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Earl Howe: I thank all those who have spoken—the noble Baronesses, Lady Barker and Lady Howarth, and the noble Lord, Lord Turnberg. I was grateful to the noble Lord, Lord Turnberg, in particular for his support, in principle, for some of my points, even if not for my amendment. Between them, they have prompted a reply from the Minister that provides at least a glimmer of hope, and I thank him for what he said.

I believe that my amendment is quite modest. Most bodies that have lobbied on the issue have proposed a minimum period of five working days, which is

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reflected in the Liberal Democrat amendment. That struck me as something that the Government would not warm to, but I thought a three-day period seemed reasonable.

I am grateful for the Minister's undertaking to take these matters away for consideration. Perhaps he will not be surprised if we table these or similar amendments again at a later stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 75 and 76 not moved.]

Baroness Barker moved Amendment No. 77:

    Page 4, line 16, at beginning insert "Subject to subsection (4A),"

The noble Baroness said: We come to a series of amendments which, in different ways, point to the fact that one of the significant reasons for delayed discharge is NHS failure to provide appropriate community health services. Another is the failure of other statutory bodies to provide services which older people need in order to enable them to return home.

The Health Select Committee report set out in detail the complex reasons why discharges can be delayed. For example, the committee pointed to the practice in some hospitals of timing consultant discharge rounds. Given the Minister's answer about the timing of days, I imagine that every acute NHS trust will shortly be re-scheduling the consultant ward rounds, either to beat the clock or not.

The Minister laughs. I am not as up on NHS practices as he is. I am involved with social services. If I were a director of a social services department, I would be sitting down with my staff now and talking about time and day planning.

Lord Hunt of Kings Heath: I am shocked by the noble Baroness's cynicism.

Baroness Barker: No, it is not cynicism. That is life—that is professional life in the NHS and in social services departments. I am not at all cynical. If I were a director of a social services department in charge of a team responsible in this area, I would begin to look at shift patterns now. That would be wise in the NHS as well.

Lord Hunt of Kings Heath: I understand what the noble Baroness says. There is a big difference between sensible shift patterns—trying to make this work as speedily and effectively as possible—and what the noble Baroness describes, which is what I would call gaming. We would expect the inspectorate to pick up problems in those areas. That is why I agreed on the importance of monitoring in the first debate. Obviously such practices would be unacceptable.

Baroness Barker: I thank the noble Lord and I take some heart. It is no secret that earlier this year one acute hospital changed its definition of social services delayed discharges and, lo and behold, within three days its rate of social services delayed discharges went

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up by 40 per cent. We have talked about perverse incentives. Those sorts of things are going to happen—that is what is life is going to be like.

All these amendments reflect the fact that a failure by the NHS to supply continuing healthcare services is a big factor in delayed discharges. Given the fundamental imbalance in the Bill, I am not sure that that is adequately addressed. We have sought to do that in this series of amendments. I beg to move.

Earl Howe: I should like to speak to Amendments Nos. 78 and 93 in this group.

I have mentioned previously the importance we attach to the principle of equity in this Bill. Equity and fairness are not easy to achieve when the whole basis of the Bill is a one-sided arrangement that places local authorities at a constant disadvantage in their relations with the NHS without giving any reciprocal leverage.

Ministers have made helpful noises about reconsidering that balance and I welcome what they said yesterday on this. If local authorities are to be penalised, the least we can do is to make sure they are penalised only when they have failed to act as they are required and when that failure is entirely their fault.

What happens if it is not entirely their fault? It is easy to imagine a situation in which the local authority has done everything that has been asked of it but the patient is unable to leave hospital because something else is not quite as it should be. What happens when the NHS itself is at fault? For example, let us imagine that a place has been found in the care home of the patient's choice but there is no suitable health support in the community for that care home in the form of a health visitor or GP coverage. In those circumstances, the home might say that it could not accept the patient.

Under the Bill, as I read it, the fault in that situation still lies with the local authority and the acute trust could turn round and say, "You have not performed. Tough."

