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Baroness Maddock: I shall speak to Amendments Nos. 15 and 31, to which my name is attached. Their purpose is to ensure that provision to deal with bed blocking is more explicitly tied to other government programmes and initiatives. The programmes with which I am especially concerned are those that deal with poor housing conditions, especially damp homes, and the closely associated problems of fuel poverty.

I declare my interests as the vice-president of National Energy Action, a charity that fights to eradicate fuel poverty, and the vice-president of the National Home Improvement Council. I shall briefly outline why those areas are so relevant and suggest to the Minister one or two things that he could do to assist.

Between 4 million and 6 million households in England live in cold, often damp, homes that they cannot afford to heat. They are in fuel poverty. We know that cold, damp homes are associated with premature mortality, physical and mental illness and the impairment of quality of life. They aggravate a wide range of medical conditions; they increase suffering; and they make it much harder to care for vulnerable people at home, thus adding to the burdens on our national health system.

The effects on the national health system are seen annually, particularly in winter, with our waiting lists for admission and bed blocking—the issue of the Bill. Unnecessary admissions to hospital can be avoided by ensuring that homes are warm, dry and in good repair. Bed blocking would also be prevented because a patient's home would be fit to return to. To return to the line that the Minister used earlier, we will require fewer care homes if that happens.

The National Service Framework for Older People is relevant to this debate, because 93 per cent of excess winter deaths are among people aged 65 and over. I went into the matter in detail in my Second Reading speech, so I will not do so today. Let it suffice to remind the Committee that Britain has a poor record in this regard compared with other northern European countries. Strand 3 of the National Service Framework for Older People states that,

That is particularly relevant to addressing revolving-door syndrome, which is part of the Bill, whereby people fall ill because of their cold, damp homes; they recover in hospital; they then get discharged back to cold, damp homes; they go back into hospital, and so on.

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The chief executive of the NHS sent out Improvement, Expansion and Reform: The Next 3 Years' Priorities and Planning Framework 2003–2006 in October last year, which outlined the need to develop local plans. The problem of patients staying in hospital for longer than necessary because their homes are unsuitable and unhealthy can be addressed through such plans. There are 1.5 million unfit homes in Britain. Most are owner-occupied and most are lived in by older people. There are recommendations that winter task forces in primary care trusts should produce local plans to deal with those problems. They would help to increase awareness of the links between housing and health; to identify households at risk; and to establish referrals to fuel poverty programmes and good energy advice. We can tie those aspects into the Bill, because it is about referrals. When patients are assessed, the condition of their homes is examined. They are exactly the sort of people who could be referred to programmes to help them to get money to rectify insulation and heating problems in their homes.

DEFRA, which is reviewing its Warm Front scheme, is being urged to introduce a fast-tracking mechanism that will prioritise people eligible for heating and energy efficiency grants. I agree with the point made earlier by the noble Lord, Lord Turnberg, that the care package should be looked at when people arrive in hospital. For example, if a patient will be in hospital for six weeks, that period will be needed to fix a heating problem.

Home improvement agencies and other service providers have developed effective, fast, small repairs and adaptations processes—for example, repairing heating systems. However, delays can arise where large capital investments are needed for heating systems. As a preventive measure, key departments should assess older people's homes in the sorts of circumstances that we are discussing. It would be a good idea to have an emergency fund for work to be completed within 24 hours either by Warm Front contractors or other bodies. Care and Repair has a proposal for a rapid-response fund for hospital discharge services. Energy efficiency and heating measures should be part of that. If the Government want to make a big difference, not only to discharges but to people admitted to hospital, the issues that I have discussed will be important. The problems that I am concentrating on—poor housing, cold, damp homes and fuel poverty—should be part of all the relevant legislation that the Government are looking at.

We had a brief discussion in another place, during which lip service was paid to those issues. The Minister also recognised their importance at Second Reading. I am grateful to the Minister's department for sending me a copy of Discharge from hospital: pathway, process and practice. I agree that it needs a snappier title. However, I was disappointed to find that, although there is a small section on housing, there is almost nothing about the role of heating in cold, damp homes.

I look to the Minister today for confirmation that the matter will be given greater consideration; that there will be more joined-up thinking—I hate to use

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that word—and that he will ensure that the issues I mentioned will be looked at in any primary legislation, secondary legislation or guidance that is produced. There are people who can refer individuals to the schemes. Local authorities are heavily involved in that area. I hope that I can receive assurance from the Minister that the matter will be given greater priority.

The Lord Bishop of Hereford: I add my support to the plea for these amendments, particularly the need for greater attention to good housing conditions, warmth and addressing fuel poverty. The recent census figures provided shaming statistics about the poor quality of our housing stock and the large number of people, mostly elderly, who have no form of central heating. We have made some progress in recent years with the Warm Homes and Energy Conservation Act two or three years ago, which was a move in the right direction. But, if those provisions can be written into this Bill, the discharge of people from acute hospital care will be a good opportunity to make a serious check on the conditions in which people are living and to take action.

We need joined-up caring if not joined-up thinking. This is an opportunity to introduce it. I speak not just about statistics in census returns and official documents, but from 20 years' work as a parish priest. I have entered terrible houses, where people have to go to bed all day because it is the only place where they can be warm. They come out of hospital, where they are in bed, and they go home, where they have to go to bed, because there is no other way of keeping warm. I have seen people huddled over pathetic, extravagant, inefficient, two-bar electric fires. There is no warmth and no possibility of dealing with inherent damp and coldness in such housing conditions. I have seen it time after time. It is a serious issue. There is the question of the capital cost of installing central heating in a house, but one can do a remarkable amount with modest storage heaters, which can transform the quality of life and atmosphere in a building, drying it out and keeping it at least habitable at a relatively modest cost. It can be done quite quickly.

