My Lords, I begin by making my customary declaration of interest in that I work for Age Concern. The debate on the gracious Speech is perhaps one of the most interesting points in the parliamentary calendar. I very much welcome the changes that we have made this year as regards the way in which we have improved the structure of the debates compared to previous years. That struck me particularly when listening to the wonderful speech made by the noble Lord, Lord Fowler, with his apposite and moving comments about AIDS. On whatever day the draft plan for Africa was being discussed, I suspect that the subject of AIDS would have been mentioned. That highlights some of the remaining structural problems with these debates. As the noble Lord so rightly said, we can no longer turn our backs on problems in Africa.
The gracious Speech provides an opportunity to stand back and consider the extent to which joined-up government has become a reality. It is also a moment when those of us who provide effective opposition are challenged to do so outwith the restrictions that apply to debates on specific legislation. This year's debate on the Loyal Address has given those of us on these Benches a welcome opportunity to set out our own approach to the funding, the delivery and, crucially, the governance—a word which has not been heard today—of health and social care.
For the past 20 years, this Government and their predecessor have grappled with a key issue: how to fund old age. Both governments have sought to address the issue against a background of real reductions in state pensions. In her opening remarks, the noble Baroness, Lady Hollis, set out the plethora of initiatives which this Government have introduced, but she neatly side-stepped the issue of the real level of the basic state pension. She mentioned one of the key themes which I should like to talk about today, complexity, but she avoided a central concern—the crisis in private and company pensions, which was expertly explained by my noble friend Lord Oakeshott of Seagrove Bay.
Governments have tried in various ways, both negative and positive, to increase private provision for retirement income. For some, it has taken many years for the message to get through that any state pension they might receive will not sustain the standard of living that they envisaged. Currently, those who have been prudent and saved, often in company or private pension schemes, are looking at the closure of final salary schemes and starting to lose faith. For the past decade, for many investment in property has been a far more attractive option, offering a higher rate of return and certainty about the control of assets. However, with the property market surging at a seemingly unsustainable rate in some parts of the country, one wonders how long it will be before those who invested in property as a security for retirement also find themselves staring at an extremely bleak future.
This Government and their predecessor—as the noble Earl, Lord Howe, and the noble Baroness, Lady Noakes, might concede—have returned time and time again to one fundamental issue: how to cope with increasing demand for health and care services; with demand for new and effective but costly treatments; and with greater demands from an increasingly older population who are living longer. The National Health Service and Community Care Act 1990 was a first attempt to align health spending with what was then called community care spending. At that stage, however, a fundamental decision was taken which created an in-built flaw in health and social care planning which has persisted ever since: the decision to concentrate resources on acute conditions and high dependency. Only this year, that policy was reinforced in the fair access to care services guidance in which commissioners were told to allocate people to four eligibility bands—critical, substantial, moderate and low needs.
The guidance explicitly states:
"Councils should prioritise needs that have immediate and longer term critical consequences for independence ahead of needs with substantial consequences".
It is doubtful whether any authority in the land seriously envisages making any provision whatever for low-level needs. Yet there is evidence—cited, among other places, in the National Service Framework for Older People—that low-level interventions which enable older people to manage their own lives independently pay massive dividends in the avoidance of acute care and in continued mental health.
Such thinking on the subject of managing demand was the starting point for a policy paper on the public services which the Liberal Democrats developed and adopted earlier this year. We saw our task as policymakers as the need to develop systems which enable the development of services that meet needs effectively, appropriately and—above all—sustainably. We realised that the best way of reaching effective solutions would be to enable users, practitioners and those in the local community who know the real problems and issues to develop frameworks and solutions that work.
We also realised that this approach, if it was to work, would have to be based on various important requirements, the first of which is agreement on basic minimum service standards, discussed and negotiated from the bottom up, not the top down. Secondly, adequate resources, coupled with local tax-varying powers, need to be in place nationally. Thirdly, democratic local control and accountability of decision-making must be coupled with an effective flow of information and evidence. It is on that basis that we on these Benches judge the two main health and social care measures in the gracious Speech, on foundation hospitals and delayed discharge. I have to say that, on that basis, we have found some very big holes in both pieces of legislation.
The proposal for foundation hospitals was trailed as long ago as last May. From the outset it has been clear that they are destined to be entities built on contradictions. They are to be selected from hospitals that have gained three stars by meeting centralised targets. Whether or not they have succeeded in meeting local health needs, or have simply met arbitrary targets for waiting list management, they are to be handed over to public benefit organisations. As I listened to the noble Baroness reel off the official line on waiting times, I could not help but note that the time that it takes to get on to some waiting lists—for example, for minor surgical procedures or for outpatient services such as audiology—did not get a mention and yet the preventive value of such services is commonly agreed to be high.
As my noble friend Lord Clement-Jones said, foundation hospitals will provide services that are commissioned largely by PCTs and the funding of PCTs is determined by their ability to meet targets which are set in Whitehall. In view of that, the notion of local accountability begins to seem unreal.
