed discharge date to ensure that the local authority has enough time to put the necessary services in place.
Clause 4 of the Bill introduces the financial incentive for local authorities to carry out promptly an assessment of the patient and to put services in place. The local authority will have at least two clear days in which to carry out an assessment of the patient's needs and to put services in place. However, in most cases it
If, by the end of the pre-notified day of discharge, the patient cannot be discharged because the local authority has not carried out an assessment or because the social services needed to discharge him or her are not available, the local authority will be required to make a payment to the NHS for each day that the patient is delayed in order to reimburse the NHS for the costs of providing bed, board and personal care to a patient who should be the responsibility of social services. It will be required to make a payment only where the reason for a delay is that community care services are not in place. If NHS services are also not available, the charge will not apply. I believe that it is completely fair to expect local authorities to meet their responsibilities and where they fail to do so to make a payment to the NHS in that way. We have provided them with the funding to put in place the services and capacity needed to avoid delays, and they also need to live up to their side of the bargain. I do not believe that the NHS should pay the price for local authorities' failure.
I return to the point I made at the beginning of my speech. The Bill is not just about placing an incentive on local authorities. The NHS has responsibilities too. There are many cases where the NHS is responsible for creating the delay because it does not have effective discharge practices and procedures in place. Perhaps I can give an example of one area where consultants used to do a weekly ward round at which decisions to discharge were made with the unbelievable result that some patients had to wait an extra seven days before the decision to discharge was made. The contents of the Bill will be as tough on the NHS as on local government in relation to sorting out its act and ensuring that robust procedures are in place. In effect, the Bill will force local authorities and the NHS to look at how they handle their discharges and to put formal systems in place to deal with them. That alone will make an enormous difference to the numbers who currently experience delay.
Some consider it unfair that there is a financial incentive placed upon local authorities but not upon the NHS. The NHS already has considerable incentives to tackle delayed discharge because it is the NHS that loses out from the delayboth financially and because of reduced ability to meet its access targets. The NHS will also be judged for its star ratings on performance with respect to delayed discharge.
The new powers are general in scope but specific in intent. Clause 13 means that it will be for the National Assembly for Wales to decide how independently of England to exercise the new power. The only limitation to the powers applying to both England and Wales is that accommodation under the National Assistance Act 1948 and personal care, including to carers, may only be provided free for up to six weeks.
The Bill is not intended to penalise local authorities, as has been suggested by some. It is intended to create a genuine incentive for them to use the funding increases that they have been given as we intendedto put a wide range of services and capacity in place for older people in the community. It is also just as much about placing new responsibilities on the NHS to ensure that it notifies local authorities in good time and works in partnership with them to effect prompt and effective discharge.
The Bill represents an important opportunity to ensure that the money invested in older people's services results in older persons having more choice about where they go when they leave hospital. It will bring an end to thousands of older people suffering needlessly each day as they wait in an acute hospital bed. The Bill deserves the support of the House.
Earl Howe: My Lords, the Minister hasas alwayspresented a clear and helpful analysisand for that I readily thank him. Regrettably, however, today is not one for rejoicing. It would have been pleasant for me to welcome the content of the Bill, not just its exposition, but the most I can say is that Part 2 will not cause us to fall out.
Part 1, however, is so fundamentally misconceived that I tend to feel that there is no help for it. At one time I was tempted to table a Motion to defeat the Bill on Second Reading. With some reluctance I concluded that that would have been wrong, bearing in mind the customs and practice of the House. I did feel, however, it right to express my deep reservations about the Bill in the form of an amendment to the Second Reading Motion. In doing so, I align myself fully with the noble Lord, Lord Clement-Joneswhose amendment takes precedence over mine.
The fact that my party and the Liberal Democrats are united in opposition to the measure is a reflection not of party politics but of a united opposition in the country at large. This is not a party issue. After all, the Bill is designed to tackle a feature of our health and
When someone is fit to leave hospital, it does that person no favours to be left in hospital when they could be looked after at home or in residential care. The longer an elderly person stays in hospital, the more their confidence dwindles and the less accustomed they become to ordinary life. At the same time, other patients in need of that same acute bed have to wait longer. If at the last minute the bed is not available, they may even find that their operation has been cancelled. For the hospital itself, a blocked bedif I may use that rather insensitive expressionis a serious waste of resources.
One of the Government's achievements, for which I give them full credit, has been to encourage hospitals and local authorities to work in partnership in an effort to minimise delays in discharging patients. In many parts of the country those partnership arrangements have worked well for a number of years. There is no doubt that best practice and a spirit of co-operation are more and more in evidence.
From the statistics, it is striking that not only is the number of people waiting to leave hospital on any one day coming down but also fewer people are waiting for a lengthy period. Of course there is still a long way to go. Even now, more than one third of people who suffer a delayed discharge wait for more than one month. That is unacceptable. Equally unacceptable is the rising number of patients who are discharged prematurely, then readmitted soon after as emergency cases.
Among the root causes of delayed discharges, one above all stands out. That is the current lack of capacity in the care home sector. Estimates vary as to the number of care home beds lost since the Government came to office. The most authoritative indicator is that of Laing and Buisson, who found that more than 60,000 places in long-stay residential settings disappeared between 1997 and 200214,000 of those in the past year alone.
That decline has occurred at the very time when the key population group most in need of social carethe over-80shas been rising. The average level of occupancy in care homes for the elderly is currently over 90 per cent. Some parts of the country, especially southern England, are experiencing an acute shortage of care home places, not only as a result of closures but because London boroughs are able to purchase places outside their own areas at top rates.
The closing down of care homes is a subject that the House has debated on a number of occasions, so I do not intend to take up time today reiterating my diatribe against Government policies that have brought about that situation. The key point in the
In Sweden, where the policy apparently originated, there is no shortage of capacity in the care home sectorwhich, in the main, is publicly owned. In the UK, the care home sector is a diverse mix of private and public. There are simply not the same levers for a local authority to pull to ensure that the right care home place is available when needed. It is not clear, either, that the Swedish experience has been entirely happy. Both in absolute terms and in proportion to its population, Sweden still has more people blocking hospital beds than does the UK. That alone should cause the Government to think again as to whether their policy will actually work.
But other more serious considerations should have instilled doubt. The Government believe in partnership. What happens to a partnership when one partner is issued with a gun and told to fire it at the other? To move from a situation in which trusts and social services co-operate in a common cause to one where trusts have the whip hand over social services and can exercise it with impunity is a recipe for conflict. It moves diametrically against the flow of recent policy designed to cultivate joint working.
Joint working will not disappear, of course, but instead of being creative it will be confrontational. Sometimes it is not easy for two organisations to build up a relationship of trust, but it is easy for that trust to be broken. I have no doubt that some hospital managers, given the opportunity, will decide to put their own budgets before the interests of external partners.
The Bill will foster a claims culture between two arms of the public service. One has to ask whether that is healthy or constructive: I do not believe that it is. We should not underestimate the extent to which local authorities whose budgets are stretched to the ultimate will wish to dispute and contest the payments imposed on them. The threat of such penalties will undoubtedly skew the day-to-day priorities of social services. An elderly person living at home in need of domiciliary care will take second place to an elderly person waiting to be discharged from hospital who is also in need of domiciliary care. The threat of financial penalties will create an imperative to find the hospital patient a place to go before others have a look in. It may not be the right place or the best place.
That will, in turn, lead to a certain culture. We will move from services centred on the needs and wishes of patients to a situation in which the patient becomes a parcel or commodity to be shifted from here to there, so long as he does not continue to occupy a hospital bed. The patient's voice and choice may no longer influence the care setting selected. The Bill says nothing about the right of patients to be consulted on what happens to them.
The Minister may believe it is harsh to call the Bill dehumanising, but I do not think so. It opens up all kinds of questions; for example, patient confidentiality. The Bill contains no rules or criteria
Not all patients are assertive about their wishes. I dare say we all know people who adopt a stoical approach to life. It is not hard to imagine an elderly person, who is made aware that every day he or she is occupying a hospital bed will mean a fine for social services, deciding that they do not want to be a nuisance to anyone and agreeing to go wherever they are told. The Bill brings no benefit to such people if they find themselves discharged into the wrong setting.
It is not a satisfactory answer to say "Ah well, there is always the local authority complaints procedure". Making a complaint after one has been shunted out to somewhere unsuitable is no substitute for being able to exercise an element of choice in the first instance. Many elderly people will find making a complaint far too daunting and will simply not do so. We will find patients being moved to any old care home as a temporary expedient and then being moved on again; or else having to stay permanently somewhere they do not like. It is in these subtle ways that the dehumanising effects of the Bill will be felt.
All this presupposes that a system of financial penaltiesor "incentives" in the new speak of the Billwill reduce the incidence of delayed discharges. The example of Sweden should suggest that there is a limit to how effective such a mechanism can be. But the shortage of care home capacity means that there is another dimension to the policy; it will create unintended perverse incentives. If a GP is looking for a care home for his patient and is unable to find one, the obvious thing will be to refer the patient to hospital. The problem will no longer be his, but the local authority's. That is not a fanciful hypothesis. The net result will be more hospital beds that are blocked, not fewer.
A further perverse incentive will arise for care home owners. In a suppliers' market, with local authorities managing tight budgets, the existence of penalties will enable some care home owners to hold social services to ransom by ratcheting up their weekly charges. It will be cheaper for the local authority to pay up than to pay the fine. The existence of the fines is therefore unlikely in itself to act as a spur to the one thing we need, which is the creation of additional capacity in the system. It will simply be a spur to inflation and a drain on resources.
That is just one way in which a system of financial penalties risks distorting the market. It would of course be helpful if the new money that has been promised to social services next year were to enable them to launch an expansion of home care services. However, regrettably, that is not likely, at least not to any great degree: the number of households receiving community care has gone down quite sharply in recent years, so there is a great deal of ground to make up at a time when the recruitment and retention of care workers is almost intractably difficult.
What we have in this Bill is someone's bright idea for tackling a single symptom of a problem that is much wider than blocked beds in hospital. The Bill does nothing to address inappropriate admissions to hospitalin fact, as I suggested, it may exacerbate them. It does nothing to promote preventive care, which is one of the key ways to help keep elderly people out of hospital in the first instance. I am a paid-up fan of two rather unsung professions: chiropody and physiotherapy. I am convinced that investing in those areas would reap dividends far in excess of any that are likely to emerge from re-erecting barriers between the NHS and local government. Certainly, we should aim to try to spread best practice in hospital discharge procedures, but do not let us imagine that this Bill will help to do that.
It is depressing to have to be so negative about a Bill whose origins, I am sure, are well-intentioned. But it cannot be allowed to pass through this House without the severest of protests. No group of people whom it directly affects will gain from it: not patients, not social services, and not the NHSdespite the extra money that may flow to it. I await the speeches of other noble Lords with interest, but I hope it is not too late for the Government to recognise a poorly thought-through idea when they see one and withdraw this measure before it has the chance to do any damage.
The Lord Clement-Jones rose to move, as an amendment to the Motion that this Bill be now read a second time, at end to insert "but this House regrets that the Bill fails to tackle the causes of delayed discharges of patients from hospitals, creates perverse incentives which will undermine joint working between local authorities and the National Health Service, and will distort priorities for care of elderly people by placing the requirement to meet discharge targets ahead of measures to avoid hospital admission".
