I beg to move amendment No. 87, in
clause 12, page 7, line 18, at end insert 'and that local authorities are not to charge for social care; if that social care is
(a) personal care defined in section 121(9) of the Care Standards Act 2000 as assistance in connection with bodily functions;
(b) nursing care, whether or not from a registered nurse; or
(c) the care of a kind mentioned in Schedule (Social care not ordinarily charged for) to this Act.'.
With this it will be convenient to take the following:
Amendment No. 88, in
clause 13, page 8, line 7, at end insert 'and to Schedule (Social care not ordinarily charged for) of that Act'.
Amendment No. 89, in
clause 13, page 8, line 13, at end insert 'and to Schedule (Social care not ordinarily charged for) of that Act'.
Amendment No. 90, in
clause 13, page 8, line 19, at end add 'and to Schedule (Social care not ordinarily charged for) of that Act'.
New schedule 1—Social Care Not Ordinarily Charged For—
'(1) As regards the personal hygiene of the person cared for—
(b) cleaning teeth and providing assistance in rinsing the mouth;
(c) keeping fingernails and toenails trimmed;
(d) assisting the person with going to the toilet or with using a bedpan or other receptacle;
(e) where the person is fitted with a catheter or stoma, providing such assistance as to requisite to ensure cleanliness and that the skin is kept in a favourable hygienic condition;
(f) where the person is incontinent—
(i) the consequential provision and changing of continence pads;
(ii) caring for the person's skin to ensure that it is not adversely affected.
(2) As regards the person's eating requirements, assisting with the administration of food.
(3) If the person is immobile or substantially immobile, dealing with the problems of that immobility.
(4) If the person requires medical treatment, assisting with medication, as for example by—
(a) applying creams, lotions, or administering eye drops;
(b) applying dressings in cases where this can be done without the physical involvement of a registered nurse or of a medical practitioner.
(5) With regard to the person's general well-being—
(a) assisting with getting dressed;
(b) assisting with surgical appliances, prostheses and mechanical and manual equipment;
(c) assisting with getting up and with going to bed.'.
In tabling the amendments, the Liberal Democrats seek to improve and clarify the range of services that are available free to those in need of care.
Four years ago, we felt that the royal commission on long-term care would end the scandal of the forced sale of homes that has been necessary to pay for care, particularly on the part of elderly people. The royal commission reported that charges for personal and nursing care should be scrapped. Four years on, sadly, that situation has not been arrived at. The Liberal Democrats will continue to campaign for what was described in the 2000 NHS plan. It said:
''charges increase the proportion of funding from the unhealthy, old and poor compared with the healthy, young and wealthy.''
Further, the plan said that charges
''discourage use of necessary services.''
Given that the NHS plan, the royal commission on long-term care, and not only the Liberal Democrats but many members of the public have said that, I very much hope that the Government will listen to a further plea to resolve the difficulties that older people face when they deal with—
I am interested in the hon. Lady's speech. She is making the case, which she has in part made before, for free residential care in the way that Scotland has introduced—
I am sorry; free personal care. In the case of home care charges under the National Assistance Act 1948, it is within the power of local authorities to decide whether and what to charge. Will the hon. Lady say which Liberal Democrat local authorities in England operate a zero rating on charges for home care?
If the hon. Gentleman would be happy to listen to the remainder of my answer, perhaps he would learn a little more. The remainder of my answer is that more recent legislation requires local authorities to charge for a proportion of home care services.
I thank the hon. Gentleman for his questions. Although I do not have to hand the precise legislation, I am happy to provide information on the background, which made it clear to me when I was a chair of social services that a proportion had to be paid for, and was expected to be paid by those who could afford to pay. If I am proved wrong, I will say so, but that is my understanding.
Does my hon. Friend share my concern and disappointment that Conservative Members still seem to take the view that they adopted during the passage of the Health and Social Care Act 2001 of not supporting the idea that basic personal care should be free on the basis of need, in keeping with a long-established NHS principle?
I am grateful to the hon. Lady and would like her to answer my original intervention because, contrary to what she says, four local authorities in England do not charge for home care, which contradicts her belief that there is a law that says that they must charge a proportion. I repeat my question: can she name a Liberal Democrat council, to join those four local authorities, which does not charge?
To answer the point made by the hon. Member for Sutton and Cheam (Mr. Burstow), I intervene not to put forward my view, but to emphasise the fact that Liberal Democrats say one thing—
Again, I am grateful for the intervention. We seem to be taking a long time to tease out whether Liberal Democrats tell the truth or whether they say one thing in one place and something else in another.
I reiterate that, from my experience as a chair of social services, it was entirely necessary to introduce charges for home care because, unless they were introduced, grant was stopped. Some local authorities may not have charged so far, and no doubt the hon. Gentleman will tell us which ones they are.
In giving the official Opposition spokesman an answer to that question, my hon. Friend might recall that it was a Conservative Government, in their standard spending assessment methodology, who made an assumption about how much local authorities would recoup through charges for services, which drove many local authorities to introduce charges in the first place. Although that is no longer explicit in the SSA methodology, it exists in practice.
I thank the hon. Gentleman for his further intervention, but I wonder whether, given the searching series of questions that has been put, we can make some progress.
I was quoting the words of the NHS plan. The Conservatives may say that we have moved on, but the point is that we should consider where we are now. Liberal Democrats are asking that assistance with such elementary tasks as washing, feeding and lavatory needs—tasks that nobody capable of doing them for himself would wish a paid helper to do—should be paid for. The royal commission said:
''We should expect to meet our housing costs all our lives.''
Liberal Democrats agree with that. However, we also believe that care costs are a risk that we should meet together as a society. The Government say that if someone has £18,000 in a bank, a pension or a home, they should not become frail or sick or old because it will be taken away. Our care system should not be a substitute for a tax system. The Government have a very narrow definition of what they will pay for. They will pay only for the costs of a registered nurse providing, delegating or supervising care—not the costs of the care assistant, who carries out the bulk of the work.
The amendments reproduce the provisions of the Scottish legislation, placing a duty on local authorities not to charge for personal care.
The hon. Lady is making a case, but does she realise its full implications? Many people who need low levels of care are unable to get them if excessive amounts of money go into providing high-level care in residential and nursing homes. Her proposal would prevent such people from receiving the low level of care that they would need in order to remain at home.
I thank the hon. Lady for her intervention, but I do not accept her point. Need
should govern what people get, not arguments that one person's needs should not be met because another person will miss out.
New schedule 1 defines the types of social care that the Liberal Democrats believe should not ordinarily be charged for, such as shaving, cleaning teeth and providing assistance in rinsing the mouth, keeping fingernails and toenails trimmed and assisting the person to go to the toilet or to use a bedpan or other receptacle.
I thank the hon. Lady for another helpful intervention. Once again, the argument can be made. Are the Government saying that people's needs should not be met, as the royal commission said that they should? Obvious needs should be met, and the costing has to be made and dealt with.
I should like to make some progress. I was discussing the new schedule, although I shall happily give way when I have finished doing so.
As well as such assistance—with going to the toilet, or using a bedpan or other receptacle—someone who is fitted with a catheter or stoma will need assistance to ensure cleanliness so that the skin is kept hygienic. Someone who is incontinent will require consequential provision and the changing of incontinence pads—caring for their skin to ensure that it is not adversely affected. Often too, they will require assistance with the administering of food.
People who are immobile or substantially immobile will need assistance in dealing with the problems caused by that immobility. Some will require medical treatment or assistance with medication—for example, the applying of creams or lotions or the administering of eye drops, or applying dressings if it can be done without the physical involvement of a registered nurse or a medical practitioner. To ensure their general personal well-being, some people may need assistance with getting dressed, or with surgical appliances, prostheses and mechanical and manual equipment. Some will need assistance when getting up and going to bed. We need from the Government greater parity and an expansion in services not charged for.
The hon. Lady seems to be developing an argument that suggests that needs just exist ''out there'' and that there is no way of determining exactly what level of resource will be allocated to services. Will she say which Liberal Democrat councils do not operate eligibility criteria?
I am not altogether sure what that question points to. I understood that pretty well all local authorities were forced to operate eligibility criteria. No doubt the hon. Lady will correct me if I am wrong.
We need greater clarity and an expansion of services not charged for. I hope that the Minister will listen not
only to the Liberal Democrats but to the royal commission's findings and to older people and their representatives.
I welcome you back to the Chair, Mr. Conway, for what I hope will be a more precise and more rigorous debate than we have had so far.
