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Lord Lucas: Perhaps I may respond on a couple of points. First, the Minister mentioned 100 million to help with the Bill's implications. How will that be distributed? Will, as usual, those who have done nothing in the area get all the money while those who have worked hard on their limited resources get nothing? Secondly, will the Minister answer the question posed by the noble Lord, Lord Turnberg: what has happened to convalescent homes? One of the great shortages in the country is of somewhere to deal with patients during the two or three weeks of post-hospital stress. Where are they?

Lord Hunt of Kings Heath: I am afraid that, in today's jargon-laden health service, convalescent homes are now called intermediate care. We are developing many new facilities for just the conditions mentioned by the noble Lord—up to six weeks' care, enabling people to rehabilitate after an acute episode of care and return to their own home or another care setting. I certainly agree that convalescent homes have always had their part to play. In their new guise, they will have an increasingly important role in future.

The noble Lord asked an interesting question about how the 100 million is to be distributed. I cannot answer that because we have not reached final decisions, but I understand his point. There will always be a tension here. I agree that there are parts of the country and local authorities whose record in the area is splendid. I am sure that they will say that they should have their fair share of that sum. Equally, we are naturally concerned about those parts of the country where performance is poor. Improving that performance is partly about better organisation but will be partly an issue of resources. So a careful balance will have to be drawn, but I cannot go further than that at present.

3.45 p.m.

Baroness Noakes: When does the Minister expect the 100 million to be distributed? He will be aware that if the scheme of fines is to be introduced on 1st April, local authorities will have little time to work out its financial implications. When they will know is almost as important as how much they will get.

Lord Hunt of Kings Heath: I am glad that the noble Baroness recognises the need for urgency. I take it that that means that she will not support any moves to

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delay the Bill's introduction. I understand her point. I cannot give her a day or date, but I understand the need for speed in the area.

Lord Lucas: To return to what the Minister has just said, how will the incentives built into the Bill affect the construction of new intermediate care facilities? Do they not encourage the National Health Service to say, "Let us not bother with this sector. We can now just chuck these people at local authorities"? Under the Bill's structure, why should the National Health Service spend a lot of money on intermediate care facilities?

Lord Hunt of Kings Heath: Because, if we do not develop sufficient intermediate care, we will not tackle waiting lists and times as we need to do. That is an essential part of the modernisation of the NHS and the NHS Plan. The Government have no intention of stepping off the pedal of developing more intermediate care.

The Lord Bishop of Hereford: We seem to be straying from the substance of Amendment No. 1. To return to that and make a brief philosophical point, the Minister agreed with much of what the noble Lord, Lord Clement-Jones, said about the need for multi-disciplinary team decisions. The question is whether writing that into the Bill will make that more likely to happen.

I suspect that if we recognise that that is a serious problem and that more rigour is needed in addressing it, the problem with the Bill is that it is confrontational. It is not the first time that the House has received a confrontational Bill that needs to be changed in style and character to make it more acceptable and bring on board the people necessary to get a perceived problem dealt with rigorously. The noble Lord, Lord Clement-Jones, was right to introduce the amendment, because it would encourage multi-disciplinary working and make it more likely that more rigorous practice would be introduced sooner.

Lord Hunt of Kings Heath: I am grateful to the right reverend Prelate for those comments. The Bill is not meant to be confrontational. It is meant to put in place proper incentives for both the NHS and local government to get their act together and sort out the problem. We know that some parts of the country have been able to sort out the problem. Even in the South-East, which faces many pressures on resources and staff recruitment, there are boroughs and local authorities that have done excellent work in that area.

First, the issue of confrontation derives from language that is used in Bills—that may be inescapable. Secondly, although I am second to no one in my belief in multi-disciplinary working, it must be rigorous, not the sloppy working that occurs in some parts of the country, which allows people to run away from their individual responsibilities. That is why the Bill in itself does not change any current statutory responsibilities. The health service remains responsible for its parts; personal social services remain

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responsible for their part. They are meant to exercise those responsibilities within a context of partnership and multi-disciplinary teams. But my great fear is that, if we built multi-disciplinary teamwork into a statutory relationship, or gave it statutory backing, as suggested, we would give many hostages to fortune. If agreement between statutory agencies could not be obtained, it is difficult to see where one could go. That would be the great risk in proceeding as the noble Lord, Lord Clement-Jones, proposes.

We need certainty about who is responsible for what. We need agencies to work together, but we must not run away from the certainty of the health service being responsible, with local authorities having responsibility for another aspect of the delayed discharge procedure.

Baroness Greengross: If someone is discharged from hospital to intermediate care situated in unused wards in an acute hospital, as mentioned in the excellent workbook on the subject, will the same agreement need to be made so that the other authorities are brought into the decision?

Lord Hunt of Kings Heath: For instance, when a patient has been moved from an acute bed to intermediate care, one would expect health and local authorities to work together to ensure that, when that person leaves intermediate care, any required care facility is available. In those circumstances, the normal statutory community care services kick in.

Baroness Finlay of Llandaff: I prefer the term "multi-professional working" to "multi-disciplinary working", because we are talking about different healthcare professions. As the Minister rightly cited, in areas where things are working well, teams speak to each other. My concern is that, where things do not work well, the lack of team-functioning in the NHS will be used as a wonderful excuse as to why the discharge was not safe in the first place. In a team that functions well, nurses and doctors will be able to say that a patient does not need a physiotherapy or occupational therapy assessment because there is good understanding of the roles of those therapies. In teams where that does not exist, and where medical and nursing professionals are arrogant towards the other professions, patients go home with unmet needs, particularly in physiotherapy and occupational health. Yet, when the patients are home, social services will be able to claim that the discharge was not proper in the first place.

It is precisely to avoid lengthy disputes that I have supported Amendment No. 1 in the belief that a clear definition needs to be included in the Bill. By including "multi-disciplinary working" or "multi-professional working" in the Bill, teams that do not communicate well would be forced to consider the other professions that they should be considering on discharge.

Lord Hunt of Kings Heath: I understand what the noble Baroness is saying. Of course I agree that multi-professional working is how we wish to progress.

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I agree with her that, although much of the debate on this group of amendments and at Second Reading has been about the role of local government, the Bill will come down as hard on the health service as it will on local government.

The noble Baroness raised some of the current problems with delayed discharge. It is also about the National Health Service not getting its act together. There are examples of that. I say to the noble Baroness that we have published Good Practice in Hospital Discharge, which we will follow up with further guidance. In response to my noble friend Lord Turnberg, that publication emphasises the points that the noble Baroness raises.

It is important to remember that this Bill does not seek to change current statutory responsibilities. That is the problem with seeking to include "multi-disciplinary working" or "multi-professional working". It would detract from current statutory responsibilities. Committee Members should have no doubt that we shall stress continually in our guidance the need for multi-professional working.

Earl Russell: When the Minister said in response to the right reverend Prelate the Bishop of Hereford that it was not a confrontational Bill, I am sure that he made an absolutely accurate statement of his intention. But, during the past month, I have perhaps spent longer watching what is happening in one of our best NHS hospitals than any other noble Lord. I observed that this Bill and its prospect would make it even harder than usual for the hospital to maintain the primacy of clinical judgment. They endeavoured to do so with great gallantry, and, I believe, with success. But the Bill would not make the task easier. It is one effect of the culture of targets that, because the interests of patients are a seamless robe, as soon as you isolate one single factor and turn it into a target regardless of its effect on anything else, you risk creating something that acts against the supremacy of clinical judgment and against medical need. Whitehall as a whole has yet to take that on board. I hope that it will think about it.


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