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Baroness Morgan of Drefelin: My Lords, I shall have to write to the noble Baroness about the number of Sure Start centres in rural areas. However, it is clear that we know what a community is. It is a place where a reasonable number of parents have reasonable access to a children's centre, and you will also find there a

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community school, a children's centre and possibly a walk-in centre. These are all facilities that a Labour Government are committed to promoting.

Baroness Pitkeathley: My Lords, in view of the great success that there has clearly been in recruiting staff at Sure Start centres, including outreach workers, are there any lessons to be drawn about recruiting social services and social care staff in general?

Baroness Morgan of Drefelin: My Lords, we must always be committed to learning the lessons. We know that there are significant pressures on children's social services-I think that that is what the noble Baroness is referring to. Working in a Sure Start children's centre can be a very positive experience and we should be learning from the training that is made available from the interaction with parents and making sure that those lessons are learnt across children's services.

St David's Day

Question

3 pm

Asked By Lord Roberts of Llandudno

Lord Davies of Oldham: My Lords, I begin by wishing the noble Lord, Lord Roberts, and our compatriots a very happy St David's Day. No such consultation has taken place, but I must stress that, for the people of Wales and for Welsh people all over the world, the absence of a public holiday on St David's Day has not diminished the appetite to celebrate 1 March in style and with pride.

Lord Roberts of Llandudno: My Lords, I think that I thank the Minister for that Answer on Dydd Gwyl Dewi, which is Welsh for St David's Day. However, we have almost without exception the fewest public holidays of all the countries of the European Union. When we look to have a new public holiday, could we give priority to the national days of Scotland, Wales and England? St Patrick's Day is already a bank holiday in Ireland, of course. Will the Minister initiate consultation soon with the devolved Administrations so that, when another opportunity comes to have a public holiday, we can move immediately, without any hesitation, to ensure that Wales, Scotland and England have their national holidays?

Lord Davies of Oldham: My Lords, bank holidays have to be established on the basis of consultation because they reflect the work-life balance, on which this Government have a proud record. It will be noted that we now have five and a half weeks of statutory entitlement. I bring to the attention of the noble Lord the fact that any decision on St Patrick's Day is for a totally different country and Administration. As far as Britain is concerned, the position is clear: the Scots

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decided to opt for St Andrew's Day; the Welsh Assembly Government have not as yet made a bid in the present programme for a public holiday for St David's Day. If such a bid comes forward, we will consider it.

Lord Davies of Coity: My Lords, does my noble friend agree that the noble Lords, Lord Roberts of Llandudno and Lord Roberts of Conwy, rather than being concerned with the unemployment figures and bank holidays on St David's Day, would be better advised to look at the latest opinion polls?

Lord Davies of Oldham: My Lords, I thought that there was cause for much celebration today, but for some of us opinion polls are always attended to with some degree of scepticism and doubt. If there was cause for celebration in some parts of the House, that probably took place earlier than today.

Lord Wright of Richmond: My Lords, is the Minister aware that the noble Lord, Lord Roberts of Llandudno, might be well advised to have a holiday in the Lebanon? When I was posted in Beirut, many years ago, it was reputed to have more national and religious holidays than any other country in the world.

Lord Davies of Oldham: My Lords, the UK does not compare well on bank holidays with other countries-the noble Lord draws the attention of the House to a particular illustration-but we do not do badly on holidays as a whole in comparison with others.

Lord Howell of Guildford: My Lords, if there are to be more holidays in the land of my fathers, which I personally would welcome, might it be wiser not to make them bank holidays? Most of us feel that holidays are not the appropriate thing for the banks at the moment; they should be working rather harder to pay us back all the money that we have lent them.

Lord Davies of Oldham: That is a very interesting point. Almost the only thing that the banks are associated with favourably at the moment is bank holidays, but we ought to bear in mind the point that the noble Lord has made. I think that the noble Lord, Lord Roberts, is emphasising that there is an enthusiasm in Wales and among Welsh people everywhere to celebrate 1 March, as I think the Welsh do.

Lord Avebury: My Lords-

Lord Anderson of Swansea: My Lords-

Lord McColl of Dulwich: My Lords-

Baroness Royall of Blaisdon: My Lords, I think that we should hear from the Liberal Democrats.

Lord Avebury: My Lords, is the Minister aware that in the Bank Holidays Act 1871 it was wisely provided that additional days could be added to the original list by royal proclamation? This power was used to add St Patrick's Day in 2003 and the successor to the original Act was used to add St Andrew's Day in 2007. Does the Minister think that, after all this time, it would at least be worth consulting the people of Wales

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on whether they would like a national day to be celebrated by a bank holiday in accordance with the practice elsewhere in these islands?

Lord Davies of Oldham:My Lords, I emphasise, with the most apposite example, that St Andrew's Day is not an additional bank holiday; it is a substitute for another holiday in Scotland. If the Welsh Assembly chose to go down that route, we would look at the issue very seriously, but in the bid for legislation this year the Welsh did not ask for that power.

Lord Elystan-Morgan: My Lords, may I endorse, with great pleasure and with humility, the candidature of St David? He was a British-born saint who lived all his life among his people, which is a record not shared by all his saintly colleagues.

