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Baroness Maddock: My Lords, I speak to Amendment No. 13. Earlier, the Minister said that the Bill was about health and social services working together. I wish to add home improvement services to the list.

The amendments have two purposes. First, to highlight the connection between poor health and poor housing; and, secondly, to enable the Minister to reassure me today that the issue of home improvements will be regarded as important in drawing up the regulations and the best practice guidance that will follow.

I make no apology for raising this issue yet again. Thirty years ago, I went to live in Sweden. I was very impressed by the standard of health of elderly people there. It was fairly obvious that it resulted from the fact that they lived in decent homes—homes which were warm, not cold and damp as they are in this country. Here I am, 30 years later, in Britain—one of the richest nations in the world—and, still, one in 14 of our population live in homes that are unfit for human habitation.

I shall not repeat all the statistics that I gave in Committee. I merely highlight two of them: the tendency to live in poor housing conditions increases with age, particularly after 80, and lone older women are more likely to live in unfit housing; and 1.7 million people need adaptations in their homes. There are all kinds of reasons for those facts, including poverty, frailty and disability. The one that concerns us in debating this Bill is the lack of information about the help that is available and how to obtain it.

Those assessing patients for discharge from hospital are in an ideal position to ascertain the problems of home disrepair—whether it be the lack of adaptations, general disrepair or a lack of suitable heating. They have the ability to ensure that patients are referred to the appropriate agencies. They might be referred to the warm front scheme if it is a question of heating. I am particularly disappointed that the Government are cutting the budget for the scheme this year—they are cutting the DEFRA budget. It might be a question of other heating schemes through the energy efficiency commitment that the Government have imposed on the utilities; or it might be a question of Care & Repair schemes.

There is one area about which I feel particularly incensed; namely, the inability of our services to enable older people to have a level-access shower in their homes. I draw attention to the Adjournment debate in another place on 27th January in which Helen Jackson, Member of Parliament for Sheffield, Hillsborough, spoke about this issue. She gave the frightening example of one of her constituents who had been turned down for a disabled facilities grant by his assessor because he was able to have a strip wash and was not incontinent. My mother was discharged

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from hospital following a knee operation. She did not have a shower. She was not able even to strip-wash herself because of various things that were happening.

I find it amazing that people still have to wait for up to a year for this type of adaptation when we know how much it costs to keep people in hospital. The cost of a shower pales into insignificance. Will the Minister assure me that this matter is being pursued vigorously by the health service in conjunction with other agencies?

In some areas home condition is taken very seriously when examining programmes where social services and health services are working together. I can recommend a particularly good scheme that was brought to my attention by the LGA in south Shropshire. Perhaps I may recommend to the Minister the work of the Care & Repair scheme in this field. It has put together good examples of best practice and guidelines to enable good discharge services, which include home improvement agencies. I hope that the Minister's department will draw on those.

When I raised this issue at an earlier stage, the Minister agreed that it was important. Will he reassure me that the health service is working to ensure that, when a patient comes into contact with the health service, that person will as a matter of course, every time, be asked about their home circumstances in order that they might be referred to the appropriate agencies as soon as possible? There are examples of good schemes up and down the country.

In this country we are taking far too long to recognise the role of poor housing in the ever-rising cost of healthcare. By recognising fully in this Bill the implications of poor housing, we can take the issue forward and help to tackle the very large backlog. It is not rocket science and it does not cost money. In the 21st century, we jolly well ought to be doing it.

6.45 p.m.

Baroness Greengross: I strongly agree with the remarks of the noble Baroness, Lady Maddock. I have heard her speak on this matter on other occasions, and I have been involved with some of the home repair agencies over the years.

A house has a life. At the stage when one elderly person is living there—usually an elderly woman living in a building that is in poor repair—a small amount of money will keep that home going for the few remaining years of the person's life. After his or her death, a young family will come into the house, invest in it and make more major repairs. In that way, it gets a new lease of life. So for a very small outlay of money one can help to keep people much healthier than is imagined for that small investment. When we talk about collaboration between health and social services, we usually forget how important housing is in making that happen.

Earl Howe: My Lords, I rise to speak briefly in favour of Amendment No. 28, which in many ways harks back to the previous group of amendments on

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the issue of continuing care. If a patient in hospital is assessed as needing nursing care in a care home when he leaves the hospital, it is unacceptable for that decision to be taken without its implications being fully spelt out to him. The main question that will occur to anyone in that situation is: "How much is the after-care likely to cost me?"

The Government made a great fanfare about introducing free nursing care in care homes. As we now know, the reality is a little different. NHS nursing care in care homes is not always completely free. You have to find out what band you fall into before you can calculate how much it will cost to be looked after in a particular home. There is no current guidance about this. The previous guidance laid down that social services ought to,


    "provide written details of the likely cost to the patient of any options which he or she is asked to consider . . . and that hospital and social services staff should ensure that patients receive written details of any continuing care that is arranged for them. This should include a statement of which aspects of care will be arranged and funded by the NHS".