One of the challenges of scrutinising legislation, as well as of implementing it, is that we need to be precise about what we propose, how much it will cost, what its implications will be and what constraints will be imposed on it. The Government accept that challenge. Unfortunately, it seems that the Liberal Democrats do not. As my hon. Friends the Members for Sheffield, Heeley (Ms Munn) and for Erewash (Liz Blackman) pointed out, the Government take seriously their responsibility to ensure that we improve the range and quality of care available for older people, not just take a simplistic approach, as the hon. Member for Cheadle (Mrs. Calton) did.
That is why, on 23 July, my right hon. Friend the Secretary of State announced that we would remove charges from intermediate care and community equipment. The clause enables us to do that. We have also made it clear that the purpose of the Bill is specific. In July, we set these reforms in the context of the expansion in services that is meant to help support social services, to provide more community-based services and to improve hospital discharge arrangements. In his statement, my right hon. Friend told the House why we had chosen intermediate care services. It is, as he said, because they help avoid older people going into hospital or help them to leave hospital speedily. Community equipment services are important, because they
''can make the difference between older people becoming dependent or remaining independent in their own homes.''—[Official Report, 23 July 2002; Vol. 389, c. 871.]
In other words, the Government have a clear idea of the objective to be achieved through the provisions in the clause.
Yes. As it says in the explanatory notes, the cost, on our generous assumptions, will be some £18.5 million. If the hon. Gentleman would like me to go through with him why that is so, I would be happy to do so. We cost our decisions; the Liberal Democrats do not.
Both services rely on co-ordination between the NHS and social services. That is why we made integrated community equipment services across the country a national service framework milestone by 2004. That is also why we recommended a jointly appointed intermediate care manager across the NHS and social services, responsible for a pooled budget wherever possible. However, charging can be a barrier to pooled budgets and integrated services. Even where those things exist, it is sometimes hard to explain why integration still means that people are charged for an aspect of a service that is supposedly integrated. The removal of charging will therefore further support
those places that have not yet integrated services and where it contributes to delayed discharge.
Perverse incentives will also be removed. Income from charging is often offset by the administrative costs of making the charge, and charging perpetuates inequity for users in different parts of the country. Sometimes, because services are not integrated, the person is left without equipment—one agency has all its hoists out on loan, for example, while identical hoists are sitting on the other side of the store, but cannot be issued because they belong to the other agency and are charged for. The clause seeks to ensure integration and more effective community and intermediate services provision for those who need it.
The amendments tabled by the hon. Lady seek to reopen the debates on providing free personal care. Points on that debate were made during proceedings on the Health and Social Care Act 2001, in the 2000–01 Session. In response to some of the hon. Lady's points, I reiterate the Government's objections, and raise the issues of choices and responsibility, both of which were absent in her contribution.
The Government have made a choice to spend new resources made available in the spending review on improving the quality and range of services provided for older people. Those services will support old people in their own homes, are tailored to their needs, and will mean that they will not remain in hospital unnecessarily when they need further care, whether in their own home or a care home. We have made the choice to change and extend the system, not to perpetuate the status quo, albeit with extra amounts of money thrown at it.
Personal care is currently provided on a means-tested basis. That means that seven out of 10 people in residential accommodation receive all or some of their personal care free. If we focused resources on free personal care, we would be making a distributional choice to direct funding away from people on lower incomes and towards people who are, by definition, at the higher end of the distribution of income under discussion, although I entirely accept that they are needy none the less.
However, we made other changes in response to the royal commission. I take very seriously the concerns of older people who feel that they must sell their property, and we have raised capital limits so that people are entitled to keep more of their capital before they are charged. The value of people's homes will also be disregarded for their first three months in residential accommodation so that those who are moderately well off have more of their care paid for from the public purse and have longer to consider the implications of their long-term care needs for their home.
We have also introduced a scheme to reduce the number of people who need to sell their home to fund their care. Deferred payments agreements will allow them to keep their homes on admission to residential care. Such agreements will allow the council to make up the difference between the care home fees and what
residents can contribute from their income. Guidance on fair access to care services will be introduced in April and will ensure that assessments reflect individuals' needs. It will also give guidance on risks arising from immediate and future needs, which should be reflected in councils' eligibility criteria.
I am not clear whether the amendments' aim is to promote equity, but we are already doing plenty of work and spending money in various care settings to make care services more equitable. If the amendments are about personal care per se, however, we simply do not agree with them, for the reasons that I have spelled out. The proposals made by the hon. Member for Cheadle would mean that no one received a better service. They would do nothing to improve the quality of services that older people received. Nor would they increase the quantity of services. More important, the investment that we are making in services would not be possible.
That is where the issue of choice comes in. I am afraid that the hon. Lady gave away the fact that when the Liberal Democrats control local authorities and have the opportunity to make the hard choices that must be made in government, they do not do so, but simply talk generally about the issues. That is the crux of the matter. We have made a decision and answered the question as to whether we want to spend £1 billion on personal care.
I am sure that the Minister would not want to gloss over the fact that when the joint Labour and Liberal Democrat Administration north of the border, in Scotland, had to make choices about prioritising their expenditure, they resolved to introduce free personal care. Not only Liberal Democrats but Labour Members of the Scottish Parliament are taking the credit for that.
We are on a devolved subject, and the Minister may not be aware that the system in Scotland has not been as successful as expected, although I would hope that the hon. Member for Sutton and Cheam is aware of that. Highland council and several other local authorities have notified the Scottish Executive that they do not have the money to meet the statutory requirements on free personal care.
I accept what the hon. Gentleman says. He highlights the fact that difficult decisions must be made about limited resources, and different parts of the United Kingdom may make different decisions. I reiterate, however, that even where Liberal Democrat councils have the opportunity to make certain choices, they do not always do so. Unlike us, they have not made the choice between spending £1 billion on personal care or—as we will—on providing 130,000 additional carers services, 500,000 extra pieces of community equipment, 70,000 more intermediate care places, 30,000 more home care places, 6,000 more council-supported residential care places and 6,900 extra care housing places. The Government are committed to doing all that in the next three years, supported by ring-fenced money. That will ensure that social services can provide more
community-based social care services and give more people the care that they need to continue living independently and, ideally, at home.
We could not have done that if we had made the decision to make personal care free. The final choice is between whether we use the new power responsibly, focusing on the two services in which integration can reduce delayed discharge but in which charging gets in the way of integration, or whether we use it in such a way that the expansion in services for older people is jeopardised. Funding personal care is the wrong choice. I strongly urge the Committee to reject the amendment.
I thank the Minister for her response; I am not at all surprised by its level and quality. Those who are not simply playing with words in this Room but are listening outside have a different view of such matters. Although it is okay for a Minister to rattle off a long list of how many of this and how many of that, after five years people in the community know that promises do not always come to fruition. They will believe the long list at the end of three years when it has been delivered. Delivery is not always the Government's high point.
The Minister made the point that the intermediate care for six weeks and community equipment had been fully costed at £18.5 million. On what estimate of demand was that sum based? It seems singularly low for the quality of care that I would expect.
The £18.5 million was based on returns in relation to the spending currently undertaken by local authorities on community equipment services. The extra community equipment services that I mentioned would be covered by the additional £640 million that will be made available through the access grant. The costing for the free intermediate care was made on the basis of research into that portion of intermediate care provided by social care, multiplied by the portion provided by the authorities that currently charge. The additional money is also aimed at providing the additional intermediate care places outlined.
''Understanding the underlying level of demand'',
''A critical first problem is that service commissioners and providers generally have no idea of the underlying level of demand for equipment services. Unmet need is a serious problem as without equipment, people can face social exclusion. Data on the numbers of people who need help are not readily available. This hinders service planning and the ability to monitor changes in patterns of need and demand over time. By no stretch of the imagination can equipment services be described as 'needs-led'. And, of course, the failure to assemble such vital information could be said to be discriminatory—no such dearth of information exists in services for people with coronary heart disease or cancer.''
I should like to finish my point. To use current levels as a base is simply to miss the point, as
those levels do not meet the needs. I made the point earlier that if something that is needed is to be charged for, it is likely that not all the need will be met.
The hon. Lady is right. However, does she accept that I explained to her that we were funding both the current estimated levels of provision of community equipment services, and an increase of 500,000 pieces in the next three years? We could not make that expansion had we made the choice that she suggests that we have made.
