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5.7 p.m.

Lord Ashbourne: My Lords, I have been asked by the noble Baroness, Lady Ryder of Warsaw, to speak on behalf of the Sue Ryder Homes this afternoon as the noble Baroness is unfortunately unable to be in your Lordships' House in person this afternoon owing to a series of previous engagements. She has asked me to thank the noble Lord, Lord Ashley of Stoke, for putting down today's Motion and for giving your Lordships an opportunity to discuss these critical matters.

The nub of the matter is that the noble Baroness is greatly distressed by the effect that the implementation of the National Health Service and Community Care Act, which came into force on 1st April 1993, is having on the finances of the Sue Ryder Homes. Perhaps I may refer to one of the Sue Ryder Homes budget reports. It states:


apologise for the length of that quote, but it seemed important that the Minister had the information in some detail so that she can reply. I understand that out of 24 Sue Ryder Homes in Britain, this affects 14 of them. Consequently the average deficit amounts to £120,000 per Sue Ryder Home.

It has been estimated that the losses resulting from the Government's decision only to partly fund those patients who were in Sue Ryder Homes before April 1993 currently amount to £1.7 million per annum. That figure is likely to increase in future years as the disabilities of those patients increase and government funding is frozen.

Potential residents of Sue Ryder Homes are either being kept in acute hospital beds, or at home, without nursing care, rather than going into Sue Ryder Homes where the basic social services funding is insufficient to cover the costs. With the finances of social services in many counties being overstretched, it will not be long before the welfare and wishes of potential residents are ignored in favour of the cheaper option. For example, Cambridge social services are forecasting an overspend of approximately £3 million and have started to cut back on funding, including for respite beds which are urgently needed by desperate patients whose families or neighbours simply cannot cope any more.

As I was unable to give the Minister more than the most cursory notice of those concerns and questions perhaps she will write to the noble Baroness, Lady

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Ryder, and myself giving the Government's views on the multiplicity of problems which affect the Sue Ryder Homes.

5.12 p.m.

Baroness Robson of Kiddington: My Lords, I, too, wish to thank the noble Lord, Lord Ashley, for introducing the debate. I add my best wishes for his recovery from his present problem.

We have had 17 speeches. Those speeches leave no one in any doubt that confusion exists about who is responsible for providing long-term community care in our society. In the past, we have asked the Government for guidelines. They have now issued guidelines. However, in my view those guidelines have done little, if anything, to clarify the situation.

I regret the lack of specific national guidelines. It means that access to long-term care now depends on where one happens to live, not on what one needs. It also means that standards vary enormously between different authorities. The guidelines seem even to encourage different standards. On page 2, the guidelines state:


    "Different models of care may be appropriate in different parts of the country".

can understand that. But they also provide the escape clause that, because one cannot afford it, one does not have to keep up to the national standards laid down by the Government.

When we changed the emphasis from hospital to community care, most of us agreed that it was the right move to make. We have since moved away from the principle of an NHS which is free at the point of need. The noble Lord, Lord Ashley, referred to the large decline in numbers of long-term care beds in the NHS. In 1990 the figure was 73,000; in 1993 it was 59,600. Before the implementation of the community care legislation, large numbers of elderly people were transferred to private nursing homes. Many of them have now become the responsibility of their local authority. At the risk of being boring, I wish to emphasise yet again that we should have introduced the community care legislation before we started the reform of the NHS so that we did not run the risk of a large number of people being without adequate support. Perhaps I may plead with the Minister that there should be no further reductions in hospital beds or long-term care until the problem has been resolved.

The final paragraph on page 2 of the guidelines refers to the need for hospitals to take account of the needs of other patients in deciding how long a patient can stay in an NHS bed. Of course, one can understand that if and when the number of beds is reduced to such an extent that there are not enough, long-term patients may have to be given alternative accommodation. But that is because we have failed to provide them with long-term beds in the NHS.

Some long-term patients in the NHS regard such a place as their home. How does the removal of patients from the place in which they are presently being looked after fit in with previous guidelines which stated that,

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    "no NHS patient should be placed in a private nursing home, or residential care home against their wishes if it means that they or a relative will be personally responsible for the home's charges".

A large number of elderly people are cared for at home by relatives or friends. When they require greater care than can be provided in their homes and are referred to a nursing home—almost all of them now private homes—those elderly people are means tested to see what they can afford to pay. It is not only what they can afford to pay, but what their relatives can afford to pay. Occasionally the result is the sale of the patient's home. The former carer —in many cases someone aged between 70 and 80—who has lived in that home all his life, stands the risk of losing it. Some private nursing homes have helped patients to stay without forcing the sale of the house. However, when the patient dies there is frequently an enforced sale of the home in order to pay off the debt incurred in the nursing home. Those are earth-shattering experiences for people. We must do something to solve the problem.

