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Lord Clement-Jones: I strongly support the amendments, ably introduced by the noble Baroness, Lady Noakes. The amendments attempt to define the relationship between the various public bodies charged with inspection of health and social services, the number of which has grown over the years. Indeed, as the noble Baroness, Lady Noakes, said, we never know what new bodies may be created in the next few months or possibly relabelled in the NHS reform Bill to which we all look forward. They all have their part to play within both social services and the NHS.

It is also necessary—this is where the second amendment is so important—to ensure proper parliamentary scrutiny of the direct effects of the Bill and, in particular, to ensure adequate monitoring of its effects on individuals. It is not too much to ask both that there should be parliamentary scrutiny and that those inspection and audit bodies should be

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responsible for monitoring how this highly controversial Bill will impact on individuals once it is introduced.

Almost everyone but the Government believes that the Bill will mean that patients could be forced into care situations not of their choice or possibly inappropriate for them. Unless there is some monitoring of whether, for instance, an older person can later move from a care home, he or she could be left indefinitely in a home to which they did not choose to go. That is where monitoring is badly needed. In respect of those discharged too quickly from hospital to their own homes, we are aware that the emergency readmission figures to hospital, which are monitored, are just the tip of the iceberg compared to the other problems caused. We are concerned that such problems will increase as a result of greater pressure on discharge caused by the Bill.

As well as the welfare of the patient, it is also important to monitor the demands placed on the carer and to ascertain how frequently caring for someone discharged from hospital without sufficient support undermines the health and long-term capacity to care of the carer. Attention should be given to the many instances where the person discharged is the main carer for another person. We need monitoring of the effect of rapid discharge back to their caring responsibilities on their health and the welfare of the cared-for person.

Research published in 2001 by Help the Aged showed that 75 per cent of co-resident older carers received no regular support from health or social services. That is an interesting and unfortunate statistic. I hope that the Minister will pay careful attention to the amendments.

Baroness Greengross: I support Amendment No. 68 and I am sympathetic to Amendment No. 67. We need more detailed information on hospital discharge and the impact of the Bill—from whichever date it is implemented. The recent National Audit Office report demonstrated that clearly. For instance, it should be easier to obtain information on delayed discharge and emergency readmission by primary care trust area. That information is still not placed on the departmental website. Amendment No. 68, or something worded to that effect tabled by the Government, is therefore appropriate.

As for Amendment No. 67, bodies such as the newly merged CHI and the National Care Standards Commission should in any case be taking an active interest, not least because of the Bill and in response to the recent NAO report and the earlier Audit Commission report.

The Lord Bishop of Chelmsford: I clearly touched a nerve yesterday when I referred to patients being described as commodities. That is a valid interpretation of some of the thrust of the Bill. So I warmly welcome the amendments, because they

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underline the importance of regular monitoring of the care of patients and of carers themselves. I wholeheartedly support both amendments.

Baroness Finlay of Llandaff: I support the amendments and I am grateful to the noble Baroness, Lady Noakes, for the way she introduced them. In Wales, a database on delayed discharges is currently held by the Assembly government. It has been in operation since April 2001. It is only as good as the information put into it, but its existence means that it can be interrogated. It shows that at any one time about 10 per cent of hospital beds are occupied by delayed discharges. The Government have constantly called for evidence-based clinical practice. Evidence-based medicine has been the subject of many editorials. The amendments represent a plea for evidence-based management within the NHS and in the relationship between the NHS and social services. It is essential that we have evidence-based decision-making.

Lord Hunt of Kings Heath: I have no problem at all with the suggestion that monitoring of the Bill's introduction must take place. I give the assurance that monitoring will indeed take place. The noble Baroness, Lady Noakes, was rather unkind about the Government's intention in future legislation. She may think that we are interested in name plates, but if I go back over the record of the previous government during 18 years I lose count of the number of restructurings and changes they made to the health service.

The forthcoming legislation, which I know we shall all thoroughly enjoy, is not about name plates; it is about enhancing the moves that the Government have already made to set up robust, independent inspection. Setting up the Commission for Health Improvement and the National Care Standards Commission and the enhanced role of the Social Services Inspectorate are all part of national architecture, setting national standards and having robust, independent inspection, under which local services can be given much greater freedom to operate. I do not recognise the right reverend Prelate's description of patients as commodities under the Bill. We do not want to go over the ground that we debated so extensively in many amendments yesterday; but if the right reverend Prelate looked at current practice in many parts of the country, it is there that he would find that patients are not put first. There he will find self-serving statutory authorities that have failed in so many cases to get their act together; and where patients have been left inappropriately on acute-hospital beds because of minor issues that could have been sorted out if people had tried to.

The fact that local NHS authorities throughout the country, despite the difficult circumstances under which many operate, can ensure that there are effective delayed discharge procedures has convinced me more than ever that we are right to take the robust approach in the Bill. But I accept the need for monitoring. The Social Services Inspectorate will continue its role of monitoring the quality of services to older people. In

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addition, we have performance indicators both for the National Health Service and for social care, which cover emergency re-admissions and home care to help people to live at home. We are introducing indicators on speed of service provision. Those who are concerned that patients with complex care needs will be transferred into interim care under this Bill will be pleased to know that we will also set targets on how long they have to wait for community care services compared to other members of the public. A whole-system approach will be taken.

The current inspection bodies already monitor the quality of discharge arrangements. We expect that the new bodies—the commission for healthcare audit and inspection and the commission for social care inspection—on which we will introduce legislation to your Lordships' House in this Session, will strengthen the accountability of those responsible for the commissioning and delivery of health and social services. The Government will take great care to ensure that the reports by those inspectorates and the information that they produce are considered and reviewed carefully. We do not need to legislate in the way suggested because we already have the monitoring processes and the inspectorates. We will improve the system in future legislation and we intend that the two new inspection bodies will report to Parliament. Through the action that the Government already intend to take, we will meet what Committee Members seek to achieve. I have no hesitation in saying that monitoring will be an important part of the duties of the inspection bodies.

Lord Clement-Jones: What guarantee is there that the totality of the system will be looked at? Many will be worried that the monitoring process will be like two railway lines meeting; that is to say, instead of looking across the inter-change between social services and healthcare, one inspection body might look at healthcare and another at social services, but no inspection or audit body will look across the piece. Who is empowered to do that?

Lord Hunt of Kings Heath: That is a fair point. I agree that it would not be satisfactory simply to have a health service inspectorate and a social care inspectorate looking only at their separate areas. We expect the inspectorates to work together. It is instructive that, as part of our response to the Laming report into the tragic case of Victoria Climbie, we already identified a joint role for the current inspectorates. I very much agree that there should be a whole-system approach.

Baroness Finlay of Llandaff: I commend to the Committee the system in Wales, which attempts to have joined-up government. The National Assembly for Wales government database shows, for example, that the discharge of 22 patients from my own hospital was delayed over 10 weeks between May and July in 2002, with an average delay of 14 days. The reasons for seven delayed discharges was waiting for a social services care package or settlement. The other reasons

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were health, equipment, waiting for a place in a nursing home or continued care funding, and awaiting a transfer. Such a database allows social services delays to be linked to NHS delays.

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