The noble Lord said: My Lords, I join the noble Earl, Lord Howe, in thanking the Minister for his succinct introduction. I did not feel it had his usual enthusiasm, but perhaps I am reading into his speech something that did not existperhaps I should hope that it did not have his usual enthusiasm.
In the Bill we have yet another product from the hyperactive Secretary of State for Health's department of bright ideas. As the noble Earl, Lord Howe, mentioned, the model adopted in the Bill hails from Sweden, yet the Swedish system operates completely differently, with responsibilities for health and social care allocated in very different ways to very different bodies.
Furthermore, the evidence is that the Swedish model has actually worsened relationships between municipalities and county councils, which run the hospitals. As it is, 6 per cent of Sweden's acute beds are apparently still blocked despite the reforms. But the Government have such faith in their health tourism experience that no pilot scheme is planned in the UK.
The timing planned for the introduction of the Bill ensures the maximum penalty on local government. The increase in funding of 6 per cent to social services announced last year will not have flowed through into improved or new services by this spring. At the very least, pilots should be conducted and implementation delayed across the rest of the country until 2004.
The dangers of the Government's approach are enormous. Their own figures show clearly that taxpayers' money is being wasted in ever greater sums on readmitting the elderly to NHS beds. During the past two years, there has been an increase of 19 per cent in emergency readmissions to hospital within 28 days of discharge. Figures from the second quarter of 2002 show that 8 per cent of people aged 75 and over are now being readmitted within 28 days of discharge.
Delayed discharge figures are running at about 5,000 patients at any one time. As both the Health Select Committee and Wanless reports highlighted, that is due to a major loss of beds in residential and private nursing homes between 1997 and 2001. The Government do not like the Laing and Buisson figures cited by the noble Earl, Lord Howe, so let me put the Wanless figure to them. Wanless estimates the total at 25,700. However, it is only this year that the Government have committed to above-inflation increases for social services to address that crisis.
Allied to that is a great shortage of occupational therapists15 per centwho are so necessary to the discharge process. The Government have finally come up with increased funding for social care that will start to match the rise in NHS funding, but it is doubtful that that increase will be enough to make up for past underfunding. It is hardly surprising that in those circumstances, coming on top of that major care bed crisis, the Bill has generated something akin to panic in both the NHS and social services.
NHS trusts will also take the risk of readmission by discharging early, which may lead to more emergency readmissions. The Bill may encourage the simplest residential home solution rather than the more complex home-based solution. There may be pressure to move into second-best residential care if a place is available, rather than wait for a more suitable care home.
As a result of the Bill, social services will prioritise NHS patients over those in hospices, because of potential fines, so the former will be assessed urgently and will benefit from quicker service on home adaptations. We have already had plaintive briefings from the hospice movement, which says that it wants to be included in the Bill because of its fears in that respect.
A further, central criticism of the Bill is that it sets up a blame game between the NHS and local government. The arrangements will be carried out in a punitive, blaming spirit, not one of partnership and collaboration. They tear up the slow and painful progress made in the Health Act 1999 and the Health and Social Care Act 2001 from joint working through to partnership arrangements and care trusts. The Government used to talk of tearing down the Berlin Wall between health and social care. Now we have the equivalent of the reintroduction of Checkpoint Charlie by the same Ministers.
Despite what the Minister said, the sanctions for failure set out in the Bill are totally one-sided. There are no sanctions on the NHS. The Bill unfairly shifts all the blame to local government. Even the Minister, in his briefings to Members of the House, admitted that that is not how to approach the situation. The Government first claimed that local government would be able to cope with the 6 per cent increase and then announced that £100 million extra would be given to local government. But in another place, the Minister, Jacqui Smith, admitted that there had been no consultation on whether that £100 million was adequate. It seems to be based on some spurious calculation of an estimated 4,200 delayed discharges. I wonder whether the Minister can clarify that.
Furthermore, the £100 million, if levied in fines, will go in entirely the wrong direction. The fines will be a drain on local government resources, not directed to creating more capacity in social care. Money spent on fines should go to those needing social care, not to the NHS. At the very least, it should go to primary care trusts and should be applied only following consultation between health and social care stakeholders. To cap it all, under the Bill the dispute procedure between the NHS and social services will not be independently conducted but will be under the aegis of strategic health authorities.
It is well known that early discharge from acute care settings can have ill-effects on older people or the terminally ill. The Hospital Discharge Workbook, a revised version of which will, I believe, be available today, may set out the procedures for discharge, but it does not set out the circumstances in which a patient is considered fit for discharge. The definition of eligibility for discharge is crucial, but can be specified by each acute trust. Without provision for proper consultation of patients and carers, the procedure for disputes on discharge, with appeal to continuing care panels, will become ever more frequently invoked. I fear that patients and carers will have to become legalistic entirely as a result of the Bill.
The Bill even runs counter to the National Service Framework for Older People, which states that older people must be treated as individuals and enabled to make choices about their care. I see none of that in the Bill.
As for assessment under the Bill, it is clear that there is no time for comprehensive assessment while patients are in an NHS hospital; there will be only a partial assessment. The Bill will disrupt progress towards the single assessment process between health and social care envisaged by the NHS Plan, which stated that a single assessment process was meant to come into universal effect in 2004. Older people need good care provided at home or a good care home. It is imperative that there is a clear statement of rights of patients and carers and that they have the right to a single assessment process within a set time. The Bill provides neither.
Let me emphasise once again that my criticisms are not criticisms derived only from these Benches. The common theme among all those involved in this field is that the Government have not listened to any alternative. Let us look at some of the responses to the Government's consultation document issued in July 2002. One hundred per cent felt that April 2003 was too soon for implementation of the Bill; all felt that three days for putting together a care plan was unrealistic if patients and carers were always to be involved; 77 per cent of respondents believed that reimbursement proposals could damage partnerships.
Those are substantial criticisms with substantial support. But does the Secretary of State take any notice of that consultation? What is the point of consultation if the Secretary of State takes no notice? It always seems that the Secretary of State knows better. Yet there is massive agreement between the Association of Directors of Social Services, the NHS Confederation and the Local Government
The Wanless report, coming with the seal of approval of the Treasury, talked of whole systems modelling to provide better understanding of the interaction between health and social care. "ithink" is the whole systems model being put forward by local government, health service managers and social services directors. It involves joint local protocols and local action plans prepared in co-operation. Yet in another place the Minister, Jacqui Smith, cast doubt on all this in her anxiety to make the argument for the Bill. The Government have not even listened to the Chief Inspector of Social Services. As we often find to be the case, there are also lessons to be drawn from Scotland.
In conclusion, this Bill puts a price on patients' heads. The Government are turning vulnerable older people into commodities to be haggled over by the NHS and social services. Fining social services for delayed discharges is a simplistic solution to a complex problem. Our view is that the Bill in summary does not tackle the fundamental problems of delayed discharges. It creates perverse incentives. It will undermine joint working between the NHS and local authorities and will distort priorities for the care of older people.
When this Government were in opposition, the Labour Party bitterly criticised arbitrary mechanisms like the internal market. But this Bill is creating a far worse monster which will be far more divisive to health and social care. I beg to move.
Moved, as an amendment to the Motion that the Bill be now read a second time, at end to insert "but this House regrets that the Bill fails to tackle the causes of delayed discharges of patients from hospitals, creates perverse incentives which will undermine joint working between local authorities and the National Health Service, and will distort priorities for care of elderly people by placing the requirement to meet discharge targets ahead of measures to avoid hospital admission".(Lord Clement-Jones.)
Any scheme that reduces the number of delayed discharges from hospitals, particularly acute hospitals, should be welcomed because more patients can then be admitted for essential treatment. Reducing delayed discharges will also reduce the cost of caring for older people who no longer need hospital treatment. The local authority, through its social services, is responsible for putting in place the community care needed by older patients in order that they can be safely discharged from hospital.
Through this Bill the Government aim to reduce the number of delayed discharges affecting older people by a system of reimbursement whereby a local authority makes a paymentin reality a fineto the healthcare provider, usually a hospital. The Bill also provides the power to remove, in circumstances set out in regulations, local authorities' power to charge for certain community services. The Bill makes no mention of any measures to prevent the admission of older people into our hospitals, or to their readmission.
The care of older people in the community requires partnership between local councils and the NHS, as emphasised by the Minister and by the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones. But the scheme described in this Bill could undermine existing local partnerships by creating financial and practical barriers. Social services are liable to make a payment amounting to £120 per day in London and £100 per day elsewhere in England and Wales for every older person whose discharge is delayed. That payment will be seen as the penalty for social services failing to make or complete the assessment and for failing to provide the community service they decided was necessary.
The NHS trust must give formal notice that a patient is likely to need community care on discharge from hospital. Social services must then assess the patient and determine what community care is needed. Social services have a minimum of three days to carry out an assessment once the NHS trust notifies it of the day of the patient's discharge. After that period social services have to pay a fine for the delayed discharge.
It does not take much imagination to realise how easy it will be for disputes to arise between the NHS trust and social services. My first question is therefore to ask what steps have been recommended to prevent disputes from arising and what mechanism will be in place to deal rapidly with disputes between NHS bodies and local authority social services in order that disputed delayed discharges do not take more than two weeks to resolve.
In order to strengthen local partnerships between the NHS and social services, a preparatory period is needed to ensure adequate numbers of social workers are available to respond to assessments for the discharge of older people from hospital. In many local authorities there continues to be a 20 per cent unfilled vacancy for social workers. The Bill will add pressure to an already understaffed service.
In order to reduce delayed discharges, adequate nursing home beds in the community should be available as one important measure. In Wirral, for example, so many local authority and private care homes have closed in the past five years that there is now a shortage of accommodation. In addition, intermediate care facilities are poorly developed. Equipment for older people with chronic conditions and disability to help them live at home in the community is another essential. But such equipment is currently in short supply as we cope with an increasingly older population.
The Government have decreed that the reimbursement scheme should be implemented from April this yearless than three months away. By comparison, as mentioned by the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, when a similar scheme was introduced in Sweden a two-year preparation period was in place. I therefore ask my second question: should not more time be given to local authorities to ensure community care provision is adequate for older people before this Bill and the penalties to be paid are introduced?
Finally, the money paid by social services under the reimbursement scheme will go to the NHS hospital where the patient's discharge is delayed. There is no guarantee that the money will be used to improve services for older people. There is a suspicion that it will go to cover the increased costs of general hospital services. Would it not be better to give the money to PCTs to improve community services for older people?
The Government have announced the allocation of £100 million every year for three years from the NHS budget to social services to help fund this scheme. However, the total annual cost of 5,000 patientsthe number currently involved in delayed dischargesis estimated to be £180 million. At worst, the scheme could become a perverse incentive so that delayed discharges from hospital do not become a priority to be tackled, particularly if partnerships within the NHS and local authorities break down. It may be more convenient to pay the fine and keep the patient in hospital rather than increase expensive home and community-based services in districts where older people form a substantial part of the population, as in Wirral.
Finally, I ask the Minister to make a statement about money generated by the scheme being used to improve services and equipment for older people in the community. I support the amendment moved by the noble Lord, Lord Clement-Jones.
