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The Earl of Arran: My Lords, I am not aware of that particular situation. I have not heard that rumour. On investigation, whatever information I come across, I can assure the noble Baroness that she will receive a prompt reply from me.

Lord Archer of Weston-Super-Mare: My Lords, will the Minister be kind enough to express to the

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Turkish Ambassador the appreciation of the Kurdish people in northern Iraq, especially remembering the unpleasantness they have received from the PKK?

The Earl of Arran: My Lords, I know that the Turks are well aware of our appreciation of their co-operation over Operation Provide Comfort.

Lord Kilbracken: My Lords, were the Turks to refuse permission for the flights to continue, is there any reason why they should not continue from some other base or country in the Eastern Mediterranean?

The Earl of Arran: My Lords, it would be idle speculation to make any comment on that. We have strongly intimated the necessity to the Turkish Government that the agreement should remain for a further six months. We very much hope that that will be the case.

Welsh Local Government: Issue of Guidance

3 p.m.

Lord Hooson asked Her Majesty's Government:

    When they intend to fulfil the undertakings given by and on behalf of the Secretary of State for Wales during the passage through Parliament of the Local Government (Wales) Act 1994 to issue "guidance" under Section 27(ii) with respect to the proportion and content of decentralisation schemes.

The Lord Advocate (Lord Rodger of Earlsferry): My Lords, the Welsh Office has established a working group of officials, including officers of both county and district councils, to consider issues relating to the preparation of decentralisation schemes and to help prepare guidance for the new unitary authorities. My right honourable friend the Secretary of State for Wales hopes to issue the draft guidance for consultation in February and substantive guidance before the new authorities are in place.

Lord Hooson: My Lords, does the noble and learned Lord appreciate—I am sure that personally he does—that time is important? The draft guidance was issued last January. During the debates promises were made that general guidance would be issued. The transition committees are now meeting but have no general guidance from the Government. Is there any reason for the delay, save that a party—it may be some parties —to the committee to which he has referred is dragging its feet?

Lord Rodger of Earlsferry: My Lords, we all recognise the importance of the guidance being issued. As the noble Lord said, during the passage of the Bill draft guidance was made available and Members of this House were able to consider it. That guidance has also been available to those considering their options over the period.

Nonetheless, a committee was set up. It was difficult to get that under way because, it has to be said, after Royal Assent the county councils operated their boycott until August. It was only after that period that the

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committee was able to set to work. It has met twice. It will meet again in the first half of December; it will have a further meeting in January. At that stage it is hoped to issue a further, more final draft. We shall certainly have the final version available before the new authorities are in place next April.

Lord Prys-Davies: My Lords, first, I thank the noble and learned Lord for the information that he has given the House. Did I hear him say that the working group has met only twice since the Bill received Royal Assent in July? Secondly, is there an awareness at the Welsh Office that the effect of that very tight timetable to which he referred is severely to weaken the capacity of the unitary authorities to construct workable schemes of decentralisation? Such schemes would have to be put together in a rushed fashion, possibly without adequate thought and without adequate consultation.

Lord Rodger of Earlsferry: My Lords, it is correct to say that the body has met on only two occasions. That is not to say that work has not continued between the meetings of the body, nor that it will not continue between the other meetings envisaged. As I explained, the structures in the Act are already available for consideration. Since earlier this year draft guidance has also been available. Many who are involved and interested in those matters are represented on the working party and are therefore aware of the issues under discussion. It is also true to say that the matters will have to be finalised within a relatively short timescale. However, applications for the decentralisation schemes can be made until the end of the year.

Lord Cledwyn of Penrhos: My Lords, the noble and learned Lord properly stated that draft guidance was available during the passage of the Bill through the House. Will there be a significant difference between the final guidance and the draft guidance? Why does not the Secretary of State for Wales take a more urgent interest in the matter? Is it because he seeks guidance from other sources?

Lord Rodger of Earlsferry: My Lords, I do not know to what extent the guidance will be radically different at the end of the day. However, it will take account of the many practical issues being raised by representatives of the county councils and the district councils who are therefore able to put more practical flesh on the bones than was perhaps available at an earlier stage. It is precisely in order to gain the input from those councils that such a committee was set up. Therefore we would expect the guidance to be more useful at the end of the day.

Lord Harmar-Nicholls: My Lords, is my noble and learned friend aware, as will be anyone who attends this House regularly, that the Welsh point of view will always be put forward so long as we have present the noble Lords, Lord Cledwyn of Penrhos and Lord Prys-Davies, who have the parliamentary means of so doing?

Lord Rodger of Earlsferry: My Lords, although I particularly appreciate the contribution often made by the noble Lord, Lord Cledwyn, many other noble

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Lords—the noble Lord, Lord Callaghan, is present—when appropriate, put forward the Welsh point of view; and we welcome it.

Baroness Hamwee: My Lords, does the noble and learned Lord accept that, knowing the penalties that the Government can impose when, having set an impossible timetable, the local authorities do not act in quite the way that they wish, the English local authorities sympathise with the Welsh local authorities?

