Amendment proposed: No. 37, in page 7, line 32, leave out from 'require' to end of line 33 and insert
'any of the following services to be provided free of charge for a period of more than six weeks—
(a) the provision of accommodation under Part 3 of the National Assistance Act 1948;
(b) the provision of personal care to a person in any place where that person is living, other than accommodation provided under that Part of that Act;
(c) a service provided to a carer under section 2 of the Carers and Disabled Children Act 2000 which consists of the provision of personal care delivered to the person cared for (in accordance with subsection (3) of that section).'.—[Jacqui Smith]
Question put, That the amendment be made:—
The House divided: Ayes 464, Noes 50.
I beg to move, That the Bill be now read the Third time.
Throughout Second Reading, in Committee and during today's deliberations, we have given this Bill fair and measured consideration, and I want to thank all who were involved in Committee for that. Combined with a significant package of extra funding for older people's services, the Bill will bring an end to widespread delayed discharges, and ensure that older people get the services that they need when they need them. It is a Bill that is about the approximately 5,000 mainly elderly people who are delayed unnecessarily in an acute hospital bed. We know that an acute ward is very much the wrong place for someone to be when they are no longer in need of acute hospital care. To be delayed on an acute ward is demoralising for the individual;
it can damage their confidence and their prospects for living independently or returning home in future. It is worrying for their families and carers, and bad for the taxpayer and the NHS, and that is why we are determined to tackle the problem.
We have made progress. Fewer people are delayed in hospital now than in 1997, but each person stuck in hospital when they want to be out is an argument for change. Throughout the passage of the Bill, Opposition Members have been quick to oppose but slow to suggest alternatives. As we have heard this afternoon, the Liberal Democrats propose lots of plans, but they have been short on solutions. We know that the Conservatives, who we have learned are the new-found friends of local government, oppose the extra investment that the Government propose—they voted against it—but they cannot even claim to be reformers. In their opposition to the Bill, they certainly cannot claim to be the friends of older people.
The Bill reflects our determination to match our extra investment with reform of the system to ensure that the needs of older people come first. It will do that, first, by creating a strong financial incentive for local authorities to comply with their existing duties to assist the needs of individuals who are likely to need community care services on discharge from hospital and to provide services to those individuals.
Secondly, the Bill strengthens partnerships and brings about increased co-operation between the NHS and local authorities by introducing new duties for them to consult each other in assessing the patient's needs and deciding what services they will make available within set time scales.
Thirdly, by removing local authorities' power to charge for community equipment and intermediate care, the Bill simplifies the existing charging system, making it easier for users to understand and easier for local authorities and the NHS to provide those vital services jointly. Contrary to the concern that has been expressed today about partnership between health and local authorities, I believe that the Bill will lead to increased co-operation and joint working. For the first time, there will be a strong incentive for partners to get together to ensure that their discharge procedures work.
In certain ways, the Bill is already having a positive impact. Local authorities and their NHS partners are coming together in order to find common solutions to common problems and acknowledging the different parts that they have to play in achieving success. We know that planning for the implementation of reimbursement has led many partners to agree, for example, that they need to speed up their plans to implement fully a single assessment process. I feel confident that with so much good work and innovation already going on around the country, by the time reimbursement is implemented later this year, many local authorities and their NHS partners will have been able to find new and creative solutions to the problem of delayed discharge.
Opposition Members have worked hard during the Bill's passage to paint local authorities as victims. In fact, there is only one victim—the older people who are stuck in hospital when they should be out there getting the sort of services and support that we know they want and deserve. Let us be clear: the Bill does not place new responsibilities on local authorities. It simply seeks to add maximum time scales for the assessment and provision of services for which local authorities already have responsibility and places communications between a hospital and a local authority about a patient's case on a formal legal basis.
Of course, the Bill places new responsibilities on the NHS to inform local authorities when someone may need ongoing care in order to leave hospital and when people are fit to be discharged. We know that the NHS has not always taken its responsibilities to communicate with social services departments as seriously as it should. The Bill rectifies that and places the responsibility for payment where the responsibility for provision already lies.
As I have said already, these are not new responsibilities. Councils have had 18 months and #300 million in building care capacity grant, which has provided vital funding for councils to invest in the services and capacity needed to prevent delays. That investment has brought results. Almost 7,000 older people were trapped in hospital in March 1997, but by September last year that level had been reduced to 4,147. However, we have recognised that there are funding pressures for social services. That is why, in addition to the #1 billion package for older people announced on
There has quite rightly been a focus during our debates here and in Committee on the needs of individual patients and their carers. That is right, because it is that focus that is at the centre of the Bill.
