Clause 2 — Notice of Patient's Possible Need for Community Care Services

Community Care (Delayed Discharges Etc.) Bill – in the House of Commons at 2:12 pm on 19th March 2003.

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Lords amendment: No. 5, in page 2, line 5, after "hospital" insert "after 1st April 2004".

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

I beg to move, That this House
disagrees with the Lords in the said amendment.

Photo of Sylvia Heal Sylvia Heal Deputy Speaker

With this it will be convenient to discuss Lords amendment No. 47 and the Government motion to disagree.

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Lords amendment No. 5 would delay for a year until April 2004 the implementation of the policy outlined in the Bill. When we announced the policy in April 2002, we were keen to implement it by April this year so that older people could benefit as quickly as possible from the improvements in services and procedures that we firmly believe the Bill will bring. They include: focus on the individual, and ensuring that people get the right care at the right time and in the right place; the introduction of incentives to invest in alternatives in the community so that older people are not trapped in hospital when they would be better treated outside; and a clear framework for partnership between health and social care locally.

We know from the implementation team that we have established that many areas have made significant achievements since we announced the policies. The Bill has led to an unprecedented wave of activity around delayed discharge with local authority and NHS partners discussing shared problems and finding common solutions. Several areas have initiated reviews of whole systems to consider discharge processes and community service capacity so that they are well prepared for reimbursement.

Other areas have planned staff increases or co-location to speed up assessment and improve discharge planning. The Bill can therefore be considered a success already because people know that if they do not make efforts to improve discharge procedures and put services in place, they cannot benefit from the extra funding that we are transferring from the NHS. They will have to reimburse the NHS.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health) 2:30 pm, 19th March 2003

Before the Minister embarks on a spinning fantasy, will she clarify the reason for her use in Committee and now of words such as "incentives", "bonuses" and "improvements", when the Secretary of State describes the penalties under the Bill as "fines"? Indeed, that is what they are.

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Despite having been involved with the Bill for a long time, the hon. Gentleman fails to understand the principle that payment follows responsibility. His failure to understand is not my fault. When responsibility for providing services based on the individual's needs shifts from the NHS to social care, so should responsibility for payment.

The Bill can already be considered a success and we are worried that amendment No. 5 in particular puts that at risk. One social services manager stated that in the past five years he had never witnessed so much commitment to reducing delays in the NHS and social care. That is not an isolated remark. People who attended a recent conference, which our change agents team ran, stated that, far from wrecking partnership—Conservative Members have sometimes alleged that—the pressure to improve discharge that the Bill generates led staff from the NHS and social services to discuss together, sometimes for the first time, plans to reduce delays in their local hospitals.

There is a genuine risk that the benefits of that concentrated effort will be lost.

Photo of John Bercow John Bercow Conservative, Buckingham

I fear that the Minister risks creating a pervasive cynicism about the Bill—even more pervasive than that that has existed hitherto—unless she responds properly to the point of my hon. Friend Mr. Burns. If people incur a financial cost for doing something that they should not, or for failing to do something that they should, can the Minister think of a shorter or more accurate term for what they face than "fine"?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

A fine implies that someone is not supposed to be doing something. It is strange that the hon. Gentleman does not realise that we are considering putting right a position in which all the incentives in the system are for leaving people in hospital over a longer period because the NHS effectively pays for the needs of largely older people, responsibility for which should rest with social services departments.

If the hon. Gentleman wants to argue for cost-shunting and shifting responsibility, he should do so. The Bill aims to put matters right.

Photo of John Bercow John Bercow Conservative, Buckingham

If the Minister will allow me, I will exercise my discretion over the language that I deploy. I would not settle for the rather down-market lexicon that she has in mind for me. If she will not use the word "fine", why does the Secretary of State continue to do that regularly?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Perhaps the hon. Gentleman should ask the Secretary of State. My right hon. Friend and I share an understanding that at present—[Laughter.] We can laugh and banter about words, but Conservative Members should be ashamed of the underlying reason for the measure. In 1997, 6,800 people were inappropriately delayed in hospital. Our investment and reforms have reduced that number.

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

I should be interested to know when that happened. There is a significant reduction in the number of delayed discharges that we inherited from the previous Government. Investment and some top-down management have brought that about. We have argued that such a system is not sustainable. We need to ensure that the system includes incentives for the considerable extra investment in local authorities to be spent on alternatives that provide that older people can get out of hospital when necessary. The Bill will achieve that. As I said earlier, to some extent it already ensures that that happens. It gives an impetus to the joint working that we need and the focus on the needs of individuals when they are ready to be discharged from hospital.

