The amendments would impose a permanent statutory duty on inspection bodies to monitor the impact of the Bill on patients and carers, and a permanent statutory duty on the Secretary of State to report annually to Parliament. The implication seems to be that health and social care professionals will irresponsibly discharge patients with inappropriate care packages, but we do not believe that this will be the case. Of course, they will also duplicate safeguards and inspection mechanisms already in place, and will jeopardise the independence of those that are planned.
NHS and local authorities should, of course, already monitor the quality and effectiveness of their discharge arrangements, which are subject to the normal performance management, performance assessment and monitoring and inspection arrangements. Current inspection bodies already monitor the quality of discharge arrangements and the effect on patients and carers as part of their normal inspection and monitoring activities. For example, the social services inspectorate monitors the quality of services to older people. This will include the achievement of national priorities and targets—including the proportion of those helped to live at home, compared with residential care—as well as local improvement plans. As part of that, it will of course look at the quality of community support following discharge from hospital. It will also question the balance between investment in services and the amount spent on reimbursement charges.
In a similar way, when the Commission for Health Improvement reviews clinical governance arrangements within a hospital, it covers planning of patients' entire hospital stay and their discharge. That is an important part of its review methodology. Of course, where a combination of performance indicators and inspection points to particular problems in a given area, the inspection bodies and, ultimately, the Secretary of State have an escalating power to intervene, and to ensure that action is taken to improve outcomes and performance.
As hon. Members know, we have introduced legislation to establish two new health and social care inspectorates: the Commission for Health Care Audit and Inspection and the Commission for Social Care Inspection. We have already stressed that those bodies will strengthen the accountability of those responsible for the commissioning and delivery of health and social services, and an important part of this role will be for both inspectorates to report annually to Parliament on the provision of NHS and social care. However, we have also stressed their independence from the Department, so although they will agree priorities with the Department, it would not be appropriate for detailed instructions such as those proposed in the amendments to pass from the Secretary of State to the inspectorate concerning the details and the frequency with which they need to inspect particular elements of older people's services.
We do not believe, therefore, that it is necessary or appropriate to impose that permanent and specific statutory duty on the inspection bodies to monitor the effects of this Bill, or to impose a duty on the Secretary of State to report every year to Parliament specifically on the Bill's effect.
I should say at the outset that I am very disappointed with the Minister's assessment of, and views on, two very valuable and important amendments for the raising and maintaining of standards. This Government have rightly—I am not criticising them—always maintained that patients, the NHS itself and the professionals who work in it should attain the highest possible standards, and that the quality of care should be of the highest level. I can assure the Minister that I do not disagree with her one iota on that important issue. As constituency MPs, we owe that to those of our constituents who may use the national health service, and to the NHS itself because of the professionals who work within it. What surprises me is that the Minister, by rejecting the amendments, does not seem to share our enthusiasm for ensuring the highest quality and standards in all areas of the NHS.
For example, Lords amendment No. 24, notwithstanding the Minister's comments, seems eminently reasonable. It asks that
"The Secretary of State shall specify to the bodies charged with inspection of health and social services that they should monitor, at regular intervals, the impact of this Act on patients and their carers."
On the face of it, that seems to be a welcome added benefit to health and social care. So that the Minister fully appreciates the intention behind the specification that the Secretary of State would be expected to make, I confirm that the bodies that would be charged with the responsibility would be the Audit Commission, CHI—and its successor, if and when other legislation is introduced—and the social services inspectorate.
The Government have been in power for six years now, during which time they have taken a perverse pleasure in examining every nook and cranny of our national life. They have not been averse to increasing bureaucracy, but when the other place makes an eminently sensible suggestion to ensure that standards are maintained, they—somewhat churlishly on this occasion—reject it. Under the Bill, the patient should be the most important part of the equation of the provision of health care, but the pressures that will be placed on social services by the fines system will mean that the patient will be the piggy in the middle, caught between the NHS and local authority social services departments.
My hon. Friend is making an effective case and demolishing the Minister's arguments. Is not the Minister wrong when she says that the amendments imply that some sort of wrongdoing is likely to take place? The words added by the other place refer to monitoring and to reporting back to Parliament and, in a democracy, that is eminently sensible and desirable.