The noble Lord, Lord Turnberg, made an eloquent speech. I took to heart his point about health inequalities and the question that people in the NHS have about how a system as currently set up for those hospitals that already perform well can possibly work to reduce health inequalities. As the governance of those hospitals will be turned over to communities, I believe that in areas where there are more articulate people with time, energy and resources to become involved in the running of the hospitals, that is bound to lead to some of the problems mentioned by the noble Lord, Lord Turnberg.
One aspect of this sudden and somewhat unconvincing rush to decentralise is the proposals on delayed discharge. The Government's proposal is part of just one of a series of initiatives that first arose in the Wanless report. Noble Lords may remember the Wanless report, which was commissioned by the Treasury and which was produced earlier this year. Referring to a point made by the noble Lord, Lord Hodgson of Astley Abbotts, it is interesting to note that many reports often lie about for a long time before they are given a response, but this one was picked up within 24 hours.
I say it is only part of the response because the Wanless report advocated three points, only one of which the Government have chosen to implement. First, Mr Wanless stressed that it is impossible to make accurate predictions about future healthcare demands without a thorough analysis of future need and patterns of provision of social care. He advocated that there should be a strategic view, a recommendation on which there has been silence. Will the Minister say whether future social care reforms will be based upon such a strategic view, or are we to expect a series of piecemeal measures?
The Secretary of State in another place in his speech to the National Social Services Conference on 16th October stated that the strategic commissioning group chaired by Jacqui Smith will produce a report on how local and community groups can take a bigger part in the delivery of services. That is not the same as an analysis of need, but it is an important element of working out the future of the whole health and social care economy, so I ask the Minister to update us on the progress made on that.
Secondly, there is the matter of the disappearing measure from the Wanless report. It advocated a system of fines to local authorities, but it did so in conjunction with a system of fines for hospitals where re-admissions were deemed to be the result of inappropriate discharge. The Government must have seen some merit in that proposal because it is included in Chapter 8 of Delivering the NHS Plan. However, more accurately, over the course of the summer that proposal disappeared. I simply ask the Minister: why? My honourable friend in another place Mr Paul Burstow has produced evidence of re-admission rates growing at an alarming pace—up 18 per cent in the past two years. Moreover, voluntary organisations, such as my own, are beginning to detect patterns where re-admission rates climb in the same areas where discharge rates have increased. Common sense suggests that there must be a correlation.
Unlike the noble Baroness, Lady Greengross, I have many reservations about the forthcoming Bill, but the aspect that should cause the greatest concern is that nowhere does it mention informed consent. Under the Bill, patients will be discharged apparently without ever having had the opportunity to agree whether they should be, or to exercise any choice at all. For those of us who work in the field, that is worrying—not just for those older people but, as the noble Baroness, Lady Pitkeathley, said, for their carers, many of whom are extremely elderly and unable to care for people with complex health needs.
Furthermore, the Bill makes no mention of mental incapacity. There appears to be no mechanism to establish what is in the best interests of the most frail older people—those who cannot express their own will. That seems totally to contradict standard 2 of the National Service Framework for Older People, which requires that older people receive the care that meets their needs as individuals.
Many noble Lords have mentioned bed-blocking and the lack of care homes as a causal factor. It is indeed. However, as we consider the Bill—I must tell the noble Baroness, Lady Greengross, that I expect that it will be here sooner rather than later—we shall hear an acronym that we all know and love: "sit reps", situation reports on hospital discharge. They are the common currency of social services and acute hospitals, the locally collected statistics that give the reasons behind delay of discharge.
No noble Lords have mentioned, and nor have the Government made much of the fact, that a substantial proportion of delayed discharges—up to 25 per cent, and in some areas a great deal higher—are caused by delays and inefficiencies within the NHS: failure to communicate within departments; failure to have discharge procedures in place; or failure to agree a process between acute and other wards. The Bill is not aimed at the right targets or in the right way.
Finally, I turn to accountability. One reads reports that the legislation came from Sweden; but it has been plucked from a different health and social care context. In Sweden, both health and social care are largely monopolies; in this country, social care most certainly is not. It is difficult to envisage at either a strategic level or for individuals where accountability for what may happen to people will lie and where complaints and advocacy are properly to be sited.
In view of all that, I have been desperately searching for an analogy. I have come to think that this is a community care congestion charge. Rather like Mr Livingstone's proposal, of which the Minister will no doubt be well aware, this provision is premature. Rather than being based on a whole system of care, it is an attempt to address one particular bottleneck. That may deal with the symptom but not with the cause.
The noble Lord, Lord Chan, in an excellent speech, highlighted one area of concern: the ability of primary care trusts to deliver the current system. In view of what he and other noble Lords had to say, there is a strong case, not necessarily for delaying the Bill for a long time, but for saying that the Government's hopes of having the system up and running by April 2003 are somewhat premature.
I fear that the wheels are beginning to come off the Government's perpetual revolution in the NHS. NHS forecasts are beginning to have all the credibility of Soviet five-year plans for the wheat harvest. Taking these two single measures, I believe that the future for older people in this year is beginning to look very much starker than it was previously. These measures, in particular, will receive thorough and tough scrutiny as they move through this House.