§ Order for Second Reading read.
§ Mr. Deputy Speaker (Sir Alan Haselhurst)
I should inform the House that Mr. Speaker has selected the amendment in the name of the Leader of the Opposition. There is also a 10-minute limit on Back-Benchers' speeches.
§ The Secretary of State for Health (Mr. Alan Milburn)
I beg to move, That the Bill be now read a Second time.
Today's older people are the generation who created our great public services. Labour Members believe that they, above all others, deserve to get the best from them. Indeed, the mark of a civilised society is the way in which it treats its most senior citizens. The Bill is, therefore, first and foremost about promoting the well-being and independence of older people. It is about ensuring dignity and security in old age.
Labour Members are proud of the progress that we have already made. The average pensioner household is £840 a year better off today than in 1997. As my right hon. Friend the Chancellor of the Exchequer said yesterday, there is more help to come for Britain's pensioners.
Eye tests are again free for pensioners; that also applies to nursing care. For the first time, almost 150,000 women over 65 have been invited for breast screening. In the next four years, more than 1 million more will be screened.
It is for others in the House to explain their opposition to reductions in VAT on heating, extra winter fuel payments and free TV licences. More than 11 million pensioners have been helped by those measures, which the Labour Government introduced.
Ours is an ageing society. We should not fear but celebrate that. However, it poses formidable challenges for our key public services in providing better, faster care to higher standards for older people. It means providing services that promote what older people say they want: independence not dependence, and breaking down the Berlin wall between health and social care. Older people need one care system, not two competing systems.
When I visit health and social care services around the country. I am always impressed by the power of partnership. When the services work well together, older people receive first-class care; when they do not, older people suffer.
Delayed discharge from hospital occurs when partnerships do not work. The Bill is designed to tackle that problem. On any single day in England, approximately 5,000 people—mainly older people—are trapped in a hospital bed when they are fit to be cared for at home. Consequently, everyone loses.
For patients who are ready and able to leave, hospital is not the right place. The longer that they are forced to stay, the greater the risk of losing their independence and confidence. For the patient's family and carers, 502 normal living is suspended, doubt replaces certainty and lives are put on hold. Hospitals incur unnecessary costs from looking after patients who are not their responsibility, and the beds that they need are lost. Other patients who are waiting for the beds pay in longer waiting times for treatment and, in the worst cases, in cancelled operations.
That vicious cycle has existed for too long and we must find a way to break it. Of course, there is no magic wand that can be waved to make the problem disappear. In the past few years, we have tried to introduce policies to deal with it. The Bill builds on what we have done so far.
We have introduced national standards for the first time and a national system of inspection to improve the way in which services work together for the benefit of older people. There was a time when there were no national standards and a local lottery in care. No one who is serious about ensuring equity in social care wants to go back to those days.
We have provided extra investment for the health service and social services. Many of my hon. Friends have long argued that social services have too often been the health service's poor relation. The evidence is on their side. I am pleased that the hon. Member for West Chelmsford (Mr. Burns) nods his head. In the last five years of Conservative government—I believe that the hon. Gentleman was a Health Minister then—spending on social services increased by only 0.1 per cent. a year in real terms. Today, it is growing by more than 3 per cent. From next April, the rate of growth will double to an average of 6 per cent. a year for the next three years.
Some people, even some of my hon. Friends, will say that that investment is not enough. Perhaps I can do more to help social services. I want to say a little more about that shortly.
§ Mr. Milburn
In a moment. I shall not take lectures from the Conservative party about how social services cannot afford the Bill's provisions. In government, the Conservative party failed to make the necessary investment, and failed to commit the resources that we are providing. In opposition, it fails to agree to match the extra resources that we are committing for the future. Its record on social services is compound failure: the failures of the present are piled on those of the past. The Conservative party offers only failure for the future. Speaking of that, I shall give way to the hon. Member for Eastbourne (Mr. Waterson).