The Lord Bishop of Hereford: My Lords, parliamentarians usually express themselves in fairly measured termscertainly in your Lordships' Houseso it came as something of a surprise to me to discover just how outspoken some of the comments on this Bill had been in another place. In the course of the Second Reading debate there on 28th November, there was general acknowledgement that this Bill addressed a real and pressing problem of bed-blocking in acute hospital wards. I need to declare a non-direct interest as my wife is a non-executive director of an acute hospital trust. She knows all about blocked beds and the problems they create for the trust.
This is a serious and growing problem which exacerbates the related problem of waiting lists for elective surgery and medical treatment and adds to the periodic crises which arise in most acute hospitals over emergency admissions.
Honourable Members would say that, wouldn't they, because they were speaking from the Opposition and Liberal Democrat Benches in another place. However, sharp criticisms were also levelled at the Bill from the Government's own Benches. The Secretary of the Church of England Board for Social Responsibility has called it an "appalling Bill".
I have a strong sense of deja vu. I am reminded of the Animal Health Bill. There was a real and acknowledged problem, but the Government tried to tackle it with a Bill that was provocative, punitive and divisive. Here, once again, we have a nasty little Bill which really ought to be stopped, but at the very least will need to be amended. Therefore, I gladly support the Motion in the name of the noble Lord, Lord Clement-Jones, regretting only that it did not go further. I would have been glad to see it echoing more fully the Early Day Motion put down on 5th December by Mr Paul Burstow in another place. I quote it because it seems to me to summarise ideally what is wrong with the Bill:
If the outspoken criticisms of the Bill that I have just quoted may be dismissed as coming from the fevered brains of party politicians, the chorus of condemnation from a very wide range of highly responsible professional organisations simply cannot be ignored.
The Royal College of Nursing remains unconvinced that charging social services for delayed discharges from hospitals will lead to better discharge practice. The British Medical Association is opposed to imposing immediate penalties on social service departments which have been faced with historical underfunding. The move could distort decisions taken by social services departments, influenced by the need to avoid fines, with funds diverted from "non-fineable" areas such as children's services and services for the disabled and people with learning difficulties. Therefore, the BMA is asking at least for some delay and for some kind of pilot scheme. It points to the real risk that money will be taken away from other areas simply to avoid the fines that will be imposed for social services not receiving patients discharged from hospital.
The BMA also points to a seldom-recognised aspect of early discharge simply to release blocked beds, which is that 17 per cent of elderly people currently living in nursing homes no longer need nursing care. The decision to admit to a nursing home may have been prematurely made before it was known how far rehabilitation could go. That argues for constant monitoring and review of what the needs of elderly people really are and for the provision of an adequate range of care home places offering a variety of levels of care.
It has already been pointed out that the statistics for the reduction in the number of such places in care homes are alarming. There was a rapid and fairly unplanned increase during the 1980s, but in recent years there have been dramatic reductions, including a net loss of what I calculate to be 12,800 places in 2001 aloneand that in the context of a rapidly growing population of old people. It is vital to see the whole picture. This Bill addresses one part of what is a huge problem with many interrelated issues.
Concentrating on delayed discharges avoids looking at the whole picture. It is as though we were looking at a jigsaw puzzle with various bits missing. The Government have found one piece of jigsaw which does not quite fit any of the gaps and they are pretending that forcing that piece into one of the holes will somehow do the job as a substitute for a painstaking and thorough organising of all the missing and misplaced pieces.
There are downstream questions, too, about convalescence, follow-up, proper post-hospital care and the whole care pathway. In introducing the Bill, the Minister mentioned that and made some encouraging comments about an attempt to see a slightly wider picture. The trouble is that the Bill as it stands does nothing but address this one particular issue. Financial incentives to discharge people even sooner, in the absence of a total-care package, will add to the problems of readmissions. There were 500,000 readmissions in one single year. It is hardly believable. But if there is further pressure to discharge patients, how many more will there be? And what will that do to the people who are readmitted, having had a great deal more pain and anxiety meanwhile? It is medical and financial nonsense. Worst of all, it is pastorally insensitive and profoundly unkind. It ignores the real well-being of elderly people. As has already been said, it treats them as commodities and as financial liabilities to be shunted around. It is contemptuous of the interests of carers.
My Lords, there must be a warm welcome for the promise of better funding for social services and for the provisions of Clause 12 of this Bill. But it remains deeply unsatisfactory in its present form. It addresses one aspect of a hugely complicated area of care. As we have already heard, it derives, in part, from one aspect of Swedish practice, not fully understood nor related to its own context. It then parachutes this into the United Kingdom system, where, like a piece in a jigsaw puzzle, it just does not fit. Far from encouraging or enabling growth in co-operation and an harmonious partnership, which we all wish to see, it introduces a concept from the criminal lawthe concept of the fine. It does not hold out the prospect of a better deal for vulnerable and anxious elderly people, whose needs deserve to be much more imaginatively and sympathetically met. It will encourage suspicion, hostility and confrontation from all the hard-pressed professionals having to cope with this on top of everything else.
Baroness Pitkeathley: My Lords, improving hospital discharge procedures has always been very close to my heart. In the mid-1970s I wrote a book entitled When I Went Home which detailed the experience of older people when they were discharged from acute wards. I well remember some of the experiences of those interviewed: "They only gave me 10 minutes' notice"; "They told me that I was fit to go
Over the years I have revisited those experiences, especially in my work with carers, and the story has been depressingly familiar: lack of notice, lack of planning, no consultation with either patients or their families, lack of communication with general practitioners and, above all, the lack of a co-ordinated approach between health and social services. Furthermore, we are all aware of the very distressing number of readmissions that take place because discharge was not properly planned.
The solutions which everyone has agreed upon over the years have also been depressingly familiar, and we have never had any problems agreeing on them: discharge planning must start on or before admissions, the needs of both carers and patients must be properly assessed, information must be exchanged in good time and communication between agencies is vital.
It is my impression and that of many other people, too, I believe, that things have got better in recent years. I speak here not only as a professional but also as a long-term patient on an acute ward. I do believe that some improvements have been made. With the advent of computer-held patient records, it is now common to consider the discharge plan when the patient is being admitted. That would have been unheard of hitherto. The much quoted Berlin Wall which always existed between the NHS and social services departments is, in many areas, a thing of the past. Pooled budgets and agreed care packages have gained momentum. Integrated care trusts are another very helpful development.
Clearly, there are still some consultants who swoop down on a ward on a Friday afternoon and declare the patient not only fit but essential for discharge. However they are very many fewer than they used to be. I am particularly glad to note that the discharge workbook about which I have been asking for some time, has now been updated and reissued today. The Government are to be congratulated on that.
However, there are still some pockets of resistance to proper discharge planning. There are, we know, some 5,000 patients occupying hospital beds when they should be discharged to more suitable care. I am in favour of anything which tackles that. I say that not from the point of view of saving money for either the NHS or local authorities, but because I know only too well how easy it is to become institutionalised in a hospital bed. It is tempting for any person, old or youngand I speak from personal experienceto settle back into that hospital bed and that hospital routine. They then lose, in an amazingly short timeamazingly shortthe ability to manage outside in a setting which will enable independence not dependence.
So I do not start from the premise that the Bill is necessarily bad. Indeed, I find elements in it to praise. Your Lordships will not be surprised to know that some of these concern carers. The original drafting of
Part 2 was also amended to ensure that, following discharge, certain carer services would be free of charge for a limited period of time, in the same way as disabled and older people's services would be free. Carers UK has warmly welcomed these amendments. They not only improve the rights of carers, but move closer towards ensuring that carers are an integral part, rather than an ignored part, of the hospital discharge process. I should like to pay tribute to the officers and Ministers who worked so hard on these amendments.
The amendments are an important step forward towards ensuring that the assessment is holistic, both in looking at the needs of the disabled or older person, and the carer. They should ensure that carers are assessed quickly at the right time; that their needs for services are considered; andthis is an important developmentthat services are put in place before discharge. The original drafting of the Bill omitted any reference to carers' services but we very much welcome the amendments which now ensure that certain community care services provided following discharge will be made free for a limited period of time. I am sure that your Lordships will agree that that is essential since carers already save the state an estimated £57 billion annually.
I want also to celebrate the acknowledgement that has been given to the great improvements which have been made in the relationship between the NHS and social services in recent years. I believe that that relationship has been transformed in terms of understanding and co-operation. It is entirely because of those improved relationships that this Bill will apply, we are assured, to so few people. Commitment and partnership working, which these agencies have shown, is very much to be praised.
I turn now to my concerns about the Bill which I want not only to flag up but to suggest ways in which they could be overcome. My first concern, as many other noble Lords have said, is that the Bill may have the effect of influencing negatively the very much improved relationship between health and social services which I have just welcomed. I know that that is not the Government's intention, but I am concerned lest it happen by default.
Secondly, there may not be enough choice for older people and families at a very important point in their lives because the timescale suggested is so short. I understand the reasons for this but I worry that unsuitable decisions will be made simply because of the short timescale.
That also links with my concerns about the outstanding issues for carers. As carers still have to ask for an assessment, with the exception of those who requested an assessment in the previous 12 months, they will need to know their rights before they can exercise them. Legislation in Scotland and Northern Ireland has placed a duty on local authorities and health trusts to inform carers of their right to an assessment. I believe it is vital to ensure that carers are aware of their rights. I hope that the Minister will be able to acknowledge that making carers aware of their rights is part of the Government's intention.
My concerns could be addressed by placing more emphasis on the fact that this is an NHS as well as a local authority problem. Again, I know that it is not the Government's intention to say that. But the presentation of the Bill thus far has been unfortunate and I am glad to hear the Minister's reassurance that it is a mutual problem. If we emphasise that, it will go a long way towards continuing the development of the co-operation which is now so excellent in many areas, while encouraging areas in which it is not so good to tackle what should be seen as a mutual problem. I certainly do not wish to see the fining element become a cause of suspicion and lack of trust between agencies.
In that regard, increased budgets for social services departments are especially welcome. We must monitor very carefully how the money is spent. We must ensure that it is spent on discharge services and not on extra bureaucracy, a risk run by any new system. Of course we need good systems of paperworkor, more likely, better computer communicationbetween agencies, but we must ensure that the money is spent on services which will benefit patients and carers. Of course more money may be spent on residential care places, thus increasing supply and choice for older people, but it must also be spent on innovative services provided in the home.
As to carers, I am particularly concerned lest the fines reduce the funds available for other community care services. In areas where hospital discharge practices are poor, local authorities might be tempted to cut corners in order to avoid fines, with disastrous results for carers should that happen.
I am also concerned about the way in which patients and carers will be able to make complaints. It is important that the principle of patient and carer participation is carried through. The success of the Bill must be judged not by the experience of the provider but by the experience of the receiver of care. We must monitor extremely carefully the timescale and what can be expected within it. Patients must be at the centre. Can that be ensured within three days? I should like to be reassured about what exceptions to the three-day rule will be acceptable. I understand that a panel will be established in each strategic health authority area. How will fast tracking of complaints be carried forward? I hope that the Minister can assure me about that.
The plain fact is that we cannot recruit people to give home personal care. For example, in Henley we paid £6 per hourthe national ratefor the provision of such services. This rate has recently been revised to £6.35 by direction of the director of social services. But people in Henley demand £10 per hour to clean middle-class homes and, given the choice between cleaning middle-class homes and providing personal care to an elderly person, I am sorry to say that most people will go and clean middle-class homes.
