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Lord Bradshaw: I support my noble friend Lady Barker in moving Amendment No. 42 and shall ask some specific questions. The problems that we in the South East face are of a grave and growing shortage of homes and a shortage of money. The recent National Audit Office report stated that we have lost 2 per cent of residential homes and 10 per cent of nursing care homes since 1998. The loss has been especially acute in the South East, because property prices have risen significantly—a subject on which the noble Earl, Lord Howe, touched earlier.

Not only are places difficult to find, but staff require much more pay to work in the difficult and demanding job of providing personal and nursing care. The National Audit Office reiterates what we all know: it is better to support people in their own homes. Local authorities are being dragged in several directions at once. They face higher fees—if they can find a home. Paying those higher fees means that there is less money to spend on care in the home. So authorities are having to tighten the eligibility criteria to make the money go round, but that leaves people in the community without proper care and fewer people being admitted to fewer homes.

What specifically is being done to alleviate pressure on homes, and what is being done to alleviate the pressure on local authorities, whose costs—in admission to homes and payments—in the sector are rising much faster than inflation?

We are used to the term tightening eligibility criteria. But it means that more and more people are refused necessary care and treatment in their own homes and increasing pressure is put on carers—to intolerable levels. We need answers. The Government must recognise that those problems exist and are

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probably worsening. Council tax is being increased to record levels—13.4 per cent in my case and 15.8 per cent in Suffolk—yet we know that that money is insufficient to cover our existing costs. The costs are running away on us.

9 p.m.

Baroness Noakes: I thank the noble Baroness, Lady Barker, for introducing this complex series of amendments with such precision. We on these Benches are concerned about the bureaucracy associated with this fines system. Nevertheless, we believe that there should be an adequate degree of precision and proper reference points. Therefore, there should be a more formal record, such as written discharge notices and plans, provided that the process does not become too bureaucratic.

Many of the amendments in this group are technical and relate to the nature of the assessment process. I hope that we do not hear again from the Benches opposite that the provisions are implicit. Frankly, the Bill is drafted in such general terms that it could leave both NHS bodies and local authorities unclear as to what they are intended to do. We welcome the attempt to make the Bill more precise.

Baroness Finlay of Llandaff: I wish to speak to Amendment No. 38, which is part of this group. Its purpose is to emphasise the need for joined-up thinking. The noble Baroness, Lady Barker, laid out eloquently the complexities of the need for joined-up thinking. Written plans are needed. At present, care plans are written in patients' notes, but there must be clear documentation, otherwise it will be impossible to track who has done what, and when. Those notes must be available to patients if they wish to see them, just as they have a right to see their clinical record at present.

My concern is that, when patients requiring a complex care package go home, the social services assessment cannot be taken in isolation from all their other needs. The needs of patients with rapidly changing clinical states who go home with severe, often progressive, conditions such as neurological, cardiac or respiratory disease, will fluctuate. Provision of social care needs to be an integral part of the care provided by community health services and all the NHS services. They must be dovetailed, otherwise there will be a deficit or a plethora, either of which will be ineffective in cost terms, apart from anything else. If there is a care deficit, patients will bounce back into hospital. If there is a plethora, it will be a waste, and more will be put in than patients need.

The difficulty is that clinical states are not clear-cut—oh, that they were! It would be wonderful if one could state that a patient was purely the responsibility of social services or purely that of the health service. But they often bridge, or fluctuate between, the two. Often the patient concerned is elderly and lives with someone else with care needs. There must be a complete picture of the needs of two, perhaps three, people with different care needs that must be integrated—in the name of efficiency and streamlining, apart from anything else.

Baroness Andrews: The amendments have been dealt with with great clarity, despite the fact that they

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came in an industrial-sized group. I am grateful to the noble Baroness and to all noble Lords who spoke for making sense of them.

I shall deal first with the government amendments. My noble friend and I apologise for not being able to inform the Committee about them. Amendments Nos. 19 and 21 are simple amendments which are there to close a loophole in the drafting of Clause 2. Clause 2(2) states that the responsible NHS body must give the Section 2 notification to the local authority that appears to be the authority in whose area the patient is ordinarily resident. It is not certain how the NHS body would fulfil its duty to issue a notice under the clause if there was no residence—for example, in the case of a homeless person.

We do not wish such patients to remain unnecessarily in a hospital bed when they are ready to leave because we had not made clear what should be done in such a case. The amendment will remove that uncertainty by providing that the Section 2 notification should be given to the social services authority in whose area the hospital is situated. I hope that the Committee will support the amendment.

Amendment No. 17 proposes the insertion of a reference to,

    "a named Discharge Officer acting on behalf of the responsible NHS body".

Amendment No. 26 would insert a requirement to include in the notice the name of the person dealing with the discharge for the NHS. The amendments are in line with our thinking but the problem is that they are not workable in their current form. The post of discharge officer is not defined elsewhere in the Bill or in any other relevant legislation. I take the point about the title: it sounds rather draconian.

The draft regulations will have the force of statute and will do the business with regard to giving the name of the person at the hospital who will be responsible for liaising with the social services authority on discharge. We are consulting on the regulations and do not anticipate removing that provision. Along with good practice, it should be sufficient. There will be as strong a duty in regulations for the NHS to include the name of the individual as there would be if it were spelt out in the primary legislation. However, without making a commitment, we will examine the matter again and consider what the noble Baroness said.

