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Baroness Andrews: My Lords, we all share the concern that discharge should be as safe as possible. That is one reason why we have given such careful thought to the ideas that noble Lords put forward. I assure the noble Earl, Lord Howe, that we will certainly consult local authorities on any further changes and take advice, as we have done before.

I am conscious that the noble Baroness, Lady Howarth, knows more about good practice in social services than does any other Member of the House. She has rightly spoken about the need for proper workforce assessment and planning to determine the impact. Many professions are changing the way they work. Social services have already done so. The changes that we are proposing will be a natural development from where social services are at the moment, taking into account where they want to be in the future. I hope that in time the changes will be positively welcomed in the modernisation of the profession.

On Question, Motion agreed to.


35After Clause 4, insert the following new Clause— "Delayed discharge payments: supplementary

    (1) In prescribing an amount under section 4(4) the appropriate Minister must have regard (among other things) to either or both of the following matters—

(a) costs to NHS bodies of providing accommodation and personal care to patients who are ready to be discharged; and
(b) costs to social services authorities of providing community care services to, and services to carers in relation to, persons who have been discharged. (2) Any payment which the responsible authority is required to make under section 4 in relation to a qualifying hospital patient shall, subject to subsection (2), be made to the responsible NHS body.

(3) In case of any description prescribed in regulations the payment shall be made to the person prescribed in relation to cases of that description.

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(4) Section 4 shall not come into force until 30 days after the Secretary of State has determined that the systems of incentives within NHS bodies operate to discourage NHS bodies from discharging patients inappropriately."

    The Commons agreed to this amendment with the following amendment:

35ALine 16, leave out subsection (4)

Baroness Andrews: My Lords, I beg to move that the House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35.

Subsection (4), which Amendment No. 35A removes, would delay the coming into effect of the part of the Bill that deals with delayed discharge payments until 30 days after the Secretary of State has determined that there are sufficient incentives within the system to prevent the NHS from discharging patients too early. Noble Lords will know that we had some problems with the amendment, because it does not fit with the main structure of the Bill. However, I understand the concerns of noble Lords, and the noble Baroness, who has been particularly concerned with this, that we have over-focused on social services and that there should be an explicit fairness between them and the NHS so that patients are not discharged too early, with all the consequences that brings.

Noble Lords are right to want to ensure that discharge follows proper procedures and is safe. We certainly do. The existing Commission for Health Improvement has a remit to monitor quality and to ensure that trusts provide a high standard of care. Clearly, they would not provide that standard of care if they discharged patients too early. I referred earlier in the debate to the successor body to CHI, which will be more independent of the department and will have a remit to monitor and report on patient experience and behaviour. The noble Baroness was very concerned that we should get away from data and statistics to look at real people and real hospitals. That monitoring will clearly cover aspects such as the patient's journey through hospital and discharge to another care setting. Noble Lords will recall that older people's services are the subject of a forthcoming Audit Commission study.

The National Centre for Health Outcomes Development is working with the department on improving data on readmissions. In the light of what the noble Earl said in our previous debate, that is very good news. We will certainly keep noble Lords up to date on that. It will help us discern when readmissions are caused by bad discharge factors and not, for example, by the epidemiology of the area, the demography or the high rate of chronic illness.

However, in response to concerns that the NHS may have got off lightly, we need to emphasise that strategic health authorities have a particular role to play through their performance management, because readmission rates are a specific performance indicator and therefore also have a direct effect on waiting times and access targets, which are all used to determine a trust's star rating. It is not in the interests of a trust to discharge patients too early and risk their being readmitted, because the impact on a trust's star rating carries with it a real financial penalty for trusts, in that access to

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performance funds is limited to high-performing trusts. So, a trust with a high rate of readmissions risks losing access to extra funding and freedoms. A core discharge policy that led to readmissions could also lead to a trust failing its clinical audit.

