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The Countess of Mar: My Lords, order. The noble Lord has now had eight minutes.

Lord Brimelow: My Lords, I beg your Lordships' pardon.

4 p.m.

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Ashley of Stoke, for initiating this debate which I hope will bring to the Government's attention some of our concerns over the grey areas of health and social services. There are two great differences between health and social services. Health provision is free at the point of delivery while the provision of social services is being means-tested.

To illustrate what a dangerous situation long-term disabled people can find themselves in I shall tell your Lordships of a case history which ended in tragedy this summer. In North Yorkshire a paraplegic woman, who was one of the most uncomplaining and splendid of people who gave much of her time to helping others, became ill. She had two separate attacks of pneumonia and diarrhoea. She lived at home with her brother who had an alcohol problem and a terminal condition. He was not adequate to help her in any way. She was the organiser at home. Two of her friends and neighbours felt that she should be in hospital. A trainee doctor visited, but did not send her to hospital. Her friends, neither of whom could give her a bath because of back problems, kept requesting help. A district nurse called, saying that she could have help with a bath only once every two weeks. With diarrhoea and being weak as a paraplegic, is that adequate?

The case was passed to the social services. This is the grey area: what is "health" in such a case and what is "social services"? Her friends became more and more concerned, bringing her food and trying their best. Her doctor came back from three weeks' holiday and admitted her to hospital. She was by this time very ill and dehydrated. In the early hours, she fell out of bed. The next day she died of an undiagnosed perforated ulcer. Care in the community had let her down. The community had lost a good member. Her friends, who were her carers, were devastated.

As president of the Spinal Injuries Association, I can assure your Lordships that when severely disabled people become ill they are very much more at risk. They do not need less help. They need constant monitoring and attention. When feeling is non-existent or partial,

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very careful diagnosis is needed. When the Minister replies, I hope that she can give some assurances and say that there should be safeguards, not vacant spaces, in the care system.

People who have lived carefully, who have worked and saved, always seem to be the ones who get little help when they need it. Buying in care, be it privately or paying the social services, can leave them without enough to live on. Is there not some way in which they could buy their care and have some tax relief?

Much is going on in the strategic development of primary health care, but much has to be done to improve the system. Family health services authorities and health authorities are working closely together. Many have joint executive officers in preparation for merging. The continual change within NHS structures costs a great deal in terms of time, work and uncertainty, but there is still a great deal of good will. Local communities and voluntary bodies are keen to be involved. Everybody wants to see improvements in the equity and effectiveness of the services.

One area of concern is the shortage of doctors now going into general practice. I should like to ask the Minister what is the reason for that. With so much more health care taking place in the community, doctors need to be trained and resourced for the job to a high standard.

Everyone, I am sure, wants to see patients receive the care that they need safely and in the place that best suits their needs and wishes. Patients and GPs need quick and helpful access, when needed, to a consultant, and health workers and patients need to have confidence that hospitals will be there when needed. It must not be forgotten that in rural areas there are extra expenses in terms of time and travel when providing care in the community.

Alcohol and drug detoxification centres and treatments are examples of the need for health and social services to work jointly. Incontinence is another aspect which can fall between two stools, with the Department of Health providing some care and social services the rest. There need to be national explicit criteria clarifying National Health Service responsibilities. When social services carry out an assessment, there needs to be the provision of care if necessary.

The big "in" word at the moment is "assessment". I end by asking the Minister: Is there a time limit on how long people have to wait? Are there enough occupational therapists to do the job?

4.6 p.m.

Lord Jenkin of Roding: My Lords, I welcome the opportunity that has been provided by the noble Lord, Lord Ashley of Stoke, to say a few words on this subject. It is in the nature of a debate on such a subject that one hears more about the failures and shortcomings of the system than about its successes. No noble Lord has questioned the rightness of the policy of community care. Indeed, as my noble friend Lady Seccombe said, there is nothing new about community care.