Lord Davies of Oldham: The history of the saints throws up some interesting illustrations, but I am happy to testify to the authenticity of St David.

Lord Anderson of Swansea: My Lords, if we believe in devolution, should this decision not sensibly be left to the National Assembly?

Lord Davies of Oldham: My Lords, it is in one sense but, at the moment, this requires primary legislation. If the Welsh want to make changes, they need to make representations for the British Government to consider against the background of the other factors involved, which I have mentioned. I am merely saying that the Welsh Assembly Government have not made a submission thus far.

Third Parties (Rights against Insurers) Bill [HL]

Third Reading

3.07 pm

Bill passed and sent to the Commons.

Personal Care at Home Bill

Main Bill Page
Copy of the Bill
Explanatory Bill
Amendments

Committee (2nd Day)

Clause 1 : Free provision of personal care at home

Amendment 21

Moved by Earl Howe

21: Clause 1, page 1, line 22, at end insert-

"( ) make provision for those persons eligible for, or in receipt of, the free provision who are also deemed eligible for NHS continuing care"

Earl Howe: I have tabled this amendment to ask the Minister questions about the potential for dispute in the way that the provisions of the Bill are implemented. My main questions centre on the interface between personal care at home and NHS continuing care.

The number of people currently in receipt of continuing care from the NHS is roughly 45,000. It is likely, although I confess that I have no figures to support this, that a high proportion of those people will be assessed as being in critical need of personal care

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under the FACS-fair access to care services-definition. The FACS guidelines, which are currently the subject of revision, set out the criteria for determining a person's level of need, the four categories being "low", "moderate", "substantial" and "critical". As we know, the Bill is designed to cover only those in critical need, and then only those who require substantial help with four or more activities of daily living.

The Minister will know that NHS continuing care has provided a field day for lawyers over the past 10 years. A senior lawyer described it to me the other day as a sub-specialisation in the field of litigation, such are the quantity of challenges brought by patients, and also very often the families of patients, against decisions taken by the NHS about eligibility. With this Bill, we have in prospect another dimension of this type of challenge, one in which the NHS itself is likely to argue that at least some of the burden of looking after people in their own homes should be borne by local authorities. The assessment process is set to become even more fraught than it has been up to now. We can envisage local authorities resisting the idea of providing someone with free personal care at home and directing them instead towards residential accommodation with additional nursing, while at the same time the PCT will resist that idea and argue in favour of personal care in the home with little or no nursing element. Somehow, there will have to be protocols to deal with this type of situation.

Of course, we all, I am sure, subscribe to the idea of pooled budgets, but that will not of itself get round the potential for disputes. If we look at the draft regulations and at the list of qualifying services that are to be the basis for determining whether someone's needs are critical, we see that they include,

I am surprised to see the administration of parenteral nutrition classified as personal care. In hospital, parenteral nutrition is almost invariably overseen by a qualified nurse as it is classed as a form of medical treatment. Similarly, the list includes washing and bathing. It would be helpful if the Minister could say whether this means we have finally overcome the arcane distinction between an NHS bath and a social services bath. If we have, I am quite surprised, because underneath that example of what sounds like a daft distinction lies a substantive issue in terms of the degree of care and skill required to give a bath to one patient as compared to another.

Similarly, oral care is included as a qualifying service for personal care. Certainly, some oral care will be quite straightforward and will not require a nurse, but will this always be the case where a person has some medical complication relating to their mouth, gums or teeth? Equally, in the list of so-called activities of daily living, we find management of treatment which consists of a prescription-only medicine. I agree that a care worker is perfectly capable of reminding a frail, elderly person that it is time to take their medicine. That is not a nursing task. But things become more difficult if we imagine a confused elderly person who takes a different combination of different pills at different times of the day. The level of responsibility required in a care

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worker to ensure that the right number of pills are taken at the right times of the day is considerable. This is the kind of thing which, in hospital, only a qualified nurse would do. I worry that we may be creating a potential minefield here, in terms of where responsibilities will lie, as between the NHS and local authorities. In many ways, it is helpful to define in black and white what we mean by personal care, but the other side of the coin is the scope that is created for arguing over what is meant by the various terms listed in the regulations. It is on that point, in particular, that I should be glad of any reassurance from the Minister. I beg to move.

3.15 pm

Baroness Barker: My Lords, my Amendment 23, which is grouped with Amendment 21, was tabled for exactly the same purpose as that of the noble Earl.

After I tabled it last week, some individuals in my other working life, who did not know who I was and did not know that I had anything to do with your Lordships' House, happened to have a conversation which I simply sat in on and observed. They were all workers for a voluntary organisation who have had experience of assisting older people with the process of assessment for continuing care. They were trying to establish between themselves-they came from three different areas-whether there was any consistency at all in the decision-making processes to which they had been party.