Thirdly, the impact that high numbers of readmissions will have on the hospital's capacity acts as a disincentive to discharging patients too soon. If hospitals need to treat the same patient twice because they have come back as an emergency admission, they will have less capacity to treat patients on waiting lists. We are talking about enlightened self-interest as well as proper performance management.

It is essential to ensure that the system that we put in place is fair to patients and to social services and does not have any unintended consequences, such as causing a riot and readmissions. I believe that we have robust systems in place to prevent that occurring. Noble Lords will remember the commitment I made in our earlier discussion on Amendment No. 23, that we will issue guidance requiring social services to review the care package within two weeks of an older person returning to their home from hospital. This review will take place earlier if that person is particularly frail or vulnerable or living alone, which means that any problems can be picked up. As I said, this guidance will be issued under Section 7 of the Local Authority Social Services Act 1970. Councils will be under a duty to follow it.

The three-month period between October and December when reimbursement operates in shadow form also provides extra time for the NHS and social services to ensure that the new systems introduced by the Bill function properly and to make any necessary changes. I believe that the monitoring that will be carried out by the new inspection bodies, the two-week review of the care package, the period of shadow operating and the existing incentives on trusts to perform well are powerful enough to prevent the NHS from trying to cut corners in its discharge practice and will ensure that patients are protected when reimbursement is introduced.

This may be the last time that I shall speak with, as it were, any freedom on the Bill, so I conclude by saying that I am grateful to all noble Lords who have informed and illuminated the Bill and its impact on people leaving hospital in a vulnerable condition. It has been a robust but extremely positive and constructive debate. We are all agreed that the Bill is the better for it and it sends a strong powerful signal to those implementing the Bill that Parliament is fully behind it.

I also pay tribute to my noble friend Lord Hunt of Kings Heath who carried the Bill through four-fifths of its passage and responded with his usual commitment and intelligence—and slight scepticism at times—but always in good heart. At the end of the day there is absolutely no distance between us. As the noble Lord, Lord Clement-Jones, said, we have the common interest of the individual patient at heart. We very much hope that this Bill will make a material difference to their prospects when they leave hospital.

Moved, That the House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35.—(Baroness Andrews.)

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5.30 p.m.

Earl Howe rose to move, as an amendment to the Motion that this House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35, leave out "agree" and insert "disagree".

The noble Earl said: My Lords, the noble Baroness will know that one of our objections to the Bill—and she has implied this in her remarks—is its one-sidedness. There is a yawning absence in it of any financial incentives and penalties which would bear down on the NHS in a manner commensurate with those bearing down on local authorities. I do not believe that it was an unreasonable expectation on our part that it should have been a more balanced affair than it is. This indeed was the impression conveyed by the Secretary of State when the Government's policy was originally announced. Without such a balance, the risk is that there will be nothing to deter hospitals from discharging patients too early or from rushing through the discharge procedure with excessive speed.

I believe that that is a very real worry. We are not convinced that the gradual introduction of financial flows over the next few years will represent an adequate counterbalance to the measures contained in the Bill, and certainly not for a considerable time. Nevertheless, I do not think that any purpose would be served by sending the amendment back to another place today. I say that partly because of the concessions which the noble Baroness has already made on the issue of monitoring. I was glad to hear what she had to say on that topic. I cannot stress too strongly that it will be the monitoring of how the Bill works in practice that will be of most value in informing and shaping future hospital practice.

That is not to say that ex post facto monitoring is as powerful a determinate of behaviour as financial incentives. We could have hoped for such incentives to be in place from the outset. Alas, they will not be. Nevertheless, I think we have some powerful substitutes in the work that will be done by CHI and its successor.

In the light of that perhaps cautions acceptance of what the noble Baroness has said—I welcome all the thought and care that she has devoted to the Bill since she took over the mantle from the noble Lord—I beg to move in order to give the noble Baroness, Lady Barker, an opportunity to say a few words. I beg to move

Moved, as an amendment to the Motion that this House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35, leave out "agree" and insert "disagree".—(Earl Howe.)

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