Accepting the amendments will convey the message that the work can be put on hold for a year. The impetus that has built up will be wasted and a continued and sustained reduction in waiting times for discharge will be delayed.

We have listened to the anxieties of the NHS, local government, the voluntary sector and responsible hon. Members about the speed of implementation and the need for time for new investment in services to bear fruit. The Government have therefore proposed delaying implementation for six months until October 2003. As Lord Morris said in another place:

"The benefits of this Bill are urgently needed and I believe it is not too late to avoid delaying their delivery . . . There is still time for consensus to be reached on this Bill and those it seeks to help deserve no less."—[Hansard, House of Lords, 17 March 2003; Vol. 646, c. 19.]

Photo of Nigel Waterson Nigel Waterson Conservative, Eastbourne

Will the Minister explain to a simple soul like me why it makes things better for the people who have to implement the measure in the real world to introduce it half way through a financial year? Is that sensible? What sort of chaos will that produce in the system?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

We would have preferred to introduce the measure in April but we listened to what people in the real world said about their worries. [Hon. Members: "Lords."] Whether hon. Members in another place are the people in the real world is questionable, but we listened to people who operate in the real world and we shall ensure, through the delay in implementation, that the considerable extra investment from April 2003–04 makes the necessary impact without delaying, to the detriment of largely older people, the incentives that the Bill establishes and the action that it has prompted. Those older people will benefit from the provisions and already benefit from the reduction in delayed discharge that the prospect of action has brought about. I do not understand what can be gained from delaying implementation for a year. There is something to lose from that.

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

The Minister has been telling us that the Government have been listening to real people outside this place. Will she comment on why the Government chose to ignore their own consultation results, which showed that primary care trusts, social services departments and voluntary organisations of all sorts told the Government that they wanted a delay of at least a year, and to see implementation no earlier than 1 April 2004?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

As I was explaining, we listen not only to those who provide the services, but to the people who need them. They are the older people who, in too large numbers, are being trapped in hospital when they would be better off being treated outside. We believe that the Bill will make a difference to those older people, and that is why we are keen to ensure that it is implemented as soon as possible. Of course we need to listen to the people who provide the services, but those—largely older people—who are being delayed in hospital when it would be more appropriate to treat them outside are at the heart of the Bill and of our concerns.

Photo of George Young George Young Chair, Standards and Privileges Committee

If it really is the view of elderly people that the Government should proceed as she has just outlined, why has Age Concern written to every Member of Parliament totally disagreeing with her?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Various groups have taken various positions on this, but I reiterate my view that the Bill is about ensuring that those older people who are currently not getting the deal that they deserve can get a better deal. That is why I do not believe that we have anything to gain from delaying implementation for a whole year. Indeed, as I was saying, we have something to lose. The Secretary of State announced on Second Reading, having listened to the concerns of people—particularly those in local authorities who had the responsibility of providing those alternatives in relation to community care—that, in addition to the doubling of the real rate of increase of social services funding, we would also make a transfer from the NHS to social services budgets. If implementation were delayed for a full year, councils would not receive any additional funding in 2003–04. If it were delayed for six months, and councils received £50 million for that period, they could invest that money during the first part of the year and be able to invest in the staff or services that they needed, in order to avoid reimbursement charges when the scheme is implemented.

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

Will the Minister share with the House the conclusions that the Government had reached about how they would have distributed the £100 million? Would it have been targeted at those authorities that were doing least well in facilitating discharges from hospital, or those that were being the most effective? What decisions had the Government taken on that?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Depending on the progress of the Bill, we hope to be able to issue for consultation our decisions on how that would happen. The whole point of the investment is that it should facilitate the necessities contained in the legislation. The hon. Gentleman makes an important point about one of the disadvantages of the considerable investment—in the form of the building care capacity grant—that has been distributed to local authorities during 2001–02 and 2002–03. We took the decision—rightly, I believe—to focus that investment on particular hot-spot authorities. That was characterised by some local authorities—wrongly, in my view—as rewarding failure, or rewarding those authorities that had not properly tackled the problems of delayed discharge. That bears heavily on our consideration of how—given the successful passage of the Bill—we should distribute the money that is being transferred from the NHS. That will be part of our consideration.

Photo of John Bercow John Bercow Conservative, Buckingham

I am extremely grateful to the hon. Lady for giving way. She knows the high esteem in which I hold her, but I am bound to say that she has not persuaded me, she has clearly not persuaded the House and it seems uncertain whether she has yet managed to persuade herself of this argument. How many individuals or organisations have written to her to express their opposition to the idea of an implementation date of April 2004? She said that there was a miscellany of different opinions: how many, and who?

