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Lord Davies of Oldham: My Lords, I think that I have already confessed to the House that I am no lawyer and so I cannot give the noble Lord an immediate reply to his question. However, the Bill will become one of many Acts which permit public servants to carry out inspections. Legislation which relates to taxation and Customs and Excise contains such measures. There is no doubt that in the Bill we have followed a process whereby we have defined the manner in which inspection should be properly conducted. We have allowed a degree of freedom in the drafting to ensure that the authority itself will lay down what is to be expected as regards the conduct or, if the noble Lord prefers, the actions to be undertaken by an inspector when going into private premises.

I repeat: I hope that the noble Lord will recognise that we have taken seriously the points he raised on Report, but we have satisfied ourselves and, I hope, the House, that the word "conduct" is accurate and defines clearly what is expected of an inspector and how the process will be governed.

Lord Swinfen: My Lords, I am not a lawyer, but I know that court cases often arise over the exact construction and meaning of words. If it is not made clear, it is far more likely that court action will ensue. I hope that the Minister and his advisers will look at

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this again closely, because I am still not convinced by what he has said. It may well be that the word that I have proposed--"actions"--is not the best word, but I am sure that it is a great deal better than the word "conduct".

However, the House is thin and time is moving on. I shall not delay the House by dividing, as I had thought I might. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 2 [Activities liable to control under the Act]:

Lord Cope of Berkeley moved Amendment No. 9:

    Page 27, line 19, after ("such") insert (", or under his supervision and authority,").

The noble Lord said: My Lords, we discussed this matter earlier in our deliberations on Amendment No. 1. It concerns accountancy staff. I know that the Minister is going to write to me. However, if he accepts this amendment, it would keep the position in play, as it were, should he wish to reverse it. I hope that he finds that acceptable. I beg to move.

Lord Bassam of Brighton: My Lords, I would like to be able to accept this amendment, but I cannot do so. Perhaps I may explain carefully why that is the case. We held a debate on this matter earlier, as a result of a concern raised quite properly by the noble Lord on Report. It was then suggested that the government amendments to exclude qualified accountants should not extend to all staff in an accountancy practice.

As I indicated in our earlier debate, the Government wish to ensure that the provisions of the Bill are targeted at those specialist providers of security services whom we have stated we wish to regulate, and that they do not inadvertently catch groups which are not relevant to our policy aims and objectives. This latter group includes accountants.

The Government have accepted that the wording of paragraphs 4 and 5 in Schedule 2 did not make it abundantly clear that we were not seeking to take accountants into the regulatory framework. Your Lordships' House therefore approved amendments to provide a clear exemption for accountants from the definitions of private investigators and of security consultants. Those amendments were based on exemptions for members of relevant accountancy bodies, as the noble Lord had encouraged us to do and, indeed, as we have been encouraged to do privately. That is now defined in Clause 25.

This amendment would extend the exemption to those employees of accountancy firms who work under the authority and supervision of an accountant, but who are not members of the accountancy bodies listed in the Bill. It is worth reminding ourselves that we are talking about those people hired out under a contract to supply clients with specialist services. Members of the relevant accountancy bodies and their staff who are working "in-house" fall outside the scope of the Bill.

Employees of accountancy firms who are not members of the relevant accountancy bodies as now defined may, of course, be hired out to provide

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accountancy services. In that case, they are not providing any of the designated activities which are the focus of the Bill and would not, therefore, fall to be licensed under it. However, as I said in my response on Report, it is not necessarily the case that only members of those relevant accountancy bodies may be hired out under contract to provide services that are relevant to the provisions in the Bill.

Many of the large and well-known accountancy firms now have extremely diversified business interests and provide a wide range of services. In some cases, those services will be "designated services" as defined in the Bill. It may be the case that accountants who are members of the accountancy bodies listed in Clause 25 will take part in some or all of these services. However, even if those services are "designated activities", the accountants undertaking them are now excluded from regulation under this Bill.

However, I am quite clear in my mind that in many cases these large, diversified accountancy businesses will also hire out members of their staff who are not members of the relevant accountancy bodies to undertake activities that are designated activities as defined in the Bill. This amendment would exempt anyone undertaking those activities from the need for a licence simply by virtue of their working under the authority or supervision of a suitably qualified accountant. As I indicated on Report, I do not believe that that would be right.