Obviously I recognise that there has been an expansion. I am querying whether £18.5 million reflects the need. My view is that the expansion will not meet the undoubted need. The charges effectively prevent much of the need coming to light. Until they are removed for these necessary services, we shall not know the full extent of the need. Although I accept what the hon. Member for West Chelmsford (Mr. Burns) said earlier, decisions have to be made in government, and those decisions have been made in Scotland.
I thank the hon. Gentleman for his intervention. We must remember that this is not a debating society issue—it does not require a button pressed here or there. Complex needs have to be taken into account. If insufficient funding is made available, that must be considered and decisions must be made about further funding. To say that because there is insufficient funding one cannot afford something without testing or piloting is a nonsense. I cannot agree with the hon. Gentleman.
We have been told that the proposals do nothing to improve the situation. I do not see how we can provide choice if we accept that charging discourages the use of necessary services. That is what the Audit Commission said. The necessary services are still there—it does not matter what we say in this Room. If services are needed in the community, they are needed. It is not good enough to say that we cannot do something because we cannot afford it. We afford a great many things in this place, and looking after the intimate care needs of older people should be given a very high priority.
Question put, That the amendment be made:—
The Committee divided: Ayes 2, Noes 9.
I beg to move amendment No. 50, in
clause 12, page 7, line 22, after 'provided', insert 'following the patient being informed of the costs of services following this free
period and an assessment made for continuing NHS health care and for community care services of that patient'.
I also welcome you back to the chair, Mr. Conway.
The amendment aims to ensure that patients are not discharged to free intermediate services without some knowledge of what the costs will be once that has ended and it has also been established that they do not qualify for fully funded NHS care. We on the Conservative Benches are concerned that older people, perhaps not in the best state of mind because of a recent operation, will accept intermediate care without realising either that, according to the Department of Health's circular HSC 2001/001, that is normally limited to six weeks or that they might qualify for fully funded NHS care on a longer-term basis.
Although it has caused confusion in some quarters, most patients will not be aware of the ruling in the Coughlan case, which found that if a person's need for care home accommodation was primarily driven by health requirements, and that it was beyond what a social care package could provide, then that person was entitled to free, fully funded NHS care. We are concerned that the system might inadvertently funnel patients down the intermediate care route, after which they might be left to their own devices. Alternatively, those same patients could be entitled to fully funded NHS care which—although more expensive for the NHS—would be better for the patient, and possibly more cost-effective for the NHS, in the long term.
At that point in their treatment, perhaps because they have just had operations, patients could feel particularly isolated and vulnerable. There is no guarantee that they will have relatives or carers close to hand. Meanwhile, there is no guarantee that home care staff will be fully aware of the rights of the patients, particularly their NHS entitlements. The amendment aims to ensure that patients are fully aware of the implications of the options available to them and of whether, if a full assessment had been made, they were entitled in the first place to fully funded NHS care. The amendment is important, not just because of the state of health of the patients but because they might be feeling vulnerable and isolated. We should do all that we can to ensure that they are fully aware of their options.
Does the hon. Gentleman understand that an elderly person who no longer requires—in clinical terms—acute care is in a vulnerable position in that setting? Moving the care pathway into a much more settled situation, such as intermediate care, is underlining that acute care is not good for older people. It should not be continued, and to allow it to continue increases the risk of problems with mobility and of getting infections. It is very bad for them and it would not be advisable to ensure that the situation continued. Moving on to intermediate care is the best option.
I do not necessarily disagree. I am just saying that patients should be made fully aware of their options. I doubt that the hon. Lady would disagree with me in the sense that, after an operation,
patients have—broadly—a choice of two routes and should be aware of that. It seems only fair and logical that they should be aware that costs may be involved after intermediate care ends and that they may qualify for fully funded NHS care. On that basis, I commend the amendment to the Committee.
I want to flesh out some of the issues. Although I have some sympathy with what the hon. Gentleman is trying to achieve, there is a real difficulty with how the processes work. As my hon. Friend the Member for Crawley (Laura Moffatt) has just said, there is a need to move on elderly people as soon as possible. An assessment of their need for intermediate care services can be carried out, but it would be premature when they leave acute services to determine the outcome of their stay in intermediate care. It is impossible to give a person a realistic assessment of the services that they may need and their likely cost at that time. I have some sympathy with the view that people should know the range of services that will be available. After all, that is part of the usual assessment and care management process, but it does not seem sensible to consider delaying a move until it is possible to be more definite about that.
From my experience gained working in the area for several years, I am aware that, when people first leave hospital, they often feel vulnerable and believe that they will need more care and support than they actually subsequently need.
The hon. Lady is making an entirely fair point. Of course, we all share the common objective of wishing to see people who are fit and well, or on the way to being fit and well, in the most appropriate care setting, which, as the national service framework says, is often intermediate care. Does she agree that it is important that the NHS should continue to cover the costs of a person's care, pending the outcome of a review of their continuing needs?
We need to return to what actually happens, rather than dealing with a theoretical description. It is not a matter of carrying out a review. An initial assessment is carried out and, if it is determined that a safe discharge to their home—the first preference for most people—is not possible, and that a person would benefit from some intermediate care support, a reassessment is necessary to consider the different options available. What the hon. Gentleman says may be right, but the process of assessment is ongoing.
The benefits of intermediate care are such that some things that cannot be assessed while the person is in hospital can be assessed in other settings. Therefore, the process of moving a person on to intermediate care is, in itself, part of the ongoing assessment. Hopefully, through that process, people will become more confident and more able to look after themselves and, perhaps, manage with less support than they would have thought was possible when they were in hospital, in an unusual situation, and feeling vulnerable. We need to have a care for the reality of the situation and understand that too much
information about a range of possibilities early on in the process may not be helpful to the person and their family in determining what care they need.
Mr. Baron rose—
The hon. Lady is very kind.
We are not suggesting that continual assessment should suddenly cease. We are suggesting that, wherever possible, patients should be given the necessary information so that they are informed about the choices available to them, because intermediate care usually, although not always, ends after six weeks. Patients can sometimes be left a little in the lurch, not knowing what will happen thereafter. In other cases, patients are offered intermediate care when they are entitled to fully funded NHS care. We are arguing under the amendment that patients should be more fully informed of the options that are available.
The hon. Gentleman makes a fair point, but I am not sure that that is what the amendment would achieve. I refer Opposition Members to legislation that has been enacted for nearly 10 years. The whole process of assessment and care management and the exploration of options for care is part of the expectations of current practice.
I have some sympathy with the points made by the hon. Member for Billericay (Mr. Baron). However, the amendment is unnecessary and potentially detrimental to the assessment process. I shall explain why.
I agree with the hon. Gentleman that it is important, subject to people's ability to understand them—and therefore subject to the information being provided in a suitable way—that people should be fully aware of the options and implications. That is why, when someone is going for elective admission—we are talking about intermediate care following a period in hospital—the earlier that social services are notified to carry out an assessment the better. That links to what we were discussing earlier. However, I disagree with the hon. Gentleman's suggestion that, whether or not someone has continuing NHS care or intermediate care, it is primarily a choice for them. Those types of care are for different functions. If someone needs continuing NHS care, someone should get it. Intermediate care, as my hon. Friend the Member for Crawley pointed out, is for a completely different purpose—for rehabilitation, or for getting people back to independence.
Good practice is drawing up a care plan for intermediate care that is based on an appropriate assessment, and that assessment should determine at the outset whether someone needs continuing care—and if they do, they should get it. If they need long-term care following intermediate care, they will get that as well. That assessment should include anticipated outcomes and a clear idea of the services that will follow. As my hon. Friend suggested, it should include a mid-point review to check progress and to adjust the services if necessary. We made that point last year in the intermediate care guidance that the hon. Gentleman
cited. The guidance on single assessment and on fair access to care emphasised the importance of reviews and of reassessing people's needs.
Is not the central point about the amendment—forgive me for asking—that patients should be able to express what they believe should happen and that they should be made fully aware of possible unexpected costs? I accept that one should not worry a patient with the idea of costs immediately after an operation. Some sensitivity must be shown when discussing those issues. However, to regard the matter as something that patients have done to them, instead of something in which they should be actively engaged, is concerning. Have I missed the point?
On this occasion, the hon. Lady has not missed the point. I do not disagree with her. Indeed, I had already said that it was important that patients and their carers should be aware of the different options and the costs that might result. We have gone further than that. Guidance on assessment requires that care options and the associated charges and contributions that individuals might have to make should be discussed with patients and their families. I do not disagree with her about that. The definition of intermediate care in the guidance issued by the Department refers to provision
''on the basis of comprehensive assessment''
''cross professional working within a single assessment framework''.