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In the field of mental health, it was Enoch Powell who nearly 40 years ago sounded the death knell of the old, remote mental hospitals. The process is steadily proceeding whereby the great majority of such patients can be cared for in the community. I remember that it fell to me to open many of the new community facilities that were provided under the Worcester Project, as it was called, when the Powick Hospital closed and a whole range of community facilities were provided. Since then, great strides have been made. The milestone was what is sometimes called "Griffiths II", which placed a very firm and continuing responsibility on local authorities for patients being cared for in the community.

I should have liked to follow many of the points that were made by the noble Lord, Lord Ashley, but time is inevitably limited, so I shall address just one aspect. I refer to a point that was picked up by my noble friend Lady Masham; that is, the importance of collaboration between all the various agencies involved. I see it from the point of view of an NHS trust, which is not only a hospital trust but an integrated trust having responsibility for community health services in the area. The Forest Health Care Trust covers an area surrounding Whipp's Cross Hospital in the north-east of London. We are heavily involved in various aspects of community care. I should like to give the House some examples of what is being done to make good community care a reality. It will not surprise noble Lords that much of that depends on partnership, on working with others and on ensuring that we are all working towards the same end.

The noble Lord, Lord Brimelow, mentioned the district nursing service. We attach enormous importance to expanding and developing the district nursing service to ensure that as much care as possible can be delivered to people in their own homes, in residential care or wherever they may be. Having abolished the hospital door, as it were, because we manage on the basis of client care groups, we find as an integrated trust that providing such care comes completely naturally as one moves services out into the community and works alongside the other agencies and voluntary bodies that are involved in the same area.

We are building up the local GPs—and here again I agree with my noble friend Lady Masham—by the establishment of primary health care teams, involving a wide range of disciplines including the community psychiatric nursing service, which is something of enormous value. We are increasing the outreach of physiotherapists and occupational therapists to make sure that services can be delivered in people's homes and that they do not need to go into hospital.

I should like to draw your Lordships' attention to three specific projects. We have a joint project, jointly funded by the trust and by Waltham Forest social services. It is managed by Age Concern and it enables quicker and more appropriate discharge of elderly patients from hospital care. The project aims to supply an after-care service to elderly people who are discharged from hospital but perceived by hospital staff as not requiring statutory services as part of the discharge plan. It also helps other patients prior to admission when they have been in receipt of social

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services care and who are also visited as part of the aftercare project to ensure that all is well on discharge and that the social services have started efficiently.

It is actually filling a gap in the service provision on discharge from hospital and testing the criteria for the need for social care, as perceived by ward-based professionals and with the help of their social service colleagues. It is in its early stages and we shall have an evaluation coming to my board in February. I hope that we are going to be able to show that this is a very specific model of collaborative care that is making a reality of community care.

To take another example, we have what is called the Larkshall Young Disabled Unit. It offers specialist health provision to highly dependent, younger and physically disabled patients. It has a highly skilled specialist nursing workforce and they offer a valuable contribution towards multi-agency assessment of need for highly dependent younger disabled people, following trauma or medical conditions such as severe strokes, who wish to remain in the community and do not want to be in an institution. A lot of the work involves confidence building among users and carers who are in touch with the service, empowering patients to live independent lives in the community.

There are obviously facilities for respite care and so on. Here again, this involves a great deal of collaboration between all the various agencies which are involved and which can make a reality of community care. We have a proposal coming before us for a primary intervention service —sometimes called a hospital at home—which is being developed jointly with the primary health district nursing service, with the services for the elderly with social services, with the general practitioners and with the residential home owners. This is to enable the health trust to be able to deliver health packages to those living in the community and who can be helped to maintain an alternative to hospital admission. In some cases, we would expect this help actually to avoid the need for hospital admissions for selected acutely ill episodes.

Here again, we are working very closely with Waltham Forest social services, interested local home-owners, and with one general practitioner practice to research the possible extension of the hospital at home scheme into the residential care home environment. Again, a pilot scheme will be set up; it will be monitored, evaluated and eventually reported. I suppose the point that I should like to make on this, and then I must sit down, is that this is possible in an integrated trust. I think we are going to be able to demonstrate that that is actually a very good model for the delivery of care.

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