Those employees, if hired out under contract, would be undertaking the same type of work as people who legitimately offer their services as private investigators or security consultants, but not as accountants. They would be offering services such as the investigation of corruption, asset recovery and fraud risk management. In the Government's view, it would be wholly anomalous for non-accountants in accountancy firms to be exempt from licensing, when private investigators and security consultants offering exactly the same services would be caught.

Indeed, since we debated the Bill on Report, I have received representations from non-accountancy companies offering precisely these types of services who argue that if we were to exclude non-accountants who undertake services similar to theirs, it would create an uneven playing field. I find the arguments wholly persuasive. The counter-argument is to say, "Yes, we are undertaking designated activities as defined by the Private Security Industry Bill, but we are employed by accountants, so we should be exempt". I cannot accept that.

I also have great difficulty with the notion, advanced on Report, that such an exclusion was needed because in today's business world it is often difficult to define strictly what is "accountancy" and what is not. I accept that there may be certain difficulties surrounding definition here, but I am not convinced that the answer to those difficulties is to give such a broad and sweeping exemption to everyone employed by an accountancy firm.

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For those good reasons, I continue to resist the amendment. Having heard what I have to say on the matter, and given his great experience in the world of accountancy, I hope that the noble Lord will feel able to withdraw it.

Lord Cope of Berkeley: My Lords, the Minister is wrong to say that I have "great" experience in the world of accountancy, although I have some. He must not exaggerate my professional career.

I accept that definitional problems exist, as the Minister suggested. I hope that he is right in his interpretation of what the Bill now says. I admit that I do not think he is right, but I hope that he is. On that basis, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

An amendment (privilege) made.

Lord Bassam of Brighton: My Lords, I beg to move that this Bill do now pass. In doing so, I thank all noble Lords who have taken part in the debates and who have helped in enabling the Bill to complete its passage.

On Question, Bill passed, and sent to the Commons.

Health and Social Care Bill

5.41 p.m.

Lord Hunt of Kings Heath: My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.--(Lord Hunt of Kings Heath.)

On Question, Motion agreed to.

House in Committee accordingly.

[The DEPUTY CHAIRMAN OF COMMITTEES (Baroness Serota) in the Chair.]

Lord Clement-Jones moved Amendment No. 1:

Before Clause 1, insert the following new clause--

The purposes of this Act are, inter alia, to--
(a) institute reforms relating to the National Health Service (including in health service funding, employment, public and patient involvement, scrutiny, consultation, independent advocacy, intervention powers and regulation, recruitment and discipline of general practitioners and dentists),
(b) provide authority for local pharmaceutical services' pilot schemes,
(c) extend prescribing rights,
(d) introduce provisions relating to Care Trusts and partnership arrangements,
(e) introduce free personal care (including nursing care) after an assessment of need for those in receipt of community care services, and
(f) introduce provisions relating to the control of patient information."

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The noble Lord said: Given the number of amendments that have been tabled, we are in for a number of fairly long sittings in Committee. However, I make no apology for placing the issue of personal care right at the forefront of our Committee stage deliberations.

The issue of personal care draws a clear line between the approach of these Benches and, as I understand it, that of both the Conservative Party and the Labour Party. Regrettably, the Bill promises to be a missed opportunity in that respect.

We on these Benches have strong support for our approach from a considerable number of sources--not least the Royal Commission on Long-Term Care of the Elderly, which originally highlighted the inequity in the current system whereby a patient receives free nursing care in hospital but is means-tested for that same nursing care in a residential home.

The Government's plans set up an artificial distinction between nursing and personal care. This will mean that many people in nursing homes, or at home, will still be means-tested for care such as being dressed, bathed or washed, which they would certainly not pay for in an NHS hospital. The classic example used by many correspondents is that of the dementia sufferer based in a residential home who requires a high level of care but who receives little medical intervention. In those circumstances such people will be paying for their personal care.

We on these Benches believe it right that all nursing and personal care should be paid for, whether in a care home or in people's own homes, according to an assessment of need. We believe, as did the Royal Commission, and as do a number of Members on the Government Back Benches who spoke in the debate initiated by the noble Lord, Lord Ashley, that this is the only long-term, principled and practical solution. We believe that the risk of needing long-term care should be spread across the whole population and over the life-time of that population as the most efficient way of addressing both the risk and the cost of ensuring against it. There should be a shared responsibility between the individual and society to meet the cost of old age. At the same time, the guiding principle of policy should be to make appropriate early interventions to support people in independent living.