I question, however, whether the mandatory approach taken by the amendment is appropriate. We already have in place the single assessment process, which covers assessment of continuing care, long-term care services and intermediate care.
As I understand it, the single assessment will be in place from April 2004, so it is not in place everywhere yet. We shall come to the partial assessment process in the Bill. Will the Minister confirm that continuing care needs will be assessed at that point as well? Alternatively, will they be assessed post-discharge?
As we discussed on Tuesday, the hospital part of the process in clause 3 will be part but not all of the single assessment process. Things will depend on the situation. It may be obvious that someone needs continuing NHS care as soon as they are assessed, in which case it should be made available to them. It may be obvious that what they need is a package of community care services, and in that case the social services department would clearly have responsibility for providing those services under part 1. There may be disagreement, and the patient may believe that they should be entitled to NHS continuing care. Nothing in the Bill changes the current rights of a patient who believes that they should have such care. That might deal with the intervention that the hon. Member for Billericay made earlier.
Let us go back to what is already in place in the assessment process. Local authorities already have a specific duty, under section 47 of the National Health Service and Community Care Act 1990, to assess a person's needs for community care services when it
appears that a person may need services. When social services think that a person might also need NHS or housing services, they are required to notify the relevant body and ask for its involvement in the assessment process.
The purpose of single assessment is to ensure that the scale and depth of assessment is proportionate to older people's needs, that agencies do not duplicate one another's assessments, and that professionals' time is not wasted on duplicate assessments. That is important when considering the amendment. When we talk to older people, I suspect that we all hear their frustration at a troop of different professionals coming to assess them, asking the same questions and duplicating their own and the professionals' effort.
I want to pick up on something that the hon. Member for Sutton and Cheam said. If the single assessment is not coming into place fully across the country until April 2004, and the Bill takes effect from April 2003, what measures will the Government implement to bridge the gap over those 12 months?
The single assessment process should be seen in the context of section 47 of the 1990 Act, which contains the statutory duty to assess. There are milestones on the way to full implementation of the process. We have issued guidance on how the process should work, and plenty of work is going on at a local level to begin to develop the protocols and relationships important for it. As people introduce or continue with assessments and improve them in the light of the single assessment process, they will obviously bear the guidance in mind. The fact that full implementation is not until 2004 should not prevent us from saying that the principles should begin to be included in assessments, or that the principles of the Bill should be held up until then.
We are backing up the need for assessments to be proportionate and speedy, with a new target for assessments to begin within 48 hours and to be completed within four weeks. Most importantly, the reforms put the users' needs centre stage. In contrast, I fear that the amendment would promote the duplication that the single assessment process is designed to stamp out. It would also not be proportionate to the needs of the majority of individuals, which is a point that I think my hon. Friend the Member for Crawley was making. Last year, a district audit carried out a survey of 213 intermediate care schemes. Evidence from that survey showed that most intermediate care services lead to older people returning to or remaining at home. Between 65 and 90 per cent. returned to independent living after intermediate care.
If an average of 75 per cent. of people across intermediate care schemes return home to enhance independence, a mandatory assessment for continuing NHS health care over and above what should have been given at the beginning of the assessment process—which is what the amendment appears to propose—would be wasted on most people. One of the
major complaints of older people is the unco-ordinated and sometimes slow assessment that they receive. The amendment would add to those complaints, and for that I reason I believe that it should be rejected.
I am not convinced by the Minister's response. I am not happy with the fact that the single assessment process will not come into force until April 2004. There is a gap, and the Minister has not denied it. I am not convinced that the Government have put enough resources into ensuring that that gap is bridged. The Bill appears to be being rushed through and will take effect from April 2003.
I could understand the hon. Gentleman's concerns if it were not for the fact that many authorities have operated single assessment processes effectively for a long time because it is, after all, good practice to do so. We are talking about getting the authorities that do not do so up to that level. As the Minister has fully explained, those authorities are well on their way. It is wrong to give the impression that some 150 local authorities are nowhere near implementing the single assessment process.
One is not suggesting that no authorities are moving forward—it is quite obvious that many are. By implication, however, a number of authorities are not. Therefore, if some authorities make little or no progress in 12 months, it is only right that we, as Members, fully consider those types of situations, and those patients who get very little attention when it comes to single assessment generally. Some authorities are moving forward, but many are not.
I turn to another reason why I have a slight reservation. One or two members of the Committee have perhaps not picked up on the fact that one of the main aims behind the amendment is to ensure not only that patients have some say in the big scheme of things, but that they are consulted when possible. There are clearly situations in which patients cannot be consulted and may not even be able to express a view. However, we should recognise that patients have a certain right in such decisions. The amendment attempts to put that in the Bill, as it is not there at present.
There may be a tonne of regulation coming up. The Bill is barely a skeleton—I will not use the analogy of a Christmas tree. Unless we include the amendment, we cannot guarantee that patients' views and concerns will be acknowledged, or that they will be consulted. For that reason, I would like to press for a Division.
Question put, That the amendment be made:—
The Committee divided: Ayes 7, Noes 8.
With this it will be convenient to take the following:
Amendment No. 92, in
clause 12, page 7, line 31 , at end insert 'or
(c) community equipment, including aids to daily living, mobility aids, adaptations to the home, equipment for home nursing, communication aids and other items listed in Schedule (Community Equipment); or
(d) intermediate care as defined in Schedule (Intermediate care).'.
New schedule 2,
Community Equipment shall be taken to include—
(a) equipment which may assist with daily living: special seating, shower chairs, bath-mats, raised toilet seats, teapot tippers and liquid level indicators;
(b) minor adaptations to the home, such as grab rails, lever taps, improved domestic lighting, and improving the use of contrasting colours;
(c) equipment for home nursing such as pressure relief mattresses and commodes;
(d) mobility equipment such as walking sticks, zimmer frames and wheelchairs for non-permanent wheelchair users;
(e) ancillary equipment for people with sensory impairments, such as flashing doorbells, low vision optical aids, textphones and assistive listening devices;
(f) telecare equipment such as fall alarms, gas escape alarms, health state monitoring and ''wandering detectors'' for people who are vulnerable.'.
New schedule 3,
Intermediate care should be regarded as describing services that meet the following criteria—
(1) community care services targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care;
(2) services provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery;
(3) have a planned outcome of maximising independence and typically enabling patients to resume living at home, typically within a time limit of up to six weeks or more;
(4) involve cross-professional working, with a single assessment framework, single professional records and shared protocols;
(5) short-term programmes of therapy and enablement in a residential setting (such as a community hospital, rehabilitation centre, nursing home, or residential care home) for people who are medically stable but need a short period of rehabilitation to enable them to regain sufficient physical functioning and confidence to return safely to their own home;
(6) services covering a short-term period of nursing or therapeutic support (or both) in a patient's home, typically with a contributory package of home care support and sometimes supported by community equipment and/or housing-based support services, to enable earlier transfer of care from an acute hospital and to allow a patient to complete his rehabilitation and recovery at home.'.
community care services as free. The amendments would introduce a more detailed list of equipment that would ordinarily be deemed to be available on the basis of need rather than means. The amendments probe the Government's thinking. Paragraph 46 of the explanatory notes states:
''Community equipment (also known as aids and minor adaptations) is aids to daily living to promote independence in the home, ranging from walking sticks to grab rails and shower mats, predominantly provided to older people and disabled people.''
That is a very brief description. Can the Minister give a clearer indication of what sort of equipment older people should expect to receive? What latitude is to be given—can we be sure that when the legislation is rolled out there will not be wide variations in practice around the country? We should like to have the aims of the policy and the Minister's expectations clearly on the record.
Will the Minister confirm that the clause will be used to extend the provision of free equipment to all care settings, not just as an aid to speedy discharge? If it is the latter, it will be useful to know how the distinction will be drawn. If it is not, that will be very welcome. Has the Minister considered the findings of the Audit Commission's report ''Fully Equipped 2002—Assisting Independence'', which was published in June? It says:
''In the case of community equipment services in particular, social services departments were finding themselves under increasing pressure to cope with the demands of people being discharged earlier from acute hospitals. The policy to support the immediate needs of the NHS was putting pressure on other parts of social services home-care budgets, and driving up eligibility criteria for those who needed less intensive support to help them to stay at home—risking unnecessary hospital admissions and increasing demands on the NHS.''
We have been telling the Minister that that is a concern. What safeguards will be put in place to ensure that the fines system in part 1 does not exacerbate that trend, which auditors across the country were already observing when they compiled that update on equipment?