I am indebted to my right hon. Friend. Perspicacious as ever, he has anticipated a point that I was about to make. In all candour, I was surprised and shocked by that comment from the Minister, because it was unfair. Nothing in any amendment to health legislation that I have supported has ever criticised or cast doubt on the huge professionalism of the staff at all levels of the NHS. It perplexed me, listening to the Minister, and I carefully read the words again in case the other place had—uncharacteristically—slipped up. I could not see that it had, and I am sure that the Minister will wish to rectify her comments later.
I shall try to be charitable to the Minister and suggest that she and my hon. Friend are simply and genuinely at cross-purposes. When the Minister talks about the existing inspection and audit regime, that is fine, but we are talking about a Bill that may have all sorts of unintended consequences. If those consequences are undesirable—because, in the real world, it is just possible that the Minister could be wrong about the Bill—the sooner that we identify by specific audit any national trend that suggests that, the better for all of us.
My hon. Friend has made an important point, and he is right. We must ensure that we get the legislation right at this stage. I must say that I took umbrage at one point in my hon. Friend's intervention when he suggested—unless I misheard him—that the Minister was at cross-purposes with me because she wanted the best in this legislation. I find that difficult to reconcile in one respect. How can the Minister want the best for the Bill when she is bringing in a rather nasty system of fines on local authorities? That does not equal wanting the very best from the Bill. The Bill will do exactly the opposite of providing the very best.
Before those helpful interventions, I was saying that the Bill will mean that patients become caught, like piggy in the middle, between the NHS and local authorities. That will happen because the Bill will pressure authorities to discharge patients to avoid a fine. I am sure that the Minister does not want patients to suffer in any way. She is talking to her silent Whip at the moment; if she were listening to me, she would be able to hear what I want to tell her in all sincerity. However, she is clearly not listening and will therefore have to read Hansard.
The Minister says that she has heard it all before, which is odd, as I have not presented this amendment before. It has come from another place, where common sense has prevailed and caused the Government to suffer a defeat. The Opposition in this House are trying to save the Government from making another mistake in overturning the amendment.
Before that rather cruel intervention—the Minister cannot have heard my speech before—I was saying that it is important that patients do not suffer. I am sure that the Minister agrees with that. However, the Bill could cause them to suffer as a result of the possible early discharge from hospital to residential care or to domiciliary care in their own homes. That discharge could happen because local authorities want to avoid fines. The result could be emergency readmissions, or an unacceptable level of readmissions to hospital, within a seven to 28-day time scale.
In an earlier debate, I set out the rising incidence of emergency readmissions to hospital among people aged over 75. The statistics show that there is a problem, and I argued that it could be exacerbated by the Bill. Amendment No. 24 would help to minimise that potential problem.
Similarly, in the rush to avoid a fine, patients could be discharged into inappropriate care, or into the least appropriate care. No one wants that to happen, but it may be an unfortunate consequence of the possibility that local authorities could be fined. Alternatively, patients could be discharged to their own homes without adequate support services from either the NHS or the local authority social services department. Carers could suffer because undue burdens are placed on them when patients are discharged—by local authorities wishing to avoid being fined—without the support of a proper and comprehensive care package.
Amendment No. 24 would alleviate those potential problems. It would allow the situation to be monitored, as reports would be made to local authorities and the NHS. In that way, the problems that could arise would be minimised. For that reason, the Minister got it wrong when she criticised the amendment in her opening comments. She should think again.
Amendment No. 25 is eminently sensible. It would straightforwardly require the Secretary of State to report annually to Parliament on the outcomes of patients affected by the provisions in the Bill. I should have thought that the Government would warmly welcome that. Certainly, in opposition, they were strong proponents of open government. We have heard the rhetoric—they have talked the talk, but they do not often walk the walk—that people should be empowered with information and knowledge. The amendment represents a classic example of that. It is justifiable that Parliament—which will, if the Government get their way, pass this unpleasant Bill—should be made aware of the outcome of the legislation that it passes. That is not an unreasonable requirement, and I should have thought that the Government, in the spirit of open government and empowering people with information, would be prepared to accept it.
There may be an overriding reason why the Government do not want the Secretary of State to be required to report annually to Parliament on the outcomes of patients affected by the legislation. Perhaps, in their heart of hearts, they accept the arguments that my right hon. and hon. Friends and I, as well as the Liberal Democrats, have been making for many months—that the Bill is counterproductive and highly damaging, that it will destroy partnership working between the health service and local authorities, and that it will have an adverse impact on patients because it will increase pressures on the early discharge of patients, especially elderly patients over the age of 75. As is shown by the statistics that the Government have produced in recent months, those pressures have led to a rising level of emergency readmissions. In fact, it is probably the case that the Government do not oppose the principle of amendment No. 25, but fear its consequences, in that it would annually reveal to Parliament the failings of the legislation. Moreover, it would show how right the Opposition have been to oppose the Bill root and branch and how misguided Ministers and their followers on the Back Benches have been to press ahead with it in defiance of all the evidence that it is not a good piece of legislation.