In north Oxfordshire, we have about 13 people waiting for every home care place. We have done our very best to provide more home care placesone centre is being built by the St John Ambulance care trust in my own town for 60 old people, including the nursing care which is now essential in an old persons' homebut there is an enormous gap in the finances between what is received by the county and what has to be spent. In the year about to end, we have spent £105 million, and yet the SSA applicable for this year was £85 million. Therefore £20 million was required from the general rate account. Because of the extra money flowing through this year the difference will be less, but there will still be a substantial gap between what we believe we have to spend and what the Government believe we should spend. That causes enormous problems in providing the kind of services referred to by the noble Baroness, Lady Pitkeathley.
If carers are to receive the kind of help they require to provide services to old people, the local authority must have the resources to pay for it. Those resources are not available. This year there will be a Band B council tax rise of 13.7 per centa lot of moneywhich I am sure many elderly people will have difficulty in paying. A large proportion of that money will be going into social services because we are trying desperately to meet the targets laid upon usan uphill battle which will not be helped by the Bill at a time when co-operation between the National Health Service and social services is beginning to bear fruit.
While £100 million extra may sound like a lot of money, by the time it is divided up our share will be small and will take time to pass through the system. It has taken nearly three years to build an old people's home, which is quite quick. We have followed the advice of the Government in terms of harnessing the
I shall not speak for long, but I plead with the Minister not to go ahead with implementation in 2003. We need to see the benefits of the extra money working through into the system now that we can at last see the development of serious co-operative relationships, not the kind of antipathetic relationships that will be created.
We do not have the infrastructure in the county to manage these enormous problems. My county is a nice place in which to retire, which means that it contains an enormous number of elderly people. My own town is very popular for building the kind of residences to which old people are attracted, but it is the council which will be left to care for them. I ask the Minister to think very carefully about the impact of the proposed legislation on social services. They are trying to do a good job but find that the goalposts are ever being moved further away.
Baroness Greengross: My Lords, poor and inefficient discharge procedures for elderly people have been a festering sore for more years than I care to remember. In the 1970s, I was involved, as was the noble Baroness, Lady Pitkeathley, when an admirable woman, Geraldine Amos, from Birmingham, led a campaign to end poor and delayed discharge practice. The organisation with which I work, Age Concern, was involved in many hospital discharge schemes, as was the Red Cross and other voluntary organisations.
I set out my views and my concerns in the debate on the Queen's Speech. I am still concerned, but I support the Government's aim to try at last to get this matter right. I recognise the important improvement in relationships between health and social services in the past few years. The Government recognise that they have to balance the equation, as the Minister described, by preventing hospitals from discharging patients prematurely. I would like more details about the extent of the tough approach towards the NHS, which the Minister mentioned. The Government need to publicly demonstrate their commitment to fair play and an even playing field between health and social services. They need to demonstrate as well that it is part of a wider and comprehensive reform which includes the free aids and adaptations covered by Part 2 of the Bill and more money for intermediate care and social care announced last year.
Efforts should be made to gain higher status for people working in community care, which I am sure will emerge eventually as the National Care Standards Commission does its work. But we are talking about the problems which exist now. Can the Minister further clarify what those free aids and adaptations
I shall give three examples of cases which have come to my attention in the past couple of months. The first concerns an elderly gentleman who was delayed for discharge over Christmas and the new year. Nothing was in place until mid-January when his health had greatly deteriorated. He was sent home. That was a relatively straightforward case, but it revealed enormous complexities. It was a nightmare for everyone directly involved.
My second example shows how the use of agencies contracted by social services needs to be looked at because of the importance of social care standards. There is a need to raise competence; otherwise, as we know, it leads to emergency re-admission. Polly Toynbee's articles over the past few weeks show how care workers are very much undervalued and underpaid. That is an importance point which we need to take into account.
The third example involves a person discharged one day after it was decided that she needed a place in a nursing home but before that place had been found. That was not entirely the fault of the social services department. The problem needs to be properly looked at so that procedures can be genuinely improved.
Those cases demonstrate that hospital discharge is a shared responsibility including extra care housing options and nursing home placements, not just domiciliary care. All sectors are involved, including the private and voluntary sectors. The key point is flexibility of approach. It is not always possible for a person to be rehabilitated and to cope at home after six weeks. For people who have had strokes it can certainly take longer. That is the maximum period for intermediate care and for the free aids and adaptations. We must have greater flexibility than that.
Schemes which encourage a convalescent period are very valuable. I hope that the Bill will encourage more of that type of intermediate care. There are some wonderful schemes, not just here, but in Europe. They involve flats where husband and wife can work together to develop new skills because a person needs to be rehabilitated slowly and with care.
Best practice must be shared much more. We must not re-invent the wheel. Many organisations, including Age Concern England and the Local Government AssociationI am vice-president of bothhave very deep reservations about the date of implementation. I ask the Minister to reassure us that there is enough time for the new social care arrangements and intermediate care schemes to be set up. Has the National Care Standards Commission yet had the impact it needs to raise standards?
I have other points for clarification, which I hope the Minister can answer. There has been mention of the danger of perverse incentives by the noble Lord, Lord Clement-Jones. A GP might well admit a patient into acute care to get social care packages quicker. The dispute mechanism could be used as a delaying tool because people will be desperate to find ways round the procedure if it is not properly introduced. We know that it is based on an apparently admirable Swedish model, but as we do not have unified health, social care and housing services we ought to consider in the longer term whether these should be brought together. That is a bigger question than this Bill can deal with.
Extra money is always welcome, but can the Minister clarify how much it is, for what and for how long? We also need to know the cost. I understood that the figure was £100 million, but the estimated cost is said to be £180 million. Is there some clarification which would help me in understanding this matter?
Are we certain that the older person's and the carer's consent are always sought on the care plan and for bringing social services into the equation? It is essential that watertight monitoring is carried out on re-admission rates; otherwise we shall be unable to tell whether the Bill has worked. I plead for this detailed information to be on the Department of Health's website in full.
I share the regrets of the noble Lord, Lord Clement-Jones, but I shall give the ill my support if the Government can clarify the points I have raised and reassure me it will make life better for a group of very vulnerable older people. I am totally committed to that goal.
While I have much sympathy with the amendment moved by the noble Lord, Lord Clement-Jones, and its truncated clone proffered by the noble Earl, Lord Howe, I believe that their Bill blocking, to coin a phrase, is perhaps regrettable for the basis of this Bill does address in rather crude terms an extremely worrying problem. Surely, it would be better to live up to all the claims that we made in your Lordships' House last week, that we are brilliant at revision, and ensure through persuasion, debate and sheer common sense, that a thoroughly amended Bill, humane and meaningful, agreed by all noble Lords, returns to another place for its final approval.
At least this Bill sets us somewhat unsteadily on our starting blocks. Let the starting pistol be fired as long as we are not arrested under new firearms legislation and let the reformers be the winners.
I now offer my initial contribution with some hesitation. I want, somewhat predictably, to speak as president of Mencap and focus on people with a learning disability. I am sure that I would be ruled out of order if I succumbed to the temptation to link the purpose of this Bill to those of the White Paper, Valuing People, in seeking to rescue people with a learning disability from long-stay hospitals in which about 1,000 of them still live. So with Lent and resisting temptation looming up, the concept of financial incentives to secure homes in the community for people who have spent a lifetime in hospital, before they die, does appeal to me.
But this Bill is not just about older people stuck chronically in an acute hospital. It is about people with a learning disability, younger or older, in the same position. Some hospitals support them very well. I know from personal experience that others struggle: a few hardly try. A busy hospital ward is not a good living environment, at the best of timesmost of us want to get up and go home. If you do not know what is going on and you have difficulty communicating with others, and they with you, it is, of course, much worse.
I share the Government's desire that nobody should stay in hospital longer than necessary and should be able to go homewhether home is the family home, a residential home or supported living. But going home must be planned and supported, and it must be going home to livenot going home to struggle and to suffer. Moreover, it should not mean being dumped inappropriately in a nursing home. In short, I am concerned that a policy designed to improve things might inadvertently make them much worse. I commend the care programme approach in its newhow I loathe this phraseperson-centred planning guise in which the individual is consulted, those close to them are consulted, personal wishes are respected and support, accommodation and back-up are all planned.
Sadly, people with a learning disability who have a longish spell of hospitalisation face an increased risk of not going back to their own home, because their family can no longer cope, their residential home is reluctant to provide increased support or their supported housing is not geared up to providing enhanced support.
Fining social services does not and cannot provide an adequate solution if it means rushing into a nursing home place where the person is going to be even more unhappy, and stuck indefinitely. We want planned and tailor-made solutions as a result of this increased financial investment, and a place in the community, not a place in a small institution.
If we are to secure the principles of choice, rights, independence and inclusion, as set out in the White Paper, Valuing People, we need to ensure that choice is not replaced by expediency. The Government have
Baroness Wilkins: My Lords, being unable to leave hospital because there is nowhere else that can meet your needs is a miserable fate. It is one that I have been too close to not to welcome the Government's determination to take effective action on the problem of delayed discharge. For far too long, this has been an area in which older people and disabled people have been particularly vulnerable to the boundary disputes between health and social services.
The Government should be commended on the many broad-ranging measures that they have put in place to encourage health and social services to work together to provide "seamless care". Measures such as the new flexibilities empowered by the Health Act 1999, with its pooling of budgets for agreed projects, the ability to delegate responsibilities to a lead commissioner working on behalf of both agencies and the possibility of integrating NHS and social services staff are all leading to far more effective forms of local partnership.
The working through of the national service framework for older people's standards of care, with the emphasis on integration and preventionincluding a single assessment process and the promotion of intermediate carealso challenge local health and social services authorities to work together. Furthermore, the Department of Health's joint health and social care unit is actively promoting "whole system working" throughout the country. That directly encourages local partnerships to focus on hospital discharge, supported by the new manual of discharge practice, and intermediate care and extra-care housing.
However, I join with other noble Lords in serious concern that all this positive activity to encourage joint working could be seriously jeopardised by the Bill's precipitate imposition of fines for delayed discharge. I ask the Minister to think again and delay the date of implementation for at least a year after the proposed date of April 2003.
Surely it would be more effective if the Bill could be seen as a warning shot across the bows of under-performing local authorities. If the implementation of sanctions were delayed for a year, it would give time for the new resources given to social services to be used to good effect in developing alternatives to hospital care. It would also give notice to the under-performing authorities to match the example of those where the complex issues of hospital discharge of older and disabled people have been tackled successfully.
The vast majority of older and disabled people are, however, discharged to their own home and that is what they prefer. Ensuring that those homes are fit and adapted can contribute to fast and efficient discharge, as well as enabling people to live independently.
I argue that the housing dimension needs far greater attention than it receives in the Bill. Home improvement agencies and other service providers have developed fast, effective, small repairs and adaptations services which help to improve discharge arrangements and reduce the risk of hospital admission. The following example, taken from On the Mend, the 2002 publication of Care & Repair England, demonstrates how essential it is that local authorities and health bodies should incorporate housing in the discharge process. It says:
It is where the local housing authority, social services and the health authority all work together and each allocates resources for hospital discharge repair and adaptation costs that the most effective hospital discharge services can be established.