As I have explained this afternoon, the Bill does nothing to weaken a patient's right to consent or not to treatment. By creating a financial incentive for local authorities to carry out their duties, it will help to ensure that the needs of individual patients are met more quickly, and it will increase the choice that is available to them in terms of the services that they receive.
In the amendments that we have tabled today we have recognised the concerns about the needs and role of carers. We have also ensured that carers' services for discharge will need to be in place and that carers can benefit from free community equipment where they need it for their caring.
Reimbursement and other proposals in the Bill will lead to increased quality and choice for older people. If local authorities are to avoid delays, in the long term they will need to use the extra investment made available by the Government to invest in a wide range of services and capacity so that they can respond flexibly to an individual's needs, not just with residential care but also with intermediate and interim care, extra sheltered housing, equipment and adaptation services, and packages of intensive support at home, among other provisions.
The Bill presents an important opportunity to end widespread delayed discharge and to ensure that thousands of older people do not wait needlessly on an acute ward every day but are provided with a range of high quality community care services to meet their needs as soon as they are ready to leave. Ultimately, a safe transfer from an acute ward to a place where their needs can be more appropriately met is the minimum that older people should be entitled to and expect. That is what the Bill will ensure happens and I commend it to the House.
To listen to the Minister, one might think that the Bill, which has almost completed its passage through this House, had emanated from a group of young Labour researchers meeting in some chi-chi wine bar in Islington, who, as the chardonnay got to them, thought they had come up with the most wonderful wheeze to deal at a stroke with the problem of delayed discharges. More worryingly, it seems that when they awoke the next morning they did not realise that the hazy wheeze of the night before was not such a good idea, and proceeded to pass the idea on to Ministers who, desperate for a quick fix, immediately embraced their ridiculous proposal and got the parliamentary draftsmen to produce a Bill which the Minister tells us is a series of incentives. We all know that the Bill is not a series of incentives: it is a straightforward system to fine local authorities.
What is so deeply disturbing about the Bill and the complacency of Ministers in the Department of Health is that the Bill in no shape or form recognises the crisis in long-term care in Britain—a crisis that has been gathering speed since 1997. Nowhere does the Bill address the problem of the loss of more than 60,000 care home beds, the closure of more than 2,000 care homes, or the fact that 100,000 households are no longer receiving domiciliary care compared with five years ago. That is what is so disgraceful about the Bill. It is a wasted opportunity.
By creating a system in part 1 that will effectively bamboozle local authorities into ensuring that patients are discharged from hospitals to avoid a fine, the Government think they have found a panacea, whereas in fact it is a short-term fix that will end in disaster. I predict now that in the next two years readmission rates for elderly people leaving hospital will increase at a higher level than the current rises. People will be taken from hospital and placed in what is not necessarily the most appropriate care for their needs because the local authority may be charged a fine.
The Government have got it wrong; that is not the right approach. As hon. Members have said, it will undo and damage partnerships between the health service and social services, which have taken a long time to achieve because of natural problems and jealousies in relation to who is responsible for funding. Under the previous Government—and, to their credit, this Government—the process of breaking down the barriers between the health service and social services has moved significantly forward, which is to be welcomed. This Bill will do great damage to that process, as it will create tensions between the two sides and reintroduce a blame culture that we all hoped was being banished as a thing of the past.
Although the Government have made money available for three years for local authorities to try to offset, in theory, the impact that the fines will have on social service funding and spending, there are also problems with that, as the fines are to be introduced on
For all of those reasons, I remain implacably opposed to part 1 of the Bill. I am disappointed that the Government have not been prepared to listen more carefully to those who oppose the Bill and who have highlighted its failings. I am a realist—I know my lot in life—and I understand that the Minister of State, charming as she is, will not necessarily listen to my helpful advice. But she does not have to listen to my advice: from her point of view, there are far more credible critics of this policy. There are Back-Bench Labour Members with great experience of social services and local government or the health service who are gravely concerned about this aspect of the Bill. There is the Local Government Association, whose leader, Sir Jeremy Beecham, unless I am wrong, is the Labour leader of Newcastle city council. There are most of the voluntary groups and charity groups in the long-term care sector. The care home owner associations and operators also believe that the Bill is a disaster. Many local authorities throughout the country genuinely believe that the Government are wrong and that the Bill will not solve the problems that they expect it to tackle.
I do not know whether the Minister has had an opportunity to phone social services departments in England and Wales. My office had a charming conversation with her social services department. We also contacted that of the Under-Secretary, Ms Blears and of the other Minister of State. We even spoke to the social services department in the Prime Minister's constituency. Not one had a smidgen of enthusiasm for fines, and they were worried about the amount that they might have to pay in fines in the next 12 months. Despite that, Ministers have not been prepared to reconsider.