Is not there another argument that the Minister might find more attractive—that is, that if the legislation works well, members of the Government would have an annual opportunity to come to this House to say so?
My right hon. Friend makes an interesting point. He knows as well as I do that some members of the Government are not as keen on coming to this place as others. In some cases, the amendment could represent an opportunity to ensure that they are here, and it could become an annual visit, so it has that extra potential benefit.
I hope that the Minister will, in the spirit of maintaining the highest possible standards and of open government, be minded to think again. I am not confident about that, but perhaps I can encourage her by saying that I will ask at the appropriate moment to divide the House on amendments Nos. 24 and 25.
I support the amendments because it is appropriate to ask the various inspection agencies covering health and social care now and in future to monitor the implementation of the legislation, and, not least, because the Minister has been unable to answer several questions in the course of the debate, and by monitoring the situation closely we might begin to get some of those answers. Earlier, I referred to the National Audit Office report—and specifically to the accuracy of data that were being supplied on the numbers of people who are suffering delays in their discharge. I was a little disappointed that the Minister was unable to cast any light on Government actions in response to the NAO's findings and was unable to say whether the Government accepted the NAO's conclusion that there were difficulties that would impact on the Government's ability to implement the system of fines that the Bill would introduce. More than four out of every 10 NHS bodies that are responsible for submitting data on the numbers of people who are experiencing delays appear not to be following the Government's definitions. That is a problem.
However, it is not only what the NAO is saying that causes concern. Not surprisingly, local authorities, in partnership with their local NHS, are trying to test how the system would work. A colleague of mine from a metropolitan authority in the midlands told me:
"There is also a problem over definitions (there almost always has been but local work had, we thought, given . . . agreed definitions). A recent batch of 9 discharges from a local hospital went through a trial run to see what the results of the delayed discharge scheme would be, and the social services department thought they had agreement that only one of the discharges would count" for the purposes of the fine system. However, when the department went back to the NHS trust, the trust declared that nine would be counted as delayed under the legislation. That was clearly a trial exercise to see what would happen, but it bears on the issue of clarity of definition. That clarity is still not in the Bill. The NAO has raised concerns about that.
Another issue that I hope will be contained in an annual report to Parliament, and that certainly ought to be subject to monitoring by the Commission for Health Improvement and the Commission for Social Care Inspection, is the interface between health and housing and social care. From
One cause of dispute in the Chamber and in Committee, relating to whether this Bill can be implemented effectively, can be examined. It is the shortage of specialist staff. The NAO report found that two groups in particular—social workers and therapists—are in short supply. It was not only social services departments that foresaw a problem; it was the overwhelming view of primary care trusts that such shortages would continue to hamper dealing with issues of delayed discharge.
I have one final question for the Minister, and I feel that this amendment could allow this issue to be monitored. It concerns the dividing line between what is NHS-funded continuing long-term care and what are NHS part-funded registered nursing care contributions—also called free nursing care. I have raised a concern with the Minister and others on a number of occasions. The criteria for the highest band of registered nurse contributions are setting a threshold that requires a higher and more complex level of need than the eligibility criteria for fully funded NHS continuing care. It would be useful for that to be looked at.
The nursing care practice guide and workbook states:
"People with high needs for registered nursing care will have complex needs that require frequent medical, technical and/or therapeutic intervention. They will need frequent intervention and re-assessment by a registered nurse throughout a 24 hour period and their physical/mental health state will be unpredictable."
That is the definition used to enable a nurse to determine whether someone is in the top band and will receive a contribution of £110 towards their nursing care in a nursing home.
The case studies in the workbook are examples that help nurses to apply the guidance meaningfully. However, it is interesting to compare them with the health ombudsman's report, which deals with real cases. The workbook stated that a woman who had suffered a cerebrovascular accident—CVA—would be placed in the highest band of nursing because she had suffered
"loss of speech and was unable to swallow; partial paralysis and poor balance and co-ordination, doubly incontinent, pressure sore and tearful and distressed. She requires peg feeding and enemas to maintain bowel function, the use of a hoist to ensure safe transfer, and monitoring of the pressure sore, teaching to improve sitting balance, review of need for anti-depressant therapy and work to maintain social interaction."
