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Community Care

(Delayed Discharges etc.) Bill

8.47 p.m.

Consideration of amendments on Report resumed on Clause 4.

Baroness Noakes moved Amendment No. 46:

"( ) This section shall not come into force until 30 days after the Secretary of State has determined that the system of incentives within relevant NHS bodies operates to discourage NHS bodies from discharging patients prematurely."

The noble Baroness said: My Lords, we come again to one of the major causes of concern about the Bill. It is a one-sided Bill which punishes local authorities for

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delayed discharges but has no corresponding provisions to incentivise NHS bodies or to punish them if they discharge patients incorrectly.

Amendment No. 46 would add a new subsection to the end of Clause 4, deferring the implementation of the clause—that is, the imposition of fines and not any other part of the Bill—until 30 days after the Secretary of State has determined that the system of incentives within relevant NHS bodies operates to discourage them from discharging patients prematurely.

It is already clear that the incentives created by the Bill are exactly as one would expect. NHS bodies are working out how they can maximise their income from fines. I am sure that several noble Lords will have received the interesting briefing from the Local Government Association which shows how in one local authority area, a trust has virtually absented itself from discussions about how to reduce delayed discharges and has instead started to forecast a revenue stream from the new fines. I do not blame trusts for that because it is a rational response to a financial system. I blame the Government for creating the system.

The logical next step for the trusts is to accelerate the declaration of readiness for discharge so as to get fines running as soon as possible. Local authorities will, logically, try to avoid the fines by making arrangements for the patients' discharge even if those arrangements are sub-optimal.

The real sufferers are the patients. The Government have been congratulating themselves on reductions in delayed discharges, but have kept quiet about the record levels of emergency readmissions. The latest quarterly figures show more than 36,000 emergency readmissions for the over-75s—a rate of 8.2 per cent, which is up nearly one percentage point on a year earlier.

The Minister may like to reflect on the performance of Barnsley, whose low delayed discharge rate he glorified in Committee. Barnsley may get patients out of hospital quickly, but 20 per cent of them—over double the national average—go back within 28 days. That is why the Bill is so dangerous. We are talking not about statistics, but about the human misery of readmission.

The Minister said in a letter to my noble friend Lord Howe last week that there is no connection between readmission rates and speeding up discharges and that the data are suspect. However, the plain fact is that the Bill will encourage early discharge. It is simply not credible to suppose that that will not lead to more readmissions.

When we debated the amendment in Committee, the Minister confirmed that the Government intended that the new system of NHS financial flows would work from 2005-06, so that the cost of patients readmitted within a certain period could not be recovered by the trust. I think that the new system is based on the assumption that early discharges result in emergency readmissions, so I am a bit confused about the Government's real views, given the letter sent to

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my noble friend Lord Howe last week. Do the Government believe that there is a connection between early discharges and readmissions? If there is not, why are they introducing a complicated embellishment to the financial flow system from 2005-06?

I could go into the many question marks that hang over the scheme that will operate from 2005-06, but the purpose of the amendment is not to adjudicate on whether a system of incentives in the NHS will exist. We know that it will not exist in October 2003, when, according to the Chief Executive Bulletin two weeks ago, the Government will be implementing the Bill, notwithstanding the clear view of your Lordships' House that it should be delayed at least until April 2004. Incentives will not exist in 2004-05 and whether they will exist in 2005-06 is a matter of extreme conjecture.

The amendment would simply delay the fining aspect of the Bill until there is such an incentive system in place. That may or may not be in 2005-06, but it is unlikely to be any earlier. There is no incentive system in the Bill to ensure that the NHS does not incorrectly transfer patients out of NHS care, as highlighted in the recent report of the health ombudsman, which we have discussed a couple of times earlier today. When fining is introduced, the NHS trust will have an incentive to discharge the patient as rapidly as possible and the local authority will be seen as a convenient whipping boy. That view will be aided and abetted by the PCT, which will also want the local authority to pick up the bill. Where are the incentives in the Bill for the NHS to discharge patients properly? I beg to move.

Lord Hunt of Kings Heath: My Lords, I disagree with the analysis of the noble Baroness, Lady Noakes. I refute her assertion that the Bill is one-sided. It will not work unless the NHS and local government pull themselves together and start to act together in a way that, unfortunately, is not happening in a considerable number of places in the country at the moment. The effect of the health service and local government failing to get their act together is the problem of delayed discharges. People are suffering. We know that there are examples of good practice where health authorities and local government seem able to ensure an integrated approach, and delayed discharges are kept to a minimum.

I emphasise a point that I made in Committee. Local government is not being treated as a whipping boy, as the noble Baroness suggests. The incentives, controls and monitoring will seek to ensure that the system is as robust on the national health side as it is on the local government side. We must ensure that there are no unintended consequences from the Bill. There is nothing that I would want to see less than the NHS declaring patients ready for discharge too early.

I remind the noble Baroness of Clause 2(1)(b), which refers clearly to a situation in which,

    "the responsible NHS body considers that it is unlikely to be safe to discharge the patient".

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In other words, the notification of a patient's likely need for community care services cannot kick in when the body considers that to discharge a patient would be unsafe.

We have the single assessment process, and the incentives in the Bill aim to get that process right. That should lead to a much more integrated approach between the local authority and the NHS trust.

All trusts are subject to rigorous performance management by strategic health authorities. Readmission rates are a specific performance indicator used to determine a trust's star rating. Anyone who has worked in the NHS recently or knows senior people in individual NHS trusts know that performance indicators leading to the star rating of an individual trust bite on the behaviour and actions of the senior management.

The Commission for Health Improvement has a remit to monitor quality and ensure that trusts provide a high standard of care, which they would not be doing if they discharged their patients from hospital too early. The Commission for Health Improvement provides an effective way in which to monitor what is happening.

The impact that high numbers of readmissions will have on a hospital's capacity acts as a disincentive for a hospital to discharge patients too soon. If hospitals need to treat the same patients twice because they have come back to hospital as an emergency readmission, they will have less capacity to treat patients on waiting lists and will not meet access targets, which will damage their star rating. These incentives are powerful enough to ensure that hospitals will not discharge patients from hospital before they are ready to go.

By 2005-6, the financial flow system will enhance the incentives that we already have. I do not see what benefit would be gained from delaying the introduction of the charging element of the Bill when it is the repayment that will provide strong incentives for all local authorities to put in place the services that they need to allow the prompt discharge of older people from hospital. Without the repayment element, the Bill will not be as effective. To delay it would simply mean that in many places it will take longer before older people ready for discharge from hospital can benefit. The noble Baroness omitted to mention the £100 million that is being made available in a full year from the NHS to local government to fund the additional element in relation to the cost of dealing with the current numbers of delayed discharges.

Taken together, I believe that the incentives are right. I believe that the Bill is even-handed. To delay its introduction and the financial penalties would be a disservice to those whom the Bill is intended to help.

9 p.m.

Baroness Barker: My Lords, before the Minister sits down, I should like to deal with two points raised in his reply. I follow what he says about performance management and star ratings. However, what will be the position when a hospital has become a foundation hospital? How will this system respond to that? Some hospitals will soon be foundation hospitals. Will he

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also respond to the point from the noble Baroness, Lady Noakes, about the Chief Executive's Bulletin which was circulated last week and has been the subject of some comment in professional circles?

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