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Lord Campbell of Alloway moved Amendment No. 4:
- Page 2, line 8, at end insert "and Fire Brigade Services"
On Question, amendment agreed to.
Clause 3, as amended, agreed to.
House resumed: Bill reported with amendments.
Lord Davies of Oldham: My Lords, I beg to move that the House do now adjourn during pleasure.
Moved accordingly, and, on Question, Motion agreed to.
[The Sitting was suspended from 7.54 to 8.39 p.m.]
Community Care (Delayed Discharges etc.) Bill
House again in Committee on Clause 2.
Baroness Barker moved Amendment No. 17:
- Page 2, line 9, after first "of" insert "a named Discharge Officer acting on behalf of"
The noble Baroness said: I now set off on a rather extensive group of amendments, which deals with several issues. No doubt Members of the Committee will stay with me and we shall get through them all. It is in the nature of the Bill that several issues run throughout as a thread. Some we have already discussed to an extent; some we shall return to again.
Amendment No. 17 seeks to insert the requirement for there to be a named discharge officer. As I believe I said earlier, it is enormously helpful to see the draft regulations, and I note what the Minister said about that requirement being included. The amendment has been tabled not from pedantry on our part; it was very much informed by something to which the Minister referred earlier—the report of the Climbie inquiry. One issue which, in a different context, comes through loud and clear from that report is that systems, however good they are, depend on identifiable people and on people being familiar with one another in their professional roles in order to make them work. That
was the motivation behind this amendment and behind Amendment No. 26, which concerns the job title of the person.As I alluded to during debate on one of our earlier amendments, the process of discharge from a hospital involves decisions which are usually taken by more than one person. It is often the case that different parts of the NHS will say different things to patients. Therefore, I believe that if someone has a title—a number of hospitals have now moved to having a named discharge officer—that is helpful not only to the patient but to NHS colleagues as well. It provides a locus for the discharge decision. Therefore, I welcome that point in the regulations.
Amendment No. 20 touches on the issue of responsible authorities. I shall no doubt be told that my amendment is defective. However, I tabled it in order to raise a question. I know that on its immense website the department is currently holding a discussion to determine what "responsible authorities" are. But, in particular in the case of older people, where the experience of hospitalisation may lead someone to make a life-changing decision and to move to another authority—perhaps to be nearer his family or whatever—I have doubts as to whether the NHS alone should decide what constitutes a responsible authority. I see a role for social services as part of that decision-making process. I say that not least because different authorities provide and, crucially, charge different rates for services. That involves the complex issue of the authority in which a person lived before going into hospital being different from the one in which he goes to live after being in hospital. Different rates may be involved, in particular in relation to self-funders.
Amendment No. 23 deals with one of the big flaws in the legislation—that is, the failure for there to be a trigger for the comprehensive assessment of patient needs. In responding to the debate on the previous set of amendments, the Minister talked about the partial assessment which will be made in order to determine whether or not a person is fit to leave hospital. I have no problem with that. I also accept that an acute hospital is perhaps not the place in which to carry out a full assessment of a person's ongoing needs. However, there is nothing in the Bill to safeguard an older person from having that incomplete assessment done and not having a fuller assessment of their needs.
As noble Lords know, at present the single assessment process does not have a statutory basis. It exists only in guidance. It is due to be implemented in 2004 and all social service departments and NHS bodies are working towards that. However, there is a real fear that partial assessment may lead to people being discharged into care which is not suitable for their long-term needs and that people will be stuck there and left on the basis of that partial assessment.
The amendment seeks to ensure that that full single assessment process should be triggered. The National Service Framework for Older People states:
- "Decisions about admission to long-term care should follow upon a multidisciplinary assessment and take account of the patient's and carer's wishes".
- "If admission to long-term care is a possibility, full multidisciplinary assessment should take place to identify opportunities for rehabilitation and to reduce inappropriate admission".
We have debated all afternoon whether or not such multidisciplinary assessments need to be in legislation in order to make them happen. I listened with care to the Minister's response on the last group of amendments. I wish I could be as confident as she is that they actually happen. I am afraid that I am not.
Amendments Nos. 25, 26, 27 and 29 refer to the need for written plans. Written plans appear in regulations. I was a little surprised to see the LGA state that it is against those. Again, reading the Climbie inquiry, the failure to pass on written information between agencies had a fundamental impact on the lack of care given to that little girl. In many years of working with people who run hospital discharge schemes through voluntary organisations, I see there are two enduring criticisms of the NHS. I refer first to the inability to obtain the information that they need in order to ensure that what they are doing is correct. Secondly, when hospital discharge schemes work well, they work really well. However, there are people who slip through, who never get into the whole track of a hospital discharge plan and are then lost. That is another reason for suggesting that there should be a greater emphasis on written plans.