My party found the key recommendations of majority view set out in the report of the Royal Commission that personal care should be free, subject to an assessment of need, persuasive and we regard this as a key priority for future expenditure.

Living and housing costs are legitimate items which people should expect to meet themselves. The straightforward living costs of staying in residential care should remain the responsibility of the individual, subject to means-testing. However, personal care costs fall heavily and unexpectedly, and are beyond the control of the individual. For this reason, we believe that personal care costs should be exempted from means-testing in all settings and that they should, instead, be based on an assessment of need. These are

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defined by the Royal Commission as the care needs that give rise to major additional costs of frailty or disability associated with old age.

The Royal Commission went on to say:

    "Personal care is care that directly involves touching a person's body (and therefore incorporates issues of intimacy, personal dignity and confidentiality), and is distinct both from treatment/therapy (a procedure deliberately intended to cure or ameliorate a pathological condition) and from indirect care such as home-help or the provision of meals".

Between 100,000 and 125,000 people in residential settings would benefit from excluding personal care costs from the means test, as compared to the 35,000 who would benefit from free nursing care alone.

Personal care costs at home should also be exempt from charging. The Government's recent consultation paper on charging policies for home care is a profoundly depressing document. Location should not matter when people need intimate care such as bathing, dressing or feeding. It is a disgrace that in this country debt collectors are chasing after dementia sufferers for money to pay for their care. If the Bill is passed in its present form, they will simply be chasing the sons and daughters of dementia sufferers instead.

As regards the arguments advanced by the Government regarding the fact that some of the better-off may benefit, the health service is not there to redistribute wealth from the rich to the poor, but rather to redistribute resources from the healthy to the sick. There is clear evidence from recent research carried out by the King's Fund that most people will struggle to pay for both long-term care--or long-term care insurance--and a second pension, as envisaged by the Government.

The proposed definition of "nursing care" which we shall debate later in Committee will leave care home residents unclear about what they will actually have to pay for. Indeed, it is our view that it is virtually impossible to devise a watertight definition of nursing care which will avoid disputes.

Over 15 voluntary organisations involved in the care and representation of older people have condemned the Government's plans as set out in the Bill, including Methodist Homes for the Aged, Age Concern and the Royal College of Nursing. The Scottish Executive is now moving down the path proposed by my party in the coalition. I very much hope that the Government will have the sense to do the same in England and Wales. I beg to move.

5.45 p.m.

Lord Morris of Manchester moved, as an amendment to Amendment No. 1, Amendment No. 2:

    In subsection (e), after "nursing care)" insert "and care by professionals supplementary to medicine"

The noble Lord said: In moving this amendment to the proposed new clause, I shall speak briefly also to my Amendments Nos. 265, 268 and 269 to Clause 56 of the Bill to which it relates.

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All these amendments have the same goal; namely, to ensure that healthcare provided by any health professional-- not just that provided by a nurse or a doctor--is made available to people in long-term care without charge.

Before setting out the case for the amendments, I have a non-pecuniary interest to declare. As some Members of the Committee will know, I have the honour to be president of the Society of Chiropodists and Podiatrists, and it is my work in that capacity which, for me, makes self-evident the need to make the Bill less restrictive in defining healthcare. As well as being a trade union, the society is the professional organisation of state registered chiropodists in this country. It works both assiduously and with success on their behalf as the providers of more than 8 million appointments for patients each year. Here I pay special tribute to Pam Sabine and Hilary De Lyon, the chairman and chief executive of the society, and to their fellow officers past and present.

Much of the debate about the Bill has so far, rightly, focused on whether only care by nurses and doctors should be free, or whether personal care more generally should be provided on the same basis for everyone in long-term care. The purpose of my amendments is to face the reality that essential healthcare in the UK is provided not only by doctors and nurses, but also by other health professionals.

The professions supplementary to medicine are 12 highly important and quite distinct professions. They include, as well as chiropodists and podiatrists, speech therapists and physiotherapists among other essential health professionals, all of whom have one thing in common: they provide real, measurable, tangible, clinical, healthcare benefits.

