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Baroness Finlay of Llandaff: I rise to support the amendment. One of the difficulties in determining whether someone is ready for discharge is that clinical states vary. It is essential that there is a clear definition of what constitutes a delayed discharge if one sector is to be able to impose a fine on another sector of care. It would be wonderful if patients' disease trajectory or recovery trajectory was in a straight line but frequently it is not. Patients can seem well in the day but slightly confused at night. They can appear to function well in hospital but when taken on a home assessment it becomes obvious that they cannot cope in the environment of their own home. Indeed, they may function with people with whom they are familiar but when moved to an unfamiliar setting may appear to deteriorate.

The other difficulty is that many of the cases which are causing blocked beds at present are medical cases. Those are the very people whose condition fluctuates much more than surgical cases. It is the surgical cases which are being kept out of hospital. Therefore, it seems imperative that the whole team is involved, not simply one or two groups of professionals. The different aspects of a patient's functioning need to be considered in determining whether a patient is fit and safe to be discharged home. Patients must also be able to understand the clinical decision that has been taken for them to be discharged. It is for those reasons that I support the amendment.

Lord Turnberg: Perhaps I may tease out a little more background to the amendment and to this state of affairs for patients in hospital. It is vital for patients that social services and NHS trust staff work closely together in a co-operative, co-ordinated series of activities. Where there is conflict or blame, only the patients will suffer. No doubt from the patients' point of view, when they do not need the high-tech, high-cost facilities of a hospital they are much better off out of hospital—in the community; at home; in nursing homes or in what used to be called convalescent homes. I wonder what happened to convalescent homes.

We all know that hospitals can be dangerous and uncomfortable places. They are certainly noisy. The food is not always what an individual wants, and patients are isolated from relatives and friends. So, the quicker they get out, the better.

We need more money for support in the community. Thankfully, the Government are now providing some funds for that purpose but more is needed. However, that money is not provided so that it can be given to the NHS to look after patients. The way forward seems to be to give that money to NHS trusts only rarely. That can be achieved only by close collaborative working between the trusts and social services. I do not believe that we can legislate for that kind of co-operative behaviour.

However, we can offer guidance to people in organisations on best practice. Is the Minister willing to consider guidance which includes strong direction to good practice? That would include, for example, the encouragement which can be given to hospital staff to

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begin working with social services from the moment a patient is admitted and way in advance of the three-day statutory notice period on which we are focusing.

It should be obvious that particular patients are vulnerable from the time of admission. Even though their condition may change during their time in hospital, as has been suggested, one can suspect that a patient is vulnerable. Elderly patients with a stroke, unstable diabetes, heart failure or even simple dizzy attacks which tend to keep repeating themselves are common. They will not be able to cope at home without some sort of support.

Given a week or two of extra notice, assessments of need can begin. Social services can take advantage of and work closely with hospital staff—nurses, occupational therapists, physiotherapists, and so forth—from the beginning. A joint effort will then pay dividends so that when staff decide that a particular patient will be ready to leave hospital in three days' time, statutory notice can be given and the process can move easily and click into action.

If the three-day notice is the first that a social service department hears about a patient who has been in hospital for two or three weeks or more, resentment creeps in, planning is frustrated and patients suffer. Instead of going to meet patients' needs in the community, money will go back to the hospital. That cannot be right.

Therefore, I ask the Minister whether he would consider drafting guidance for best practice along those lines to encourage the sort of collaboration which I suspect the best hospitals and social service departments already operate. If he were to do that, we would not need this kind of amendment.

Lord Chan: Perhaps I may also comment on the amendment. As regards the third party, care in the community, the position is not clear. Care in the community is supplied by primary care trusts. However, one also needs to consult the family and carers. I believe that that should be made clear. I agree that more time is required in discussion. There has to be a whole systems approach to the patient. Obviously the patient must be involved from the start.

