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Baroness Barker: My Lords, I support the amendment tabled by the noble Baroness, Lady Noakes. Anyone who has followed our debates on the Bill during recent weeks will be in no doubt that, as my noble friend Lord Clement-Jones, said, there is no monopoly on concern for the patient. However, we greatly fear that the lack of reciprocity on the NHS in the Bill is a fundamental flaw.

I shall make only three observations. First, readmissions to hospital of older people who have been sufficiently ill to be in acute care are damaging. According to the research from Leicester to which I have referred throughout the passage of the Bill, readmission is often such a disruption that there is an increased mortality rate among older people who are readmitted. That is probably one of the most serious statistics. That is why we want a penalty imposed on the NHS for inappropriate discharge. I reiterate: that is what the Government said they were going to do in the NHS Plan, but they have not.

Secondly, we should do well not to forget that another proposal runs alongside: the flat-rate tariff for treatment. Older people will turn out to be—and already are—in many ways some of the NHS's most expensive patients. On average, it takes older people longer to recover from surgical intervention. It is therefore likely that they will be the biggest drain on NHS resources under a flat-rate tariff system. So there again the NHS will have an incentive to discharge older people before they are ready.

My final point is that during our discussion on 10th March the Minister mentioned the Commission for Health Improvement and performance management. I then invited him to tell us how that would relate to

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foundation hospitals. He was unable to do so, saying that he could not comment on the legislation at that point. We were overjoyed to receive the Bill, so I therefore ask again: how will the measures work in relation to foundation hospitals?

4.30 p.m.

Lord Hunt of Kings Heath: My Lords, I was surprised by the tone used by the noble Baroness, Lady Noakes, to describe the Bill. The Government have listened and sought to reach a consensus on many of the important issues that have been debated. For example, there was the decision about regulations and directions on continuing care, the consultation on Section 2 notification and agreement to what we thought was a reasonable compromise—a six-month delay in implementing the Bill—and consultation with local authorities about panel members in case of dispute.

We responded to the requirement of the Select Committee on Delegated Powers and Regulatory Reform for more detail about the size of the charge. We made changes to the giving and withdrawing of notification and the proposed discharge date notification, so that both the NHS and social services will be clear about where each is in the process. We published the draft regulations, as requested, so that noble Lords are aware of the details and, of course, the Government tabled a raft of amendments in another place to bring carers into the Bill. We also announced that we would transfer 100 million in a full year to local government to meet the additional costs of dealing with the number of delayed discharge cases. I therefore think that it is very unfair to say that the Government have not listened, or been ready to discuss or compromise. I am sorry that noble Lords have not acknowledged that.

Of course nursing homes in some parts of the country have come under pressure. The figures that I have show that the number of care home places has fallen by 6,320 between 1997 and 2001. It is a fall, but it is only about 1 per cent of all care home places. That takes account of the number of homes closing, homes opening and existing homes extending capacity. Those are the figures that should be borne in mind—not the highly exaggerated figures that are often quoted.

The amendment relates to the issue of re-admissions to hospitals, and the suggestion that the Bill is an incentive to discharge patients prematurely. We define re-admission as admission to hospital within 28 days of discharge. I do not deny that re-admissions should be a matter of concern if they indicate failings in the care the person received during the earlier period of treatment. But it would be wrong to assume that that is inevitably the case. There are situations in which it would be wrong to blame the NHS for having failed to treat the person properly the first time. The article on re-admission rates in Leicester, to which the noble Baroness, Lady Barker, referred, surely provides evidence of that. The study showed that nearly 60 per cent of re-admissions were due to new problems or chronic medical conditions.

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Noble Lords will know that my department has been focusing intently on how to reduce delayed discharges since October 2001 when the building care capacity grant was first distributed. In the period since then delayed discharges have fallen significantly. If the connection between delayed discharge and re-admission were correct, we would expect an equivalent rise in re-admissions, but there has been a rise of under 1 per cent. I do not overlook the fact that re-admission rates can indicate potential problems around discharge, which is why we need to monitor the situation clearly. But there is no justification for arguing that pressure to reduce delays leads inevitably to premature discharge, and hence unnecessary re-admission. I do not believe that the figures back that up.

I found the Leicester study interesting. It showed that social reasons, either alone or in combination with other factors, can contribute to re-admissions. That is hardly surprising. A frail, elderly person returning from hospital without sufficient or timely support could have problems, which might then lead to re-admission. It is extremely interesting to note that the study reported that improper communication among various members of the multi-disciplinary team and with the general practitioner accounted for a significant number of re-admissions. That is the point. It is the point of what we are discussing and the point of lessons from Climbie

and elsewhere in the health/social care interface.

It is precisely that problem, which the study described as improper communication, that the Bill will prevent. Many of the problems that we face are not down to enormous pressure on health care and local government, nor are they down to impossible pressure on individuals. They are caused by the lack of proper processes and procedures, lack of proper supervision and a seeming inability among professional practitioners to write matters down so that there is an audit trail. Those are the issues that the Bill is attempting to grip. Because the NHS has a new duty under the Bill to communicate to the local authority that it has a patient who may need help, social services will be brought into the planning process early on—not the situation that has been described when the health service can ring social services departments at 4 p.m. on a Friday saying, "Here is a patient we are just about to discharge".

This is an example of the Bill placing a great deal of responsibility on the NHS to sort out the matter. The NHS will have to inform social services of the date of discharge at least 24 hours beforehand. Social services will have advance notice of when services will be available. Because both the hospital and the primary care trust will consult the local authority about the services that they will provide after discharge, the patient's needs for health and social care will be considered by all parties.

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It is not justified to create a link between the Bill and premature discharge. The incentives that are currently in place, and which will be in place with the financial flows in the future, will ensure that the incentives work in the right way towards effective discharge procedures and effective relationships and partnership between the health service and local government. Above all, they will ensure that when a person is ready for discharge, the community care package can be assessed and put into place as quickly as possible. On that basis, I hope that the noble Baroness will not press her amendment.

Baroness Noakes: My Lords, I thank the noble Lord for his reply. I did not say in my opening remarks that the Government had not listened. He seemed to accuse me of claiming that, but I did not say that. I said that the Bill was unbalanced when it arrived, but because of amendments tabled by us and those on the Liberal Democratic Benches, it is now better balanced, but it is not yet balanced enough. The Government, or at least the House, listened to many of the amendments. But there is one area that remains outstanding, which is the issue of reciprocal incentives.

I have no doubt that the Bill creates powerful incentives for social services to act as rapidly as possible, but I fear that it creates a harmful incentive on the NHS. I do not claim that early discharge results inevitably in every patient being re-admitted, but there is likely to be a correlation. The statistics that we have seen show that the proportion of re-admissions attributable to early discharge has nearly doubled in the past couple of years, just as we have seen the ticking up of the rate of re-admission.

This is too dangerous an area of the Bill to leave without corresponding incentives on the NHS. I have heard the Minister but the Bill would be inappropriate if it were left without corresponding incentives. I should like to test the opinion of the House.

4.38 p.m.

On Question, Whether the said amendment (No. 13) shall be agreed to?

Their Lordships divided: Contents, 145; Not-Contents, 112.

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