§ Mr. Waterson
Before the Secretary of State leaves the subject of funding, is he aware that his proposals would mean a fine of £2.5 million, on current figures, for East Sussex, equating to 240 residential or nursing placements or 800 home care packages?
§ Mr. Milburn
I am sure that that is what the hon. Gentleman has in front of him, but whether it is true is an entirely different matter. As I shall say in a moment, there are growing resources for social services. Indeed, I made a statement to the House in July this year, in which I set out an earmarked package of measures specifically 503 to build capacity in elderly care services. I do not believe for a moment that local government or social services simply will not spend that money. They want to spend it; they are the people who have been arguing for it. We have listened to their argument, and conceded it. We have provided extra resources for social services, and we now expect that they will use them to build up the necessary capacity.
That brings me to my third point, the question of building up extra capacity across the care system. In the NHS, for the first time in 30 years, the number of beds in hospitals is rising, not falling. In the community, while it is true that the number of care home beds has fallen, the quantity of care provided in other settings has risen. Our latest estimates are that the number of people helped by intermediate care services has risen by 126,000 in the last couple of years, and that 43,000 more older people receive intensive support at home today than in 1997. As I told the House in July, we will build up capacity further still in the next few years, with a £1 billion package of measures for elderly care services. These resources will allow local councils to pay higher fees to care homes, if that is what is needed to stabilise their local care home market. Although care homes are a good option for some older people, they are not—and must not become—the be all and end all of elderly care services in our country. A broader spectrum of services is needed for older people, to widen choice and to promote independence.
§ Mrs. Angela Browning (Tiverton and Honiton)
Is the Secretary of State aware of the independent research by Exeter university, which shows that, in Devon, the 100-plus intermediate care beds allow discharge to take place approximately seven days earlier than would normally be the case, thus saving the NHS about £3 million? Devon county council is concerned, however, that, having achieved that—no doubt, with support from the Secretary of State—it will now be penalised by £1.5 million as a result of having provided that care.
§ Mr. Milburn
The hon. Lady is absolutely right. This is interesting because, all too often, we hear from Conservative Front Benchers—I cannot speak for Conservative Back Benchers; I cannot speak for Front Benchers, come to that—that extra resources in public services do not produce results. But they do, and the hon. Lady is right: intermediate care is working. We have provided extra resources, and, as a consequence, capacity is being built up. We are also providing further extra resources for the next few years. If I know local government and social services at all, I know what they want to do—not least from my discussions with directors and members of local authorities. They want to spend more on social services provision. We have given them the opportunity to do that over the next few years, and we will do so further into the future, too.
§ Mr. Simon Burns (West Chelmsford)
So as not to confuse the House, on the question of help for the elderly outside the residential care setting, will the Secretary of State confirm the answer given by the Minister of State, the hon. Member for Redditch (Jacqui Smith), on Monday that the number of households receiving domiciliary care has fallen since September 1997 by 97,900?
§ Mr. Milburn
What the hon. Gentleman is alluding to is simply the number of households receiving some form of home care. However, that is not the only category of people who receive help. Indeed, the number of older people helped, through the public purse, to live at home has increased, not decreased—I can give the hon. Gentleman the latest figures—from 638,000 to 661,000, so his allegation is simply not true.
§ Mr. Gerry Steinberg (City of Durham)
Will my right hon. Friend clear up a tremendous confusion in my local authority in Durham? At Question Time recently, he promised to investigate whether the money given to deal with bed blocking in Durham has been used for that purpose. Durham county council's social services department tells me that it has not received the money from the primary care trust; the PCT says that it has. I am not sure how many beds were unblocked by the money that was supposedly given—£1.8 million. He said that he would come back to me, but he has not. Can he clear this up?
§ Mr. Milburn
I am amazed that confusion is reigning in Durham. That sounds a very unlikely state of affairs. The Minister of State, my hon. Friend the Member for Redditch (Jacqui Smith), who has responsibility for social services and community care, is looking into the matter. Two things are necessary. First, the local community bodies concerned—PCTs, social services and the acute hospitals—must come together and agree a course of action. That has not always happened. Secondly, if we can be helpful nationally, we will be. If our investigation or our involvement can help, we will be glad to provide such help.