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health 2:45 pm, 19th March 2003

Nobody has written to us to oppose an implementation date of April 2004. Having said that, nobody—so far as I am aware—has written to us to oppose an implementation date of October 2003 either. People recognise that the Government have proposed a sensible delay of six months, which would maintain progress rather than stymieing it and kicking it into the long grass—as Conservative Members want to do—to the detriment of the older people who will benefit from this legislation. We must maintain the momentum, so as to build on the good progress that has been made. If we do not, the older people who are trapped in acute beds will continue to suffer.

Conservative Members have attempted to introduce a variety of ways of wrecking this legislation, aided by their colleagues in another place. The first was to delay the implementation. The second is represented by amendment No. 47, on which I also urge my colleagues to disagree with the Lords. It is effectively a sunset clause, under which the part of the Bill that puts in place the necessary incentives would cease to have effect after five years. This is an entirely inappropriate use of a sunset clause. They are generally used only in Acts that are passed because of national emergencies or are restrictive of civil liberties. Clearly this is not such a Bill. It is, however, a Bill that the Opposition are trying to limit in every way that they can, by delaying the start and limiting its life.

The argument for this amendment in the other place appeared to be that, because the provisions in the Bill would make a difference, it was necessary to limit their life. Certainly under this Government, the majority of Bills—in fact, all the Bills that we introduce—contain elements of policy that are new, because they are intended to bring improvement and changes. Of course, all policies should be evaluated and monitored—how else can the Government ensure that they are successful, and improve them if necessary? However, we already have reliable and well-established procedures and monitoring systems in place to monitor the impact of particular policies.

In the unlikely event that the Bill does not work in the way that we want it to, we would want to act well before the end of five years. If, on the other hand, as I expect, it drives action on delayed discharges to the point at which hardly any charges will be changing hands at the end of the five-year period, why do we need a sunset clause? Although I suspect that the good practice around planning and assessment underpinned by the Bill would continue, with or without legislation, there would be little additional activity moving funding around. However, one would not want to repeal the Act, since the possibility of charging would remain to ensure that performance on delays did not drift again. As we have heard in the interventions that have been made today, the two amendments are clearly about wrecking and limiting the effects of the Bill. On that basis, I hope that hon. Members will disagree with the Lords.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

May I say from the outset that the Conservatives would like two separate votes on Lords amendments Nos. 5 and 47 at the appropriate time?

However loveable the Minister might be, one has to admire her sense of humour and her nerve in trying to convince the House about certain issues today. I want to deal briefly with two of them. One is the ongoing battle over the question of fines. To her credit, the Minister has found every word in the thesaurus to try to describe the main thrust of the Bill, except the one word that describes it completely. That word is "fines". It is to the Minister's lasting annoyance that her Secretary of State

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

No, I will not.

It is to the Minister's lasting annoyance that her Secretary of State caught her out in his statement after the Budget, when he described his own legislation as "fines". Finally, on Report, the Minister herself had the honesty to use the F-word.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I will, although I am slightly surprised that the hon. Gentleman has spoken as he has. I, too, read Ceefax a few days ago, when he announced to the world in bold terms that because of the Government's policy on Iraq he would not support the Government—his Government—in any Divisions on any matter.

Photo of Mr Hilton Dawson Mr Hilton Dawson Labour, Lancaster and Wyre

That just goes to show that you should not believe all you read in the press. I am proud to support the Government on this, and on many other aspects of their legislative programme.

As the hon. Gentleman may recall, we have been around the block before. Will he put himself in the position of a nursing home owner looking after a person who need not remain in the home because his or her needs have changed, who is faced with all the costs of having to care for that person? Is not the use of the word "fines" entirely misplaced? We are talking about a charge for services. When the hon. Gentleman next goes to a hotel, will he expect to pay, or will he complain to the proprietor that he has been fined?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I know that there will be a reshuffle shortly because of losses on the Government Front Bench, but I must tell the hon. Gentleman that regardless of whether I believe what I read in the press, the press know what he said. I do not want to disappoint him, but I think that as a result of what he said he will not be considered by the Whip who is currently on duty, or by her colleagues, in the forthcoming reshuffle. As for his narrow point on fines, "fines" is his own Secretary of State's terminology for what the Government are doing. By all means let the hon. Gentleman be a help to the Government from the Back Benches, but let him at least be consistent with his Secretary of State.

Let me deal briefly with a point of fact. The Minister challenged my hon. Friend Dr. Fox about the number of detailed discharges, saying that when my Government left power in May 1997 the figure was just over 6,000 and that since her Government came to power the figure had always been lower and falling. I remind the Minister—for I too have the facts—that in 2001–02, four years almost to the day after this Government came to power, the figure was 6,361, and that in the second quarter it had risen to 7,065. She really must not try to confuse the House with spin that is not based on factual reality.