However, the family and relatives are equally important. Certainly, that is our experience in the North West. That being the case, there is a need to ensure that the definition of "delayed discharge" is carefully considered at a time when all considerations in a whole systems approach have reached an end and an agreement. Otherwise, if the matter is left to the clinicians they would want to consider getting patients out of their beds within three days whatever happens. That would be disastrous.

Baroness Pitkeathley: I rise in support of the last two speakers. Perhaps I may add to the comments of my noble friend Lord Turnberg on the issue of guidance. This is as much a health service responsibility as it is that of the local authority. We cannot state that too frequently as far as concerns the Bill. Only this morning I spoke to someone whose mother is in

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hospital. She had been admitted with suspected Parkinson's disease and it was the tenth day before she saw a neurologist. We cannot calculate a three- day period in that kind of situation. I hope that the guidance can be drafted in such a way as to bring everyone's responsibilities into the frame.

3.30 p.m.

Lord Hunt of Kings Heath: Perhaps I may respond to a number of noble Lords who have spoken to this group of amendments. The noble Earl, Lord Howe, regards the Bill as misconceived. The noble Lord, Lord Clement-Jones, is concerned about what he describes as the bureaucratic or rigid approach which he alleges will be forthcoming if the Bill is implemented. He is concerned that it will undermine good partnerships.

I start by making absolutely clear that the Bill has not been brought forward to undermine current good working. It is based on the experience of health and local authorities, which work well together, to enable a proper assessment to take place, with all the factors mentioned by Members of the Committee. It will ensure that a proper package of care is available; that it is undertaken as speedily and as effectively as possible; and that the patient can be discharged either into his own home with community care support or into another care setting, or into interim care if he has complex needs.

The Bill seeks first to put rigour into the relationships between health and local government. The report of the noble Lord, Lord Laming, on Victoria Climbie addresses a completely separate area of practice. I looked at what he said about the practice within the health service—the lack of communication, the lack of proper records and the lack of clarity as to which member of staff was responsible for discharging a certain patient—and at what occurred within four social service departments—again the lack of clarity, lack of case notes and lack of supervision. I was led to the view that in order to ensure that we sort out the difficult problem of older people having to wait far too long in acute hospitals where, first, they have deteriorated, secondly, they have become much more susceptible to hospital infection, and, thirdly, the beds are being used inappropriately, there is a case for more rigour in the relationship.

The Bill aims to address that. It is intended to provide incentives. We have said that we will provide to local authorities in a full year an additional 100 million of expenditure, which is our estimate of the cost to them of dealing with late discharges. That, alongside a more rigorous approach, will lead to an enhanced improvement in the current situation. We are building on the experience of those parts of the country where both local authorities and the NHS have got their act together.

As regards definitions, the important point is that the Bill changes no principle of responsibility by either the health service or by local government in the provision of services. It seeks to put in place a series of measures to incentivise those authorities to do their best. Therefore, it is unnecessary to add to Clause 1 a

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definition of "delayed discharge" or "eligible for discharge" because the terms are not used anywhere in the Bill. We talk about "delayed discharge" payments and the "delayed discharge period", both of which are adequately defined in the Bill, but we do not talk about "delayed discharge" or "eligible for discharge", because the Bill has changed nothing.

The second issue in relation to Amendment No. 1 is the role of the multi-disciplinary team in deciding when a patient is ready for discharge. I welcome the Committee's support for the work of those multi-disciplinary teams. I echo noble Lords' support for the professionals concerned to work together. But it is very important that that takes place within current statutory responsibilities. The legal position is that the decision to withdraw health services is for the relevant NHS body. The Bill maintains that position. Therefore, it would be inappropriate to change that by building in a statutory role for the multi-disciplinary team. However, in the context of good practice, the definition of "delayed discharge" that is already used by the department, and which was discussed at the Health Select Committee, already includes a role for the multi-disciplinary team. Furthermore, discharge guidance already emphasises the need for its involvement.