The situation described by my hon. Friend the Member for City of Durham (Mr. Steinberg) is the nub of the problem. When partnership works, it is great; when it does not work, it is a disaster. The problem is that it relies purely on voluntary endeavour. If relationships are good, they are good; if they are bad, they are bad. We do not have an incentive in the system that allows each part of the partnership—health services on the one hand and social services on the other—to accept their responsibilities. That, fundamentally, is what the Bill is about.
§ Dr. Liam Fox (Woodspring)
Will the Secretary of State please answer my question simply? If relationships are to improve under the Bill, why are three of the 10 clauses about dispute resolution?
§ Mr. Milburn
The hon. Gentleman knows fine well why that is so. If the world were a perfect place and if partnership were happening everywhere, there would be no need for my hon. Friend the Member for City of Durham to stand up and complain, no need for Opposition Members to stand up and complain about the same issue and no need for the Bill to be introduced. Partnership is a very cosy idea and, like every Member, I support it, but to make it work everybody has to accept their responsibilities. Sadly, sometimes they do not do so, which is why legislation is necessary.
§ Mr. David Hinchliffe (Wakefield)
When I met consultants at Pinderfields hospital in my constituency over the summer, they told me that about a third of the 505 hospital's beds were occupied by people who did not need to be in them. Some were delayed discharges, but others had been admitted inappropriately by GPs. Does my right hon. Friend intend to extend the principles behind the Bill to fining others who are involved in health care? Is my hon. Friend the Member for Dartford (Dr. Stoate), who is a GP, likely to be fined for wrongly admitting his patients to the local hospital?
§ Mr. Milburn
No, I do not think that that is needed, partly because there are incentives in the system in respect of that. However, my hon. Friend makes a good point. It is perfectly self-evident that one problem that bedevils health and social services is the fact that people are all too often in the wrong part of the system at the wrong time. We are putting the incentives in place to correct the deficit in the NHS that he rightly describes so that in future—not before too long, I hope—I shall be in a position to give PCTs budgets for the longer term rather than just a year. They will have discretion over how to spend that money, whether on primary care, community care or hospital-based care.
One thing is absolutely certain, and my hon. Friend has argued this over many years: the problems for hospitals will not be resolved purely in hospitals. This country, and elderly people more than anyone else, require a broad spectrum of services—services in hospital, in the community and in primary care and, crucially, social care services.
§ Dr. Howard Stoate (Dartford)
My right hon. Friend is very generous in giving way. May I clarify the comment of my hon. Friend the Member for Wakefield (Mr. Hinchliffe)? GPs sometimes admit patients inappropriately purely because they cannot get the care packages in the home that they would like and which would keep people in their home. Improving social services care would make that a thing of the past.
§ Mr. Milburn
I agree. I was coming to that. The Opposition, however, all too often seem fixated with the idea that the only form of care that counts is either hospital care or care in a care home. Care in homes is important, giving frail and disabled older people in particular the opportunities that they need; but there should be a broader spectrum of care choice, not just for those older people but for general practitioners and others working in the community who want to ensure that patients are placed appropriately.
Our extra investment in social services over the next few years will help to finance a 50 per cent. increase on the 1997 total in the number of extra care housing places, or very sheltered accommodation. A further 70,000 older people will receive rehabilitation services each year to prevent them from having to go to hospital unnecessarily in the first place, and to help them leave hospital speedily when it is safe for them to do so. The Bill, moreover, will make those and all intermediate care provision—whether provided by the health service or by social services—free to the user.
More older people will be able to choose to live at home. In the past, too many have faced a choice between going into a care home and struggling on in their own 506 homes. As a result of our investment, by 2005 twice as many older people will receive the intensive help they need in order to live at home as received it in 1995.