Bristol's rapid response hospital discharge service is an excellent example. The social services department provides the home improvement agency, Care & Repair England, with a budget for small adaptations; the housing authority makes available a ring-fenced home repairs assistance grant budgetoperated on a fast-track system for hospital discharge casesand the health authority co-funds a handyperson service. Consequently, many repair and adaptation jobs are completed within 24 hours and the majority are done within a week. As a result, a very small urgent response team manages the interventions and repairs needed for some 500 older and disabled people to return to their own homes from hospital each year.
It is schemes such as these which need to be replicated throughout the country. Paying attention to the housing dimension is vital if delays in hospital discharge are to be diminished. The Bill puts notice on health and local authorities to put services for effective hospital discharge high on the agenda. However, it would be a tragedy, as many noble Lords have said, if the precipitate time scale in the Bill for the imposition of fines resulted in jeopardising all the excellent work that is taking place.
The Government can take pride in their determination to improve joint working and to end the disgrace of disabled and elderly people being buffeted between authorities, having their needs ignored while the authorities fight interminable turf wars. I hope that
Baroness Maddock: My Lords, I share many of the concerns about the Bill outlined by noble Lords this afternoon and, of course, support my noble friend Lord Clement-Jones in his amendment. I wish that I could share the optimism of the noble Lord, Lord Rix, that what we say in this House will have a big effect on what happens in another place.
The right reverend Prelate the Bishop of Hereford said that this was only part of a jigsaw. My contribution forms a piece of that jigsaw and concerns the role that the condition of housing plays in the area of delayed discharges. That matter was described eloquently by the noble Baroness, Lady Wilkins, and forms part of a much wider connection between the condition of our housing and the health of our nation.
Money must go into improving homes if we are to change the health of the nation. I declare an interest in that I am associated with many housing bodies, particularly the National Home Improvement Council. There is a great deal of evidence that putting money into home improvement is an extremely cost-effective way of enabling many patients to return home quicker. The Joseph Rowntree Foundation, which is well-known to many noble Lords, has researched this matter. It reached the conclusion that minor adaptations produce a range of lasting, positive consequences for virtually all recipients and that they constitute value for money.
As other noble Lords have outlined, the installation of aids and adaptations can cause particular problems for people who are waiting to leave hospital. The legal and financial framework for the provision of such adaptations is complex. Often, reaching agreement on the assessment of what a person needs and where the money will come from takes an interminable time and adds to the slowness of discharge.
I refer to the scale of the problem of unfit housing in this country. There are 1.5 million unfit homes in the UK: that is, one home in every 16. The majority of those unfit homes are owner occupied. Some 75 per cent of the people living on the lowest incomes and in the worst housing are of pensionable age and 1.7 million people need adaptations within their homes. The tendency to live in poor housing conditions increases as people get older, particularly after the age of 80. Lone older women are more likely to live in unfit housing.
A proportion of the finance for dealing with home improvements comes mainly from local authoritiesthe very same local authorities in many cases which will see money taken away from them if the Bill is enacted. The sums spent in this area have diminished over a number of years now. Admittedly, the Government recently freed up the way in which local authorities can tackle home improvements by allowing them to allocate grants. However, the overall spend is still very low. The Minister did not mention that
How can we improve the situation? Obviously, policy making on health and housing needs to be linked up and requires appropriate funding. We do not want money to be taken away from local authorities. The good, joined-up work that is undertaken between health authorities and local authorities needs to continue. The noble Baroness, Lady Wilkins, mentioned some good examples of that. I shall mention others later.
I am sure that the Minister is fully aware of, and has been well briefed on, the work of Care & Repair England in the field that I am discussing. I hope that he can reassure me that priority for financial support will be given to such bodies and to other home improvement agencies that are involved in this area. I draw his attention to a point that has already been mentioned this afternoon; that is, the role of prevention, particularly as regards handyperson schemes, of which there are many around the country. Such schemes are particularly important in terms of preventing people entering hospital. West Devon has a very good handyperson scheme for elderly people to replace light bulbs, fit door chains, repair rotten window frames, rehang doors and put up shelves and pictures. Those involved in the scheme get up ladders and carry out the kind of jobs that can result in elderly people falling in their homes.
I hope that the Minister will reassure us that priority will be given to preventive work. As I said, much of Britain's housing is old and poor. Many people end up in hospital as a result of falls or because their homes are cold. Cold homes have been mentioned briefly. In this country many winter deaths and many winter illnesses are still caused simply because people cannot keep warm in their own homes. I hope that the Minister will mention that point when he replies to the debate.
I refer also to the connection that was made with Sweden. I lived in Sweden some 30 years ago. The standard of housing in Sweden is much higher than that in this country, and was 30 years ago. No one in a hospital in Sweden will have a discharge delayed due to the condition of his or her home or because they cannot keep warm in it. Noble Lords have said that the
Will the Minister assure me that best practice will be drawn up with regard to partnership schemes and delayed discharge? I could not find any mention of that in the Bill. Perhaps it is the Government's intention to provide best practice recommendations in guidance notes or secondary legislation. Local authorities, which are so often partners in such schemes, will have less money to spend working with others on the kind of issues that I and others have highlighted today. There is a better way to provide the mechanism and funding to assist the work that I have outlined and it does not involve starving local authorities of much needed money.
I hope that the health Minister will put the case for improving housing to the Office of the Deputy Prime Minister as such a measure would certainly save his ministry much money. If he wonders from where to obtain the necessary funds, I suggest that he talks to the Chancellor about the £6 billion extra that the Government have received since they came to office in stamp duty due to rising house prices. A very small amount of that money would go a long way to improving the condition of housing and our nation's health. As I said, we are talking about just a small part of the jigsaw. However, I believe that it is an important part that has long been undervalued in our country.
Baroness Howarth of Breckland: My Lords, I declare an interest as a professional social worker and an associate member of the Association of Directors of Social Services. I have links with the board of the National Care Standards Commission. I do not speak on behalf of any of those bodies but, obviously, those interests clearly influence the way I view this issue.
It seems that the Government have made a distinctive impact on services in health and welfare since coming into office. In recent years, they have revolutionised relationships with professionals in the caring sector, which in my working life had reached an all-time low. They have developed an image of being a listening Administration, and were recently praised by Care and Health Magazine, which said:
As that commentator points out, the response from the Government is not necessarily a response to majority views, and that is right. However, there are many including me who hope that, as we progress through the Bill, the Government will listen to the voices asking them to think again about much of the proposed legislation.
The principle and aim are splendid: the timely move of people out of hospital into alternative care, either at home or elsewhere, following proper assessment and planning. I welcome the thought that we will have
Through that process, hospital beds will be freed up for patients on waiting lists, which meets another government target. However, that is to be achieved by a very curious mechanism, which appears to penalise one part of a complex system without consideration of the whole. I had thought that the Government had started to think in terms of framework and strategic systems.
Of course, there remains a conceptual problem. Are the fines for social services failure, or do they, as a Minister put it in another place, simply ensure "appropriate financial flows" between services? Are they incentives, reimbursements or just plain fines? That is curiously important for local authorities. The Minister has spoken positively about local government throughout my time in the House, but the device in the Bill will further bring down the feeling among local authorities about how the Government perceive what they are trying to do in very difficult circumstances.
Those on the ground working to implement the policy day-to-day know how complex the system and the decisions can be. Most, if not all, want to provide the best service possible to the user. Will the listening Government hear the objections raised by those who see the implications for the whole system of care?
During the consultation, it was not only social services that saw flaws in the proposals. Other noble Lords have mentioned the BMA and the Royal College of Nursing. Both indicated that a scheme that penalises one partner can only damage relationships with the others. Partnerships and joint planning, under government guidance and encouragement, have been steadily improving. There will be a very heavy spanner in the works.
If users are central to the thinking, what has happened to the question of choice? When the clock starts ticking on the day that the hospital notifies social services, I fear that all sensitivity will disappear. Where assessment indicates the need for a complex package of care, two days is simply not enough to put the services into place. Instead, between the pressure of targets on the one hand and fines on the other, it would be a case of finding an alternative place.
I can think back to the days when we had to find placements for children in care under fit person orders, and sat in waiting rooms with poor children. I can see how old people and people moving out of acute care from other groups will be placed in real difficulty. If people rather than systems are at the centre of government thinking, I am sure that the Government will listen to the carers' organisations, which relate that 77 per cent of carersthat is a figure for now, not for the pastwere not given a choice about taking on caring.
When those assessed are old and frail, recovering from a serious illness or facing a future of disability, preparing for that requires time and sensitivity. As we have heard time and again this afternoon, proper planning will avoid readmission, a real and continuing problem in healthcare. What happens if, despite assessment, the patient exercises his or her choice not to accept what is on offer? Delay can arise from a patient genuinely disputing the suitability of an offered placement, possibly through a complaints procedure or judicial review. If the preferred service is not available, will users be forced into the next available slot? Will someone have time to listen and discuss alternatives? Will the clock stop ticking while the reassessment takes place?
As we heard from the noble Lord, Lord Bradshaw, the measures will increase pressure on social services already struggling with problems of capacity. That is not an excuse. However much funding the Government make availableI am sure that every pound is more than welcomeproviders know that it takes time to build up alternatives decimated by years of cuts. Capital and revenue projects are affected. Shortage of placements in residential care, and workforce planning problems run throughout the system. Noble Lords have only to read the two recent and powerful reports from the King's Fund, which demonstrate the shortage of skilled workers in residential and domiciliary care. Even without the device in the Bill, that shortage is likely to lead to a crisis, so strategic planning is needed.
Add to that the need for good social work assessment and the problems are compounded. If social services are to meet the assessment timescales to respond to the ticking clock, will social workers be diverted from other areas of social workfrom mental health, family support and, most worrying, child protection? Home care is already in crisis. I can tell noble Lords of dozens of old people whom I have met who need only two or three hours, but that time is not available.
I know at first hand what happens when pressure is placed on one part of the system and there is a shortage of capacity in the whole. Something else gives. Next week, when we discuss the Climbie report, we will want to put pressure on yet another part of the system. What else will give?
If the Government take a strategic view, will they also look at the role of the voluntary sector and the problems that it faces in supporting provision of good-quality alternatives? I have campaigned for most of my working life to remove adult disabled people from inappropriate hospital placements, but there are still difficulties. For instance, the problem of agreeing appropriate fees for residents has been well documented, but still needs addressing.
As vice-chair of John Grooms, a charity providing services including cutting-edge residential care for severely disabled people, I am totally disheartened not only by the issues of appropriate fees and raising money to subsidise both capital and revenue projects,
Were there more time, I would want to raise issues regarding the dispute panels. Surely the make-up of such panels, if we are to have them, should not be left to draft regulations. Some even-handedness of representation should be placed in statute.
I welcome the introduction of free aids and minor adaptations, but wish to ask questions about funding and assessment. The noble Lord, Lord Clement-Jones, pointed out that one of the skills shortages was in occupational therapy. The key is that there needs to be more discussion on timing, and questions should be asked as to why the statute cannot wait for better overall planning when it becomes extended to other areas such as mental health.
There are financial questions to explore. The London project on the commissioning of services for older people has worked with London directors of social services to monitor the delayed transfer of care data. It estimates that, at current levels of delay, the potential reimbursement fine for London alone is approximately £24 million. How will that central pot be redistributed?