As I remarked in Committee, doing this for a patient is a matter of basic human courtesy, but the evidence is that in many, many cases it does not happen. The situation is compounded by the opaqueness of the rules surrounding the £110 band of nursing care compared to the criteria for fully funded NHS healthcare. Deciding who qualifies for one as opposed to the other requires a degree of insight denied to most mortal men. It baffled the health ombudsman and I think we can safely say that it would baffle most of us.

This really has to be sorted out before the Bill comes into effect. I am delighted that the Government have recognised in an explicit way the importance of consulting the patient, but I ask the Minister: how is it possible to consult the patient about his aftercare in the truest sense of the word "consultation" if you cannot, in so doing, tell him the basis on which he will need looking after and who will be responsible for doing what? That is the issue in Amendment No. 28. I hope that the Minister will feel able to respond sympathetically.

Baroness Finlay of Llandaff: My Lords, I support the remarks of the noble Baroness, Lady Maddock, in regard to the importance of home improvements. We have heard about home improvements in terms of whether someone is eligible. A further point is that they must be timely—they need to happen early, not late. There are many patients who have neurological diseases which are slowly progressing. If those patients are to be returned home and are to benefit from home improvements, the improvements must happen quickly; otherwise, the tragic situation arises—as we have heard in meetings with groups outside this Chamber, particularly from those with motor neurone disease—that by the time the patient has the home improvements done, his or her condition has deteriorated so much that he or she cannot benefit fully from them. Home improvements always lag behind the clinical condition. The costs of care then escalate enormously. The care services are never freed up from providing care because the improvement is

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not in place that would have relieved the burden on them and would have maintained people's independence for weeks, months or, one hopes, even years longer.

Baroness Andrews: My Lords, we have had a series of interesting and important discussions on this group of amendments.

On Amendment No. 12, the noble Baroness, Lady Barker, was quite right that we have high expectations of the single assessment process. It is an extremely important step forward. Particularly important is that it puts patients at the heart of the assessment process. It is very explicit in taking account of their needs and wishes. I take her point about involving them in the design and implementation of the guidance. It is not yet fully operational but I hope that as it evolves there will be opportunities to do just that—it makes perfect sense. The guidance brings together the health and social care professionals. It was issued as Section 7 guidance, which means that it must be acted upon.

In relation to the amendment, I am glad to say that the process already extends to hospital settings. It will be the means whereby assessment of all care needs over and above clinician diagnosis and discharge planning is undertaken in hospital settings for older people. We know that good work is being done on rolling out the process.

The noble Baroness made a plea that we put the amendment on the face of the Bill to act as a trigger. We have already put the local authority's duty to carry out a Section 47 assessment on the face of the Bill in Clause 3. All assessments under Section 47 will be made by way of the SAP. Having that in the Bill makes it clear that everything will be a Section 47 assessment, which is linked to the SAP. I understand why the noble Baroness makes such a strong case for this proposal, but it is not necessary because the provision is so clear in the Bill.

When my noble friend Lord Hunt wrote last week to the noble Baroness with details of how the Department of Health emphasises to the field the importance of adherence to the SAP, he spelt it out in some detail. Because of its importance, it comes under Section 7 guidance, and any attempt to avoid compliance would be quickly picked up by the strategic health authorities and the social security inspectorate.

We are encouraged by the fact that our scrutiny so far suggests that the field has taken the SAP to heart and is dealing seriously with it. That suggests that it is going with the grain of the very best practice and that people are happy to put it into effect. I hope that the noble Baroness will agree with me that it is not necessary to list the responsibilities again here. However, it will be made clear in the official guidance accompanying the Bill that the SAP is the fundamental means of assessment and that it must be followed.

Let me turn to the speeches of the noble Baronesses, Lady Maddock, Lady Greengross and Lady Finlay. The noble Baroness, Lady Maddock, made a powerful speech about the need to link home improvement services to the discharge process. Nothing divides us

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on the importance of this. The examples given by the noble Baroness, Lady Maddock, were as powerful as the ones she gave in Committee. At that stage, I said that we would be looking at how we could reinforce the guidance to make it certain that social services authorities would identify housing needs, informing their housing counterparts and working together to ensure that what could be done was done. Under the Bill, social services are required to consult where there is a housing need. The responsible authority, as defined in the Bill, will not always be the housing authority, so we have to make provision for that communication to take place. I should like to reinforce what I said in Committee and to give the noble Baroness the assurance that she seeks.

We have responded to the need in a very specific way. We have put in new resources. We are aware of the difficulty of putting the disabled facilities grant in place in some local authorities. There is no question but that there are delays. However, we have put new plans in place. On 23rd July 2002, the Secretary of State said that part of the package financed through additional funding for social services would be a 50 per cent increase over the 1997 total in the number of extra-care housing places—very sheltered accommodation. The noble Baroness, Lady Maddock, spoke about home improvement agencies, and the noble Baroness, Lady Greengross, referred to the cost-effectiveness of installing a walk-in shower. A walk-in shower costs about £5,000 so that would come under the DFG. Some of the other very small adaptations, which are extremely cheap and make all the difference in the world, come under the CSDP Act. We want to see the point of connection being made between the social services and housing authorities when they are looking at the sort of conditions that elderly people will go back to when they are discharged.


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