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Earl Howe moved Amendment No. 278:


On Question, amendment agreed to.

[Amendments Nos. 279 to 282 not moved.]

Clause 44 [Quality in health care]:

Baroness Barker moved Amendment No. 283:


    Page 16, line 20, at end insert "; and


(c) services to support independent living and rehabilitation"

The noble Baroness said: My Lords, we return to an issue on which we spent some time in Committee regarding the duties of the health service vis-a-vis services which are designed to bring back and facilitate independent living. The latter amendments in the group—Amendments Nos. 354, 355 and 356—concern the lack of clarity regarding the role of the NHS and the inspection of some long-term conditions.

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When we debated this matter in Committee the noble Lord, Lord Warner, gave one of the most surprising and disappointing responses that we have had during the whole of the proceedings on the Bill. He questioned the role of acute trusts and foundation trusts in relation to rehabilitation and prevention. I greatly appreciate the information that the noble Lord supplied to noble Lords on this side of the House in his letter of 4th November to the noble Baroness, Lady Noakes. In that letter he greatly clarified the situation as he pointed out—perhaps more fully than he could in Committee—that he believed that the bulk of the responsibility for rehabilitation and independent living lay with primary care trusts. However, in so doing, the noble Lord led us to the exact problem. In our original amendments we did not—and we are not doing so in these—refer to the role of primary care services or, indeed, community services. We referred specifically to the role of foundation trusts and acute services regarding rehabilitation and independent living.

During our previous discussion the noble Baroness, Lady Finlay of Llandaff, talked about the role of acute trusts in physiotherapy. A great many services that, historically, were carried out in the premises of acute hospitals are no longer dealt with in that way. A number of services, including cancer services, are now carried out in community-based premises as opposed to acute hospital premises. With the growth in intermediate care in particular—that is an area that I know particularly well, but there are others—an increasing number of people who for one reason or another would have received treatment in acute hospitals now receive similar treatment in other settings. It is the responsibility of the acute services provider, and of the inspection regimes under which the providers provide those services, that we seek to establish. That is perhaps clearer in the later amendments in the group which concern drug and alcohol services. Another area would comprise the role of medical services in care homes and in nursing care homes.

The amendments are tabled because there is a huge lack of clarity about exactly how CHAI and CSCI will work in relation to these services, which have moved from their typical location but which continue to be medical services run alongside social services. The responses that we received in Committee served, if anything, to highlight the confusion but they did not add any clarity. That is why we present them again for further debate today. I beg to move.

Baroness Finlay of Llandaff: My Lords, I support the amendment. I agree with the noble Baroness, Lady Barker, that there certainly was some confusion when the matter was discussed in Committee.

There used to be a clear dividing line between health and social care particularly for those patients who are cared for at home in the community. However, some very complex clinical scenarios now exist where independent living and rehabilitating someone back into society can occur only where there is a very high

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quality, highly specialised outreach service from the hospital combined with other infrastructure services to provide support in the patient's own home. A good example of that is patients who require intermittent positive pressure ventilation at night. The respiratory team will set that up and will be based in the acute hospital. The patient may be at home and may even be at work during the day but needs to be on ventilation over night and requires careful monitoring and support with the equipment, particularly if he or she has had a tracheotomy.

There is an increasing shift towards providing services where the patient wants them with more and more outreach services. The Bill's present wording seems to suggest that everything stops when someone has been treated. However, these patients have a continuum of rehabilitation and supportive care that often continues right through the rest of their lives. In some cases the acute medical infrastructure—I use the word "medical" in the broadest sense meaning all the medical health services—can later be withdrawn and the patient cared for with more of a social services infrastructure of support.

I have a slight concern that the amendment should contain the word "health" before "services" to make it read,


    "health services to support independent living and rehabilitation".

That might remove some of the confusion. That is my only reservation with the wording of the amendment. I completely support its spirit.

