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Baroness Gardner of Parkes: My Lords, I am sorry that the noble Baroness interrupted, because that is not the usual custom when a debate is time limited. Even so, I could argue about that point because the new dental contract provides for continuing care for two years whereas that did not apply before. There are many points of discussion, but I cannot spare any more time to respond to that point.

The underlying principles of community care are that the care should be patient-focused, not in the self interest of the people providing the care but in the interests of those receiving it. I take into account the points that have been made about carers, who are relevant too. However, as regards community care, the prime consideration is the patient who is receiving that care. The individuals who do not require hospital care should be cared for in their own community. The social services are correctly the fulcrum for the co-ordination of an individual's full range of longer-term needs.

The National Health Service and Community Care Act provides a framework for translating these principles into specific benefits for individuals. At the strategy level, community care plans provide the mechanism for bringing the plans and policies of health services, social services, other local authority services and voluntary and community groups into a coherent strategy. At the level of the individual, case management and assessment procedures, referred to by the noble Baroness, Lady Masham, ensure that the needs of the individual, and not the separate interests of the service providers, drive the delivery of care.

That has led to the development of innovative collaborative arrangements to secure flexible care packages; that is, meeting the needs of the individual, including the carer. Respite care is a most essential and valuable way of ensuring that more patients and carers obtain relief. The philosophy of community care has been embraced by health service providers which have sought to develop new approaches to delivering health care in the community; for example, home dialysis, palliative care teams for the terminally ill and discharge teams. They are examples of collaboration between the health service and community care.

The National Health Service and Community Care Act created a single unified budget to cover the costs of social care. By transferring to social services departments the social security payments for people in residential or nursing homes the perverse incentives for moving people out of their homes and into residential care were removed. The financial flexibility that the Government have provided has promoted the innovative flexibility in the delivery of care.

However, with the level of need in the community and an increasingly older population, there will always be pressure on resources. The community care framework enables individual needs to be identified and provides the flexibility for resources to be deployed in a manner that is responsive to those needs. There has been a great deal of talk about people being asked to

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contribute to their social care. I believe that that is correct and that it should be done on a means-tested basis. Those well able to afford their own care should do their best to do so. Those most in need of financial help should receive it.

I was interested to hear the noble Lord, Lord Brimelow, refer to community care in Camden because my NHS trust is in that area. Today I read the current edition of HealthCare Today which states that the Camden and Islington Community Health Services NHS Trust has a staff of 2,500, a budget of nearly £90 million and serves the communities of Camden and Islington from nearly 100 sites. That was interesting to read because most of us regard community care as a small operation. In fact, it is large and largely successful.

The noble Baroness, Lady Seccombe, said that she was amazed that local authorities had spent their budgets. That does not amaze me because the community care Act has revealed the need that exists. Local authorities in central London had no idea of the vast demands. They were unknown and unmet. No government can afford to meet the financial demands that lie ahead. There must be a need to look at how best to use the resources. I believe that there is an opportunity to use volunteers. The noble Baroness, Lady Lockwood, the noble Lord, Lord Murray, and I are members of the Advisory Council of the Retired Senior Volunteer Programme (RSVP). Recently retired people are keen to carry on working and to fulfil their lives helping others. They can meet a need that cannot be fully met because no government can provide the amount of money that is required to meet every demand that is put on them. I wish to see the gradual use of more volunteers in community care because that would benefit both the patients and the carers.

4.35 p.m.

Lord Hollick: My Lords, I wish to apologise to the House because a prior engagement prevents me from staying to the end of the debate. Today's debate is timely because there is a rising anxiety about the provision of continuing care. There is a financial crises among various local authorities and that will prevent them from meeting their requirements in the current year. There is also a rising anxiety about the diminution in the number of continuing care beds within the health service.

My experience of the problem has been gained from working with sufferers of Alzheimer's disease. As your Lordships know, that is an extremely sad disease. It is a slow journey into an abyss of unknowing and darkness. There is, however, a journey through a "Kafkaesque" world of administration and bureaucracy. The noble Lord, Lord Ashley, vividly mentioned some of the words used in the guidelines and government publications. At a time when carers and Alzheimer sufferers are seeking to deal with a terrible disease—it is usually at the end of their lives —they are also having to find their way through a maze of bureaucracy and administrative chaos.

The journey that I have described begins with the diagnosis of the disease, after which the patient must spend time at home. The carer—the unsung hero of our

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story—looks after that person. Rapidly the time comes when, because no hospital bed is available, the carer is put into a nasty and serious financial position. As a result, the carer's health suffers and his or her future is at the mercy of the social services, which are inadequately funded. As regards the individual, we see the beginning of a war of financial attrition.

That comes as a surprise and a shock to sufferers and carers because, naturally, they expect that having paid their national insurance contributions they are entitled to free health care, particularly at the end of their lives. The Patient's Charter confirms that they are to receive health care on the basis of clinical need, regardless of ability to pay. However, many sufferers find those words to be hollow.

On 15th April the Secretary of State said:

    "The NHS provides services for everybody on the basis of their clinical need and regardless of their ability to pay",

hus confirming the Patient's Charter. She continued:

    "There are no exceptions to that rule whatever the age of the patient".

he words "clinical need" must be weighed carefully. It is the view of the Royal College of Nursing that continuing care is nursing intensive; in other words, there is a clinical need.

The August guidelines, published by the NHS Executive, confirm that the NHS remains responsible for meeting the needs of people within available resources. However, the words "where appropriate" are then inserted. That condition is causing so many problems and difficulties. The particular problem is that there is no nationally accepted definition that ensures that everyone throughout the country receives the same care and attention. There are examples of some local authorities and health trusts ejecting people from hospital into the care of social services while in neighbouring authorities patients are cared for within the NHS. I suggest that that is unacceptable.

I believe that that muddle is avoidable if there are proper definitions. What we need to do—the August guidelines call for it; and I welcome that fact—is to devise national eligibility criteria to ensure that there is a consistent approach and that it ceases to be a regional lottery. There is also a need for the Government to monitor health authorities to ensure that they are living up to the promise made on their behalf by the Secretary of State.

My concern is that there is no central monitoring of the need for continuing care. I have asked several questions of Ministers about the number of continuing care beds. I have to say that I have been given a number of unsatisfactory answers; indeed, if I were being unkind I would say that I have been fobbed off. I am always told that such information is not collected centrally. The noble Lord, Lord Thurlow, mentioned the difficulty of collecting it. But it is possible to do so. In fact, this very day, I saw an extremely good National Health Service-designed software system which gathers together information centrally about such matters. Therefore, it is possible for the NHS to have that information centrally and then to know whether or not

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the needs and requirements of the community and patients will be met. Without that sort of database, I am afraid that we shall continue in the present muddle.

I have a suspicion that the Government—and, certainly, some local authorities and health trusts—are in fact turning a blind eye to the problem. They are perfectly happy to see people and patients (sufferers) leave hospital and go into community care. By doing that, they know that they avoid the financial responsibility which I believe is rightly theirs.

In my view, it is fair to characterise some of the developments within the National Health Service on continuing care as effectively privatisation by the back door of this part of the health service which affects people at the most vulnerable time of their lives, and at a time when many of them simply do not have the financial resources to pay for it out of their own pockets.

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