This opportunity should not be missed. I suspect that the Minister will say that it is not what the Bill is about, but I beg him to consider seriously that it could be so. Introducing such a consideration to the Bill is an opportunity to make legislation that is not widely popular at the moment much more appreciated, more valued and more likely to be welcomed. It would make a considerable difference to the welfare, happiness and dignity of many elderly people.

Baroness Andrews: I am grateful to all Committee Members who have spoken in this debate. It is an opportunity to look at a range of partnership issues. It may be an opportunity to be more positive about partnership, because harsh comments have been made already in the Committee about possible conflicts, deliberate or accidental.

I am afraid that we have a problem with Amendments Nos. 13 and 14 because they are slightly defective. The Bill's raison d'etre is to promote closer

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and more effective working between the NHS and social services. The amendments do not help us to do that. It is essential that at all stages of the process we get social services and healthcare staff to work as closely as possible. We sincerely believe that the Bill enables that to happen more effectively. But it does not mean that they must be locked together at every stage of the way where it is inappropriate.

Essentially, Clause 2 is about notification. Making Amendment No. 13, which would insert the words "responsible body", would mean that the social services and the NHS would need to come to an agreement as to whether social services should be formally notified about a patient's case because it might be unsafe to discharge him without community care services. Bearing in mind that that would have to be done before assessment, it would be difficult for the NHS to come to an agreement with social services at notification stage. Until the NHS notifies social services, they may not know of the client. The case may not involve a client of the social services, and social services may not know that the person is in hospital. There is a problem there.

The NHS—the doctors, nurses and the whole professional team—must be responsible for making the decision to notify the local authority of a patient's case. They will have taken the decision to admit the patient on medical grounds. I understand that the amendment may have been prompted by the concern that, in an attempt to be speedy, the NHS will simply refer everyone to social services. We do not think that that is likely, particularly as the NHS must consider whether it is unlikely to be safe to discharge the patient, unless community services are put in place. That high threshold will ensure that there will not be casual, "just in case" referrals.

The NHS will not meet its obligations under the Bill if it simply notifies the local authority of every patient. The decision that a patient is likely to need services upon discharge can be taken only by the NHS. We checked that out with practitioners at the consultation meetings held by the reimbursement implementation team. We did not find it to be a problem. I hope that that will assure noble Lords that the clause is sound and is quite acceptable.

I stress that we believe there are better ways, in practice, of ensuring that there is joint working. We will be talking about that a lot in the context of the next few clauses. Many of those better ways have already been referred to in the Hospital Discharge Workbook, which is becoming a notorious document. In it there are some good examples of joint working. The workbook calls for joint work before admission, and there are lots of examples of that being done. Chelsea and Westminster Healthcare NHS Trust, for example, has a protocol that starts with assessment before treatment, before people are admitted for surgery. We want to see everybody follow such a pattern.

There is no reason why a hospital should not know that someone who has been on a waiting list for 12 months is coming in with a specific condition and from a particular situation. That is part of the process

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that patients should be able to expect. It will still be for the medical staff to decide whether to make the first contact with social services, particularly in the case of people who may not have any connection with the social services but who present with a need after surgery or care.

We will certainly emphasise the importance of joint planning in statutory guidance. That is important. However, I also draw it to the Committee's attention that in the regulations there is a focus on the need to inform social services of a named individual. Much of the failure to work together has been due to the failure to have someone whom everybody knows to be responsible. We hear that time and time again. The named person requirement will be in the regulations, which will have the force of law, and that will make a great difference to patients and their families. I hope that, with that explanation, noble Lords will be happy to withdraw the amendment.

Along with Amendment No. 15, I will discuss Amendments Nos. 31 and 119, relating to heating and housing. We must consider the conditions that can prevent unnecessary admissions to hospital and the conditions that must exist before patients can safely be discharged. The noble Baroness, Lady Maddock, spoke cogently and powerfully about the importance of affordable warmth, as did the right reverend Prelate. They are right: warm, dry housing will keep people out of hospital. I would not like to guess how many people are in hospital with respiratory diseases due to damp housing.

Our immediate response, however, is that the problem with including heating provision in the Bill is that it would isolate one service, when individuals require many different services or combinations of services, depending on their need. It is not sensible to identify a particular service in the Bill. That could be restrictive. Social services already have a duty to assess a person's need for community care under Section 47 of the National Health Service and Community Care Act 1990. That includes an assessment of the person's home environment. That is the law under which the assessments made under this Bill will be made; they must follow Section 47 of that Act.

The local authority would not discharge its duty if it did not check that a person's home was adequately heated. That is particularly important in the case of someone with limited mobility or a respiratory condition. Section 47 also requires the local authority to notify the relevant housing authority if, during that assessment, it appears that the patient may need help with housing, such as the installation or improvement of a heating system. Social services are under an existing duty to involve the housing authority if services appear to be needed.

The noble Baroness referred to the "Keep Warm, Keep Well" programme and the Warm Front scheme. She had some interesting things to say about the fast track scheme and about how sensitive action could be taken quickly to deal with problems. That will be of the essence if the Bill is to be the success that we hope. We want to see speedy and sensitive assessment of the

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issues. In the light of what the noble Baroness said, we should examine the guidance that will be produced with a particular view to giving heating a higher profile and ensuring that assessments accurately reflect the home situation.

6.30 p.m.

Baroness Maddock: One of the things that I failed to say was that the Government have a fuel poverty strategy. In the opening pages of the document—I will not say the name again—there is reference to other legislation, but there is no mention of the fuel poverty strategy and its targets. That seems to me to be a failure, and I hope that it can be improved upon.

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