I have read the arguments and thought carefully about the Bill, but I still cannot understand how, at a time of improving relationships and response, the Government still see a financial penalty as the only means of achieving proper performance from local authorities. With the frameworks, including that for older people, a whole strategy is being developed in the interests of users which gives a sense of value to professionals. This is a mature approach. In such a climate, where there is a complex matrix of service provision, which government adviser could be so ill advised as to see this arrangement as the best way forward? It might move people around the system faster but if my mother was involved, I should certainly want to have the time and space in which to plan for her care, to listen as she moved from independence to dependence and to know that physical and emotional needs had been taken care of for the future.
I realise that this approach is government policy and that we in this House are not here to frustrate it. However, I hope that we can ensure that the arrangement will work for those using the system of care and that it does not create a way of moving funds from the welfare sector to the acute sector when there is no real improvement for people. For it is people who should be at the centre of what we are trying to do, not simple mechanisms for shortening waiting lists. I will therefore support the amendment of the noble Lord, Lord Clement-Jones, but I want to hear what the Government have to say and how they intend to take the thinking forward.
Lord Beaumont of Whitley: My Lords, we spent two days last week discussing various matters involving your Lordships' House. One of the points that came out most strongly was the importance of expertise. In this debate, we have had an immense amount of expertise; practically every speaker has displayed it. I must apologise for not having any particular expertise although, like one or two speakers so far, including the noble Lord, Lord Rix, I have, at this time of life, reached the stage at which quite a lot of my friends and people with whom I have worked over a period of time are running into the kind of problems with which the Bill is meant to deal. I am for ever fascinated and appalled by the difference between the way in which people cope if they are well off as opposed to if they have very little or virtually no money.
Every noble Lord seems to agree that this is a Bill of good intentions, that what it seeks to achieve is worth achieving, and that those behind it should be congratulated on trying to achieve that. There is also a widespread feeling that it is not going the right way about it. If we are to put the people who really matter and should be looked after at the centre of these arrangementsif we are to look after the carers, the old, those who are ill and those who have been dischargedand if we are to give them control over their lives, we must ensure that the Bill is changed significantly.
I do not wish to detain the House by dealing with various points that have been dealt with in this debate by noble Lords with more expertise than I have. However, of all the points that have been raised, the three-day allowance for coming to an arrangement about what should happen is so imbecilic as to be almost unbelievable. I do not see how anyone can think that one could achieve such a target even at the best of times. That must be altered.
I have been briefed, as have one or two other noble Lords, by the National Federation of Post Office and BT Pensioners, which sees that its members will be hardest hit by the Bill if it is not amended. It has produced a number of amendments, which I hope I shall advance in Committee. I hope that I shall do so with the support of other noble Lords, and I hope to support them.
I opened by saying that I thought that one thing about the Bill was agreed by everyone: this is a Bill of good intentions. However, we all know what good intentions do: they pave the road to hell. In the worst casesthere are always worst casesthe authorities do not agree, there is not enough time to consult patients, and there are not sufficient places for people to go. We should also consider what will happen to a person with little money and who feels rather ill, having just come out of hospital. The good intentions could well lead to something that can be described as closely resembling hell for those people. For that reason, I intend to support on behalf of my party the amendment of the noble Lord, Lord Clement-Jones, and the approach of the noble Earl, Lord Howe. I hope that we will manage to make the Bill a far, far better thing by the time that we have finished with it.
Baroness Howells of St Davids: My Lords, at this stage, every side of the argument has been put. Having recently become a carer, I have been a recipient of the very service that the Bill seeks to address. I speak with the voice of the consumer and welcome the Bill's passage though the House. The Bill is a package which, with a very few minor adjustments, will work.
The requirement for a written discharge plan is reassuring for the patient and the family. That is vital so that all concerned with the welfare of the patient can be satisfied that all that can be done is in place for the continued care of the patient on leaving hospital. In my case, the written discharge plan was not available because the computer had broken down. That caused me, as a carer, no end of problems. Every family member had a different solution and no one from the NHS was available to answer my very legitimate queries. I shudder to think how those who are in my position but who are less able than me to contact the director of social services would have managed. It was a nightmare and I hope that the Bill will ensure that no one ever gets into the position in which I found myself.
Having contacted social services, the patientmy husband, whom I was removing from hospital on that daybecame less fragile when he realised that things could improve. Two days later, after several phone calls and not very pretty language, everything was arranged and has been working satisfactorily ever since. He is now 12 weeks into his care.
That illustrates how well a plan that is put in motion can work if we are patient and give it time. I was pleased to hear the Minister say that social services are not the only authority to be penalised. My experience was that the plan was not in place because the NHS was not able to set it in motion at the time that my husband was expected to leave hospital. That was not because the staff did not know when he would leave but because no one in the hospital was responsible for ensuring that social services would be contacted.
The Bill speaks of "joint working", but joint working will work only if both partners have equal responsibility as well as equal penalties. I am afraid that, in a complex organisation such as the NHS, we shall end up with buck-passing unless there is a named individual whom carers, patients and social services can contact. My experience showed that there was no such person. I want to appeal to the Minister because I heard myself asking, "Where is the matron?".
The Bill needs to ensure that those who need the service feel secure. Social services should not be forced into a position where the patient's needs are secondary to the risk of being fined. I trust that the Minister can reassure the House that patients and their carers will not be left in limbo at the point of discharge. The medical team should be expected to work closely with social services. I believe that that can be achieved only if there is a postholder who can follow through with both partners the patient's best interests. I ask the Minister whether there are plans in the Bill for such a postI cannot see any.
Baroness Richardson of Calow: My Lords, I believe that it is generally agreed that hospital is not a very healthy place for most peopleparticularly for the elderly and for those whose admission is unplanned and who therefore often end up in wards which are inappropriate for their condition. I recently had experience of an elderly man with a chest infection who was put in an orthopaedic ward. His condition deteriorated, perhaps mainly because the nurses did not have the time or the inclination to help him to feed himself with the food offered. That type of inappropriate admission needs to be looked at carefully. I shall return to that point.
It is in everyone's interests to discharge patients into appropriate care as soon as possible. The intention of the Bill is said to be just that. It is intended to provide an incentive, encourage better communication and increase choice. It seems eminently reasonable that proper notice will be given when the patient is to leave hospital. The patient will be put into the hands of social services where a duty of care already exists and where a proper assessment of needs will take place.
However, the Bill seems to introduce a culture of blame and a system of fines into that mutual arrangement. That threatens the good working arrangements envisaged in the Health Act 1999, with its pooled budgets, integrated provision and commissions.
Many noble Lords have received, as I have done, information regarding creative schemes of community care which are being entered into across the disciplines, including GP and primary care trusts, NHS and social services, and charitable and independent sectors. Those bodies are all seeking to work together to develop new solutions. If those practices are working well, it would seem possible to think ahead about the needs of the elderly person before he was admitted to hospital. Thus, it would not be such a surprise when an assessment had to be made before he left. However, there has not been time for all that to be put into place. The Bill now seems to depart from whole-system thinking and seeks to make one department take responsibility for what could be a failure in a number of those different arrangements.
The Bill also fails to address other issues. One is the inappropriate use of hospital beds in relation not only to discharge but also admission. I am astonished when I see television advertisements saying that, if a person adopts a certain healthcare plan and is admitted to an NHS bed, he can then be paid money. I heard of an elderly gentleman who managed to get himself admitted to hospital three times last year and funded a holiday in the Canaries on the basis of it.
Once a patient has been admitted to hospital, decisions on future care become acute rather than planned over time. Three days seems to me to be rather precipitate, particularly for putting into place specialist services. Having recently had responsibility for finding dementia care, I know that three days would be an impossibly short time for such a package to be found.
As has already been said, there is a need for additional capacity in community care, with additional services for the inevitable increased demand for homecare services, care home places and housing-with-care solutions. The Bill could divert finance so that local authorities would have to have a line in their budget reserving funds for the payment of fines whereas other initiatives could have been put in place. However, it is not only a matter of diverting finance; it is also possible that energy will be diverted from creative solutions into simply meeting this other need.
Other concerns have been mentioned, such as the fact that it is intended to implement the scheme quickly in 2003, whereas it would seem better to operate a pilot scheme in order to see how it works. It is unclear how the money generated in the scheme will be spent. I know that many of the provisions will be in the form of regulations. To my mind, the Bill will be either helped or greatly harmed by the regulations, which, of course, we have not yet seen.
Not much mention has yet been made of possible disputes arising between local authorities. That is perhaps of more interest to me than most since my husband is in residential care. That care is funded by Calderdale Borough Council in Yorkshire but is supplied by Enfield. I would hate for the decision as to where my husband is normally resident to be in the hands of the Secretary of State.
It is clear that the Bill has not been welcomed without reserve by any of the organisations that will be involved in its implementation. Therefore, I support the amendment of the noble Lord, Lord Clement-Jones.
Baroness Barker: My Lords, I declare an interest as an employee of Age Concern England. However, the views that I shall voice will be my own. We have had an extremely thoughtful and high quality debate. It is clear that on balance even those who support the intentions of the Bill have significant and grave reservations. The right reverend Prelate the Bishop of Hereford put the matter most forcefully. He outlined to the House the extent to which a wide range of
A number of the clauses are quite deep and have been mentioned already. There is a gaping hole in the Bill: the Government have given us no evidence of local authorities failing to fulfil their responsibilities for reasons other than a lack of capacity. Given that that is a fundamental assumption behind the Bill, I believe that it is right for us, as parliamentarians, to ask for evidence of that.
Many speakers have referred to the proposal to levy fines on social services departments as a service model copied from Sweden. In fact, the system currently operating in Sweden originated in the Jutland area of Denmark. The system was adopted in Sweden only after consideration of how it should be modified to apply to the particular needs of the Swedish context. Moreover, it was introduced only after substantial preparation, including radical reform of the taxation system and investment in community services such as extra care sheltered housing, increased home care packages and, crucially, investment in joint planning systems. That is a stark contrast to the situation here.
Noble Lords may not have noticed in the Government response to the Wanless report, Delivering the NHS Plan, published in March 2002, that Chapter 8 contained an explicit commitment to introduce a system of fines on acute hospitals for re-admissions caused by inappropriate discharge. That received very little coverage at the time, and although it represents a significant safeguard which would
It is impossible to tell from the Bill how such a system could be made to work in the best interests of good patient care. Apart from the unpredictability and unwieldy bureaucracy that must be required to track such a system, a reactive approach to discharge based on fines and failure must inevitably lead to patients being passed around like hot potatoes. A vicious circle of blame is not the basis on which to build good quality, sustainable services.
Like many noble Lords I read the report of the Health Select Committee into delayed discharge and I found myself strongly in agreement with its statement that delayed discharge is always a symptom of something else that is not happening or a failure in the system. If those problems are not addressed, the slickest discharge procedure in the world will not work.