Lord Rodger of Earlsferry: My Lords, I am not informed whether the English local authorities sympathise with the Welsh local authorities. All I can say is that the work is being taken forward in an appropriate way.

Lord Hooson: My Lords, while we are grateful to the noble and learned Lord for his efforts as a temporary, naturalised Welshman on behalf of the Secretary of State, will he please convey to his right honourable friend the great concern in Wales that after the months have gone by no guidance has been issued? An undertaking was given that what was said in debates would be considered; and here we are with no guidance. A transition committee is sitting on which there are representatives of the county councils and district councils. It has no guidance from the Government. The matter should surely be remedied sooner than next February.

Lord Rodger of Earlsferry: My Lords, of course one welcomes the work being done by the transition committee. However, as the noble Lord knows, the decisions on whether to have any such decentralisation scheme, and, if so, which model, will be for the new authorities. I stress that the guidance will be available before those authorities take up their office.

Baroness White: My Lords, is the noble and learned Lord aware that many important schemes and proposals are being held up because the Welsh local authorities have no idea what the position will be 12 months from now?

Lord Rodger of Earlsferry: My Lords, on that specific matter, the authorities will have plenty of guidance before they have to take the necessary decisions.


Lord Strathclyde: My Lords, after the debate on health and social services and before the debate on occupational and other pension schemes, my noble friend Lord Mackay of Ardbrecknish will, with the leave of the House, repeat a Statement that is to be made in another place on social security.

Long-Term Care: Financing

3.9 p.m.

Lord Ashley of Stoke rose to call attention to the uncertainties within the health and social services concerning the financing of long-term care; and to move for Papers.

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The noble Lord said: My Lords, I very much regret that I shall be unable to stay for the whole of the debate because I am in some discomfort which requires attention. Of course, no discourtesy is intended and I apologise to noble Lords. I shall return if I am able, but in any case I shall read avidly the speeches in Hansard on this important subject.

The central theme of the debate is the failure of the Government to deal with the health and community care problems of some of Britain's most vulnerable people: those who need long-term health care. At a time when such people need reassurance and dignity, they are faced with anxiety and distress. Today we are concerned with people whom doctors simply cannot help yet whose health is such that they need continuing care which is often nursing care.

Our aim in the debate is to seek constructive solutions. I have no doubt that the aim of the noble Baroness, Lady Cumberlege, is the same, because she always tries to be helpful. Nevertheless, it is urgently necessary to explain the ways in which the Government have created uncertainty, confusion and even despair.

The basic principle of health care is that it is funded largely by taxation and is free at the point of delivery, whereas personal care services are provided by local authorities, are means-tested and are charged at the point of delivery. The significance of that distinction is absolutely crucial, especially in view of the reduced number of NHS continuing care beds and the movement of funds from social security to community care.

The facts are staggering. In the past three years the number of NHS beds for continuing care has dropped dramatically from 73,000 to 59,000. The reassuring open-ended social security funding for people in homes has been replaced by rigid, cash-limited community care budgets. So it is no surprise that, trapped in this web of inadequacy, both district health authorities and local authority social service departments have become involved in squabbles—undignified squabbles, but squabbles nevertheless—about who is responsible. That is damaging to everyone concerned. I believe those squabbles damage the relationships between the district health authorities and the social service departments. But they damage the interests of the patients even more. There are frequent reports of patients actually being forced out of National Health Service beds. The sad case of the brain-damaged man who was ejected from a Leeds hospital led to an inquiry by the ombudsman. The question is how far that very sad and distressing case was an isolated one or how typical it was of others.

The recent draft guidance from the National Health Executive, presumably supported by the Minister and her colleagues, failed either to clarify issues or to ease the growing tension. Instead, what it actually did—although it sought to disguise it—was to introduce significant changes of emphasis and of policy. It has been widely criticised. The criticism has provoked Ministers in this House and elsewhere into claiming, with an air of injured innocence, "No, nothing has changed".

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Well, let us have a look at the assertion. The House is entitled to examine rather dogmatic insistences that nothing has changed. For a start, the guidance is ambivalent. I trust that the Minister has it on her knee. She will notice that on page 1 is trumpeted the reassuring message:

    "The National Health Service remains responsible for meeting ... the needs of people who require long term physical or mental health care".
That is fine; there is no ambiguity. It is a clear statement of fact. However, if the Minister turns to page 2, she will see that,

    "the expectation will be that the significant majority of people who require continuing care in a nursing home setting are likely to have their needs met through social services".
Not the National Health Service, but social services! We have already seen the distinction between the two: one where you pay and one where you do not, with a great variety between them. So it seems that, according to the official document backed by the Government, you choose your page and then you make your choice.

The guidance has even more tricks tucked away in the text. After reassuring us that the NHS remains responsible, it slips in the phrase "within available resources". That is a significant point for the Government to make about the National Health Service which we have always assumed to be free at the point of delivery.