§ Mr. Hilton Dawson (Lancaster and Wyre)
When he next visits Lancaster, would my right hon. Friend care to join me in visiting the Beck View extra sheltered housing project? He would see a tremendous example of partnership between Lancashire county council's social services department and Lancaster city council. Exactly the sort of work he has described is being done, enabling older people to remain in their homes for the rest of their lives.
§ Mr. Milburn
If I visit Lancaster—of which, as my hon. Friend knows, I am extremely fond—I will certainly do as he suggests. Recently, when I was in another great city—Leeds—I saw a superb example of extra care housing. If I remember rightly, it was supported by a local authority, a housing association and the national health service. As my hon. Friend suggests, such things can happen and are happening. What we need to do is build up the capacity, and Opposition Members must recognise that that can be done only if the necessary resources are committed to social services—which is precisely what we are going to do.
§ Mr. David Lepper (Brighton, Pavilion)
I am sure that my right hon. Friend is aware of the support for carers that exists throughout the House. In view of what he said about ensuring the availability of a range of care options, will he, during the Bill's passage, return to the need to ensure that the current guidance on consulting and providing information for carers about hospital discharge is given the force of law? Will he also consider the provision of free care services for carers when they are needed as part of the care package relating to discharge?
§ Mr. Milburn
I can give my hon. Friend an assurance on the second point. As for the first, we will want to issue guidance to those in all parts of the care system, but particularly to those in hospitals, about how discharge procedures should work. An important part of that is ensuring that not just patients but their families and carers are involved from the outset. Carers do a fantastic job, and the Government have no intention of trying to bypass their role. Indeed, we want to enhance it.
§ Ms Joan Walley (Stoke-on-Trent, North)
May I refer my right hon. Friend to another great city, Stoke-on-Trent? How does he intend to secure the necessary accountability in the efforts to produce joint strategies for integrated care for elderly people?
The Edwards report on services in Stoke-on-Trent and North Staffordshire resulted in the transfer of £300,000 from the NHS to social services. However, the money was not actually spent on the services that it was originally provided for. What measures will he introduce in respect of accountability, because we need to ensure that money intended for a specific purpose is used just for that purpose?
§ Mr. Milburn
My hon. Friend makes an extremely important point. The Bill provides a partial answer, and 507 in a moment I shall discuss the question of ensuring that responsibilities are also matched by resource responsibility. However, I can assure her that during this Session, we will introduce further legislation to ensure a better audit trail—in the health service and in social services—of where public money is being spent. We aim to strengthen the inspectorates on the health and the social care sides of the fence, and we intend to impose a legal obligation on both new inspectorates to work together. Otherwise, not only do elderly and vulnerable patients fall through the gap in the middle; sadly, public money sometimes does as well.
§ Mr. Milburn
I shall give way to the hon. Member for Sutton and Cheam (Mr. Burstow), but then I must make some progress.
§ Mr. Paul Burstow (Sutton and Cheam)
The Secretary of State has already acknowledged the concern of some of his hon. Friends that the additional resources that he has announced are not adequate. Given that the Government's inquiry into health service funding—the Wanless report—made a case for extra investment, and given that the report time and again flagged up the fact that no equivalent work was being done in social services, is it not time for a Wanless inquiry into social care, so that we can be certain that the additional resources are sufficient to deliver on this Government's commitments?
§ Mr. Milburn
We have made our decisions on social services for the foreseeable future—for the next three years—and as the hon. Gentleman knows full well, until very recently social services faced an annual cycle of budgets, because they had no real idea what they were getting. That is changing, and we must maintain that change and provide as much certainty and stability as possible in social services funding. I shall say something more on the matter in a moment, but we will continue to assess what social services actually need to fulfil their obligations. That is the right thing to do, and in particular we want to ensure that they have the resources to build up services in the community and at home.