A third reason concerns carers. We have not spoken much about that today but we can probably all think of instances where older people who are desperate to get home and out of hospital say to doctors and nurses that they can do things when they cannot and it is only when a carer sees what is written on a patient's discharge plan that the penny begins to drop that something is badly wrong.
Amendments Nos. 32 and 33 take us back to the single assessment process. We on these Benches feel strongly that for a single assessment process to work there has to be a joint assessment. All afternoon Ministers have been talking about the NHS having the ultimate decision to discharge a person and the fact that there cannot be joint decision making between agencies. In practice, a person's health condition is very much dictated and governed by social circumstances. The Government's absolute approach towards a decision either being medical or social is wrong. There is an area in-between.
A classic example is that of a person diagnosed with diabetes. On going home one must be sure not only that he or she will have food but that he or she will be fed at regular times. That is on the borderline between what is strictly medical and what is social care. Therefore, we think that local authorities should play a greater part. That is part of the single assessment process.
The noble Baroness made a welcome concession to us on consultation before we adjourned during pleasure. She has gone some way to allay our concerns about carers having access to assessments.
Amendment No. 42 deals with care homes and their duty to assess people under the Care Standards Act. Under that Act, providers of care home places must be satisfied that they are fit for the purpose of caring for an individual. The Minister has not made me sure that that short assessment and short notice is sufficient time for care home owners to make the decision whether they will be taking people who need specialist nursing care or specialist mental health care beyond the registration of the care home. I flag up that three days will not be long enough to make those kinds of assessments.
The Minister has made much of acute hospitals being dangerous places. We have talked a great deal about inspections. I am very sorry that the noble Baroness, Lady Masham, is not in her place to back me up on this matter. The increasing incidence of MRSA in care homes is a matter of extreme concern.
I do not know whether the Minister is aware, but last year some research was carried out with care home providers in Brighton. It showed up a number of interesting points. One example was that where patients were admitted to hospital from a care home, the care home owners regarded the home as being that person's home. We often have a perception that care home owners are unwilling to take people back from hospital. That was not true. They regarded the home as the patient's home and they very much wanted him or her back. So much so, that at times they took people back with a level of needs and dependence above their registration.
One of the most interesting, and I think frightening, matters was when the care home owners talked about their difficulty in contacting the NHS to find out exactly what the medical state was of the patients being discharged back to the home. Also, there were the frightening levels of neglect of personal care in hospitals. There were incidents of people coming out of hospital with malnutrition, not because they had not been given food but because they had not been fed. If someone has Alzheimer's and food is put at the end of the bed which is not eaten, it will get taken away. If that keeps happening that patient will wind up being malnourished. That is extremely worrying. We need to keep an eye on it. It is not just a one-way thing; it is not just care home owners being obstreperous about their rights.
Finally, these amendments address one of the key issues, which is assessment for continuing care. That is an issue to which we shall return. Many older people are confused about what care they can expect from the NHS after their discharge from hospital. That is especially true of those who continue to require NHS care—fully funded care—in a care home that provides nursing care.
Our amendments require that patients receive such an assessment; they complement the amendments proposed in relation to information about assessment for healthcare needs. Clause 3(6) merely imposes a
duty on the NHS to consult about what services, if any, it will provide. Although the assessment of healthcare needs is implicit—as the noble Baroness, Lady Noakes, said, little is explicit—the amendment imposes a duty on the NHS to carry out an assessment of those needs.We contend that the process of assessment is currently incomplete. That is why, through Amendments Nos. 115 and 116, we seek to include definitions of assessment of patients and/or carers. Amendment No. 70 mentions assessments being triggered within 42 days. Those who are on the ball—that undoubtedly includes the Minister—will have noticed that the requirement to carry out single assessments is currently shorter than that. They are supposed to be undertaken within four weeks. However, there is logic to our proposal within the Bill, which is to link the need for that assessment with the intermediate care period, which currently stands at six weeks.
This group of amendments is about ensuring that on-going assessment of people's continuing needs is carried out properly and fully, in the right place and at the right time, and that we do not inadvertently set up a system whereby people get partial assessment and wind up in the wrong place with the wrong care. I beg to move.
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