In preparation for the Bill I looked at figures of actual delayed discharges in London. The figures are compiled by the London commissioning of older people's services project, which analyses the reasons for delayed discharges. Those figures for April and May 2002 reveal that the reasons for delay were as follows: 24 per cent was due to people waiting for an assessment; 30 per cent was due to the unavailability of residential and nursing care; 9 per cent was due to lack of funding; 6 per cent was due to people awaiting domiciliary care (in the past two years while the number of hours of domiciliary care has risen, the number of households receiving domiciliary care has dropped); l0 per cent was due to patient choice; 10 per cent was due to other reasons (one discovers that that was housing, especially adaptations, as mentioned by my noble friend Lady Maddock); and 11 per cent was due to delays within the NHS. Even a cursory run through those figures is enough to show that fining local authorities, as set out in the Bill, will exacerbate rather than solve the problem.
For many older people a condition which is sufficiently serious to require hospitalisation is likely to lead to a need for either installation of aids or adaptations, as my noble friend Lady Maddock has said, yet there is no mention of that in the Bill. Can the minister confirm that when an assessment has been carried out and a discharge is delayed because of lack of suitable housing and housing adaptation, the local authority will not be penalised for something that is not its responsibility?
This is a short Bill and, as ever, much is left to regulation. However, even as it stands it contains some measures that cause alarm. The proposal to permit discharge to an intermediate care setting on the basis of a partial assessment without any requirement that a full assessment be carried out within a specified period
Furthermore, the Bill as it stands has a particularly worrying omission. While it refers to a patient having been assessed as no longer needing acute care, there is scant regard for the fact that moving older people is often damaging and in some cases dangerous. Being able to be treated in a care home, or even with a care package at home, is not the same as being able to withstand the process of moving, which can often be extremely problematic. The Bill does not mention transport, and yet anyone who has been involved with enabling an older person to leave hospital will be aware that not knowing how or when they will be transferred is a matter of immense concern to them and can be deeply distressing.
The priority and focus that the Bill will inevitably place on hospital discharge will undoubtedly mean that in many areas resources will have to be switched from preventive and rehabilitative services. Any local authority desperate to avoid fines will have to invest in OT services. That in itself is no bad thing, but if it is done at the expense of handyperson schemesI am one of the biggest fans of such schemeswhich are an extremely effective means of enabling older people to live independently, it will lead to increased hospital admissions.
My noble friend Lord Bradshaw exactly set out the dilemma facing social services departmentsnot because they are unwilling to get people out of hospital but because they do not have the resources. Any GP with any nous will soon realise that the best way to get patients to the head of the assessment queue will be to get them into hospital. The Bill will cause huge distortions in local care planning and is bound to cut across much of the good work done in the NSF.
As to assessments being done in three days, I will bet money that the Minister's response will be that most patients are in hospital longer than three days so that will be a minimum, not a maximum. True. But the point at which the information passes between social services and the hospital is crucial. It is not often that residential care places become available at three days' notice.
A further concern is the lack of funding. Much has been made of the £100 million but there are other real pressures on social services. Any department that is not planning to increase its children's services is mad.
When the system was introduced to Sweden, the tax system was changed to provide the crucial sustainability. That is in stark contrast to this country, where much of the health and social care funding introduced by the present Government is short term and piecemeal. The 6 per cent increase in funding
Furthermore, although the Government have invested much in the personal social services funding formula, as my noble friend Lord Bradshaw said, social services throughout the country are spending way in excess of their existing assessment. For example, the Social Policy Ageing and Information Network reported a year ago that local authorities are spending in excess of £1 billion over and above the Government's figure. Spending on promoting independence totalling £155 million and building care capacity costing £190 million comes to an end in March.
When one considers that most social care is labour intensive rather than capital intensive, it can be seen that the churn and turnover in the people required to do this job is a debilitating factor. One can set up the best computer systems in the world but if the people using them change frequently, the resulting lack of continuity is alarming.
My noble friend Lord Clement-Jones said that the Bill is health tourism at its worst and it is. The Government are taking a system from a country, Sweden, that has a high tax base and where health and social care are provided by sole supplierspublic local authorities. This country has a lower tax base and, while the level of private health care remains low, social care is provided by a range of suppliersincluding the voluntary sector.
Given that the Bill is such a radical departure from previous health policy, one wonders whether the Government are setting social services departments up to failparticularly when one considers the amount of administration required to make it work.
Evidence to the Health Select Committee in another place made it clear that far and away the most problematic discharges are those where the older person is mentally frail and the necessary care package is complex. At a time when the number of places for people needing dementia care is decreasing, the Bill's lack of protection for patients and patient choice, of any mention of advocacy and of any requirement for older people to consent to discharge is worrying. There is not even a requirement for patients to consent to information about them being given to a social services department, with which they may previously have had no dealings.
The Minister made much of the fact that the Bill merely compels social services departments to do what they are already required to do. When the noble Lord responds, I am sure that he will make much of varying performance in delayed discharges between different authorities. But he cannot say the extent to which a local authority which has good levels of delayed discharge does so at the expense of other admission and rehabilitation services.
If the Government really wanted to develop good models of integrated health, they would learn from the Swedish system and give time for the development of good practice on information sharing, patient
I urge noble Lords to visit the Department of Health's website. The draft regulations are not yet available, but under the Joint Unit section of the website the frequently asked questions about the Bill do not make happy reading and increase concern about leaving much of the detail to regulations. For example, the statement that anyone who refuses a care package will be deemed a self funder is extremely worrying.
Ministers in another place repeated the mantra that the Bill is about patients. It is not. It is about beds. It is about removing from practitioners the flexibility to do what is right for individual patients. It is about whether medical staff can stand up to pressure from bed managers and accountants. It is about removing from intermediate care managers the ability to decide that an older person needs seven weeks of care after a stay in hospital, rather than six. It is about grudgingly giving older people and their carers information when they ask for it, not as of right.
During the debate on the gracious Speech, I referred to this measure as the community care congestion charge Bill. Nothing during its passage in the other place makes me think that I was wrong. This Bill is bad. It is flawed in its assumptions and incomplete. It is being rushed through Parliament at a speed reserved by the Government for measures about which they are particularly worried. In this case, the Government's concern is not misplaced. Members of these Benches make no apology for giving the Bill a deservedly rough ride and the most thorough scrutiny.
Baroness Noakes: My Lords, I begin by wishing the noble Lord, Lord Rix, a very happy birthday. If all older people were as hale and hearty as the noble Lords, Lord Rix and Lord Beaumont of Whitley, there would be no need for the Bill.
We have heard some powerful speechesnot least from my noble friend Lord Howe. There is no disagreement as to the policy aim of not keeping people in hospital unnecessarily, but the Minister cannot take much comfort from most speeches today. I hope that he has got the message that the Bill in its current form is unacceptable.
My noble friend wished to use the word "deplore"not in the sense of regret but of the dictionary definition of "scandalised by". Members of these Benches indeed deplore the Bill. It is not wanted by the NHS, local authorities and social services departments in particular. It will do irreparable harm to partnership
My noble friend and others have already explained the scale of concern that exists about partnership working and the impact on patients. I want to dwell on some areas that are mundane but not without importance.
I start with money. We know that the Government tried to buy off opposition to the Bill in another place by announcing that £100 million per year would be paid to local authorities to allow them to pay the fines. The Bill is about fines, whatever euphemisms the Government use. That £100 million is part of the lunacy surrounding the Bill. It is not new money. It is part of the money obtained from the Chancellor of the Exchequer for the NHS. The Secretary of State pinches £100 million of NHS money to pay to local authorities which will then pay it back to NHS bodies by way of fines.
That would be silly enough on its own, but noble Lords will see that the money will pass through two public sector bureaucracies: local authorities and the NHS. The Explanatory Notes say that the administration costs will total £5.5 million. I tried to investigate that figurewhich seems lowin the regulatory impact assessment. But despite paragraph 58 of the Explanatory Notes, the Minister may like to know that the regulatory impact assessment is not on the department's website, at least not in any obvious place. We will have to take at face value the claim that the bureaucrats will spend £5.5 million. Hey presto£100 million that could have been spent on a multitude of provisions if allocated to primary care trusts has turned into £94 million.
There are other problems. The latest estimate by local authorities is that the new fines will cost local authorities £165 million. So, with the costs of bureaucracy, there is a gap of over £70 million. We can forget about the 6 per cent increase in social services funding about which the Government have been bragging; there will not be anything left. In many cases, council taxes will have to rise.
Local authorities remain in the dark about how the £100 million is to be allocated between them. The £100 million was announced last December but no one knows how it will be shared out. Will it be given to the local authorities that have the most problems in avoiding the new fines? Many local authorities face particular difficulties, particularly those whose care home capacity has been decimated by the Government's disastrous policies towards the care home sector. Will the money be given to such authorities? I ask the Minister to give a clear view and I should say to him that many believe that the Government will use this £100 million as yet another excuse to allocate public money on a wholly partisan basis to the areas from which they derive the most political support. Will the Minister say categorically that this will not be the case?
My noble friend Lord Howe talked about the incentives that will exist for NHS trusts to discharge patients early. That takes me to the lack of reciprocal obligations and penalties on the NHS. The Bill lacks symmetry and is unfair in that respect. Last April the Government outlined a system of fines that would apply both to social services and to the NHS. But somehow, as the noble Baroness, Lady Barker, pointed out, the NHS part has disappeared.
This system does nothing to provide compensation for local authorities. What happens if, under the Bill, an NHS trust notifies an intention to discharge? The local authority has two or possibly three days, including weekends, to rush around to make arrangements for the patient. Then on the day the NHS trust changes its mind and says, "Sorry, we got it wrong". It may not even say "sorry" because it does not matter to the trust. The local authority might have made commitments to care homes or to providers of domiciliary care. Why does the Bill not require the NHS to reimburse the local authority for such incidents? It is quite likely that the incentive structure of the Bill will make this happen much more than in the past; and there is nothing to stop inappropriate behaviour by trusts.
We are becoming used to the Government drafting Bills with major regulation-making powers without having given any thought to the details. This Bill is no exception in terms of regulation-making powers. But we understand that the Government want to implement the Bill on 1st April and therefore we expect that the details must be fully worked out. The Minister agreed informally in the briefing meeting to share the draft regulations with noble Lords when they were available. Will he say when he expects to do this? I hope that he will not expect this House to start Committee stage without having had an opportunity to consider the draft regulations carefully.
The last area that I shall address is the need to review the impact of the Bill on patients. Patients are almost forgotten in the Bill. Nobody believes that delayed discharges are good for patients. Most people loathe being in hospital for extended periods. But equally bad for patients are inappropriate discharge arrangements, perhaps forcing an old person into a care home because of a timing or other delay with home-based arrangements. So too is the prospect of being moved from pillar to post because the NHS has washed its
I do not want the Minister to be in any doubt about the view of these Benches: this is a bad Bill. The best possible outcome would be for the Government to accept that the Bill is misconceived. My noble friend's amendment urges the Government to reconsider. They do not have to take the Bill further than today. There are precedents even under this Government for that. If we find ourselves in Committee, I give notice that we shall propose a number of significant amendments to take out the worst features of the Bill and that we shall pursue them vigorously.
Lord Hunt of Kings Heath: My Lords, this has been a good debate. I look forward to Committee stage with keen anticipation. I join the noble Baroness, Lady Noakes, in congratulating the noble Lord, Lord Rix, on his 80th birthday. He looks no different from when he trod the boards at the Whitehall Theatre a few years ago. It was good of him to speak in the debate today.