We are now beginning the last 25 minutes of debate in the House on this nasty and flawed measure. Of course, it will leave the House with a majority in the next hour and go to another place. I assure the Minister that we shall continue to oppose it there, because we believe that there is a serious problem that needs tackling. I agree with her that the real losers are the patients who experience delayed discharge from hospital. However, the Bill is not the way in which to help them and minimise the problem. I therefore urge my hon. Friends to join me in vehemently opposing Third Reading.
The Government deserve much credit for the steps that they have taken and the measures that they have introduced to improve collaborative working between health and social services departments. However, the Bill does not deserve credit and I agree with some of the points that Mr. Burns made and the anxieties that several hon. Members have expressed.
The Health Committee examined delayed discharges, and we did not receive evidence from any source—health departments, social services departments or voluntary organisations—in support of the principles at the heart of the Bill. Not even Department of Health officials appeared especially enthusiastic about it. I made my anxieties known on Second Reading, but the Minister did not respond to them. She is a competent Minister, for whom I have a high regard, but I remain convinced that the Bill does not tackle those concerns.
The model is based on the policies that were applied 10 years ago in Sweden. It was interesting to visit that country shortly before Christmas and discuss with political colleagues in the Swedish Parliament whether the measure could work. I admit that some improvements have occurred in Sweden, but colleagues were concerned about the number of people whose discharge from hospital was delayed. In Sweden, county councils run hospitals and municipalities run social services, and integration is being considered.
I humbly suggest that the Government may eventually want to consider that the lack of an integrated health and social care system is the genuine problem. An increasing number of Labour Members who have examined the matter are beginning to agree that integration is the way forward.
I cannot support the Bill. It is a bad measure that has not been thought through. It will damage the good, positive relationships between health and social services departments that the Government have created in some areas. I hope that, even at this late stage, they will see sense and take advantage of opportunities in another place to withdraw the measure.
I hope that the Government will take to heart the very measured comments that we have just heard from the Chairman of the Select Committee on Health.
I preface my brief remarks by saying that, given the terrible hand the Minister was dealt in being asked to take the Bill through, she did so with competence and patience, both in Standing Committee and on Report.
I said on Second Reading, which seems very recent, given the speed at which the Bill has gone through the House, that the Bill was one of the worst I had seen in some 30 years. Despite the heroic attempts by the Opposition parties and the welcome amendment that we have just passed on carers, I think that it is one of the worst Bills to go through the House in those 30 years. If there is one discharge that should be delayed, it is the discharge of this Bill from the other place.
I hope that the Government will find that their ambitions to get the Bill through quite quickly, by April this year, are dashed by the very serious consideration that those in another place give it. We have not had proper time to consider it. There were chunks that we did not debate in Standing Committee. We lost an amount of time on Report because of the statements that, understandably, were made.
Not only has the Bill been rushed through, but the timetable for implementation is very challenging. The Minister has ignored the many pleas from those who have to implement the Bill to delay it until April 2004. That was a concession that she might well have made.
Of course, the Bill is unwanted by local authorities, but it is also unwanted by the health service. We heard in Standing Committee of representatives of the NHS Confederation and of the medical profession saying that they did not want it either, because it will damage the relationships that they value between them and social services.
The Bill has been condemned by all the voluntary organisations. Just today, we heard from Help the Aged, Age Concern and the Alzheimer's Society. I cannot think of a single voluntary organisation that has welcomed the Bill. The point made by those to whom I have referred is that the Bill is misguided, because it focuses on one very narrow part of the problem—the discharge from hospital to care in the community, a care home—instead of standing back and taking a holistic look at the problem from start to finish.
The Bill is unfair and unilateral. It involves a unilateral fine by one part of the public sector on another, with no opportunity for that other sector to obtain reimbursement when it faces costs because of delays by the NHS. If there is a dispute, as we heard earlier today, the jury is not wholly unbiased.
The Bill ignores the role that the Government have played in reducing the capacity in the care home sector, which is one of the strategic reasons behind delayed discharges. It will distort local government priorities. Local authorities will spend less time and energy on prevention to avoid the fines. As we heard today, if one wants to get somebody into a care home, the best way to do it now is to get them into hospital first. The law of unintended consequences and perverse incentives will apply.
On Second Reading, the Bill was virtually friendless on the Government Benches. Indeed, the only contribution from Labour Members on Third Reading has been deeply hostile. At a time when the NHS needs less bureaucracy it will get more, with invoices flying backwards and forwards between social services and the NHS. I know of no right-wing economist in this country who ever proposed an internal market of this nature to deal with the problem.