Will the Minister also take the opportunity to give us some much needed clarification about the provision of equipment in respect of residential and nursing homes? The Audit Commission describes that as a grey area. It says:
''Some nursing and residential homes provide equipment as part and parcel of the package of care that they provide, some rely on the NHS to provide the equipment and others require residents or their relatives to pay for it. As the policy of continuing care develops, residential and nursing homes will become responsible for residents who are more dependent. This will increasingly force the issue, and many commissioners will need to clarify their policies for providing more expensive specialised equipment, such as pressure-relieving mattresses or hoists.''
Can the Minister tell us whether pressure-relieving mattresses and hoists will be free under the Bill's provisions? Will they now be available under the provision for free equipment, or will lines be drawn? If lines are to be drawn, will the Minister tell the Committee where?
In an earlier exchange, the Minister referred to the additional 500,000 pieces of equipment that will be issued as a consequence of new investment. Will she elaborate on what assumptions were made about
increases in demand arising from that measure, and will she give us some idea of what assumptions were made on the types of equipment that would be issued in order to reach that number? Are we talking about basic items such as grab rails, or about more expensive, specialised equipment?
The other amendments concern intermediate care. The Bill introduces a strict time limit on free intermediate care of six weeks. New schedule 3 would include the definition of intermediate care in the Government's current guidance. The guidance—and the Bill, should the amendment be accepted—says that intermediate care could be free for longer. It does not have to be confined to a six-week period. Surely it is appropriate to consider the need for intermediate care case by case. Some people, particularly those who have dementia as one their conditions may find that they can be rehabilitated into the community but may nevertheless require a longer period for rehabilitation. Will the Minister tell us the Government's thinking on that? Will it be a strict rule that people will have to pay after six weeks?
I draw the Committee's attention to another passage from the 2002 update report that raised a serious question about the capacity to deliver intermediate care. It said that there are serious staffing problems for occupational therapists. It stated:
''auditors were concerned that the staffing levels of some equipment services prevented proper investment in rehabilitation and community care. In particular, the shortage of OTs was identified as being a major problem. Community OTs spent, on average, a small proportion of their time on rehabilitative advice and continuing care management, and were having to concentrate instead on their role as equipment providers.''
That is a major obstacle to realising the Government's policy intention of speeding up delayed discharges, getting people into more appropriate care settings sooner, and ensuring that they receive the care, as the Minister put it, in the right place at the right time. What assessment has she made of the Audit Commission report on the staffing bottleneck? Although there is the potential for more people to train for occupational therapy, still not enough are coming out at the other end.
Earlier this year, I surveyed intermediate care co-ordinators and I found grave misgivings among them about the overly rigid six-week rule that they perceived in the guidance. I accept that the guidance is flexible on that point. My concern is that the Bill is not flexible. I hope that the Minister can answer my questions on the six-week rule and on intermediate care and, more particularly, my questions on equipment.
That is the point, and I am grateful for the hon. Gentleman's intervention. By using the amendment to probe the Government's intentions, we are making the point that the guidance provides a basis for intermediate care that does not presuppose
that, in every circumstance, people will have six weeks and no more. Indeed, some may require less than that. The hon. Gentleman is right to make that point.
We need to hear from the Minister that the flexibility in the guidance will be in place when it comes to the free element of intermediate care, and that people in their seventh week will not find themselves suddenly having to pay for services that were free for the first six weeks.
The hon. Member for Sutton and Cheam is right that the purpose of clause 12 is to enable community equipment services and the intermediate care services to be provided free of charge. I assure him in response to the question whether community equipment would be free only if it were a matter of getting out of hospital that the answer is no. The costing assumptions and the Bill ensure that it would be free for whoever and in whatever circumstances it was needed. The same is the case, subject to the definition, for intermediate care. In other words, social care intermediate care would be free not only to allow people to come out of hospital. The same would apply if it was given to avoid admission to hospital; that would also be free.
The hon. Gentleman also asked about residential care. If someone is entitled to free community equipment in the community, that free equipment should also be available in residential care. As for those things that would be the responsibility of the NHS, interestingly enough, one important benefit of the contribution towards nursing care has been a much better relationship between the NHS and nursing homes in many places. We are beginning to see some of the equipment that the hon. Gentleman spoke of, such as pressure mattresses, being provided; the NHS is taking into consideration its responsibilities to provide that equipment, even with privately funded nursing care.
I am grateful for the Minister's answers to some of my questions. Can I be clear that, in the circumstances that she describes, she would expect hoists and the other items of equipment provided in residential nursing homes to be free in every part of England—and that it would be provided by the NHS, not as part of a package by the care home owner or by the individual?
I did not go quite as far as the hon. Gentleman wants to push me, but I did say that guidance—for example, on NHS-funded nursing care—provides that access to equipment for individuals is given on the same basis as for the community. When we come to our debate on the definitions of community equipment services, that may answer some of the hon. Gentleman's questions.
I recognise that the hon. Gentleman proposed the amendments to gain clarity about our intentions. However, not only are they unnecessary, but it would be potentially detrimental to define either of those services in primary legislation. The Bill does not refer to intermediate care or to community equipment. Instead, it imposes powers and duties on local authorities to make arrangements for different types of people who might need social care.
For example, section 29 of the National Assistance Act 1948 requires local authorities to make arrangements for the welfare of certain disabled people. Section 45 of the Health Services and Public Health Act 1968 requires local authorities to make arrangements to promote the welfare of the elderly. I am sure that all hon. Members will know from their avid reading of the legislation that schedule 8 to the National Health Service Act 1977 deals with services designed to prevent illness, for the care of persons suffering from illness and for those who have been suffering from illness who need aftercare. The reference in the clause to paragraphs (a) to (c) of section 17(2) of the Health and Social Services and Social Security Adjudications Act 1983 refers to the responsibility to provide services under those parts of the Acts that I have just mentioned. That is the most appropriate basis on which to set down in the Bill the policy intention of providing free community equipment services and intermediate care.
Amendment No. 92 and new schedule 2 are loosely based on the list in my Department's community equipment guidance, which was published last March. [Interruption.] I am glad that the hon. Member for Sutton and Cheam thinks that the list is reliable, but there is a problem with the way in which he has used it, and included only a small part in the amendment. For example, his list excludes communication aids, which are included in the guidance, but includes pressure relief mattresses, which are treated differently in the guidance. I use that example to illustrate the difficulties of including lists in legislation as the hon. Gentleman does. I take it from the fact that he is nodding that he accepts that.
Right. The hon. Gentleman is probing our intentions, and the important thing is that we set up a legislative system that lets local social services decide what community equipment is suitable, while ensuring that no charge is made. We intend to use regulations to provide a broad definition of aids and minor adaptations, and to leave social services the discretion that they now enjoy to provide the most appropriate services. We have consulted on the details of the regulations, and we will want to consult further.
I am sure that many organisations will actively engage in that consultation. That is true not least of Age Concern, which is particularly anxious to have as much clarity as possible at the earliest stage to avoid variations across the country. In drafting the guidance, will the Minister also consult on the eligibility criteria, which will have an impact on these provisions, to avoid variations across the country?
Clearly, if we say that community equipment services, as defined in the regulations, are free, we will not need eligibility criteria in quite the form that the hon. Gentleman suggests—unless I have misunderstood him.
The point that I am trying to make is that even where a service is free, different authorities may draw up different eligibility criteria to determine whether it is to be provided, and the Minister could still see variations occurring. I hope that she will at
least consider that possibility and deal with it in the consultation.
I accept the hon. Gentleman's point, but the issue is being covered in the free access to care services guidance, which provides a framework in which local authorities can determine their eligibility criteria.
In drafting the Bill, we consulted the Department's user group on community equipment services on the definition of those services. The group includes a range of user organisations and the voluntary sector. Interestingly, they did not want a list of eligible equipment. The community equipment services team, which the Department set up, also consulted people involved in providing community equipment services, and they did not want a list of free equipment. Furthermore, Age Concern's response to the Queen's Speech said that there should not be a limited list of services, so our proposals are in good company. We are taking a pragmatic approach that reflects what people want, and that is mirrored in the new power.
That comes under the same category as issues that I was talking about this morning, in that I can undertake to make available a summary of what would be included in the regulations. That may provide some reassurance. For example, when we consider community equipment, we shall think about the appropriate definition; when we consider minor adaptations we shall think about the value—probably £1,000—that would distinguish a minor adaptation from one that would, as we said on Tuesday, more properly be distributed through a disabled facilities grant process.