We understand Amendment No. 20 to be a probing amendment, designed to discover why we tabled our amendments in the first place. It relates to the question of having two authorities, as it were. I take the point about the complexity of establishing residence and deciding who is responsible. That is exactly the reason why, on the advice of parliamentary counsel, we wanted to make the change in the first place. The Bill is concerned with providing the right care at the right time, and we were concerned about the possibility of delays caused by confusion over the phrase "ordinarily resident". The change was made to clarify a technical drafting point.

Previously, Clause 2(2) placed a duty on the responsible NHS body to give notice of the patient's case to the social services authorities in whose area the

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patient was ordinarily resident. We thought that that left open the argument that there was no flexibility in cases in which it was difficult for the NHS to establish where a patient's ordinary residence was. We were afraid that that would lead to delays while that argument was concluded, and we felt that, rather than leave a patient in an acute bed while his case was sorted out, we should make it clear that the responsible authority was the authority that found itself caring for the patient.

The Government's intention was that any authority receiving a Section 2 notice would be responsible for the patient—possibly only on an interim basis—until the correct authority was identified. That would ensure that there was continuing care while the case was sorted out. We expect the NHS to make its best efforts to deliver the Section 2 notice to the correct authority within a reasonable period, and we will reinforce that in guidance.

Amendments Nos. 25, 27, 28, 29 and 54 have all raised the issue of written records. Various Members of the Committee have reinforced the incredible importance of the written record. Against the background of the Climbie inquiry who could argue with that? The paramountcy of good practice needs clear records.

Amendments Nos. 25 and 27 require regulations to prescribe that Section 2 notices are issued in writing. In fact, the draft regulations already prescribe a written form for the notice. That is important in terms of clarity. Amendment No. 29 requires the regulations to prescribe withdrawals of Section 2 notices in writing. At present, the draft regulations do not make that prescription and we may want to change that following the consultation. The point has been taken and we shall pay attention to the views of those responding to the consultation on the operation of the regulations.

Amendment No. 28 also provides a regulation-making power to prescribe a date on which notices could be issued. The Government are concerned that it could have the effect of adding days to the assessment process. That is a matter I am sure we shall discuss in more detail when we reach that part of the Bill. We consider the three days allowed as the minimum number, given that elective admissions patients will have been in hospital a considerable amount of time before then. We believe that the three days will concentrate the mind wonderfully.

Amendment No. 35 raises the issue of the initial assessment. I should like to re-emphasise that the Bill does not specify the degree of assessment, whether initial or otherwise. As regards the point made by the noble Baroness, Lady Finlay, the situation of an elderly person is very changeable. It is dynamic; it may improve or it may deteriorate within a day, not to mention a week. We want to ensure that an assessment allows flexibility for a further assessment to be made. As the noble Baroness said, often long-term needs will be better assessed either in interim care or intermediate care, if that is the arrangement, rather than in hospital, when academic judgment is being made as to the

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situation at home. We believe that while the information gathered during assessment does not need to be duplicated when the Section 47 assessment takes place, the requirements for a proper assessment still apply. It will not be acceptable for an initial assessment to be made which is not followed up. It is essentially very much the first stage. Therefore, given the requirement for assessment, this amendment is unnecessary because it is a non-existent problem.

Amendments Nos. 32, 33, 37 and 38 take us back to our earlier debate. Essentially, they are about the partnership. The noble Baroness, Lady Finlay, drew attention to the great importance of ensuring that the assessment for community health is as full, as sensitive and as flexible as possible so that the right mix of services is available.

The underlying issue raised by Amendments Nos. 32 and 33 is how patients are assessed for care required after discharge. I was interested in the example given by the noble Baroness on diabetics and how the combination of services is essential in such cases. On the surface, it appears reasonable to require joint assessment, which is what Amendment No. 32 seeks to introduce. However, there are some clear reasons why the amendment would not work.

There is a drafting error in the amendment, which requires NHS and social services to agree upon which "patients" are going to be made available. I assume that that should read "services" rather than "patients". However, the amendment requires the responsible NHS body and the responsible authority to agree what the authority will make available. It would mean that the NHS would retain the power to object to what the local authority had decided it could make available.

As with an earlier amendment, the problem arises—it is repeated here—that this could give rise to a recipe for confusion. How could the NHS and social services work well together under the circumstances because it would remove all the clarity between the respective roles of health and social care and there would be a loss of accountability? That is precisely the kind of situation we want to avoid. It is precisely the kind of situation which contributed to the catastrophe of the Climbie case.

Although the Bill has been criticised in some quarters as being unfair to social services, we believe that that is far from the truth. The Bill places new duties on the NHS to provide social services with a notice of likely patient need, and it prevents the NHS from informing a local authority that a patient is ready for discharge at very short notice. We all know of cases where a local authority has been given literally 24 hours to find a place for a patient. The Bill will prevent unjustified interference by the NHS in the operations of the local authority. We have to get the balance right and the amendment, as drafted, will not do that.

We also have to consider the fact that local authorities are by no means qualified to assess a person's health needs. That must rest with qualified health staff. In any case, in addition to the duty to assess, the Bill ensures that

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the NHS and social services should work well together. I hope that the noble Baroness will be prepared to look at the amendment again.

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