The one issue on which we are united is the need to sort out the problem of delayed discharges. I do not underestimate the challenges facing local authorities and the NHS. I say to the noble Baroness, Lady Howarth, that I am a strong supporter of local government. When I criticise local government, I try to do so as constructively as possible. I do not underestimate the potential of partnerships nor doubt the need for a holistic, whole-system approach to health and social care collaboration for older people.
What troubles me is the recognition that if 5,000 mainly older people are delayed in hospital beds when they no longer need to be there, we are failing them and their families. All of us have known or seen the consequences for older people of losing their independence and becoming institutionalised. That is my direct response to the noble Baroness, Lady Noakes.
I accept, as the noble Baroness, Lady Barker, said, that there is any number of reasons for delayed discharges, including delays in assessment, in providing a care package, in waiting for a placement, in putting a domiciliary package in place and in the performance of the National Health Service. The developing partnership between the NHS and local government and a top-down performance management approach could all be expected to play their part in improving the current situation. I congratulate many local authorities on their success in improving their performance on delayed discharge. But that cannot be left to chance.
The outcome for older patients delayed in acute hospital beds is so serious that it warrants a more robust approach. As I see it, the problem is that, despite the many examples of good practice, there are still too many flaws in the system and too many
I do not accept the suggestion of the noble Earl, Lord Howe, that the Bill will undermine partnerships. Where the current partnership arrangement works well, it has a positive impact on the outcome for the individual who is ready to leave hospital. The Bill will foster good relationships and partnerships because it will clarify much more effectively the role and responsibilities of the various agencies involved in discharge procedures. Under the Bill, there will be less scope for disagreement about who is responsible for a delay. That will help to smooth the discharge process. In other words, I do not agree with the noble Lord, Lord Clement-Jones, that it will become a name game.
The Bill's approach enhances the need for partnership and creates an incentive. That is the whole purpose of transferring the budget in the way that we propose. It will create the right incentive to bring partners to the table to discuss how best to increase capacity and make any other necessary changes in working practices.
The noble Baroness, Lady Greengross, is right: we must demonstrate that that approach will be as rigorous and tough for the NHS as it is for local government. It will be. I can confirm to my noble friend Lady Howells that there will be no buck-passing in the NHS and that regulations will include the requirement to have a named NHS individual.
Sweden has been mentioned several times. Although various countries can offer us a clue towards the solutions that we need, I point out that the health and social care system in England is not the same as that in Sweden. In fact, the Swedish reforms that introduced reimbursement also involved a major transfer of responsibility for primary care for older people to the municipalities. That threw up many tensions that will not exist in this country.
I said that the Bill will not undermine partnerships. In fact, it will build on them while providing the robustness that is often missing in some local health authorities and the NHS. The noble Baroness, Lady Howarth, mentioned the Climbie inquiry. It would be entirely wrong for me to anticipate Lord Laming's report, but we have only to read other inquiry reports to understand that time and again, alongside any structural or funding problems, what comes through is sloppiness in practice and the failure to record decisions and to communicate between agencies. Under the Bill, we will start to grip that issue as it affects delayed discharges.
I know that some noble Lords consider that we should delay the introduction of this system. All that I would say is that local authorities and the health service have been under notice for a considerable time.
I have listened with care to the points raised by the noble Baronesses, Lady Richardson and Lady Howarth, about the time taken for assessment. The noble Baroness, Lady Barker, always anticipates my response; it is uncanny how she can forecast what I am going to say. But the fact remains that the average length of stay in an NHS hospital for a person aged over 65 is 11 days. So in most cases there will be more time. However, equally, we should surely want to encourage health and local authorities to get their act together and get the assessment done as quickly as possible. Why should we delight in delay?
Of course, some individuals will have complex care needs. I readily accept the point made by the noble Baroness, Lady Howarth, that there will be individuals for whom it will not be possible to draw up a full discharge plan within three days. But I contend that an acute ward is not the place for such a person to be cared for while that care planning is completed. Surely in such cases it is much better for patients, while their long-term care is being planned, to be transferredwith all due care and attention to the issue of transport and the new place where they are to be cared for; I accept the point made by the noble Baroness, Lady Barker, about thatto a non-acute and more comfortable environment.
I was asked about bureaucracy and associated costs by my noble friend Lady Pitkeathley and the noble Baroness, Lady Noakes. I confirm that we want to keep the transactional implementation costs to the minimum. Clearly, there will be coststhere is no point in running away from that factbut they are significantly outweighed by the benefits. I return to the point raised in so many previous inquiry reports into failures of statutory services. I refer to the ability to track what is happening to individuals and to ensure that individual officials are responsible for making and implementing decisions, and the bearing that that will have on the necessary accompanying paperwork. Getting to grips with thatseeing who is responsible and making sure that those statutory agencies deliveris worth some additional paperwork.
The noble Lords, Lord Clement-Jones and Lord Chan, were worried about the whole question of dispute resolution and understandably feared that the procedure would lead to a great many disputes, which is not how we would want health and local government authorities to work. I agree: we do not want a huge number of disputes. The guidance that we will give to health and local authorities will point out that for reasons of time and resources, it is clearly desirable for two public bodies to reach amicable agreement rather than having constant recourse to the panel.
Noble Lords put great store on partnership. The test of partnership is to enable these arrangements to be bedded down in the most agreeable way possible, where everyone recognises that they are dealing with a series of cases with clear protocols and where there will not be a need for the disputes procedure. Of course, if there has to be dispute resolution, so be it. We shall give strategic health authorities the role of oversight. But I can assure the House that the panel itself will be composed of a local authority and an NHS representative with an independent chair. I hope that that gives comfort because it will ensure a dispassionate overview of a specific dispute if such a panel needs to meet.
The noble Earl, Lord Howe, the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Greengross, were worried that the Bill would produce a system where the patients revolve around the system, and that perverse incentives would come into play causing real problems for the individual. That is not the intention of the Bill. Perverse incentives will not come into play. The whole point of transferring the resources to local authorities and of the new funding flow system we shall be introducing to the NHS starting in the new financial year, fully implemented in 200506, is that there will not be financial incentives for health and local authorities to cause real difficulties for the patients involved. I do not accept the suggestion that general practitioners will seek to admit patients purely so that they have access to social services. I have greater confidence in the responsibility of GPs in that arena.
My noble friend Lady Wilkins quoted some excellent examples of good practice, about how rapid repair teams can sort out aids and adaptations very quickly. I agree. We issued good practice guidelines to the NHS today about the whole discharge area. I can say to the noble Baroness, Lady Maddock, that it includes housing issues. The noble Baroness made some excellent points in that regard. I hope that the whole process of introducing this Bill, of ensuring that health and local government have the incentives to sort the matter out, will grip some of the issues that the noble Baroness raised. The examples given by my noble friend and by the noble Baroness, Lady Maddock, about how some of the rapid handyman schemes can quickly sort out aids and adaptations are an example to those parts of the country where it takes months for similar situations to be sorted out. That gives me confidence that in the end we can ensure that the Bill will be implemented as effectively as possible.
The noble Baroness, Lady Howarth, expressed concern about the distortion of social service priorities. We are not seeking to add additional responsibilities to local government. These matters are already the responsibility of local government. We are trying to put in place incentives which will make it deliver those responsibilities more effectively.
In response to the right reverend Prelate I can say that it is not our intention to undermine a holistic approach in dealing with these difficult issues. That is far from the point of this Bill. The Bill seeks to get right
I recognise the issues raised by my noble friend Lady Pitkeathley and the noble Baroness, Lady Howarth, in relation to patient choice. These proposals are aimed at putting the patient firmly at the centre of care. The whole point is to encourage local authorities to put into place more community services to give the patient more choice. The Bill does not in any way affect a patient's legal right either to choice or anything else. The Bill does not cover that issue.
I thank my noble friend Lady Pitkeathley for her welcome of the amendments made in another place concerning carers. However, I was disappointed that so many noble Lords raised the issue of care home capacity. Of course care home capacity is important. But it has not fallen to the extent suggested in the figures quoted from Laing & Buisson; and care home places are not the only option. I pay tribute to local authorities for increasing the provision of the alternative forms of care home that are becoming available. Part of the process of the Bill is to encourage more and different care support packages to be made available. Also, it will encourage local authorities to get together with care home owners to talk about longer-term arrangements to encourage stability in the market, the absence of which has been a long-standing complaint from the care home industry. We are already seeing, as a result of the increased funding we are able to put into local government, increases of more than 3 per cent in the fees paid to those care homes.
I was asked a number of questions about research and monitoring. I confirm that we shall be monitoring the situation extremely carefully. I confirm also, for my noble friend Lady Pitkeathley and the noble Baroness, Lady Noakes, that we will be commissioning research into the impact of reimbursement, not only on the delayed discharge as it happens in hospitals, but on the system as a whole.
On equipment issues, which were largely welcomed by noble LordsI look forward to Part 2 of this Bill in CommitteeI accept the importance of OTs in the assessment process and the importance of the single assessment process. Again, the incentive here is to encourage that assessment process. OTs have an extremely important role to play. We must ensure that we use their scarce resource as effectively as possible. The signs from the NHS and local government are that that is indeed happening.
Many interesting points were raised in this debate. I say to the right reverend Prelate the Bishop of Hereford that I do not underestimate the challenges. I note the concerns of the organisations and the hard-pressed professionals. In the end those organisations and professionals are well able to stick up for themselves. My concern is for the individual older people who need sticking up for.
We know that when older people are stuck in care in an acute bed, it can lead to rapid institutionalisation. The longer they stay there, the harder it is to be discharged back into the community. This Bill will go a long way to improving the situation for those individuals. We have transferred sufficient resources to local government to enable it to do its job properly. This Bill will be a measured improvement on current conditions and circumstances and I invite the House to give it a Second Reading.
Lord Clement-Jones: My Lords, this has been an excellent debate. It has not been much of a "birthday-fest" for the noble Lord, Lord Rix, but, nevertheless, I congratulate him on his 80th birthday today.
The Minister gamely replied to the debate, but it is clear that this Bill arrives virtually friendless in this House. Even those who had a good word to say about its intentions were beset with doubts and anxieties about its effect. I was particularly struck by the speech of the noble Baroness, Lady Pitkeathley. The adage, "With friends like this . . .", springs to mind in those circumstances.
The right reverend Prelate the Bishop of Hereford supported the amendment, but complained of the weak language used in it. I am afraid that we are bound by convention and I regret the fact that we cannot use the word "deplore". If we could have used stronger language, I would have done so and for that reasonand that reason alonewe on these Benches will not press the matter to a Division. We believe that the words of the amendment go only half way to demonstrating exactly how strongly we feel about the contents of the Bill.
If by convention we could throw out the Bill in this House we wouldand I believe that the same applies to the other Opposition Benches. We have the absolute determination to improve and make radical changes to the Bill on its way through this House. One of our first demands in Committee will be for a sunrise clause to delay the introduction of these measures at least until 2004. On these Benches, we will also want to see a range of other improvements: for example, proper safeguards on patient and carer consent and mental incapacity; and a time limit by which a full assessment of care and carer's needs will be completed so that people are not ultimately stuck in care homes. We shall want to see many additional amendments.
While I have the attention of Back Bench Labour Peers, perhaps I may advise them that when they go to No. 10 tonight they should tell the Prime Minister what a bad Bill this is and how little support it has in this House. I beg leave to withdraw the amendment.