Our approach reflects the purpose of the new power to remove the charging barrier to gaining access to services, and to make joint equipment stores, with pooled budgets, much more common—but not to dictate or change the services that are currently provided by local authority social services departments. The arguments are similar with new schedule 3, on intermediate care services. It is mainly based on guidance that my Department issued last year. However, we have some concerns about its implications for what would be included or excluded. I do not think that such inconsistency is desirable in the Bill. That is why we intend to provide a broad definition of intermediate care services in regulations, which could, in time, be amended to reflect emerging best practice—backed up, of course, by statutory guidance, possibly enabling us to go into more detail.
As the hon. Gentleman pointed out, we have included the limit of six weeks in the Bill. Quite an important part of the definition of intermediate care is the fact that it is time-limited, because it is concerned with creating independence rather than reinforcing dependence. Its focus is on rehabilitation. For that reason it is justifiable that the time limit should form part of the definition.
I know that professionals such as physiotherapists are concerned about the way in which a cut-off point would reduce their professional discretion to make a judgment about a person's ability to benefit and, ultimately, to recover and live independently as a result of intermediate care. Will that cut-off really always bite at six weeks, resulting in charges from the seventh week onwards, or is there still a possibility of some flexibility?
I undertake to consider the hon. Gentleman's point—and of course, an amendment has been tabled concerning the six-week limit—but it is important that legislation should be clear about the confines of, or focus implied in, intermediate care. Of course, care provided by the NHS would be free anyway. As for social care intermediate services, our research suggests that in the vast majority of cases the appropriate period is usually about four weeks—even for residential social care intermediate services. Six weeks will not chop off the services for large numbers of people. Discretion might, I suspect, be possible in relation to decisions made by social services departments. Although the Bill provides for there to be no charging for six weeks, there could nevertheless be discretion for care managers or social services managers after the end of that period.
The hon. Member for Sutton and Cheam also mentioned the shortage of occupational therapists to make assessments. I believe that I mentioned on Second Reading some of the figures for the increases in occupational therapist numbers—those already working and those in training. The NHS plan also includes plans for further increases. Furthermore, occupational therapists and our team considering the implementation of community equipment services are interested in whether it is possible to alter the way in which assessments are carried out, and perhaps to distinguish between those that are relatively simple, and which might entail an element of self-assessment, those requiring the specialist skills of occupational therapists, and those requiring technicians working with occupational therapists. The need for work on that matter is important.
I am confident that the Bill will contribute to ensuring that, for services provided locally, charging does not, as we sometimes fear it does now, get in the way of providing the sort of integrated service that people need. The amendments would not allow that flexibility. I hope that the hon. Gentleman has been reassured by the extra information that I have provided and feels able to withdraw the amendment.
I shall comment on amendment No. 91—although I do not think that the hon. Gentleman spoke to it—about carers, and whether services provided directly to them are to be charged for. We said in the guidance that we issued last year on intermediate care that its implications for carers should be thought through carefully. Clearly it would not be in keeping with the Bill if, say, a heavy bloke—[Interruption]—not that there are any in this Room. Let us say that if a heavy person were to be discharged to his home from hospital, on the assumption that his wife or carer would assist him in moving, and if his wife was short
or had a bad back, and needed a hoist or other assistance to enable her to care for him, it would be unacceptable to charge for the equipment, because it would be designated community equipment for a carer's service. The effect would be the same as if the man who had been discharged from hospital had been given the equipment.
We have, therefore, some sympathy with the hon. Gentleman on this issue, which I know has also been raised by Carers UK, among others. We intend to return to it on Report with an appropriate amendment.
I am grateful to the Minister for her response to my inquiries about the clause and how it will work. The amendments were intended as probing amendments. I am well aware of the Government's concerns about long lists in Bills. However, I found the Minister's comments about the broad definition useful, and I hope that we shall be given as much detail as possible on that before Report. Similarly, I take the Minister's points about carers and I look forward to an amendment being tabled on Report. Whether it will pertain to heavy blokes I do not know, but I certainly hope that it will help carers to deal with their burdens. Although I might want to return to these matters at a later date, I now beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
With this it will be convenient to take the following amendments: No. 122, in
clause 12, page 7, line 32, leave out subsection (4) and insert—
'(4) The regulations may not require that the costs of accommodation and living costs (excluding the care costs of the kind referred to in subsection (1) and Schedule (Social Care not ordinarily charged for (No. 2)) referred to in subsection 3(a) are to be free of charge for a period exceeding six weeks.'.
No. 51, in
clause 12, page 7, line 33, leave out 'exceeding six weeks' and insert 'outside of the time when the patient is assessed as within the criteria for receiving services free of charge'.
I shall speak briefly, because we have already been able to explore some of the relevant issues when we debated the previous group of amendments. The amendment is focused on the cut-off point of six weeks specified in the Bill. The argument is that it should be possible for discretion to be exercised locally, based on an assessment of individual needs and the likelihood of people being able to respond to a further period of intermediate care in a way that will enable them to return home and live independently. Including the cut-off point in the Bill seems to get in the way of that aim. It also seems to be contrary to the guidance, which implied some flexibility. The amendment would give the Government the chance to think again. We hope that they will do so.
The Opposition have a slight problem with subsection (4), which appears to limit the scope of the regulation-making powers under subsection (1) in respect of what may be prescribed as a qualifying service under subsection (2)(a). Accommodation
provided under part III of the National Assistance Act 1948 may not be required to be free for more than six weeks. The explanatory notes say:
''This reflects the recommended time that intermediate care is provided in both the NHS and social services, based on current practice and existing guidance.''
The amendment aims to ensure that intermediate care in a care home is not limited to six weeks, in line with Department of Health guidance on intermediate care, which states in circular HSC 2001/001, paragraph 8:
''Exceptionally, for example following a stroke, patients may require intermediate care for slightly longer than six weeks.''
That may be exceptional, but we can all think of times when intermediate care is required for longer than six weeks, and we want to ensure that there remains enough flexibility in the Bill to ensure that such cases can be catered for. We all know that older people who require care in a care home may need longer than six weeks to recuperate, and the Department of Health circular cites stroke victims as an example.
Amendment No. 51 would enable patients who have been assessed as still requiring intermediate care after six weeks to continue to receive free services and accommodation. After all, the current guidance allows for extension beyond six weeks subject to a full reassessment and authorisation by a senior clinician. The amendment would likewise ensure that there would be an assessment to establish that free services were no longer required, rather than insisting, as the Bill does, on a rigid cut-off date for all cases. It attempts to marry the provision of free services with free accommodation, which seems logical and fair. The Bill contracts the Department of Health's definition of intermediate care by appearing to restrict free accommodation to six weeks. I hope that the Minister accepts that that provision appears illogical, and that she will respond positively.
The hon. Member for Sutton and Cheam is right; we discussed the six-week limit on the previous amendment, and some of what I said then remains important. We believe that there are sound reasons for maintaining that limit; it is specifically linked to the fact that we are dealing with the provision of intermediate care services. The provision is based on accepted good practice and reflects existing guidance.
The hon. Member for Billericay quoted the intermediate care guidance, which said that exceptional extensions beyond six weeks should be subject to a full reassessment and should be authorised by a senior clinician. I have sympathy with what he said about care that might be provided for stroke patients. I repeat what I said to the hon. Member for Sutton and Cheam: notwithstanding the fact that the definition suggests that in the vast majority of cases free care would be limited to six weeks, intermediate care provided by the NHS is not charged for. That case is slightly different. We need to ensure that people do not see intermediate care as an alternative to long-term care or other long-term provision; the NHS and social services must carefully assess a person's need for intermediate care services in order to provide rehabilitation and the active therapy that promotes
independence, not as an alternative to long-term care or community care.
In clause 11, a procedure is available to Government to extend the scope of the measure to include residential rehabilitation schemes and intermediate care schemes. That would enable them to address the concern that the Minister is voicing. Is it necessary for the Bill to include belt and braces at a specific cut-off date when a power exists to deal with the matter through regulations?
The function of clause 11 is, as the hon. Gentleman says, to ensure that if we thought it appropriate and the services were provided in care homes, we could extend the framework of incentives that the Bill sets out to other services such as intermediate care. Social care intermediate care services will not necessarily always be provided in a residential setting.