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

Does the hon. Gentleman accept that the number of people aged 75 and over whose discharges have been delayed was 3,502 in December 2002? Is that figure not less than half the 6,985 that the Government inherited?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

On the basis of parliamentary written answers I have received from the Minister, I accept that the figures have dropped. There is no secret about that. It is, however, bogus codswallop for the Minister to claim, as she did in her speech, that the result was achieved through the success of a Bill that has not even become law—although we are now used to new Labour, new spin.

The Lords amendments are at the nub of why my colleagues and I, along with many others, oppose this nasty piece of legislation. As I am sure you know, Madam Deputy Speaker, success has many fathers and failure is an orphan. One could list the examples, but as was pointed out by my hon. Friend Mr. Bercow and my right hon. Friend Sir George Young, in the real world in which people look after the elderly in hospital, care homes or their own homes on a daily basis there are no friends for the Bill: it is very much an orphan. Its only supporters are the Minister, her boss and her Back Benchers—with notable exceptions. The wise Chairman of the Select Committee does not support it, along with many other Labour Members.

Those Members do not support the Bill because it is wrong in its intent to introduce a system of fines that will do incalculable damage to the tremendous progress that has been made over the past decade or so in getting the NHS and local authorities to work together in the whole area of care for the elderly and discharge from hospital. As has been said by many local authorities and by the Local Government Association—led by Sir Jeremy Beecham, a Labour councillor I believe—it will damage, perhaps destroy, those working relationships. It will also set the NHS against social services departments. There are better ways of legislating. Moreover, the proposals are unfair. As we all know—except, of course, the Minister, who is in constant denial because this is not good news for the Government—more than 60,000 care home beds have been lost over the past six years.

Photo of Mr David Hinchliffe Mr David Hinchliffe Labour, Wakefield

The hon. Gentleman knows only too well that that figure, which he keeps parroting, is completely wrong. He knows that the Health Committee, of which he is a member, came up with a figure that, although it did not accord with the Government's figure, certainly did not accord with the Tories' 50,000 figure, which has now risen to 60,000. I respect the hon. Gentleman, who does a good job on the Committee, but he must accept that sometimes we come up with the facts rather than the fiction that he has just presented.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I respect the hon. Gentleman too. We have a mutual admiration society. If he returns to the relevant papers, however, he will be reminded that we asked the Select Committee to look into the matter and try to find a solution. The Committee said that both figures were right: my figure and the figure of about 19,000 that the Government gave about 18 months ago. The papers go on to say, though, that the Government's figure excludes the number of beds lost in the local authority sector. If the local authority figures are added to the private sector figures, we reach the figure that I have given.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

No, because this is a timed debate and I want to make progress. Along with Lang and Buisson, an independent body, I believe that my figure is correct.

The fines will put pressure on social services departments to bring about inappropriate and premature discharge of patients from hospitals. Already—although, interestingly, the Minister did not mention this—the rate of readmission of over-75s has increased dramatically in the last few years. Let me give the Minister the figures. There were 12,165 readmissions within seven days of discharge in the second quarter of 2001–02; the number had risen to 13,813 by the third quarter of 2002–03. That is an increase from 2.9 to 3.3 per cent. Similarly, emergency readmission rates for up to 28 days have risen from 2.9 to 4.9 per cent. By putting unfair financial penalties on the system, patients will be discharged from hospital prematurely, and will perhaps not receive the most appropriate care. As the figures suggest, the result will be unacceptable and unfair readmittance for those patients.

I believe that we must seek to bring down the level of delayed discharges. Everyone in this House accepts that having people in hospital who should not be there, and at a considerably greater expense than if they were out of hospital, is an utter waste of money; where we disagree is on the solution to the problem. To bring in a simplistic policy that sets local authority against the health service and vice versa, and which can lead to inappropriate and hasty discharges from hospital, and to readmissions, is the wrong way to proceed. I hope that many Members will join me in voting for amendment No. 5, which would postpone the introduction of this legislation by a year, to 1 April 2004.