Baroness Howarth of Breckland: My Lords, my noble friend Lady Finlay illustrated why I find it difficult to support the amendment, without the need for further clarification. When services move into the community many people would rather have a service that does not have a particular medical orientation. What they want to receive is a medical service in a social or community setting. One of the great difficulties that has arisen in providing services, for example, in old people's homes where people are heavily dependent on care, and with adult disabled people—I declare an interest as the president of John Groom's Association for Disabled People, so I have some knowledge of these kinds of services—is making sure that you have the right balance of care.

I do not underestimate the difficulty of making decisions as regards which camp they fall in. My great concern is that they do not all become health services with medical orientation, thus losing some of the social care issues that come with rehabilitation.

4.30 p.m.

Lord Warner: My Lords, we have already discussed the issues raised by Amendments Nos. 283, 354, 355 and 356 in Committee, and I wrote to Peers on them on 4th November. With respect to Amendment No. 283, I explained that we did not believe that we should change the existing definition of healthcare in such a way, because to do so would suggest that services concerned with rehabilitation and independent living were generally provided by NHS bodies. In fact, they

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are most frequently provided by local authorities as social services, with health services provided as ancillary to those services. I totally agree with the points made by the noble Baroness, Lady Howarth.

I want to be absolutely clear that I am not suggesting in any way that such services will always fall within the definition of social care or always be regulated by CSCI. The NHS also provides rehabilitation services and, where that is the case, those will fall within the definition of healthcare as services provided in connection with the treatment of illness, and will be subject to inspection by CHAI.

The terms "rehabilitation" and,


    "services to support independent living",

used in the amendment are so broad that they could almost cover the entirety of adult social care. To amend the definition of healthcare as suggested would therefore give a misleading impression of the services to be dealt with by CHAI under the Bill, and those to be dealt with by CSCI.

I accept the point made by the noble Baroness, Lady Finlay of Llandaff, in terms of a continuum of care, and nothing that I say would seek to go against that. I shall give some examples to illustrate the point that I have been trying to make. In some cases, a discharge will be to onward rehabilitative care provided by the NHS. For instance, where an individual had recently had a limb amputated, they would be provided with ongoing pain management and rehabilitative services. Such services would be inspected by CHAI.

In other cases, a discharge might be made to a social care facility, where rehabilitation could take place. For example, a patient who had been admitted to hospital as a result of a fall might be discharged and provided with a care package to a sheltered housing facility. That facility would be subject to inspection by CSCI under the 2000 Act, even though there may be an element of healthcare such as community nursing in the care package. I am trying to illustrate that we want to see where the balance of effort lies in particular packages of care, always accepting that there will be a continuum of care. The definition in the Bill is appropriate.

Amendments Nos. 354, 355 and 356 were also tabled in Committee, and I return to the arguments that I made then. Services providing long-term care and treatment for drug and alcohol abuse are not providing acute medical intervention, as do hospitals, for people with those conditions. They primarily provide secondary care to aid recovery or manage ongoing secondary symptoms. Those facilities may have substantial input by nurses and allied health professionals, but have limited input from consultants or other doctors.

Nevertheless, those services are also providing substantial personal care for service users, including the most intimate forms of that care with toileting and bathing. In common with other care homes providing nursing input and personal care, those services should properly continue to be inspected by CSCI so that their

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welfare needs can be most appropriately met. CSCI will of course be able to seek assistance from CHAI where healthcare professional expertise is needed.

I understand the concerns highlighted by the noble Baroness, Lady Barker, about inconsistencies in registration for facilities providing services for long-term conditions and drug and alcohol abuse. We accept that in some cases the line between health and social care is very fine, and difficulties can occur around that line, regardless of where it is drawn. I agree that a consistent approach to registration should be taken, and CHAI and CSCI will work closely together and with providers to ensure such consistency of approach. However, the issue must be solved by working with the regulators themselves, rather than revisiting issues that were discussed, at length if I may say so, during the passage of the Care Standards Act in an attempt to redraw the boundary between health and social care.

The amendments will not solve the problem, but they could create new ones. They should not be pressed or they should be rejected.


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