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In addition to his statement from the Dispatch Box, only this morning I received a letter from the noble Lord, Lord Hunt, which underlined his every spoken word. Again looking back to the world of farce, belts and braces are highly desirable if you are in danger of losing your nether garments. The Minister has ensured that my long-practised art form will not happen here today. I am grateful for his support and beg leave to withdraw the amendment.
Both in Committee and on Report the Minister made much of the benefits for the patient of a minimum period of three days. The motives on these Benchesand, I am sure, on the Conservative Benchesare to benefit patients by these amendments. The noble Baroness, Lady Greengross, said that older people will not want to be left in acute hospitals for any longer than necessary. We say "Amen" to that. But, as I said on Report, the evidence shows that week-end discharges are three times more likely to lead to readmission than discharges earlier in the week. Would patients wish to be discharged where there is that kind of risk? I suggest not.
The Minister admitted on Report that the medical part of the discharge decision is unlikely to be made at the week-end. Why, therefore, should the care decision have to be made at the week-end when key staff may not be available, pharmacies may not be open, and so on? On Report, the Minister seemed to have the horrors of a resulting minimum five, six or seven-day period. Why? In Committee, the noble Lord, Lord Turnberg, expressed his understanding of how difficult it might be for local government to run the necessary rotas over week-ends and bank holidays.
The Government's motive appears to be simply to free up hospital beds in the shortest possible time. In Committee, the noble Earl, Lord Howe, referred to "passing the parcel", and throughout the passage of the Bill we have referred to patients being treated as commodities. The minimum period without allowance for bank holidays and week-ends is all of a piece with that approach. To date, the Minister has not refuted the example put in Committee by the noble Earl, Lord Howe, that notification could take place at 4.30 p.m. on Good Friday for a discharge no later than 11 a.m. on Easter Monday.
Throughout the Bill, the Government appear to be motivated by a punitive approach towards local government. The Minister believes that statutory agencies will make "excuse after excuse" to walk away from what the Bill is intended to achieve. This clearly reveals the coercive nature of the Bill. The amendment seeks to redress the balance and, at the same time, to make the procedures safer. I beg to move.
Earl Howe: My Lords, I support the noble Lord, Lord Clement-Jones, in all that he has said. In Committee, the Minister was heard to utter the words that have become so familiar to us in our debates on successive pieces of health legislation down the years"getting the balance right". I agree with the objective. What we have to decide, in the absence of direct experience, is where exactly the balance lies.
It is worth saying that the amendment and the case advanced by the noble Lord, Lord Clement-Jones, represent a compromise between the proponents of a much longer minimum periodsay five or seven daysand the position set out in the Bill. The argument for settling on three working days as opposed to three calendar days can be stated simply: it is better for patients and fairer on local authorities. It is better for patients because to be discharged at a week-end or on a bank holiday when community services and home care may not be available is, to put it mildly, less than optimal. For a local authority to be told on a Thursday that a particular patient must be discharged on the following Sunday when the patient requires long-term care is a recipe for stop-gap solutions for that patient. If we believe in patient consultation and, wherever possible, patient choice, we should not permit the system to operate on a basis that encourages rushed or superficial discharge planning. As it is, the Bill is likely to place many patients in temporary care settings pending a permanent placement, but the disregard of week-ends and bank holidays accentuates that likelihood unnecessarily and we should remove it.
If the Minister believes that the case is being over-stated, I humbly suggest that he should note the result of the recent survey by the Nursing Standard and Community Care magazines. The principal concern among respondents to that survey was that the system of financial penalties being introduced through the Bill will result in higher numbers of older people being placed in residential care rather than their own homes as care packages can take longer to set up.
Three working days is also fairer for local authorities. Every noble Lord who spoke in Committee made the point that to ignore the patterns of the normal working week will place enormous pressures on local authoritiespressures of staff and pressures of finance. A large number of local authorities are already experiencing substantial budgetary difficulties in social services, way beyond their SSAs. To compound that, the commitments that the Bill would force upon them for week-end and holiday working are unfunded. We all know that the Bill deliberately sets out to place burdens on local authorities, but I do not think that a requirement to have fully staffed social services departments for 365 days a year is in any sense reasonable or fair.