In that way, the role of health and social care professionals, including physiotherapists, occupational therapists and social workers, is not undermined. The involvement of the multi-disciplinary team is important in ensuring that all aspects of an individual's care are taken into account and that he or she is ready to be discharged. Ultimately, the decision that a patient's state of health is such that he or she is ready to be discharged must be taken by the appropriate NHS body. As I have said, the Bill does not aim to introduce a fundamental change in the way the NHS operates in discharging patients from its care. We want to see improved practice.

The problem with a statutory footing for the multi-disciplinary team is that unless one agency has ultimate responsibility to declare an individual fit for discharge one could run into frequent disputes as to an individual's readiness to leave, with an incentive upon the local authority to hold back on agreeing to discharge in order to avoid the possibility of making a delayed discharge payment. That would not help us to succeed in our aim of ensuring that everyone receives care in the most appropriate setting. I see the temptation of saying that the multi-disciplinary team needs to have statutory force. However, I think that our approach of retaining statutory responsibilities as they are, but emphasising the role of multi-disciplinary teamworking, is the best way forward in this area.

I have listened with great care to the noble Baroness, Lady Finlay, the noble Lord, Lord Chan, and my noble friend Lord Turnberg, about how these processes will work in practice. I very much agree with my noble friend Lord Turnberg about ensuring that work with social workers begins immediately the patient enters hospital. With elective surgery, the Bill allows the notice to the local authority to be issued a maximum of eight days before admission. So we are

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already building into the process encouragement for early discussions between the health service and the social workers.

Moreover, the three-day period for assessment is the absolute minimum. From the length of stay of many older people in hospitals, we know that often it takes longer. I believe that it is important to have the three days as the minimum period because all the evidence suggests that far too many older people are stuck in these beds inappropriately, waiting for an assessment to take place.

I listened to the concerns of the noble Earl, Lord Howe, regarding the assessment process and the changes that a patient may experience during his or her stay, which I accept. The focus of the Section 2 notice—the two days provided for the process of assessment and ensuring that community care services are in place—is a much more rigorous approach to current practice in many parts of the country, which is why the Bill is so important.

On care trusts, I recognise that the noble Lord, Lord Clement-Jones, has tabled the amendment as a probing amendment. He knows that the wording is not strictly necessary because, as we debated during the passage of the previous health Bill—or perhaps the one before that—happily a care trust is either an NHS trust or a primary care trust, so it is already covered by Clause 1.

We have undoubtedly been pleased by the progress that care trusts have made—although I hope that their current emphasis on adult services is extended to children in future. The report of the noble Lord, Lord Laming, is particularly apposite to that. It shows that strong partnerships are in place, which are key to reducing delayed discharges, but having a care trust or pooled budget does not guarantee excellent performance on delayed discharge. A budget that was pooled between the community and the acute sector to commission services for older people across all three sectors would begin to work in the same way as would the incentives in the Bill, although I am unaware of any such budgets at present.

Pooled budgets have been set up between health and social service partners for health and social services in the community. The intended use of the budget must clearly be carefully considered by the partners. They must consider which services are to be provided from the budget and explicitly include that in the partnership agreement. The partners will need to consider whether the services are key to dealing with hospital discharge, and whether social services' contribution to the pooled budget reflects an intention to pay any reimbursement from the acute trust from the pooled budget. That should then be dealt with in the budgetary part of the partnership agreement.

The legal position remains that the local authority is responsible for the reimbursement but, with the primary care trust's agreement, payments may be made from the pooled budget. However, if such payments have to be made from the pooled budget, that reduces the resource available within that budget

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for the development of community care services. So, in those cases, the Bill will none the less act as an incentive to the care trust to get its act together in that area.

So although the noble Lord, Lord Clement-Jones, has raised an interesting point about care trusts, the principle of reimbursement for care in the acute sector once the patient is the responsibility of the care trust still holds. That does not detract from the overall aim of the Bill.

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