As the hon. Gentleman will be aware, people are charged for community equipment such as handrails, walking frames or bath seats. This equipment can make the difference between an older person's becoming dependent, or remaining independent in their own home. The Bill's provisions will remove these charges altogether. Ring-fenced funding for up to 500,000 extra pieces of community equipment will be provided to an estimated 250,000 additional older people, and for the first time they will be provided free of charge.
The resources are therefore in place to establish capacity in the communities where it is needed by older people. Extra support in the community will, in turn, help to relieve pressure on hospitals. However, resources alone are insufficient to crack the problem of delayed discharge from hospital: reforms are needed alongside resources. Of course, some reforms are already beginning to bite. The first care trusts are now in place, and there are more to come. Under health legislation flexibilities, more than 180 local partnerships 508 are now delivering services worth more than £2 billion a year. Finally, a single process for assessing older people's health and social care needs is being put in place.
§ Mr. Paul Truswell (Pudsey)
Given the huge welcome for the long-overdue additional resources that have been spelt out, and given that further resources are planned, why has my right hon. Friend taken it upon himself to introduce this punitive legislation before thoroughly evaluating the use and impact of that money?
§ Mr. Milburn
The hon. Gentleman will doubtless have an opportunity to make his speech in a moment or two, but it would be helpful if he would not shout at me during mine. The legislation is not punitive: it is about ensuring that the needs of the older person, rather than of any one part of the care system, always come first.
The Conservative party is in severe danger of becoming the party of the producer, and I know that it would not want to do that. It always used to pride itself on being the party of the consumer, but perhaps that has gone, too, along with its tradition of economic competence—or indeed being the party of the vulnerable.
Partnership is the key to delivery, but it works only when both health and social services are clear about their respective responsibilities. It is about giving as well as taking, and about being clear that what comes first is not the needs of any one service but those of every individual user of the service. When older people get trapped in hospital, that is a failure in partnership working.
Patients can be delayed for many reasons. In too many cases, they are delayed in hospital because social services departments are not fulfilling their responsibility to provide care in the community. Almost 1,000 older people are trapped in hospital simply because they are waiting for their needs to be assessed and their future care planned. Under the current system, for as long as elderly people remain in hospital, they do so at the cost of the national health service. There is no incentive for local government to tackle the problem. Indeed, there is every incentive to leave them stuck there. The Bill is not about imposing wholly new responsibilities on social services departments but about ensuring that they fulfil their existing ones.
§ Dr. Desmond Turner (Brighton, Kemptown)
The Brighton and Hove authority has done exactly what my right hon. Friend is asking: it has entered into close partnership working with the local health bodies, and a care trust is emerging, but despite its best efforts there is still a serious problem of bed blocking, which is outside its control. Under the Bill, it is quite possible that the extra resources that the social services department has 509 been given—thank you very much—could be used to pay punitive fines because of bed blocking that is outside its control.
§ Mr. Deputy Speaker
Order. Before the Secretary of State replies, let me say to the House that interventions are getting longer and longer, and hon. Members should really learn the art of the concise intervention, especially when they are taking time out of the time that they might hope to have later, if they catch my eye.
§ Mr. Milburn
Thank you, Mr. Deputy Speaker. I will take that as a hint to get on with it.
On my hon. Friend's question, that is precisely why we are making resources available to social services. Of course, there is a choice. We are giving £1 billion of extra cash, largely earmarked for elderly care services, and social services departments have a choice—although earmarking restricts their discretion to some extent, I suppose—about whether to use those extra resources to build up capacity, which is what they tell us they want to do, and is indeed the reason why we agreed to give them the extra money, or whether they want to transfer resources to the health service. Our understanding is that they want to build up services in the community, and they now have an opportunity to do just that. I perfectly understand that, in the days when budgets were rising by 0.1 per cent. a year in real terms, that was not possible, but we are now moving into an era in which resources will be rising by 6 per cent. a year in real terms, not only for one or two years but for three whole years.
It is not as though social services departments have not known that this measure was coming. Indeed, there are already extra resources in place. The day after the Budget in April, I stood here and announced precisely that this measure was coming. In October, we provided £300 million through the building capacity grant, so that social services could start the process of building up services in the community. However, I take my hon. Friend's point and I shall return to it later.