Baroness Greengross: My Lords, I have some difficulty in speaking on this issue because I am a vice-president of the Local Government Association and of Age Concern. I believe that the amendment is put forward with the best interests of older people at heart but it is too inflexible.
Neither the health service nor the local authority should be surprised when a person leaves hospital. I was involved with someone who was in hospital for two and a half weeks over the Christmas period and who could not be discharged because social services were not fully functioning. To put this requirement on the face of the Bill would not help the people I am most passionate aboutthat is, those who remain in hospital and who are not discharged.
It would be absolutely unreasonable for the NHS to issue a Clause 2 notice if it is impossible for the social services to comply. At the moment, social services do not work at week-ends but the NHS does. It would not be beyond imagination that in the future some people from social servicesthose who work with the acute hospitals to get people discharged and who organise the services they will needmay have to alter their ways of working to ensure that health and social services really do work together. Keeping people in hospital, for whatever reason, for longer than is absolutely necessary is not acceptable in this day and age.
On the other side of the argument, the Minister will have to be very careful when drawing up the regulations so that this cannot be seen as an attack on social services, but as legislation to ensure the rapid discharge of patients who ought to be out of an acute hospitaland who have been thrown backwards and forwards for too many years for me to remember without extreme distaste and anxiety.
Lord Hunt of Kings Heath: My Lords, I have given the matter a great deal of consideration because I recognise that the point raised by noble Lords opposite is a genuine concern about the practicalities that rest
I say to the noble Earl, Lord Howe, that I do not believe the Government are taking a putative approach to local government. Of course we want to see a marked improvement in the performance of local authorities, which builds on what is seen as good practice in a number of local authorities up and down the country. But that will not work unless the NHS also improves its performance.
I return to a point raised by the noble Baroness, Lady Barker, earlier. She talked about the problem of new nurses arriving on a ward not being apprised either of continuing care criteria guidance or of delayed discharge guidance. I agree with her. I think that that is a problem. But that will have to be tackled, as will the defects of local government performance. It is very wrong to think of this Bill as simply being aimed at local government. It will not work unless the health service and local authorities get their acts together.
I turn to the issue of social services departmentsthe fact that they do not work seven days a week and that therefore it would be impossible for them to respond to the timetable. Whether it is a weekend or a bank holiday does not mean that the older person delayed in acute hospital simply disappears or is any less vulnerable to the consequences of a delay. Although a couple of days may not sound a great deal, we know that institutionalisation can set in rapidly. I do not see why older people should suffer simply because social services do not work at weekends.
Surely, we need to move away from the perception that social services should be provided only between the hours of nine to five on a weekday. We need a more flexible approach to working hours so that the needs of individuals can be met more effectively. I think that that too was the message of the Climbie report. To exclude Saturdays, Sundays and bank holidays on the face of the Bill would, I contend, send entirely the wrong message about what is acceptable and what we expect for older people.
The other point worth making is that, where a minimum number of days is set before the charging element is triggered, delays will always tend to drift up towards that minimum. So if we set the minimum number of days as three, then, where the minimum period falls over a week-end, the patient will usually end up waiting for at least five days. For someone who is ready to go home sooner, five days is an unacceptably long time to wait.
I have already made clear that since the majority of patients who become "delayed discharges" are in hospital for a longer period than three days, there will be a longer period to plan and put services into place. The vast majority of cases where the patient is ready to go home within the minimum compliance period are likely to be simple cases where it should not be unduly challenging to carry out an assessment and put services in place. Where a patient with particularly complex
I have made this point already: an acute hospital bed is the worst place for a vulnerable older person to be when they can no longer benefit from acute care. They are at risk of losing their independence and at the unfortunate risk of picking up hospital acquired infections. We should aim for them to be moved to a more appropriate environment where they can benefit from some rehabilitative input as soon as possible. The minimum compliance period should accept that.
I have given the matter a great deal of consideration but I do not believe that it would be right to support the amendment. We must give a clear indication to the NHS and to local government of what we expect. I believe that in the interests of the individual concerned we should keep the minimum number of days as presently set out.
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