What set my mind particularly to this matter was the description of an elderly man who has multi-infarct dementia, is blind, cannot walk, is doubly incontinent, has lost the ability to swallow and therefore has to have all his food made for him and pureéd. He is not eligible for NHS continuing care. That sparked a discussion about what NHS continuing care is. I do not know whether this is right, but I am interested in the point made by the noble Earl and in these care workers' distinct impression that only when someone has to be peg-fed do they have a remote chance of being considered for NHS continuing care and that that must be but one of their conditions; there must be others, too. I, too, want to know how the criteria for this care, which will be the new revised version of FACS, will work alongside NHS continuing care. Will the Minister tell me for how long on average the 45,000 people who receive NHS continuing care have received it? I am trying to gauge how ill someone has to be to be eligible under the criteria.

The Bill is an amendment to the Community Care (Delayed Discharges etc.) Act. So far as I can see in all the debates in another place and here, one issue has not been the subject of any discussion at all, which is rather surprising. When that Act was introduced back in 2003, it introduced intermediate care-an entitlement of six weeks' intensive care which elderly people are supposed to be given to enable them to be discharged from hospital when their medical needs have been attended to. The Bill was introduced with £900 million of funding behind it. I have a series of questions to ask the Minister today. I warned her that I would because it is quite important that we do so.

When the Act went through Parliament, I asked a series of questions about how it would work. The noble Lord, Lord Hunt of Kings Heath, gave the

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assurance that there would be a target; by March 2002, at least 220,000 people would be in receipt of intermediate care, over and above the baseline for 1999. The figures that I have been able to find show that, by the end of 2003, 143,000 people were being given intermediate care. How many people-in the last year for which there are figures-are in receipt of intermediate care, and how many of them received it at home? I ask that for two reasons. First, the term "intermediate care" seems to have disappeared somewhat. I am beginning to pick up on cases in which carers are being told that their relatives are not eligible for intermediate care because they have dementia and so there is no possibility of them improving. There are specific criteria for eligibility for intermediate care, and the Bill proposes three different assessments of a person to determine what sort of care they are eligible for, where they should receive it and for how long. I really would like the Minister to answer this in some detail.

I am concerned that people are going to find themselves deemed to have met one of the FACS critical criteria, but are not deemed to need assistance with daily living because they have a carer to help them, and therefore they are going to be fobbed off. Is the decision support tool, about which the noble Baroness the Minister talked last week, going to have a consistency across all three of these assessments-NHS continuing care, intermediate care and personal care at home? Further to that, can she say when the fast-track process will be brought into play?

Finally, to pick up on the point made by the noble Earl about the potential for local authorities to challenge NHS continuing care decisions that may force people back on to the personal care at home regime, for which the NHS will not be liable to pay, can the noble Baroness say how many PCTs and local authorities have a named lead officer for NHS continuing healthcare funding issues? Increasingly there is the potential for older people and their carers to be stuck between PCTs and local authorities which are in dispute about eligibility. If cases such as the one that I just mentioned are deemed to be ineligible for NHS continuing care, we are into an area of decision-making that is going to be so fine that it is going to take a fair amount of experience on somebody's part to make those judgments with any kind of consistency and lack of bias, so that people are not unfairly dealt with and so that we do not set up yet another lawyers' charter.

I am asking a very simple thing-how can the policy behind this Bill be implemented in such as way that it does not cause confusion times three, but instead provides clarity and consistency between three different instances of decision-making. I should very much welcome some guidance from the Minister on that.

Baroness Masham of Ilton: My Lords, the noble Earl has illustrated very well how there may be confusion, and so has the noble Baroness. It will be even worse if the person needing care falls between two stools and gets no care at all.

Lord Warner: My Lords, I had not intended to speak on this. However, the eloquence of the noble Earl, Lord Howe, took me back to my days as a

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director of social services, when we policed the boundaries with the NHS, and it equally policed those boundaries, with great vigour in the 1980s and 1990s. A serious issue for the Government, which is made worse by this Bill, is the way that at a time when we are saying we want to take down this Berlin Wall, we have created, with the best of intentions, a whole range of areas with scope for more disputes between health and social services. They all had a good reason at the time-intermediate care, continuing care, and now free personal care at home. I wonder whether the Government know how many people are now engaged in these various assessments, how those numbers will be increased by this Bill, and how many people are being diverted from providing care to patients and service users in the area of carrying out assessments and policing those assessments in order to see that their particular organisation is not disadvantaged financially.

If things have been bad at a time when finances are generous on both sides of the Berlin Wall, they are about to get much worse. There seems likely to be a climate where policing of people's responsibilities organisationally and financially will increase. I ask the Government to think through this much more carefully-I think that it has been considered-and to have a serious discussion with the directors of adult social services about the number of people now entrenched in this work, which is not of great use for the provision of services to people who need them.

Lord Tunnicliffe: My Lords, I shall speak first about continuing care and what it means generally, for people sometimes have different interpretations of the term. "Continuing care" is a term for care provided over an extended period to a person aged 18 or over to meet physical or mental health needs that have arisen as a result of disability, accident or illness. The term covers both NHS and social care services.

"NHS continuing healthcare" means a package of continuing care arranged and funded solely by the NHS. A person is eligible for NHS continuing healthcare if their primary needs-their main needs-are health needs. All primary care trusts and local authorities in England follow a common process to determine eligibility set out in the National Framework for NHS Continuing Healthcare.


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