In all fairness, the costs of care should surely fall where they belong. Under the new system proposed in the Bill, when patients are ready and able to leave hospital but care is not provided for them in the community when it should be, the costs will indeed pass to social services, but there is also a requirement on the national health service to play its part in the discharge process by giving advance notice to social services that a patient may need community care on leaving hospital.
Under the Bill, where social services do not fulfil their responsibilities, they will have to meet the costs that the hospital incurs in providing care for patients whose discharge has been needlessly delayed. Where similar approaches have been used in other countries, they have worked. Opposition Members are always saying that we should learn from those experiences, and we are trying to do just that. The precise details of the scheme in Sweden are not the same as what we propose here—not least because the structure of health and social care is rather different—but the number of hospital beds occupied by delayed patients was halved in that country, and the average wait for discharge was reduced to just three days.
510 Some have objected that the Bill will create a perverse incentive for hospitals to discharge patients too early, only for them to have to be readmitted. I understand those concerns, and that is why we have put in place the necessary safeguards to prevent that happening. In future, hospitals will be rated—and therefore rewarded—according to how well they do in reducing emergency readmission rates. What is more, under the new system that we are introducing to pay hospitals for what they do, they will not receive funding for patients who, within a certain period, are readmitted to hospital with the same complaint or a complication of it. Again, the incentive will be on the hospital to discharge appropriately, not inappropriately.
The fundamental objection to the Bill, however, has been that it is all stick and no carrot, as my hon. Friend the Member for Pudsey (Mr. Truswell) noted. The criticism is that social services are being given a new responsibility without adequate resources. Let me address that in two ways. First, this is not a new responsibility: it exists today. The system simply does not ensure that costs fall where responsibilities lie. Secondly, the Budget provides substantial extra resources for social services, and the means to increase capacity in community services. Incidentally, we took account of any likely costs to social services of this measure in making those resources available.
However, I have considered this point carefully and listened to the representations that have been made today, and on previous occasions, by some Labour Members and by local authorities and local government organisations. The maximum cost that social services would face in payments to hospitals under the Bill would be about £100 million in any one year. That estimate presumes three things.
The first is that councils make no progress whatever beyond the targets that they themselves have already set to reduce the level of delayed discharges from hospitals. Secondly, the £100 million estimate pre-supposes that social services do not use the 6 per cent. annual increase in resources to put in place new services to help reduce delayed discharges from hospitals still further. Finally, the estimate presumes that none of the £1 billion—most of which is earmarked for elderly care services, as I said earlier—gets spent on those very services. I do not believe for a moment that that is what local authorities will do—indeed, they will not be able to do that, as so much of the money is earmarked. Therefore, I do not believe either that social services will have to pay £100 million to the health service.
None the less, I have decided, for each of the next three years, to transfer an extra £100 million, on top of the resources already made available, from the NHS budget to social services for each full year in which the scheme operates. I am doing so in order to provide a positive incentive to ensure that the regime is not punitive and to make the system work. This extra £100 million will now enable individual councils to gain rather than lose from the system—provided, of course, that they make available the community services needed to reduce delayed discharges from hospitals. Hospitals can gain too. As social services reduce the pressures on hospitals, their costs will fall.
My intention is not, and never has been, to punish local government but to pursue a real and sustained reduction in delayed discharge from hospital. Frankly, 511 there can now be no excuse for social services not to fulfil their responsibilities to older people. I have tried, therefore, to address the legitimate concerns that have been raised by my hon. Friends and others during the course of the debate.
§ Mr. Edward O'Hara (Knowsley, South)
I appreciate the purpose of the Bill, particularly the point about giving the social services extra funding to ensure that they are not punished. However, I have been listening carefully and there seems to be one omission from the Bill—the older people themselves. It seems that they are being treated rather instrumentally. Will my hon. Friend comment on what consultation might be available to older people or their families, or advocacy services if they are not capable?