The amendment should include provision for the inspectorate to examine such cases because the health service ombudsman found that peg feeding was a criterion for continuing NHS care in one authority but not in another. In one case, the ombudsman's report helpfully listed Mrs. N's needs. They were
"a hoist to help with transfers, a . . . catheter in place to deal with her incontinence of urine and assistance with her bowel function every three to four days; changing position to maintain skin viability, help with washing and oral care, and peg feeding. She did not appear to be depressed but smiled in response to other people."
Those cases are similar, yet in one, used as an example, the person was entitled only to a contribution of £110 towards their nursing while in the other—a real case cited in the health service ombudsman's report—the person was entitled to have all their care met and paid for by the national health service. The Department's case study guidance is issued to nurses whose job is to make those systems work and it ought to lead to the conclusion that people are entitled to continuing NHS care funding.
Will the Minister comment on that? More important, I hope that we do not have to rely only on the health service ombudsman to resolve, on a case-by-case basis, the problem of the dividing line between free continuing NHS care and nursing contributions. The Government should take the opportunity provided by the health service ombudsman's report to clarify the situation so that we stop the injustice that is undoubtedly being done to thousands of people who are being denied their rights.
I am extremely puzzled by the attitude of the Minister and the Government to these perfectly sensible and appropriate amendments. Lords amendment No. 24 would specify bodies that will monitor the impact of the measure at regular intervals and Lords amendment No. 25 provides for an annual report to Parliament. As my right hon. Friend Mr. Knight pointed out, such a report might give the Government the chance to trumpet the success of the legislation. I seem to recall that the Government used to issue an annual report to trumpet their achievements, but that practice seemed to fall into disuse two or three years ago—presumably because there was not much to trumpet.
I urge the Minister to think again about the amendment. I appreciate why she might be feeling defensive about the measure; as we have already established, the Bill does not have a friend in the world. Even some of the Government's Back Benchers, including the Chairman of the Select Committee on Health, are not willing to support it. It has caused a storm of protest throughout the country, expressed through the Local Government Association, the Association of Directors of Social Services and so on.
The Minister seems to think that the amendment will wreak a huge sea change in the position. Indeed, her thesis, which seems to go further away from reality, is that the mere threat of the Bill has enormously improved the bed-blocking position and that it will make a vast difference and improve the lives of many hundreds of thousands of patients throughout the country. She may be right. If she is, fine, but I do not think that she is. Equally, the Opposition and various bodies may well be right, and the law of unintended consequences will kick in and set at odds with one another some of the agencies that, certainly in my constituency, are now working in much closer partnership than they ever did before.
I pay tribute to East Sussex county council for its work in the past year or two, since it has been run by the Conservatives, who have got to grips with the issue and worked closely with the health organisations. Although there are occasional blips, the result is a steady decline in the number of beds blocked or delayed discharges.
I concede that the truth may turn out to be somewhere between those two views. However, on any assessment, this is a brand new regime with some pretty draconian powers, and it could all go horribly wrong or, at the very least, not produce the results that the Minister wants, so I fail to understand why she does not think that monitoring its progress is a good idea. There may be some scope for discussing whether that duty should arise only in the initial stages of its implementation. I can understand the Minister's argument that that should not happen every year, for ever, if the legislation has settled down or, even more likely, the problem has gone away of its own accord.
In the debate in the other place, Baroness Noakes said that, under the current arrangements, the bodies involved would be the Audit Commission, the Commission for Health Improvement and the social services inspectorate, and she put it extremely well. Of course we have heard that, yet again, some of those bodies are in a state of flux, and we will end up with something called the Commission for Health Care Audit and Inspection. Whatever label is attached to those bodies, if legitimate concerns are felt not just by the official Opposition or the Liberal Democrats, but by lots of people at the coalface throughout the country who deal with such problems daily, it is surely important that we should get an idea early on whether the provisions are having the effect that the Minister thinks that they should. Surely, she, more than anyone else, would wish to know whether that was the case.
If I may give the Minister a bit of friendly advice, I do not think that she should associate herself too closely with the Bill or she may turn into another Minister who never was, like Lord Hunt who used to deal with such matters in the other place.