As a sop to Back-Bench Labour MPs who were in revolt on Second Reading, the Secretary of State announced that health service money would be made available to social services to help them pay the fines that they will incur if they fail to comply with this law. However, postponing enactment of the legislation beyond the six months proposed by Lord Hunt following the introduction of this amendment would provide a year during which the money made available by the Department of Health could be invested to improve the situation, and to minimise the problems of delayed discharge. [Interruption.] The Minister nods in a negative way. Does that suggest—[Interruption.] Nodding in a negative way may be a contradiction in terms, but that is what she was doing. Is she suggesting that if this amendment were successful and the law's introduction were to be delayed by a year, the Government would not make that money available for the financial year 2003–04? If so, that differs from what the Government have been saying so far. If not—if the money will be paid out this April—it would be better to invest the money for a year in the health service, and in local authorities and social service departments, to seek to minimise the problem of delayed discharge. Then, if we have to, we could introduce the system of fines next year, after a year of investing the money to seek to minimise the problem.

If this legislation is as wonderful as the Minister claims, there should be a sunset clause—amendment No. 45—so that it is removed from law within five years of coming into force. The Minister asked what would happen if the problem were solved before then, but the answer is very easy for the Government. All that they would have to do is to repeal the law immediately; they need not wait for the sunset clause to take effect.

For those reasons, we should agree with the Lords. The Government may find it difficult to believe this now, but they will believe in time that the other place has in fact done them a favour by passing these amendments. In doing so, they have provided a semblance of improvement to what, in essence, is nasty legislation.

Photo of Glenda Jackson Glenda Jackson Labour, Hampstead and Highgate 3:00 pm, 19th March 2003

As my hon. Friend the Minister knows, I share some of the disquiet evinced by my hon. Friend Mr. Hinchliffe, who chairs the Select Committee that has dealt with this Bill. In this instance, it seems somewhat less than fair to impute blame—essentially, that is what we are doing—in respect of an elderly or frail person who is kept in hospital for an unnecessarily long time because social services have not been able to create the proper care environment past their recovery.

I shall not rehearse the arguments that I made on Second Reading, and I am grateful to the Government for listening to the concerns that have been expressed by my own local authority and by voluntary organisations throughout London. However, in a sense, a period of six months is neither fish nor fowl, nor good red herring. There are specific difficulties, of which my hon. Friend the Minister will be aware, that impact particularly on authorities such as mine, which represent inner-London boroughs. No one could argue that the borough of Camden has been lax on this issue, and I know that the Government would not attempt to do so. It is a beacon authority, and it has made extremely good use of the additional funding provided by the Government. It is assiduous in attempting to incorporate a properly constructed care package, with proper input from individuals or their carers. However, there are real difficulties in central London relating to the availability and cost of properties, and, on the most simplistic of levels, to the availability of a work force who are capable of adapting, say, an individual's private home for the necessary bathroom, shower and fitments, so that they can live within their own property. There are also grave difficulties in ensuring security of domiciliary care, when that is included in the package.

I raise these issues—I have no doubt that the Minister is aware of them—simply to ask the Government to consider, even at this late stage, delaying the Bill's introduction. As I said on Second Reading, I know that their heart is in the right place. No one wishes to see the elderly or frail kept in hospital if an alternative location would not only probably make them infinitely happier, but ensure their future health. There are real difficulties, but there is no difficulty as far as my local authority social services are concerned in attempting to create partnerships. Indeed, they have created extremely effective partnerships not only with the national health service and the voluntary sector, but with the private sector, which they deal with in many instances, to ensure the creation of a proper care package for individuals. However, there are difficulties in ensuring that internal office systems are the same—an issue that is not exclusively the responsibility of local authorities or of the NHS.

Solving such practical difficulties takes time, and I should point out to the Minister that it also takes money. I have my doubts about how beneficial it is to move £100 million from one aspect of the provision of care to another. However, it would be a shame if the money that the Government are investing were to be spent somewhat hastily not only because of the pressure resulting from the Bill's introduction, but because of the time pressure on the introduction of these requirements. As we know, more haste means less speed, but it also often means spending unnecessary amounts of money.

I ask the Government to consider the points that I have made and perhaps to delay the Bill's introduction. That would address many of the anxieties experienced not only by my local authority social services department and the NHS, but, most importantly—I stress this point to the Minister—by those who care for the elderly. They are looking for a properly structured care package, and they are anxious about the time pressure resulting not only from the Bill itself, but from its introduction. If it were possible to extend the period before its introduction, many of my constituents would be very grateful.

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

I agree with many of the points that have just been made by Glenda Jackson, and she probably speaks for all Members when she says that we do not want people to be stuck in hospital unnecessarily. That is absolutely the case, and we would support any measures that facilitate appropriate discharges. Our fear and our belief is that the Bill does not facilitate appropriate discharges. Some of the Minister's comments gave me the strong impression that the anxiety of the Government is not so much to secure the appropriate discharge of an elderly person as to free up a bed so as to facilitate other NHS objectives.

Photo of Andy Burnham Andy Burnham Labour, Leigh

What is wrong with that?

