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The Earl of Onslow: I have listened to the debate for most of the afternoon, and have heard two questions answered by the Minister. First, he said, "I don't know how to distribute the 100 million quid", and secondly, he said, "We haven't got our act together with the hospice movement". If the Government do not know where the 100 million is going and have not got their act together with the hospice movement, they cannot possibly bring the Bill in by 1st April. That simply does not make sense.

The Lord Bishop of Chelmsford: I want to add my voice to those of other Members of the Committees who have pressed for a 12-month delay in the start date. The proposals in the Bill need to be piloted in a number of areas and then properly evaluated by the Audit Commission.

It is clear to me from the great majority of speeches in both Houses that, although everyone agrees that delayed discharges need to be tackled, the Bill's provisions are bound to make things worse by creating perverse incentives. We have already heard the example of the GP. Also, we must be careful not to jeopardise relationships between agencies—in general, they are improving—and create a nightmare of disputes and appeals procedures.

I would like to cite an example of what I see as a very good pilot in my own diocese by the Barking and Dagenham health and social care trust. Julia Ross, the executive director of health and social care, has said:


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    achieved by working seamlessly with our acute providers to achieve this and on the quality of the care that we all provide. We also need to change attitudes too; all too often relatives and front line clinicians believe that the right place for a frail older person is in Nursing Home or residential care".

It takes time to change attitudes, and we need time on our side to ensure that attitudes are sufficiently changed to make the proposals in the Bill truly effective. I have in mind a conversation with a recently retired chief executive of a large NHS trust, who described the huge problems that he had faced in a very large hospital in relating to and integrating in a multidisciplinary and multi-professional way with local authorities. He gave one of no doubt many examples of the difficulties that are faced and will continue to be faced in the coming months. We need time.

By concentrating on delayed discharges, the opportunity could be missed to explore more imaginative and pastorally sensitive ways of caring for elderly people in our communities. As has already been said during the progress of the Bill, it tends to treat them as commodities and as financial liabilities to be shunted around rather than fellow citizens, each with their own human story, each deserving to be treated with dignity, respect and care. I plead for a delay.

Lord Turnberg: I believe that I used to have one or two friends in the Chamber, and I hope I still have by the time that I have finished disagreeing about the delay in bringing the Bill into effect. I really do not believe that delay is in the patients' best interests.

The noble Baroness, Lady Barker, talked about the Bill apportioning blame. I do not see that either. A Bill based on putting pressure on those with responsibility to use extra funds to good effect cannot be construed as apportioning blame. Equally, I do not see merit in delay. Many social services departments and NHS trusts already work very well together. We are talking about building on the good practice which exists, and I believe that we need to give it a jump start. We should begin to develop that now and not delay for a year. The system is in place and we know how it can be done. It simply needs some encouragement.

Lord Lucas: The noble Lord has one friend in this Chamber—the Minister, who will be delighted with what he said. I shall try to curry favour with my noble friend on my Front Bench by adding two points in his favour.

First, it is not true that social security funding is increasing this year, because there is a shift within that part of the budget away from the geriatric element towards youth. In fact, local authorities where there is a preponderance of elderly people over youth have suffered a net cut—in some cases, a substantial net cut—in their social security budgets. This is not the time to pitch them into additional expense when the Government have just cut large amounts of funding from the sums allocated to looking after elderly people.

Secondly, everything that local authorities must do to comply with the Bill is long-term. They must build relationships with the various elements of the National

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Health Service; they must build relationships with their care home providers; and they must sort out with the National Health Service a way of dealing with vanishing intermediate care. If a local authority knows that this will happen in a year's time, it will work just as hard to ensure that it is compliant as if it happened in six weeks' time. I do not see that, by delaying the Bill for a year, any cost to the patient will be involved or that there will be any effect on the velocity with which local authorities make adjustments; there will be a great number of advantages.

Baroness Masham of Ilton: Can the Minister tell the House how many care homes—both those run by social services and private ones—have closed down in the past few years? What is the estimate of the number of beds needed to unblock the present blocking? I am sure that most people want to see the number of beds increased, but it takes time to set up homes and to put in place adequate staff. Can the Minister give an assurance that people will not be placed in unsuitable accommodation because of the shortage of time?

Lord Hunt of Kings Heath: I am sorry to find myself crossing swords with the noble Earl, Lord Onslow. He and I were fellow democrats when it came to House of Lords reform and I believed that we could move forward together. Sadly—

The Earl of Onslow: Now that we are legitimate, I believe that we have the power to do far more nasty things to the Bill than was the case before the Bill was fixed up in another place.

Lord Hunt of Kings Heath: I am all for making the second Chamber as rigorous as possible. I am sure that, as we take the Bill through its next stages, the arguments that I hope to put forward will ultimately be persuasive. I believe that the noble Earl was a little unfair. I did not say that I did not know the position with regard to hospices; I am clear about that. I said that I understand some of the concerns that they have relating to how well they are supported by the NHS and social services. That is why I offered to meet the noble Baroness, Lady Finlay, and representatives of the hospice movement in order to discuss some of those issues.

So far as concerns money, the announcement about 100 million over a full year was made fairly recently during the Bill's passage in another place. I believe that it is reasonable for us to consider carefully the point raised by the noble Lord concerning where the balance of the money should go. Do we reward authorities which have done a good job in the past or do we place most money with the weakest ones? We shall make our decisions known as soon as possible.