The guidelines, under the heading "Action" state:


    "Health authorities, and ... GP Fundholders, are required to review, in consultation with local authorities ... their policies for meeting long term health care needs".

hat is right. They are the people who look after those in the community who need long term care. But up to the present time GP fundholders have not had any responsibility for residential nursing care, although they have responsibility for district nursing service care. If GP fundholders are to be made responsible for the provision of residential nursing care they will need to have their budgets increased. Without that they will be unable to perform their duty.

I began by saying that guidelines must contain nationally determined criteria about who is eligible for NHS continuing care to avoid discrepancies in care between areas. Above all, the Government must acknowledge that increased finance will be necessary because the number of people who require continuing care is increasing year by year. The funds must be made available.

Yesterday, we had an announcement of an increase in funding for the National Health Service. That is very welcome. I plead with the Minister that a large part of that funding should be devoted to long term care in the community, whether provided by the NHS or by local authorities.

5.21 p.m.

Baroness Jay of Paddington: My Lords, I should like to give my particular thanks to my noble friend Lord Ashley for his great personal courage in introducing the debate on this crucially important subject this afternoon. I am sure I am joined by noble Lords all round the House in wishing him a speedy recovery.

In his powerful opening speech, my noble friend showed his customary deep concern for vulnerable people—and vulnerable people is what this debate is about. Although the words on the Order Paper could suggest that we are discussing rather arcane complexities of local and health authority finance, what in fact my noble friend and many other speakers have

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vividly demonstrated is that the Motion reflects the considerable alarm felt, certainly on these Benches and I think all around the country, at the way in which those who are most in need in our society are being treated following the changes in the NHS and community care. The fear is that we are seeing what has been described by the Association of Metropolitan Authorities as,


    "the stealthy withdrawal of free health care".

My noble friend Lord Hollick repeated the quotation from the remarks of the Secretary of State for Health on 15th April this year:


    "The NHS provides services for everybody, on the basis of their clinical need and regardless of their ability to pay. There are no exceptions to that rule".

he problem is that what the Government have done is simply to redefine words like "services" and "clinical need" to suit their new legislation. As we have heard from several speakers, health authorities and social services are now required to differentiate, on what often seems an almost arbitrary basis, between health and social care, and, as we have also heard, that has serious financial implications.

We had another Labour debate on community care in your Lordships' House earlier this year and we predicted that there would be an acute crisis as social service departments literally ran out of money to finance their new responsibilities. My honourable friend Mr. David Hinchliffe tabled an Early Day Motion in another place just recently on the Government's failure to fund the new social responsibility adequately. I should like to thank my noble friend Lady Farrington and the noble Lord, Lord Mottistone, for highlighting the problem so authoritatively and cogently in your Lordships' House today.

The fundamental uncertainties which we are discussing are caused by the Government's determination to see the essentials of service provision and finance resolved exclusively at a local level. Ministers argue that this is an appropriate devolution of powers and the way to ensure that local needs are met most effectively. On these Benches, we see this more as the Government abrogating their national responsibilities and creating a situation where cost-shunting between individual health authorities and social service agencies leads to patchy provision and considerable inequity.

As the noble Baroness, Lady Robson, has just pointed out, the quality of long-term continuing care now depends on where you live and not on what you need. We could have no clearer evidence that the nationwide security of the National Health Service is disintegrating and, in my view, being replaced by the small business ethics of local hospital trusts and independent providers, many of them in the private sector.

There have been many demands for the Department of Health at least to set national standards for continuing care and, as several speakers have mentioned this afternoon, we have now seen new draft guidelines from the department which were issued this summer. The consultation period has now closed and the responses from both the voluntary and the statutory sectors must make gloomy reading at the Department of Health. The

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general tone of the response is summarised by one London health authority, and I quote the chief executive's written reply:


    "The guidance claims to clarify but in our view, it leads to greater confusion".

make no apology for going over some of the details of that guidance again this afternoon and the main points raised about those guidelines during the consultation. I hope that when the Minister replies she may be able to answer some of the very practical concerns which have been raised by organisations outside your Lordships' House and echoed in contributions this afternoon.

As my noble friend Lord Ashley stated at the beginning of the debate, the guidelines state:


    "The NHS remains responsible for meeting"—

ith this extraordinary caveat—


    "within available resources, the needs of people who require long term physical or mental health care".

s he also said, superficially this seems to restate the basic understandings about NHS responsibilities. But the alarming caveat about "within available resources" suggests that decisions about individuals will be driven more by financial priorities than by clinical needs.