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

It is wrong if someone is discharged prematurely. That is why we have seen a massive increase—

Photo of Andy Burnham Andy Burnham Labour, Leigh

Will the hon. Gentleman give way?

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

In a moment, when I have finished answering the hon. Gentleman's sedentary intervention. We have seen a massive increase in emergency readmissions. Indeed, the National Audit Office, in its report on delayed discharges, identified that as a serious risk. A focus on discharges may increase the number of emergency readmissions.

Photo of Andy Burnham Andy Burnham Labour, Leigh

Neither the hon. Gentleman nor the Conservative Front-Bench spokesman appears to understand that the decision to discharge is a clinical decision, and nothing in the Bill will affect the clinical decision about when a patient may be safely discharged.

Photo of Paul Burstow Paul Burstow Shadow Spokesperson (Health)

The hon. Gentleman is a member of the Health Committee and took part in the evidence sessions. He will have heard the officials from the Department talk the Committee through the definition, and they made it clear that it was not just a clinical decision. They said that the decision to discharge was a multi-disciplinary one.

When the National Audit Office published its report in February, after we had finished our initial consideration of the Bill, it included some interesting findings that we must consider when deciding whether we should retain the Lords amendments. Those findings make a strong case for delay so that matters may be properly considered.

The first is the finding of the NAO about the accuracy of the measurement of delayed discharges. According to the report, the NHS finds it difficult to provide accurate and reliable figures. Indeed, a survey found that only 27 per cent. of NHS trusts provided figures based entirely on the definition issued by the Department. Some 22 per cent. of trusts used only a vague approximation of the definition and 44 per cent. did not follow the definition at all and were, therefore, supplying incorrect and unreliable data to the Department. Those are the data being used by Ministers to frame their policy and to demonstrate a reduction in the number of delayed discharges. From the work of the NAO, we know that we cannot place confidence in those figures.

The NAO report states:

"Continued inaccuracies in this data could affect the effective implementation of the Community Care (Delayed Discharges etc.) Bill, if it becomes law from April 2003, as the data will form the basis for calculating reimbursements payable by Councils to acute hospitals as part of the new arrangements".

I hope that the Minister will be able to explain why she has such confidence in the figures, given the findings of the NAO.

The other issue that I hope the Minister will consider is the Coughlan judgment and continuing NHS care. In the light of the health service ombudsman's report last month, real anxiety still exists that the guidance issued by the Department of Health in 2001 is misleading, inaccurate and does not comply with the Coughlan judgment and is, therefore, not in accordance with the law. As a consequence, people are being passed from the NHS to social services departments, where they are means-tested for their care, when they should have continued to be the responsibility of the NHS.

I hope that the Minister will tell us more about what steps the Department will take to ensure that it issues proper guidance on delayed discharge and discharge planning to clinicians who take initial decisions about the appropriateness of discharge, so that they can make a proper assessment of any continuing health care needs. Clinicians judge not only whether the need is still acute but also whether the need is continuing. If it is, the NHS clearly has a responsibility to continue funding care whatever the patient's location after discharge. That is not clear in the present guidance or in the majority of the rules used by local health authorities to guide those who make the decisions.

My final concern, which is picked up in the NAO report several times, relates to capacity, which has been a running theme since Second Reading. The report finds that many parts of the country—especially London and the south-east—now have occupancy rates of more than 90 per cent. in care homes. The lack of capacity means that the NHS cannot discharge patients. If the Bill were to be implemented from 1 April this year, the extra resources for social services—for which I voted—would not be available in time to bring extra capacity on stream. The issue is not only care home capacity, but home care capacity, as the NAO report confirms. There is a shortage of care home workers and new ones cannot be recruited overnight.

For those reasons, the Liberal Democrats believe that the Lords amendments should continue to stand part of the Bill. The Lords were right and wise to say that the sun should not rise over the Bill until we have got the detailed answers to the points made by the NAO, which we have raised time and again with Ministers without receiving proper answers. I hope that the Minister will be able to reassure us, but I will encourage my colleagues to support the retention of the sunset and sunrise clauses in the Lobby this afternoon.

Photo of Mr David Hinchliffe Mr David Hinchliffe Labour, Wakefield 3:15 pm, 19th March 2003

When the Bill was introduced, several Labour Members wished to consider whether it would be possible to improve it fundamentally. We had grave doubts that the mechanism in the Bill was the right one to adopt in the circumstances. The only common ground we could reach on what amendment could be made is reflected in Lords amendment No. 5, so I support it as all that could be done to improve what is not good legislation. I regret having to say that, but I made my views clear on Second and Third Reading.