The right reverend Prelate spoke of his fear that older people, in particular, would be treated as commodities under the terms of the Bill. However, that is how many of them are treated at present. Poor-quality practice in many health services and in local government has led to a disastrous position for older people. They are stuck inappropriately in acute NHS beds and risk the dangers of infection, of becoming institutionalised and of losing

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their independence. As a result, it becomes much more difficult for them to return either to their own homes or to appropriate community care. That is why we have brought the Bill before the House.

Lord Tebbit: I am grateful to the Minister for giving way. Did I hear him aright? Did he say that one reason for wanting to get people who are currently bed-blockers out of hospital was the fear of infection? Surely one goes to hospital to get rid of infection—not to run the risk of acquiring it.

5.45 p.m.

Lord Hunt of Kings Heath: I believe it has always been recognised that there is a risk of infection among hospital patients. The noble Lord will probably know that the rise in infection rates in hospitals has been a world-wide problem; it is not a UK-exclusive issue. Hospitals throughout all the developed systems are facing such problems. There are a number of reasons for that. We tend to care for more vulnerable patients because we can do more for them. In addition, the excessive use of antibiotics has brought its own risks and dangers.

My point is that, where vulnerable older people receive acute care treatment, it is far better that they leave that hospital rather than stay in an acute care bed. That is why we have brought the Bill before this House. Our intention is not to treat patients as commodities. We want to reflect less on the problems of statutory agencies and on the woeful tales that we have heard this afternoon about the difficulty that they have in co-ordinating what they do.

Poor efforts by many statutory agencies over the past few years have resulted in many older people receiving a raw deal from them. The record of local government and the NHS is one of patchy performance. The fact that I can say that Croydon or Kingston upon Thames—local authorities in the South East—have been able to get their act together and the fact that I can point to Barnsley and local authorities in other parts of the country which have resolved the issues and have an integrated approach gives me confidence. It is not simply a question of money or care home places.

It is very depressing to hear so many Members of the Committee hark on about nursing home places. If noble Lords believe that the whole issue of delayed discharges is about the number of care home places available, then they have misunderstood what the Bill sets out to achieve. The quicker we can discharge people from acute hospitals once they have been treated, the fewer the number of care home places that will be required. The quicker that aids and adaptations can be fitted in an individual's home, the fewer the number of care home places that will be required. The quicker we can provide intermediate and interim care to rehabilitate older people, the fewer the number of care home places that will need to be provided.

Of course, some care home places will always be required. The Bill will encourage local authorities to enter into longer-term, stable arrangements and

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agreements to ensure that, where such places are needed, they will be available. Barnsley, where long-term agreements have been reached with care homes, provides a very good example of how capacity can be maintained and stabilised so that, when a care home place is needed, it becomes available. In response to the noble Baroness, Lady Masham, the number of residential and nursing care places in England reduced from approximately 534,000 in 1997 to 528,000 in 2001. Some of the figures quoted are excessive.

There is no question that in some parts of the country there is a problem with care home places, but it is patchy. I hope that noble Lords recognise that we need to regard care homes as but one element in a range of care packages and support to people in their own homes which need to be provided.

I listened with great interest to the noble Baroness, Lady Greengross, when she suggested that we evaluate in particular the performance of the NHS in implementing Discharge from hospital: pathway, process and practice, which we recently issued. I believe that that is a good piece of work, which I hope will encourage the NHS towards better performance. I stress again that the NHS will have to work as hard as local government properly to implement these measures.

However, I have to say to the noble Baroness, Lady Greengross, that we have issued good practice guidance in the past. In 1994 we issued the Hospital Discharge Workbook. That was very good guidance by the previous Government. However, the trouble is that it was not successful in tackling delays in many parts of the country. We need something tougher to grip the system and to ensure that statutory agencies do the right thing.

I have listened to whether we should delay the introduction of this legislation by a year to 1st April 2004. Noble Lords will know that I spent many happy years representing statutory health authorities. Whatever proposal is brought forward by government—the previous Government brought many restructurings before this Chamber and the health service—we have always said that we need more time. Indeed, if we had chosen 1st April 2004 to implement the Bill I should not be at all surprised if noble Lords said today, "It is not enough time. Let's introduce it in April 2005".

Each time we delay the introduction of a Bill, let us think about what we are delaying. Yes, we are giving more time to the statutory agencies, some of which have performed poorly in the past, but for many thousands of people we are delaying the benefits the Bill will bring. That is the essential balance to be drawn. I accept that there are some local authorities and health services which require more time. Equally, I am reluctant to agree that the Bill should be delayed by a whole year in terms of its implementation.

That is why in the spirit of listening to what the NHS and local government say to us, and reflecting on the views expressed by noble Lords today I suggest that a way forward, which certainly the Government would be prepared to support, would be to allow the Bill to come into operation six months later, on 1st October

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this year. That would get right the balance between those noble Lords who are concerned about the pace of implementation and those who feel that a year would be too long. I believe that that is a reasonable suggestion which I hope noble Lords will look on favourably.

Overall, it is important that we give the right signals to the statutory agencies about the importance of implementing the Bill. I believe that the experience of many different statutory agencies, which are doing such a good job at present, suggests that it will be implemented successfully. I hope that noble Lords will not delay the Bill by a whole year. I believe that to implement it from the autumn would get right the balance. I look forward to the support of noble Lords.


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