The Bill's effects will need careful examination in the real world. We have heard about some of the problems. Baroness Noakes referred to some of them in the other place, and my hon. Friend Mr. Burns has dealt with the problem of readmission, so I need not do so. It is possible that people will be discharged home without adequate support services, and there is a whole series of possible knock-on effects, simply because of this ill-thought-out, hurried Bill.
"the widespread feeling that patients are treated . . . as commodities."—[Hansard, House of Lords, 17 February 2003; Vol. 644, c. 975.]
Other hon. Members and I have expressed that view in earlier debates on the Bill. That is the nub of the problem. The Opposition and many other people are worried that patients and their needs are not central to the Bill and that they will be pushed aside in the interests of what I have already called this bizarre game of pass the parcel. Let us stop using the words "fines" and "incentives". I shall say that the Bill has financial repercussions—that may make the Minister happy—if people are holding the parcel when the music stops.
There will be some serious, hard cases in the real world, affecting our constituents, as well as those of the Minister and other hon. Members, so why on earth does not the Minister want to reassure people? Of course she takes the view that the rest of the world is out of step and that she is the only one in step, but if she is so utterly convinced of her rectitude, why not put it to the test? As my right hon. Friend the Member for East Yorkshire has already said, if there is good news to tell, let her blazon it in the House with an annual report and let it be reported on and authenticated by those audit bodies.
I could not agree more with the comment that Baroness Noakes made in last month's debate:
"the Bill . . . tends to marginalise the individuals who are at the heart of the processes."—[Hansard, House of Lords, 18 February 2003; Vol. 644, c. 1029.]
That has been and will continue to be our fear about the Bill. We are happy and willing to be proved wrong. Surely, the way to ensure that that happens is to use one or more of the sort of bodies that are so beloved of the Government to audit progress, see whether the legislation is working and report annually to Parliament. I cannot see the Minister's problem, as by accepting the amendments—if she will only leave them alone, they are already part of the Bill—she can at a stroke prove us all wrong and prove that hers is the lonely voice that has been right all along.
I hope that the House will support the Lords in their amendments and maintain them in the Bill.
We have just heard three very powerful speeches explaining why the Minister is wrong on the issue with which the amendments deal but not one voice raised in support from the Labour Benches.
The Minister's opening remarks sounded rather half-hearted and certainly showed a paucity of reason. We are disappointed by her attitude to the amendments because we had a debate yesterday in which the Opposition were prepared to take a non-partisan approach on a very important issue and say that, where we thought that the Government and the Prime Minister in particular were right, they had our support. All that we are asking her to do is listen to our arguments and reflect on what she will say in advising the House about how to treat the proposed additions to the Bill. What are we seeking to do? We are seeking to say that proposals that are moderate, modest and reasonable should remain in the Bill.
Amendment No. 24 states:
"The Secretary of State shall specify to the bodies charged with inspection of health and social services that they should monitor".
The word "monitor" was put into the Bill by the other place, and it does not carry with it any of the implications to which the Minister referred in relation to a presumption of wrongdoing. The monitoring process would occur "at regular intervals". If the Minister were willing to reflect on the matter again, I would be happy to accept that regular intervals do not need to involve continual monitoring, but could entail annual monitoring or even a biannual process. Surely, however, it is right to see that best practice is being followed and that it is consistent throughout the United Kingdom.
I cannot understand why the Minister is not willing to accept Lords amendment No. 25. As you will be well aware, Mr. Deputy Speaker, it used to be said in the days of the previous Conservative Government that there was terrible pressure on parliamentary time and that it was not possible always to accommodate debates on every single issue that hon. Members felt was important. However, there has been a change in our procedures since that time—the addition of Westminster Hall. Although the former Leader of the House, who has just resigned his position, and his predecessor both gave an undertaking to the official Opposition that Westminster Hall would not be used for introducing legislation, there is consensus in all parts of the House that it could and should be used for debates on annual reports such as the one in question. In the light of the fact that we now have that other Chamber a stone's throw away from this place, I am at a loss to understand why the Minister will not accept the amendment.
I agree wholeheartedly with my hon. Friend. An annual report does not have to be debated every year. If an annual report was good but was deemed to contain nothing exciting or worthy of criticism, then the usual channels could produce a system in which a debate did not have to occur every year. Clearly, cost is not an issue because the Minister did not mention it. I was apprehensive that she might argue that she did not want the amendments because of the cost to the Exchequer, but that does not seem to be a problem. I hope that she will think again. I say to her: be bold, be reckless and, in the light of the powerful arguments adduced in the debate, allow the amendments to stand.