§ Mr. Milburn
My hon. Friend makes an extremely important point. The philosophy at the heart of the Bill is straightforward. What counts is the user of the service, not health services or social services. They exist for a purpose—to serve the public and, in this case, to serve older people. For a variety of reasons—some to do with resources, some to do with historical capacity, some to do with the structural deficit in our health and social care system—too often older people are let down. That is simply not good enough.
The Bill is about doing what older people want. Older people always say that they want to be independent, not dependent. They want to live in their own home; they do not want to be in a care home, by and large, or in hospitals. Hospitals are not places where people choose to go—they want to get in as quickly as possible and to get out as quickly as possible. The philosophy of the Bill is about ensuring that the older person's needs are fully taken into account. As I said earlier, it is important that the views of individual older people and those of their carers and families are fully taken into account in the discharge process, and that is what we will do.
§ Mr. Lansley
If the Secretary of State were to act on what he said in response to the previous intervention, would the Bill reflect that patients exercising their choice under the choice directive would not lead to fines on social services? What guarantee will he give that the exercise of patient choice will not lead to costs and fines for social services?
§ Mr. Milburn
There are two issues about the exercise of choice. The hon. Gentleman talks about the direction on choice. There are two groups of people. Self-funders effectively pay for their own care and are not the responsibility of social services. However, social services have an obligation towards people who are their responsibility. There is a direction on choice, of course, and people should be able to exercise choice. However, the direction on choice has never, under the previous Conservative Administration or ours, been about older people being allowed needlessly to occupy hospital beds when they are ready, willing and able to go home. There are important issues surrounding the direction of 512 choice, as the hon. Gentleman suggests, but what most people want is simple. They want to get in and out of hospital as quickly as possible.
I have today provided further resources to local government because we have been told that the problem is resources. I have provided the extra resources; we have assessed the cost of the fines. I have covered the cost of the so-called fines and frankly, there can now be no further excuses for social services not to fulfil their responsibilities.
§ Mr. Eric Martlew (Carlisle)
My right hon. Friend is being very generous to local authorities, but he has not provided any extra money. He has actually taken £100 million out of the NHS, and that is a worry to me.
§ Mr. Milburn
That is true. [Interruption.] I hope that I am not intruding on private grief. I have transferred £100 million from the national health service to social services. It will help the national health service do its job because if we do not build up social services, NHS hospitals will not be able to do their job. I realise that the hon. Member for Woodspring (Dr. Fox) is hurriedly rewriting his speech as a consequence of my announcement, but it is no use for him to complain about transfer of resources—he is against resources. He is against resources going into the health service. He is against resources going into social services.
For the sake of people in hospital who need to come out and for the sake of people who need to be in hospital, we must address delayed discharges once and for all. The Bill is about making the system work for older people who are needlessly stuck in hospital. It is about putting older people first. It is about helping them to get the right care, in the right place, at the right time. For the first time, the Bill introduces a positive incentive to ensure that the resources of health and social services are directly linked to the responsibilities that they share. It will help to ensure that resources provided for social services are actually spent on social services. The Bill is fair to the national health service, it is fair to local government and, above all, it is fair to older people. I commend it to the House.
§ Dr. Liam Fox (Woodspring)
I beg to move, To leave out from 'That' to the end of the Question, and to add instead thereof:this House declines to give a Second Reading to the Community Care (Delayed Discharges etc.) Bill because it would be divisive and undermine successful working partnerships between the NHS and Social Services Departments; imposes a negative fining system on local authorities rather than promoting positive policies to tackle the problems facing community care; fails to redress the loss of capacity due to over 60,000 beds being closed down in residential care since 1997 and the closure of over 2,000 care homes; fails to recognise that the number of households receiving domiciliary care has fallen by almost 100,000 households; and unfairly penalises local authorities without improving the system of discharging patients from hospital.As ever, whether it be the shambles of the fire dispute, the mishandling of the economy or the Government's increasing failure to deal with the woes of the national health service, their approach is exactly the same: to ignore criticism and to pass the buck. However, the problem with which the Bill deals is entirely of the making of the Secretary of State for Health and his Ministers.