In the next paragraph the document produces another caveat:


    "Different models of care may be appropriate in different parts of the country".

s the noble Baroness, Lady Robson, has just mentioned, that could lead to local flexibility. But Age Concern and other organisations have argued in their response that:


    "to include matters such as local circumstances and resources in the guidelines makes it likely that decisions about care will be dominated by the concerns of managers and not by medical judgements".

he problems about precisely defining those who require physical and mental care are, of course, central. Several noble Lords pointed out that the guidelines do nothing to help.

How does the Department of Health define,


    "those with complex or multiple care needs"?

ho do we say will qualify for,


    "continuing and specialist medical or nursing supervision"?

urely to be of any use at all the guidelines must, as several speakers have said, give specific national eligibility criteria which can be applied by every purchasing health authority, every social services department and every provider in the country. I should be grateful if the Minister could elucidate some of the definitions in her reply and also explain the force of the provisos in the guidelines about "local circumstances" and "resource contraints".

The other major area of concern which again has been much referred to this afternoon is about hospital discharge, about how decisions are taken to discharge any patient from health service care into means-tested social care and, very importantly, what rights and choices a patient and his or her relatives have when

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those decisions are taken. Once more, the draft guidelines are frankly bald and unhelpful, and I quote from page 2:


    "Where a person, in the view of the consultant ... no longer requires acute treatment but is likely to need intensive long term support, including the possibility of nursing home or residential care, they should be eligible for a multi-disciplinary assessment of their needs".

Rightly, the British Medical Association and the Royal College of Nursing are unhappy that the paragraph seems to suggest that "acute treatment" can be properly defined as medical care appropriate for an NHS hospital, but that, "intensive long-term support", possibly in a nursing home, is seen as social care. Frankly, once more the problem is one of inexact definition, with all the ensuing and important complications of free versus means-tested treatment.

Under the same heading, "Hospital discharge", the guidelines raise but do not answer the difficult question of patients who refuse options for care outside the health service. Again, I do not apologise for repeating the quotation that was given by my noble friend Lord Ashley; namely, that,


    "the health authority and hospital will need to take account of the needs of other patients in determining how long the person can continue to occupy an NHS bed".

gain, there are no eligibility criteria, and, as many of those who have been consulted have pointed out, there is an implication that patients could be forced to leave an NHS bed against their will.

Very importantly, there appears to be a contradiction between these draft guidelines and a previous circular which was issued five years ago—HSG (89/5)—which I understand is still in force and which states that:


    "No NHS patient should be placed in a private nursing or residential care home against his/her wishes if it means that he/she or a relative will be personally responsible for the home's charges".

hen the Minister replies perhaps she can tell us whether that circular is to be withdrawn and whether the new guidelines in their final form will be clear about the choices that are available to patients and their relatives.

Overall, I can only echo the views of the AMA, the purchasing health authorities, Age Concern, the BMA and RCN, the Alzheimer's society, the Association of County Councils and many others that the new guidelines have simply added to the confusions about long-term health care which were created by the new Acts. The UK Central Council for Nursing, Midwifery and Health Visiting has gone slightly further. It has written to the Department of Health urging that a completely new text be prepared for further consultation. Perhaps the Minister will tell us this afternoon if that is what will happen.

It is possible to establish clear eligibility criteria for continuing NHS care, and I am pleased to report that the health authority of which I am a member has successfully done that in conjunction with our local social services departments. Clinicians, social services assessment staff and care managers were involved in developing a written statement which is based on using the so-called Bartell indices of physical and mental capacities. If you qualify on those grounds, you are eligible for NHS continuing care facilities. It has been

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pointed out to me that the success of this system is not based just on the formal protocols, but on strong, practical day-by-day working relationships, with regular meetings on individual assessments. It has meant that the health authority and the social services departments have not had to use the agreed arbitration procedures at all in the past 18 months.

When I asked the chief executive of the health authority for his views on that model, he told me that he had no doubt that it could be of much wider application; and interestingly, the Health Services Journal annual awards have just given a commendation to that initiative as one that could be worked on a national basis. It seems to me that it can only be dogma about local autonomy or, perhaps more sinisterly, about undermining the national quality of the health service which prevents the Government insisting on similar criteria across the country.

At the Conservative conference in October, the Prime Minister defended his support for a comprehensive NHS by asking,


    "Is it likely that I would take away the security of mind that was of such value to my parents?".

Sadly, that is precisely what is happening. On Monday of this week, the Association of Directors of Social Services held a national conference which it called "From the Cradle Almost to the Grave". If that is not to be a true description of all our care services, the Government must act quickly and decisively—not only to help health and social service professionals but, most importantly, to restore security of mind to our most vulnerable citizens.


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