With the leave of the House, I shall respond to the debate.
Hon. Members suggested that a monitoring and reporting system is not in place to ensure that the good outcomes produced by the Bill will be clearly monitored. However, I outlined a variety of ways—I do not intend to repeat them—in which that will be ensured. I think that the amendments are otiose and that it can be argued that they will have a detrimental effect on the inspection bodies that will be established.
Having feigned indignation when I suggested that the amendments were proposed on the assumption that the health and social care services might not operate in the best interests of patients, Mr. Burns then gave a string of ways in which the system might indeed not operate in the best interests of patients. I reassure him that monitoring is in place to ensure that that does not happen. The NHS and social care performance indicators, introduced by the Government to ensure greater accountability of the performance of the NHS and social care services, already include delayed discharges, emergency readmissions and home care to help people live at home. We are also introducing indicators on the speed of service provision. Those will show when substantial problems arise.
Hon. Members also asked about debating annual reports that are made to Parliament. Under the previous system—with the exception of the Commission for Health Improvement, largely inherited from the Conservative Government—annual reports were published, but not to Parliament. Under the new system, the Commission for Social Care Inspection and the Commission for Health Care Audit and Inspection will make annual reports to Parliament. We amply cover the concerns of hon. Members that both the successes and the challenges are reported to Parliament on an annual basis.
When we debate the legislation to establish the new inspection bodies, I shall be interested to hear whether Opposition Members raise concerns about the need to ensure that they are able to make an independent determination of quality in the health service and social care service. That would be different from the approach taken by the hon. Member for West Chelmsford, who believes that we should instruct the bodies in the minutiae of their considerations.
That is the implication of the Lords amendment. The other place claims to believe in the independence of the inspection bodies, but that claim lies rather uncomfortably with the proposals in the amendment.
I want to spend some time responding to the points raised by Mr. Burstow about, among other things, his specialist subject of continuing care. On the points made by the National Audit Office about the definition of good practice, one of the important features of the Bill is that it will put in place a clear process and decision points for determining a delayed discharge and, therefore, the point at which reimbursement should kick in. I heard what the hon. Gentleman said about his colleagues on the metropolitan authority in the west midlands, but perhaps that authority would welcome a visit from the Department's implementation team to ensure that some of the concerns can be ironed out before the Bill comes into force.
The hon. Gentleman asked about the broader definition of delayed discharge. Sir Nigel Crisp, the chief executive of the NHS, has written to those trusts that told the National Audit Office that they were not using the definition. All of them have confirmed that they are now using the correct definition.
The hon. Gentleman also asked about continuing care and its relationship with free nursing care. When nurses undertake a determination of NHS-funded nursing care, we have made it clear that all nurses should consider eligibility under continuing NHS health care criteria as the first step in assessing people's needs for care in a care home providing nursing. Furthermore, in the guidance on NHS-funded nursing care, we have consistently maintained the distinction between NHS-funded nursing care and continuing NHS health care, making it clear that NHS-funded nursing care is part of a spectrum of care that falls short of what one would expect to see when the primary need is for health care. As I have suggested, we have made it clear that, regardless of the eventual setting in which someone is likely to be cared for, we expect the first consideration in a joint assessment of someone's need to be always the extent to which that person meets or does not meet the criteria for NHS continuing health care.
The Minister is making some helpful clarifications. However, will she also undertake to take away the workbook that is currently used for guiding nurses in applying the tool for assessing the entitlement to free nursing care contributions? The workbook contains a case that is exactly the same as a real case considered by the ombudsman, and that must provide incorrect information and the incorrect basis for making decisions.
I was just coming to that point. I have pointed out that the first task is to assess whether someone has a need for NHS continuing care and emphasised that we must consider that on a case-by-case basis. The fictitious case that the hon. Gentleman mentioned would be considered in the assessment of nursing care only if the continuing care criteria were not met. A consideration of that would previously have been carried out. The hon. Gentleman's points about the workbook are not justified.
We are considering inspection and monitoring, and the hon. Gentleman asked whether we could consider the monitoring of the continuing care criteria. Although not solely in response to his concerns, we have asked CHI to consider local policies and criteria as part of a review of the older people's national service framework.
In conclusion, I believe I have provided the reassurance that right hon. and hon. Members wanted. The amendments are unnecessary and challenge the current arrangements and the independence of the inspectorates that we want to develop. For that reason, I hope the House will disagree with the Lords.