The Government have taken many steps to address is a major problem in the NHS and they have done much to improve the working relationship between the NHS and social services. The Government have produced a definition of a delayed discharge—on that point, I disagree with Mr. Burns, because I recall asking the previous Government about delayed discharges, but they did not even have a definition for them. It is commendable to try to establish what we mean by delayed discharge, because it is useful to know exactly what the problem is before addressing it. However, I take the point—picked up in the Health Committee's inquiry into delayed discharges—that several different approaches have been taken to the definition, which will cause problems when trying to apply a common system such as that in the Bill.

I agreed with some of what Mr. Burstow said a moment ago, and with virtually everything that my hon. Friend Glenda Jackson said a little earlier. I object to the common thread that appears in debates such as this—that our problems in this country could be solved by making more institutional care available. The lack of care home capacity is mentioned time and again. It saddens me that that is repeated as though it is factually correct. In this country, the problem is that far too often we have gone down the road of providing institutional care for elderly people. We have not examined how we could take concrete steps to develop alternatives.

To be fair to the Government, they accept that. It frustrates me that other European countries not very far away provide no care homes or nursing homes at all. People in their old age are afforded much more in the way of independence and rights than elderly people in this country are offered. It is about time that we kicked into touch the nonsensical proposition that we should have more and more institutional care for old people. It is simply untrue.

Photo of Mr Hilton Dawson Mr Hilton Dawson Labour, Lancaster and Wyre

Does my hon. Friend agree that a good example of what he describes can be found much closer to home than Denmark? Mr. Burns completely undermined his argument about care home places when he told us how successful the Government have been in introducing partnerships and in forging partnerships between health and social care services. The public, private and voluntary sectors work really well together.

Photo of Mr David Hinchliffe Mr David Hinchliffe Labour, Wakefield

Yes. It is also about time we recognised that a reduction in the number of care home places is a success, providing that we are assured that the alternatives to that form of care are being developed. Far too often, colleagues in other parties assume that the way to make progress on these matters is to provide more and more institutional care in the private sector. I profoundly disagree with that.

My hon. Friend the Minister said that there were 6,000 inappropriately delayed people in NHS beds. The Health Committee did some costings on the matter, which were very worrying. Money is being wasted that could be invested in treating the people in those beds who need treatment.

However, as I and one or two others noted on Second Reading, it is worrying that so much emphasis is being given to delayed discharges. As I know from my own local hospital, inappropriate admissions are another significant problem. If we are applying one approach to delayed discharges, it would be inconsistent not to apply a similar approach to inappropriate admissions. I would be more convinced that the proposed mechanism was going to work if it was being applied in an even-handed way, and if it was proposed to establish a mechanism that would push costs back to the people who are making the inappropriate admissions in the first place. Why are they doing that? We need to find out.

I want to refer to what the Health Committee has said in connection with the amendment. I hope that, on the many issues that we investigate, the Committee's comments are seen to be constructive and helpful. They are made on the basis of the evidence that we take, and on the basis of the cross-party consideration of matters. Committee members belong to different parties, and those that belong to the same party often have different views. Even so, we came to some clear conclusions on the matter, and I should like to refer to a couple of them now.

At paragraph 162, the Select Committee states:

"While there was some cautious support for the model"— that is, the model being adopted by the Government now—

"the predominant reaction was that the proposals constituted a blunt instrument that, rather than improving partnership, would be likely to reinforce a negative blame culture. We are especially concerned that the underlying assumptions behind the charging proposals is that most delays in the system are the fault of social services. As we have emphasised throughout this report, the causes of delay are complex and multi-factoral. It is far from clear that the issue can be resolved by such a crude solution."

The Government's approach is a crude solution. The Committee also went on to say that it agreed

"that appropriate incentives have a role to play, but we would also urge the development of positive incentives that reward good practice, rather than any precipitate and over-zealous emphasis on penalties. We recommend that any new schemes should be subject to piloting."

I am sorry that the Government have not picked up on that point. The amendment that proposes a delay of a year is the nearest sensible suggestion to what the Health Committee proposed in the report.

Finally, these problems come up time and again, in all sorts of bits of legislation. We have a go at them around the edges, but we never address the fundamental problem—the organisational division between health and social services. In the previous Parliament, the Committee, which had a completely different membership, came to the key conclusion that the only real solution is to integrate our health and social care systems. That requires common budgets. The Health Committee's most important conclusion in respect of delayed discharges is that we should integrate health and social services.

I shall say no more this afternoon. I shall go and lie down now that I have made my contribution. I hope that, at some point, the Government will adopt what is increasingly the consensual opinion among people in the voluntary sector and in pressure groups—that there is a need to examine the matter radically. Once and for all, we must end the nonsensical division between these two key areas of policy.