As I said earlier, we have good evidence of average stays for intermediate care services. The survey that I referred to showed that most services operate seven days a week and the average stay lasts for between 12 and 26 days. Even where the primary purpose is social care, the average stay is 29 days. For residential intermediate care it is 31 days—that is, four and a half weeks, well within the six week period. There is solid evidence from an independent survey, commissioned before this legislation was proposed, that social care-based intermediate care is typically provided for less than six weeks.
It is not disputed that in the majority of cases, intermediate care can be accommodated within the six-week period. The purpose of amendment No. 51 is to recognise the fact that not all intermediate care stops after six weeks. That should be reflected in the Bill, particularly in respect of accommodation.
I began to identify some flexibility when I was replying to the hon. Member for Sutton and Cheam. I repeat that if a patient needed six and a half weeks' care, we would expect social services to use common sense to ensure that those needs were put centre stage. Under section 21 of the National Assistance Act 1948, local authorities may provide accommodation—without applying the means test—for eight weeks from entry to accommodation, so it is legally possible for there to be discretion about the six-week period.
The other reason why it is appropriate to focus as we do and to apply the limits that we have specified, is that we have to be mindful of the financial impact of our proposals. The reforms will be focused and effective, but financially responsible. The six-week period makes sense on the grounds both of good practice and of ensuring that intermediate care is used to promote the independence that we want it to promote, as well as because of our responsibility to ensure that public resources are sensibly used—and it is backed up by survey evidence. I hope that the hon. Gentleman will not feel that he has to push his amendment.
I am grateful to the Minister for that further information, particularly for sharing the results of the survey. The results of that survey, rather than
supporting her contention that there is no need to go beyond six weeks, support our argument that the Bill should incorporate the degree of flexibility that we seek. We are not talking about people who suddenly decide to stay indefinitely in intermediate care—that situation can be dealt with under clause 11—so I am not convinced that we should withdraw the amendment. I urge the Committee to support it.
I, too, have reservations about the Minister's response. We are proposing an element of flexibility in the Bill, to ensure that the provision of free services and the provision of accommodation are married up. That is logical, sensible, and in the best interests of the patient. If it is legally possible anyway, why can it not be incorporated in the Bill? There is a welter of regulations behind the Bill, but the message that it conveys is important. For those reasons, I would press for a division.
Question put, That the amendment be made:—
The Committee divided: Ayes 7, Noes 8.
Question accordingly negatived.
Amendment proposed, No. 14, in
clause 11, page 7, line 9, leave out subsection (5) and insert—
'(5)Any powers to make regulations of this kind referred to in this section shall be exercisable by statutory instrument, and any such instrument shall not be made unless a draft of the instrument has been laid before and approved by a resolution of each House of Parliament.'.—[Mr. Baron.]
The Committee divided: Ayes 7, Noes 8.
I beg to move amendment No. 15, in
clause 12, page 7, line 39, leave out subsection (6) and insert—
'(6) Any powers to make regulations of this kind referred to in this section shall be exercisable by statutory instrument, and any such instrument shall not be made unless a draft of the instrument has been laid before and approved by a resolution of each House of Parliament.'.
We have already effectively had this debate on amendments Nos. 13 and 14, so I shall not detain the Committee long. Many of the issues that were raised this morning are equally relevant now. The amendment would deal with the regulatory powers of the Government in part 2, which covers clause 12, dealing with the free provision of community care services. This is a highly complex and difficult issue. If it is not handled properly, there will be great scope for confusion, misunderstanding and disputes. It is unwise of the Government to try to flesh out the nuts and bolts of their intentions through regulations. Again, we have not seen those regulations, although the Minister has helpfully sought at times to explain how the Government expect the clause to work if the Bill reaches the statute book. Despite her best intentions, however, that is not quite the same as giving us draft regulations that tell us exactly what the Government propose.
The Minister said that she hoped to introduce some regulations before Report, which is a step forward from the position this morning. I assume that that helpful indication will apply equally to regulations under this clause. That would be a step forward because it would make the Government's proposals clearer. However, that still does not get round the problem, which several hon. Members described so eloquently this morning, that the Government's approach is wrong. We are not happy about the Government using secondary legislation, and as we said this morning, the amount that they use to flesh out their proposals has risen inexorably.
I do not want to lead my hon. Friend into a circular argument, but I would like to hear his view on the Minister's comment that regulations would be introduced by Report. At first sight that appears helpful, but it actually means that debate on the regulations will be limited by the time constraints that the Government's guillotine motions impose on Report and on Third Reading. Had the regulations been introduced earlier, we could at least have extended the Committee's deliberations and scrutinised the details. That will not happen under the proposed negative resolution procedure.
My hon. Friend has rightly gone to the heart of the disadvantages of guillotining—there is no better word for it—the debate both in Committee and on the Floor of the House. As she says, that will cause us problems on Report. We will, I hope, have to consider many important amendments to improve the Bill, particularly part 1, which we are against, root and branch. However, under the new rules we shall not have adequate time to express our concerns.
I want to pick up one other point, because I do not want to do the Minister a disservice. She did not say that we would have draft regulations before Report, and I should point that out before there is any misunderstanding. She said that we would have briefings on what she expected to be in the regulations. I am afraid that I was as guilty as other hon. Members in wrongly attributing to her a commitment on draft regulations. If only she had given such a commitment.
Does my hon. Friend think that that is the way to carry out Government business? Does he agree that it is a rather shabby way of conducting Government business to put important aspects of the Bill in secondary legislation? Those regulations will not be available for scrutiny during the course of proceedings on the Bill, and nor will they available for scrutiny by ordinary hon. Members, because of the mechanism that the Government have chosen.
No, I do not think that this is the ideal way to examine legislation. It is the wrong way. My hon. Friend is right; sadly, the governing party's majority has steamrollered the proposals through so that all our debates at all levels are now guillotined. However, Labour Members will rue the day that they did that. It may be advantageous to them in the short term while they are in government, but when they are in opposition they will realise that the powers to hold the Executive to account that have been stripped from the Opposition. The Bill will be adversely affected as a result of those procedures.
That is why the amendment is important. I do not want to rehash the arguments, but you should be aware of some of our grave concerns, Mr. Conway, especially as you did not have the benefit of listening to our debate this morning. It is important that we do not encourage and enshrine in precedent the idea that important regulations and statutory instruments, which are becoming the driving engine of legislation, can be slipped through the House through the negative resolution procedure, given how small a minority of statutory instruments subject to that procedure have the opportunity to be debated in Committee.
The Minister said this morning that there was a period in which a prayer could be made against such statutory instruments. That is all well and true but she knows—I suspect that she knew it before she even said that—that even if we pray against statutory instruments, most will never go on to be debated in Committee. As my hon. Friend the Member for Billericay said, one cannot amend a statutory instrument. If there is something wrong with a statutory instrument, it has to be withdrawn by the Government. That is highly unlikely to happen unless there is some obvious fault in the text—such as that which I notably pointed out in amendment No. 12, which led the Minister generously to accept my amendment.
Alternatively, a Committee could vote a statutory instrument out, but—one has to be realistic—that is almost impossible because the governing party has such a large majority. Also, thanks to the Committee of Selection, the governing party always has the good fortune that the Labour Members who are chosen to scrutinise such legislation have rarely expressed any opposition to it in earlier proceedings on the Floor of the House.
The Minister can say that we do not have to worry about the negative resolution procedure because the system allows us to have a debate in which we can draw attention to the problems, but that is a myth. It sounds good, and may read well on paper, but in the real world that does not happen. That is why I ask her to think again. I am not confident that she will be
amenable, but I know that she is listening. The amendment is important constitutionally and democratically, and it would lead to improved and enhanced legislation.
As her majority in Redditch is only 2,400, the Minister will probably not be involved by then, but at some point in the not-too distant future her party will be in opposition. It will then realise the damage that it has done to the power to hold the Executive to account. I ask her to be generous, because she, or more likely one of her hon. Friends, may be standing in this Room in a few years' time, making exactly the same speech on a Health Bill—and I will then have to eat my words and reject it.
I shall be brief, following the brief speech of the hon. Member for West Chelmsford, but I do not want the occasion to pass without mention of the Christmas tree or the skeleton bill. The Liberal Democrats share the concerns of Conservative Members—the official Opposition—about the impact that the negative resolution procedure will have. We would like the amendment to be passed, and we hope that the Government will listen to the concerns expressed.
Having come recently from local government, I am surprised to see what happens here, because in local government, scrutiny is all. The Government promote scrutiny, as do Labour members of local authorities. When we come to this place, however, we find that scrutiny is not given the same standing as it has out in the rest of the country. I wonder why not. Surely it cannot be that the Government apply one principle here and a different principle in other parts of the country.