I believe that the Bill is flawed in concept and will be divisive in its consequences. I shall walk through the No Lobby with a spring in my step to register in the only way still available to me my deep-rooted objection to this legislation.
Mr. Burns and my hon. Friend the Member for Wakefield, for whom I have a great deal of time and respect, seem able to see only the negative points. They seem to think that the Bill will create a combat atmosphere between social services and the health services. I do not see it that way. The Bill will concentrate people's minds on better co-operation.
No, not like that.
We are talking about people, mostly old people, being trapped in hospital, and some social service departments and health authorities are doing very little to tackle that. Fortunately, in my constituency, they are doing something. Planning for discharge starts before patients are admitted for elective surgery, and that is how it should be. The team that works in Doncaster can call on a range of options. If necessary, it can use an intermediate care ward, which has been provided by joint funding, as well as aids, adaptations and all the rest of it. The proposals need not be combative at all; they can lead to more co-operation.
Let us not forget that the Bill is about getting people out of the hospital beds in which they are trapped even though they no longer need health care treatment. That is why I shall walk through the Lobby tonight in support of my hon. Friend the Minister and the Government.
I thank Mr. Hinchliffe and his Select Committee for the report on delayed discharge that they published last year. It is an invaluable piece of research, which I found very useful in Committee, and many of the questions put to officials during the inquiry provided useful answers. As I read through the evidence given to the inquiry, it suggested to me that there was a great lack of enthusiasm among officials and, indeed, anyone who gave evidence about this approach. Indeed, officials said that delayed discharges are a symptom of a wider, whole system problem and that we are lacking in capacity, in planning and in preventing admissions in the first place. Four Committee sittings and consideration on Report later, nothing fundamental has changed in the Bill.
Rather than building on and continuing to encourage the partnership between the NHS and social services departments that hon. Members on both sides of the House would wish to develop, the Bill will create an adversarial approach of game playing and cost shunting between the two. Worse still, it will turn the patient into a commodity to be haggled over by social services departments and the NHS. There is no room in the Bill for informed consent.
As the Bill has progressed through the House, I have been drawn to the conclusion that it is about beds, not the needs or interests of patients. It is a strange sort of partnership that gives one partner a stick to beat the other. That sounds rather more like domestic violence than addressing the real needs of the health service.
The Bill, as it leaves the House, will put in place a system of fines, as the Minister has confirmed from the Dispatch Box today, that will distort the spending priorities of local social services departments. Those departments will have to prioritise hospital patients for assessments and services, because a fine is attached, at the expense of those who are hidden, frail and isolated, in their own homes and who count only when they wind up in hospital because of a fall or some other mishap.
In Committee, the Minister talked about the introduction of financial flows—she did so again today—that will lead to hospitals picking up a penalty if emergency admissions take place. She conveniently did not mention that that reform would not start until April 2004. She did not tell us that the single assessment process will not start until that date; nor did she tell us that, although some extra cash for some councils will arrive in April this year, councils did not know the details of those budgets until December and are only now beginning to find out what they mean for them and their communities in terms of council tax rises and investment in services. It is hardly surprising that the services to bridge the gap in capacity have not yet been put in place. The Minister has remained blind to the issues of capacity throughout this debate.
When the Bill makes its way to the House of Lords, I can assure the Government that my colleagues on the Liberal Democrat Benches will do all that they can to ensure that it does not have a safe passage through the other place. I thank my hon. Friend Mrs. Calton and my staff for their hard work on the Bill. This is a bad Bill, and the Liberal Democrats reject it. It puts beds before patients and sets the NHS up against social services. It makes it much more likely that, in future, more people will get the wrong care in the wrong place at the wrong time.
I have sat here all afternoon listening to an unending stream of negativity and doom from the Opposition Benches. I feel compelled to rise to speak, because the Bill offers two major benefits to which the two Opposition parties have given no regard whatever. First, it will lead us, as a society, to support more people at home and lead to much less reliance on institutional care than at present. Secondly, it will bring down the average length of stay in acute beds, which will allow more patients to be treated on the NHS. All Opposition Members agreed that it would bring down the average length of stay, yet they seemed to suggest that that was purely negative. I put it to them that it might actually be positive.
Why will the Bill help more people to live at home for longer? My own family experience tells me that, once a patient has been deemed fit for discharge—that is, once a clinical decision has been made to discharge them, so there is no question of their being forced home too early—it is in the patient's direct interest that that discharge should happen as soon as possible. We have all seen examples of people who have languished in hospital for too long, then drifted into residential or nursing care and lost the opportunity to go back home and be supported there. The Bill will expedite the discharge process and, together with the provision of free aids and adaptations, get more people home once they are able to cope.