One striking example is that the clinical skills of chiropodists and podiatrists, when properly integrated into diabetic care, can now reduce--and demonstrably have reduced--amputations among patients with diabetes by 50 per cent, while their treatment of other disabling foot pathologies helps to increase the mobility and reduce the dependency of patients more generally. This explains the Health Minister's comment on the,

    "excellent contribution of podiatric surgeons to foot health",

in a recent answer to a parliamentary Question in another place.

Yet currently, where chiropody and podiatry services are provided for people in long-term care, the cost to the patient depends--strangely and illogically--not on their medical needs, or even on their financial means, but on the employment status of the chiropodist or podiatrist. If she or he is employed by the NHS the service will be free. If the chiropodist or podiatrist is self-employed and has a private contract with the long-term care institution, then a charge has to be levied by the practitioner. This is clearly anomalous. I cannot believe that Ministers are content to leave the position as it now stands.

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It may be argued that provision for people in long-term care is no different from that for other patients. Widely variable standards of NHS provision now mean that patients in some areas receive free NHS care, while elsewhere they have to pay. But that is plainly unsatisfactory and unjust, and the Society of Chiropodists and Podiatrists will go on campaigning to improve the general level of NHS provision to that of the existing best.

This is why the society now argues with such conviction for services to be provided free of charge and regardless of age. Keeping older people mobile can prevent many other ailments occurring. For example, older people who cannot walk are liable to become increasingly inactive, exposing them both to respiratory problems and depression, often resulting in complete dependency on care. Timely care from a chiropodist or podiatrist can prevent this happening and avoid unnecessary further costs to the NHS.

It was widely hoped that the Government's review of the Feet First report, which was concluded last year but has not so far been published, would by now have provided consistent and clear guidelines on the proper provision of NHS chiropody and podiatry by all health authorities and other commissioners within the service. There is still time for a rethink and, as the Minister is aware, the Society of Chiropodists and Podiatrists is seeking another meeting with him on this important issue.

Meanwhile, let us be clear about the here and now. Chiropody/podiatry is not personal care; but nor is it nursing care. It not only protects mobility and improves quality of life, but also specifically and undoubtedly treats medical conditions and alleviates clinical pain. Why then should healthcare be defined so narrowly as to deny patients the often vitally important help that chiropodists and podiatrists, like the other professions supplementary to medicine, can provide? What possible defence is there for treating their help as an optional extra--as the "a" in et cetera, as it were, of British healthcare?

The Health Minister also said in another place:

    "Our definition [of nursing care] is not task based".

That is why I have framed my amendments--both here and again at Clause 56--as generically as possible; and I look forward to a positive response from my noble friend Lord Hunt when he replies to the debate. In particular, I hope for his assurance today that all chiropody/podiatry provided for a person who is in long-term care and clinical need will automatically be available without charge.

I ask for that assurance all the more urgently since, under the Care Standards Act 2000, care homes must now include foot care in their residents' needs assessment. They must also ensure that residents' NHS entitlements are upheld and promoted. Thus all that I am seeking is consistency in legislative provision. This means ensuring that state registered chiropodists, along with others in the professions supplementary to medicine, are recognised within the Health and Social Care Bill as providers of essential care without charging.

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Although I have set out the case for the amendments mainly by reference to chiropody and podiatry, of course it can be argued just as strongly in terms of the essential role of other professions supplementary to medicine in providing healthcare. For a person stricken by a stroke, the work of a speech therapist is often critically important and, if provided in a long-term care setting, there should be no doubt but that it will be free. Likewise, when a frail elderly person falls and fractures a limb, the work of a physiotherapist can be hugely beneficial to her or his healthcare. So here again there should be no doubt but that it will be free in the case of long-term care.

Many other examples could be given of the case for inserting, after nursing care in the clause, care provided by the other professions supplementary to medicine. As I said earlier, they demonstrate that healthcare is not just about doctors and nurses. Ask any self-respecting doctor or trained nurse and they will tell you that to say otherwise is now barbarously old fashioned. Healthcare is also very much about chiropodists and podiatrists and all their fellow professionals in the professions supplementary to medicine. Ask any diabetic, any stroke victim, or any frail elderly person who has suffered a serious fall. That is the case for my amendments and I beg to move.

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