Clause 4, as I interpret it, allows for no excuses. It says that if it has not been possible to discharge the patient because the responsible authority has not made available a community care service, then the responsible authority is liable for a payment. It does not matter whether the underlying reason for that failure is the absence of primary care services. From the hospital's perspective the fault lies with the local authority, which has failed to do what it said it would. That cannot be fair or equitable.

The Minister may be about to point me in the direction of the words "and only because" in Clause 4(4)(b), but I do not find them of sufficient comfort. I accept that they will let social services off the hook in certain circumstances, but what about a situation where a patient wants to exercise a choice about where he goes after leaving hospital? What if a care home place is found for a patient but that person refuses to go there? The example given in another place was that of a Jewish patient needing a place in a Jewish care

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home, yet there is only a place available in a non-Jewish care home. Why should a local authority be fined in those circumstances, when the situation is not its fault? Why should it be fined if the care home place was available but the patient baulked at paying a top-up fee and for that reason refused to go there? Are we being asked to accept that patient choice should always been overridden in cases like that? If we are then it is a sorry reflection on the approach being taken to patient care. The human dimension disappears.

I should like to see some sensible flexibility in the arrangements along with some natural justice. That is the reason for my amendments.

Baroness Finlay of Llandaff: I should like to speak to Amendments Nos. 80 and 81.

There can be delays in transfer that are not the responsibility of social services but can result in long delays. It can sometimes need 48 hours to book a transport ambulance for non-emergency transport. The ambulance service is an independent NHS organisation and not part of the NHS hospital trusts or part of social services.

I have already referred to data collected in my own NHS trust. Let us consider two samples. From May to July 2002 there were 23 patients waiting an average of 14 days. Ten of those patients were awaiting transfer to a hospital nearer home or to a nursing home. Similarly, winter data from September 2002 to January 2003 showed an improvement but revealed 17 patients waiting an average of 16 days. Four of these were awaiting transfer. Of the 40 patients in total, 11—or just over a quarter—became unfit for discharge while they were waiting. So delayed discharges certainly represent a major problem, but the delay in transport cannot be laid at the door of social services.

There have been moves by some hospitals to establish a dedicated ambulance for discharges, but not all have done so. The ambulance services have shown great compassion for my patients who wish to go home when dying. However, as the services cannot be immediately available for routine rapid discharges, patients remain in hospital awaiting transport.

Amendment No. 81 would allow some flexibility. Everyone can have a dire day or a bad week and work falls behind. Staff sickness can arise quite suddenly. With an epidemic in every work place, work will fall behind. The spirit of this amendment would allow for understandable delays before the Bill is enacted. Currently, care packages cannot always be put in place because there are just not enough carers. Where social services are doing all they can to recruit and train staff, it seems invidious to fine them. The amendment seeks to maintain good working relationships between social services and the NHS by building in leeway.

I support Amendment No. 82 particularly because of the serious NHS equipment delays in the community. I shall, if I may, cite just two examples: hospital beds and commodes. In the BroTaf area, at any one time, up to 22 people are waiting for a hospital bed to be put in their home before they can be

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discharged. Care packages are complex and require both the NHS and the social services equally to pull their weight.

5 p.m.

Baroness Greengross: Amendments Nos. 79 and 80 cover similar territory to Amendment No. 74, which we considered late last night. I am therefore sympathetic to them. Amendment No. 80, tabled by my noble friend Lady Finlay, is particularly important to me as much anecdotal evidence and certainly my own personal experience suggests that many delays in leaving hospital are caused by poor transport services. The Minister has told us that the three-day period carries over to a fourth day. I assume that that means that there is extra time to arrange appropriate transport. However, I would not want to see a situation in which a person who is ready for discharge on the third day after a Section 2 notice is left sitting around the hospital until the fourth day. Sitting around the hospital waiting is the experience of many very frail people. Can the Minister tell us what additional responsibilities the Bill places on hospital transport services and the ambulance service?

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