Unlike some on the Conservative Front Bench, I do not believe that nursing homes are a good place to be. I saw my grandmother deteriorate rapidly after she went from a long stay in hospital to residential care and then to nursing care. Her personal possessions were stolen while she was in residential care, and her wedding ring was ripped off her finger in the last days before she died. Nursing homes are not a good place to be. We need to encourage more people to live independently at home, which is what I believe the Bill will allow us to do.
The Bill will bring down the average length of stay in NHS beds, which will allow us to treat more NHS patients. Like the Health Committee Chairman, I, too, went to Sweden. We visited the Huddinge university hospital and heard from Dr. Lars Collste.
The hon. Gentleman did not go to Sweden, so I will not let him intervene.
Dr. Collste told us that, before the cross-charging system was introduced in Sweden, the average length of stay for an in-patient episode was seven to eight days. After the system was introduced, it went down to 4.8 days. His view was that the system worked.
I will not, because other Members want to speak.
We also heard, as my hon. Friend Mr. Hinchliffe said, that the system was being reviewed by the Swedish Parliament. That is true. It is looking at ways in which the cross-charging system can be reconciled with more co-operation. It is not ditching the system; it is simply looking at how municipalities and counties can co-operate more when the system is introduced. I do not think that that is a bad thing, and the Department might like to look at the experience in Sweden before the measures in the Bill are finalised.
I congratulate the Minister on her skilful steering of the Bill through Parliament, and I look forward to it bringing the two major improvements that I have outlined to my constituents.
I welcome the opportunity to speak on this important issue. I shall preface my remarks by saying that I fully support the aims of the Bill. I have listened to my hon. Friend the Minister speak with some passion about the needs of elderly people trapped in hospital beds who ought not to be there and who need an appropriate form of care. It is absolutely vital that those people get the care appropriate to their condition or illness, whether that be a hospital bed, a nursing home bed, a place in a care home or intermediate care home, or support in their own home.
I rehearsed some of my concerns on Second Reading, and I still have concerns about the implications for local authorities, but one aspect of the Bill that I welcome is the introduction of new, robust joint assessment procedures. As I have said to my hon. Friend the Minister before, in my local area we have good working between health and social services, which I want to continue, but I am aware that the situation nationwide is variable, so it is vital that we have a new and comprehensive assessment procedure to benefit patients in hospitals.
Will my hon. Friend the Minister look carefully at the implementation timetable and listen to the concerns of local authorities, the health service and, especially, those elderly people who all need caring for? Will she carefully consider the comments that she is getting back to ensure that she is properly monitoring the implementation timetable so that local authorities, health services and, above all, the elderly people we represent are not disadvantaged?
I echo the plea of my hon. Friend Mrs. Humble for clemency for local authorities such as mine, which have been doing their damnedest to do exactly what the Government have asked. They are producing the close working, but, none the less, they face problems and circumstances that are totally beyond their control, such as shortages of nurses and elderly mentally infirm beds as well as trained care workers to provide domiciliary care services. That means that punitive measures in clause 4 will cost them about #1 million a year if they are implemented this spring.
The authorities need more time, and it would be folly and very sad if the #100 million that the Government are giving to extend care capacity for this purpose were simply taken back in fines. That would achieve nothing. Therefore, sensitive timing of the implementation of the more difficult measures is essential.
On Second Reading, I paid tribute to the absolute commitment of Camden, my local authority, to creating a multi-faceted, properly integrated, high-quality service for elderly people. Indeed, my hon. Friend the Minister paid tribute to Camden and, I believe, Croydon on Second Reading and in Committee for their abilities in reducing delayed discharges, but I must tell her that my local authority's concerns are by no means stilled or quieted. I add my voice to those of my hon. Friends who have urged the Government to pay particular attention to the timetabling of the introduction of these measures.
On going into the fine detail, my local authority discovered that, far from getting a 6 per cent. increase, it is receiving only a 3 per cent. increase in social services funding. Certain authorities suffer from a shortage of available places, because the majority of elderly people undoubtedly want to remain in their locality, which can be a particular difficulty for an inner-London authority such as mine. There are also concerns in my local authority over the costs of implementing the examination of throughput on the issue. It urges the Government to allow it time properly to track how it can better integrate the more-than-one service required to ensure that elderly people are not left in hospital past the point required by their medical care.
I urge the Government to delay, if possible, the introduction of the measures until all local authorities have properly examined such questions. I accept that not all local authorities are as effective or committed as Camden, but I do not believe that the effective and committed local authorities should be punished because others have still not got their act together.