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Lord Hunt of Kings Heath: The noble Baroness has returned to a matter that she anticipated in some of our debates yesterday. I understand the point she has raised. In what are often difficult circumstances, decisions must be reached and of course it is important to ensure truly effective dialogue between the health service and social services. I do not deny that at all. Furthermore, we know from areas where good practice is working well that there is a seamless and integrated care approach which ensures that the issues raised by the noble Baroness, along with the downsides, are reduced to a minimum.
There is a problem with the wording of the amendment. In a legal sense, the word "agree" would mean that both the NHS and social services have a power of veto over the services provided by the other agency. My fear about that situation is that while many NHS and social services bodies would operate well and would not seek to use their ability to veto any action, it would leave far too much to chance.
I return to what I said yesterday. It is important to remember that the Bill does not change any statutory responsibility of either the health service or local government. It is best to keep it that way and to accept that in the discharge procedure both the NHS and social services have decisions to make. In a legal sense, it is best that they are responsible and accountable for such decisions. But it is part of our job to ensure good practice and the right incentives, and we encourage them to work closely together. That, in essence, is what the single assessment process is all about. That is why, ultimately, while sympathising with what the noble Baroness seeks to achieve, I cannot support her amendment.
Baroness Barker: Following our discussions yesterday, I am not surprised by the Minister's reply. The Minister may be right that the responsibilities have not changed, but that begs two questions. First, why do not the arrangements work at the moment? And, secondly, what is the purpose of changing the context in which those responsibilities have to be exercised by introducing a system of fines? Those two questions are not adequately answered by the Bill.
There is merit in saying that decisions about days of discharge should be joint but, while it may be clear that there is an ultimate responsibility, I am not sure that in practice that clarity works its way through into better patient care. Patients still get left out and do not receive services to which they have a right. As the Bill stands, it gives no right to services at all.
I understand the Minister's argument but it is not a satisfactory answer to say that the relationship between the two statutory authorities must work in the way he outlined. None the less, I shall take the amendment away and consider it further between now and the next stage of our discussions. I beg leave to withdraw the amendment.
The noble Earl said: In moving Amendment No. 74, I shall speak also to Amendment No. 88. The amendment brings us to some of the nitty gritty of the Bill. Setting aside for the moment our opinions about the Bill as a whole, we do at the very least need to ensure that the rules that are put in place to bring its provisions into effect are likely to work smoothly. We also need to make sure that they are equitable as between the NHS and the local authorities. The issue that perhaps falls most squarely under this kind of heading is the period of time defined as the minimum period which local authorities are given to assess patients and to make services available to them.
It is helpful that we now have available to us the draft regulations which enshrine the relevant definitions, but I have to say that they give me no comfort whatever. What the regulations say, if I have understood them correctly, is that a hospital has to give at least two days notice to a local authority of the date when a patient must be discharged. Notice given after 5 p.m. counts as having been given the next day; and a discharge before 11 a.m. counts as having occurred on the previous day. It is not surprising that local authorities are up in arms. The Minister will no doubt tell me that two days is a minimum but, nevertheless, it is an option. In the vast bulk of cases it is a ludicrously short time for a proper assessment of patients and for proper care arrangements to be made for them.
For a start, neither the Bill nor the regulations make any distinction between working and non-working days. It may well be to the hospital's advantage to ignore this distinction, but it certainly is not beneficial to the local authority where working practices will have to change fundamentally if the rules are to operate as drafted.
We have debated on numerous occasions the financial pressures currently being experienced by social services departments. These regulations would place further, and unfunded, financial pressures on those services. The 5 p.m. cut-off point is the very least that can be done to acknowledge the practicalities of a normal working day. It is not exactly a generous recognition of those practicalities. Similarly, the leeway until 11 a.m. on the day after the notified discharge day is welcome, but again it is not giving much away. We need to look again at the whole formula.
I note in passing that the regulations in paragraph 11 contain some rather impenetrable drafting which the Minister may care to look at. If one omits sub-paragraph (a), one has a sentence that begins:
My amendment would remove the two-day period and substitute three working days, excluding Saturdays, Sundays, bank holidays and public holidays. That seems to me a more equitable and more realistic formula than the one the Government propose.
We all accept, I think, that there has to be consultation with the patient and his or her carer about the arrangements to be made for continuing care. We all accept as well that the patient's choice of care environment needs to be taken account of and, if possible, accommodated. Are we saying that the only thing that matters is for the patient to be shifted out of his hospital bed, and that for this purpose any old care home will do? Heaven forbid. But this is what the Minister implied in another place when she said that patients,
We are back to "pass the parcel". A patient is not a parcel. An elderly person is often deeply upset by a change of environment. It is not acceptable deliberately to envisage moving such a patient from pillar to post merely to free up a hospital bed in the shortest possible time. If there is a feature of the Bill that makes me recoil more than any other, it is this. It is also the surest recipe for an emergency readmission a few days later. We already see emergency readmissions rising quite dramatically across the country.
However, reverting to the mechanics, do the Government really believe that notifying a local authority at 4.30 p.m. on Good Friday that Mr Smith has to be discharged not later than 11 a.m. on Easter Monday is being fair on that local authority? It cannot possibly be. In another place the Government resisted similar amendments. I hope that they will not do so again, having had a chance to think about the matter in more depth. I beg to move.
Baroness Barker: I shall speak to my Amendments Nos. 75 and 76. Amendment No. 75 is very much in accordance with that of the noble Earl, Lord Howe. My suspicion is that opposition to this amendment will be to the effect that services should be patient focused, and not run for the benefit of those employed in them. But it is precisely because I am concerned about patients, especially older people, that I believe that the amendments are right.
Time and again, it has been demonstrated that a lack of community services in the wider sense is a cause of re-admission to hospitaland a great many services which have nothing to do with statutory providers are simply not available on bank holidays and at weekends.
In addition, the role of families in the discharge process cannot be under-stated. What happens to someone in hospital who says "I want to talk to my son or daughter about this", but he or she cannot get here from Manchester until Friday? At present, hospital authorities understand that and work around it. That is the human side of the process, which will be smashed away by the heavy hammer that the Government want to introduce. The anxiety of relatives, in terms of knowing when someone will be discharged so that they can be there to help, is well and truly under-estimated.
Amendment No. 76 deals with discharge to residential care homes. The amendment deals with three different points. First, the Government have made much of the number of people in acute hospitals and of the experience in Sweden, where this model operates. But one fact has not emerged throughout our discussion; namely, that in-patient times in acute hospitals in the UK are the shortest in the whole of the European Union. The Minister will no doubt say that three days will be a minimum period, and that most people will be in hospital for much longer. But it should be borne in mind that this model is based on a system elsewhere; it operates in a different environment, where decisions can be made over a longer period.
The second reason for tabling the amendment is to discuss the position in care homes. Three days is not a long time to conjure up a care home. When we are talkingas we often are with older peopleabout dementia care places, the Government are risking a log-jam in another part of the system. We may clear the acute beds, but we shall create enormous problems and huge pressures for people to be discharged from care homes in order to enable discharge from hospital. It is not unreasonable for there to be a longer period of time, particularly when we are talking about care homeswhich, as we discussed at considerable length yesterday, are becoming a scarcity in some parts of the country.
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