You missed some interesting debate this morning, Mr. Conway, which the hon. Member for West Chelmsford has continued this afternoon. In a revealing conclusion to his speech, he invited us to ponder two potential future scenarios—one in which, at some distant point, a Conservative Government return, and another in which he is a Minister in that Government.
Given the hon. Gentleman's valiant attempts to hold himself up as the champion of Parliament today, I think that nothing short of Leader of the House will be suitable for him. He will be knocking on a bit by then; nevertheless, it would seem appropriate.
Let us get to grips with the problems involved in what Opposition Members are proposing. The amendment suggests that each time any community care service is removed from charging there should be a debate in Committee to discuss the reasons why. I do not agree, although that is not because we want to avoid scrutiny. We have a responsibility to ensure that our legislative programme does the right things at the right time, and treats different parts of legislation appropriately. There are already procedures for ensuring that any new financial burdens on local government are affordable. We made clear the purpose of the Bill well in advance of
publication. The Secretary of State explained why the services are so important, and why charges would be removed from their provision. We set the reforms in the context of the overall expansion in community-based social care services and improved hospital discharge arrangements.
Therefore, a debate under the affirmative resolution procedure is not necessary, given that we have already shown responsibility in using that new power, making clear the intention behind policy at the outset, and satisfying the new burdens procedure. I will not repeat the arguments that I made this morning—
Mrs. Gillan rose—
I am grateful to the Minister—she is very patient with the Opposition, although we obviously feel strongly about the issue. She is keen to make sure that matters are pursued in a timely fashion, and hence is deploying that argument in support of the negative resolution procedure. At a later stage in the proceedings on the Bill, would she consider including provisions for allowing consultation on the matters covered under clause 12? As I understand the matter, there are no provisions for consultation with anybody, other than through the mechanism that she described—the negative resolution procedure that we find so unsatisfactory. At what stage under the clause can consultation take place, either with hon. Members or with community care services?
I think that I outlined in a previous debate some prior consultation on the definition of community equipment services and intermediate care services. Of course, we abide by the Cabinet Office guidelines on consultation periods. As I spelled out this morning, there will be ample opportunity for hon. Members and those outside the House who will implement the Bill to make their contribution.
I agree with the hon. Lady. If she will abide by the so-called Cabinet rules on consultation, what is her objection to saying so in the Bill? That seems a reasonable request when trying to improve primary legislation. We are not getting into the nitty-gritty of detail that, based on what she said earlier, we realise that she abhors on legislation. I would have thought that that safeguard could be added to the Bill. It would make people feel much more comfortable. Will she give it serious consideration for the later stages of the Bill's passage, so as to support her argument?
No, because my earlier point was not that I abhorred the nitty-gritty of legislation. The nitty-gritty makes things different, which is why I have been willing to spell out some of the detail that we will put in place.
Certain things are appropriate in certain places. I shall return to a point that I made earlier today. Part of the difficulty of making provisions in primary legislation is that it is right that primary legislation should set the framework, but we do not want our
health and social services to be ossified as a result of needing a new Bill every time we want to make a small change or development. That would be inappropriate for the flexible and dynamic system that we are putting in place, which will develop a relationship between primary and secondary legislation. For that reason, I reject the amendment.
Order. We may be getting a little demob happy, but it would make the Clerk's job of recording an accurate vote much easier if hon. Members' responses to him were clearer.
I beg to move amendment No. 40, in
clause 12, page 7, line 41, at end add—
'(6A) Before laying such regulations, the Secretary of State shall quantify the amount of money which local authorities will forego in revenue.'.
Clause 12 removes from local authorities the powers to charge, so it has implications for their revenue streams. My amendment seeks to oblige the Secretary of State to quantify the revenue that local authorities will forego. In the case that the Minister talked about, she explained from which services she proposed to remove the power to charge, and quantified the loss of charge income. Paragraph 54 of the explanatory notes states that £18.6 million in revenue will be lost for intermediate care and community equipment services.
If I read the clause correctly, however, powers could be used to go beyond what the Minister currently proposes. Subsection (4) states:
''The regulations may not require that any accommodation of the kind referred to in subsection (3)(a) is to be free of charge for a period exceeding six weeks.''
If we read the explanatory notes to find out what is covered, we find that community care services are primarily
''those services provided to adults and older people, including home care, residential care and respite care.''
Can the regulations be used to remove local authorities' power to charge for residential and nursing home care for a period of up to six weeks? If the Minister were to take that power, there would be substantial implications for local authorities, which would lose the revenue stream from people's first six weeks in residential or nursing home care. Perhaps she
can explain whether the powers are as broad as I have outlined and whether she plans to use them in that way? If that is what she intends, will she quantify the revenue that local authorities will forgo?
This is a probing amendment, intended to find out how broad are the powers that Ministers are seeking. If the Minister gives a satisfactory explanation, I am sure that we can make good progress.
The amendment gives us a helpful opportunity to probe further the Government's thinking and the pricing of their policies. It also allows me to return to a question that I asked the Minister earlier. She said that 500,000 additional pieces of equipment would be issued as a result of extra investment. She also listed several other large figures in the context of improvements to community services. Will she explain how those figures were arrived at, and what assumptions were made in constructing them? Perhaps she can do that today, or by placing the details in the Libraries of both Houses.
As regards the 500,000 pieces of equipment, what type of equipment was it assumed would be made generally available? Without that information, the numbers are meaningless. They can be bandied about in Committee, but they will have little substance.
It has been the Government's practice over the past year or two—this is certainly true of the Department of Health—to publish regulations and guidelines after new procedures and commitments have been implemented. In the case of the golden hello scheme, eight months elapsed between the start of the scheme and the publication of the start date. There is also the case of certain special grants. Can the Minister reassure us that the regulations will be introduced in a timely fashion so that local authorities do not have to work retrospectively?
The right hon. Member for North-West Hampshire (Sir George Young) makes a helpful point in his amendment, and we must ensure that the new power does not undermine the stability of social services finance. That is why we are using the power in a focused but financially modest way, and why we already have procedures in place to ensure that new burdens are not placed on local authorities before the requisite finance is made available. The Secretary of State and I have clearly spelled out the very specific purpose of the measure, which is to remove charges for community equipment services and intermediate care services.
The right hon. Gentleman asked whether it would be theoretically possible under the Bill to remove charging for a period of six weeks. That would be theoretically and legally possible, but the Government's intention is clear: we are taking a financially responsible approach and do not intend to introduce such measures in the Bill. The financial implications of any future regulations that become necessary would also have to be set out in the explanatory notes. Thus, were a Liberal Democrat Government to decide that such a use of public funds would be appropriate, they would have to make the financial implications clear, as they have failed to do this afternoon.
We have, as the hon. Gentleman rightly pointed out, fulfilled our responsibility in connection with the Bill by setting out clearly in the explanatory notes how much we estimate it would cost to remove charging for the current provision of community equipment services and intermediate care. We have made provision in relation to the settlement for that. We have made other provision, too, particularly through the access and capacity grant, which was announced, with some details, in the local government settlement; that relates to where the money would come from to provide other forms of service that I outlined earlier.
The hon. Member for Sutton and Cheam asked about the assumptions being made; with respect to the figure of 500,000, the assumption is that the average cost for community equipment services—and we are not talking about limiting the range of equipment that can be provided—would be £70 per item. I assure the hon. Member for Cheadle that we shall ensure, as we always try to do, and usually succeed in doing, that regulations are issued in a timely manner. We have shown that systems are in place to ensure that social services finances remain stable, and we have been clear throughout about the impact of the new power.
May I seek clarification of something that the Minister said a few moments ago about circumstances in which someone is placed in residential care, and about the possibility of regulation-making powers being used to permit the first six weeks to be provided free? If the placement in a residential setting is for intermediate care, would the entirety of the costs be free under the regulations that the Government are to introduce?
Yes, I assure the hon. Gentleman that where the placement is for intermediate care, the entirety of the costs would be free under our proposals. On the basis of our recent responsible actions and intentions, I hope that the right hon. Member for North-West Hampshire will feel able to withdraw the amendment.
I am a little surprised and suspicious that the Government are taking to themselves powers that they do not intend to use. They have drafted the measure to make it possible to provide the first six weeks free, by means of regulations, but the Minister has said that she does not intend to use them. However, I do not propose to make a meal of this, and I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 12 ordered to stand part of the Bill.
Clause 13 ordered to stand part of the Bill.