The Association of Directors of Social Services has observed that the comment is in marked contrast to the guidance issued to local authorities before the implementation of community care. That indicated that once eligibility for a service had been established budgetary constraints could not be a consideration in the provision of a service. That is a very important statement. In other words, the local authority service was a right, but continuing care on the National Health Service is now conditional on money which may or may not be available. It is a very different health service that we see unfolding, judged by the guidance of various authorities.

If the Government really want to clarify their policies, they should define their concepts. As the Minister will see in the guidelines, one of the most important sentences is:

    "For some people, and certainly those with complex or multiple health care needs who will require, on a long or short term basis, continuing and specialist medical or nursing supervision, the NHS should be responsible".

Yes, of course it should. Apart from the clumsy phraseology, may I ask what is meant by the phrase,

    "complex or multiple health care needs",

or the phrase,

    "specialist medical or nursing provision"?

I know that the Minister will try to be helpful. I invite her to give a clear and specific explanation when she replies to the debate.

The caring organisations are very concerned that no precise meaning has been attached to the words. Many are very anxious indeed; in fact, all those to whom I have spoken are anxious because on those words,

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definitions and precise meanings hangs the positioning of the future care of thousands of individuals together with major financial implications.

So it is no small issue. It affects the whole of the financing of vital services for thousands of people. That is why I press the Government for clear, categorical and specific answers. Without national definitions, national criteria, we shall have increasing conflict and growing variation as local bodies make definitions to suit themselves. The present mish-mash of decision-making is causing undignified bickering, angry conflict and deep misunderstanding. It is eroding, even destroying, the equitable provision which is the real strength of our proud National Health Service. If that equitable provision goes, it is no longer the National Health Service all of us have cherished.

There is an overwhelming need for national criteria for National Health Service provision of continuing care. The Government should take steps to provide such criteria. If they do not—and millions of people will listen to the reply to this debate—the reasoned and reasonable presumption, the moderate presumption, is that the Government are working towards relinquishing National Health Service responsibility for continuing care. That, to put it very mildly, would be deplorable.

The issue of hospital discharges is a sensitive and distressing one. Here again, the Government are ambivalent. Most people, I assume, in this House, and certainly millions of people outside, have long assumed that no National Health Service patient should be placed in a private nursing home against his or her wishes if he, she or a relative is unwilling to be responsible for the home charges. After all, that is what the current guidance on hospital discharges says. It is in black and white. It is official; it comes from the Government. That is why millions of people believe it. That is fair enough.

But the new guidance, which the Minister has on her knee, disingenuously omits that stipulation. It speaks merely about "taking account" of the person's and the family's wishes. I could take account of the philosophy of Genghis Khan, but it does not mean that I take it very seriously. The Government can take account of these issues; it does not mean that they have to take them seriously. The previous guidance made the commitment mandatory; the present guidance wriggles out of that. It avoids and evades it. This is a matter to which Members of this House and of another place should give very careful scrutiny and in relation to which they should insist on clear government answers.

The guidance goes on to say that although,

    "Every effort should be made ... to meet the ... wishes of the patient",

if a person has been assessed as not requiring NHS long-term care the question of how long the person can stay in an NHS bed depends on,

    "the needs of other patients".

It does not depend on that patient; it depends on the needs of other patients. I suggest—it is only a suggestion—that bed needs are winning when they conflict with the patient's wishes to retain a National Health Service bed.

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The Association of Directors of Social Services, a very responsible body, says that there is increasing evidence—not hearsay—that in a substantial number of local authorities there has been a significant increase in elderly people who die shortly after having to leave hospital to go into a nursing home.

What a situation to have to consider! The Minister can always contradict me if I am wrong. This is only my interpretation, not that of the association. But apparently the harsh message is: if you are dying but the shortage of beds means that your bed is needed, you must leave hospital to die; if you are a man, while you are dying your wife may have to use all the proceeds of your occupational pension scheme to pay the fees for a private nursing home; and if you linger too long before you die, nearly all of your joint savings may have to go too.

I believe that to be the correct interpretation of the present situation. To put it mildly, it is shocking and disgraceful. Without national definitions and criteria, we shall have increasing conflict and growing variations as local bodies make definitions to suit themselves. We have to be very, very careful indeed about this matter.

I shall draw my remarks to a conclusion as I am afraid I have spoken for far too long. I emphasise that in no way do I criticise the hospitals or their dedicated staffs of doctors and nurses for any of these enormously complex and difficult problems. The staff are in no way to blame. They do a marvellous and dedicated job. They are struggling to meet new obligations and to provide for people from money that has not been made available to the required extent. The fault—I wish to emphasise this—lies not with the hospitals or the doctors. It lies with the Government.

Ministers have a clear responsibility to ensure that vulnerable people who are in difficulty and distress suffer no additional burden. The Government should reconsider their policies. They should make sure that those policies are clear and constructive and that they rest on the criteria I have mentioned. They should act speedily, sensitively and generously.

My Lords, I beg to move for Papers.

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