Photo of George Young George Young Chair, Standards and Privileges Committee

It is a pleasure to follow the hon. Gentleman, who has been brave and consistent in his hostility to the Bill. I agree with what he said about the need to take an even-handed approach rather than just singling out social services for fines.

I spent yesterday speaking and voting in favour of the Government, but my generosity is curtailed on reaching this Bill, which, as I said on Second Reading, is one of the worst Bills that I have ever seen. The Minister is pushing her luck. As it stands, the Bill comes into effect in April next year. Had there been a vote on Second Reading in the upper House, it would have been lost. There was only one speech in its support and there was nearly a vote, so the Government are lucky that it still exists.

The Minister tells us that she has listened and that as a result she is delaying the Bill for six months, but when we propose a 12-month delay we are told that we are trying to wreck it. This is not a wrecking amendment. It is supported by Age Concern, the Local Government Association and several peers in another place who support the Minister's party, not mine. She says that the Bill is in the interests of older people, but I wonder whether she is the best advocate for their interests, given that we have received clear advice from Age Concern that it, too, would prefer the delay. The Bill remains fundamentally unpopular. The NHS Confederation, the organisation that it is proposed to assist, is resistant, as are the Local Government Association, the British Medical Association, the nurses and the voluntary organisations. The Bill is without friends.

Photo of Nigel Waterson Nigel Waterson Conservative, Eastbourne

Is my right hon. Friend aware that in Sweden, whose position is cited in support of the Bill—the Government clearly have to go as far as Sweden to find anyone who might speak out in its favour—it took some two years to implement similar legislation, but in a much simpler system?

Photo of George Young George Young Chair, Standards and Privileges Committee

My hon. Friend is right. That is why several organisations have argued for piloting. Of course, if the measure were delayed for 12 months there would be an opportunity to pilot it.

The Minister kept talking about the real world, but in reality the only world in which the Bill has any support at all is her world of Health Ministers. If one talks to anyone else, one finds that they are fundamentally opposed to the Bill. She has produced no new arguments. The protests against the Bill are undiminished. It remains fundamentally misconceived. It puts tension where we need partnership and focuses on just one part of what should be a holistic process.

Photo of George Young George Young Chair, Standards and Privileges Committee

I will not, because the Minister should in fairness be allowed two or three minutes in which to reply. I hope that the hon. Gentleman did not support the guillotine that imposed this time scale on our consideration of the Bill.

If the Minister is well advised, she will save the House one Division, leave Lords amendment No. 5 as it is, and thank her lucky stars that the Bill was not completely demolished in another place.

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

First, I shall respond to my hon. Friend Glenda Jackson, who identified the pressures on community care services as an argument for a longer delay than I would be happy with—I shall come back to the reasons for that later. She is right that we need to build up alternatives to hospital. We need to ensure, as has the £300 million which has been made available over a period of 18 months in preparation for the Bill, that that process allows us to build capacity in the care homes sector and to develop domiciliary care. All our evidence is that that money is already having that effect. We also base the Bill on the fact that from April we will increase investment into social services departments by 6 per cent. in real terms and that we will introduce access and systems capacity grant of £170 million—

Photo of Jacqui Smith Jacqui Smith Minister of State, Department of Health

No, I will not, because I am winding up. The hon. Gentleman should have stayed for the debate if he was that interested.

The argument therefore is that we need longer in order to ensure that that money has an effect. Part of our justification for the Bill is that, in order to ensure that the extra investment is going into those community alternatives, we need to focus both on the individual and the incentives. That is what the Bill allows us to do. I repeat to hon. Members—and this was a new argument—that we now have experience from the field about the momentum that has resulted from this legislation. I hope that I will have the opportunity later of responding to some of the points that were raised by Mr. Burstow on continuing care.

We have to put in place the incentives necessary to focus—

It being three and a half hours before the moment of interruption, Madam Deputy Speaker put the Question already proposed from the Chair, pursuant to Orders [28 June 2001 and 29 October 2002].

The House divided: Ayes 330, Noes 205.

Division number 120

See full list of votes (From The Public Whip)

Question accordingly agreed to.

Lords amendment disagreed to.

Lords amendment: No. 47.

Motion made, and Question put, That this House disagrees with the Lords in the said amendment.—[Jacqui Smith.]

The House divided: Ayes 333, Noes 203.

Division number 121

See full list of votes (From The Public Whip)

Question accordingly agreed to.

Lords amendment disagreed to.

Lords amendments Nos. 4, 10 to 13, 21 and 7, 8 and 39 agreed to.