513 For the past few years, we have been warning of the inevitable consequences of Government policy, and our predictions, unlike those of the Chancellor, turned out to be right. In April 2002, there were an estimated 511,300 places in residential settings for the long-stay care of elderly and physically disabled people across all sectors in the United Kingdom. That is a drop of more than 60,000 places since Labour came to office.
By April 2002, capacity in all those sectors had decreased by 64,300 from the 1996 peak—a decrease of 11 per cent. If we correct those figures to take account of population change, the decrease is even greater: about 20 per cent. from the peak. Most frightening of all, despite all that Conservative Members and even some Labour Back-Benchers have said, 14,000 places were lost last year—the biggest single fall since Labour came to power.
§ Mr. Dawson
Will the hon. Gentleman tell us about the quality of those residential places? Why should elderly people have to opt for residential care rather than for the wide range of options that will keep them in their homes and support them in the community?
§ Dr. Fox
Indeed. The drop in the number of care home places would not be so worrying were it not for the drop in the provision of domiciliary care. As my hon. Friend the Member for West Chelmsford (Mr. Burns) has pointed out, almost 100,000 fewer households have been supplied with domiciliary care since the Government came to office.
What is the effect of all that on the NHS itself? First, as a result of delayed discharges the number of cancelled operations has risen by almost a third since 2000. The Government's own figures show that 77,800 operations were cancelled in 2001, compared with 50,000 in the year they came to power.
Secondly, the number of emergency readmissions has increased as patients are discharged early to try to meet the Government's targets. Over the past year, more than 500,000 patients had to be readmitted; in 10 health authorities the increase in readmissions was more than 10 per cent.
Some of the Government's answers and the Secretary of State's response to the problem are ludicrous. Hospitals will not be funded if patients are readmitted, so presumably if a patient with angina is discharged from hospital, suffers a myocardial infarction and has to go into coronary care, the hospital will not be funded for that. What a brilliant proposal—extremely helpful to NHS trusts, I am sure.
§ Kali Mountford (Colne Valley)
I admire the hon. Gentleman's concern about delayed discharges. What resources would he commit to ensure that discharges were not delayed? How much money would he give?
§ Dr. Fox
It is a matter of priorities. If we were in office we would not be wasting hundreds of millions of pounds on the Government's pointless waiting list targets. We would not be employing the extra tens of thousands of bureaucrats that the Government require for an endless paperchase which today's proposals will make worse. 514 We want to talk about whether the measure will make whatever funding is available work better or worse for patient care. The answer is clear: it will work worse because the situation is getting worse.
In the first quarter of this year, 8 per cent. of elderly patients who were discharged were readmitted within 28 days, and 3.2 per cent. were readmitted within seven. That is a massive increase even on just a year ago. What is the Government's response to this very complex situation? They have produced this pointless, ill-thought-out, punitive—a word used by the hon. Member for Knowsley, South (Mr. O'Hara)—contradictory and self-defeating Bill.
§ Mr. Deputy Speaker
Order. I am sorry to interrupt the hon. Gentleman. The House must quieten down; this is a debate, and we should have reasoned argument on both sides.
§ Mr. Martlew
On a point of order, Mr. Deputy Speaker, is it right for an hon. Member to refer to another as a clone?
§ Mr. Deputy Speaker
I have heard quite a number of expressions which on the whole I would prefer not to be used, but I do not think that that word has been classified as non-parliamentary language.
§ Dr. Fox
You can always tell when hon. Members are getting desperate, Mr. Deputy Speaker.
The trouble with the Bill is that it tries to blame local authorities for something that is beyond their control. It will place new burdens and costs on them. It is based on false assumptions. It is will increase bureaucracy and red tape, damage health and social care relationships, produce perverse incentives and increase the likelihood of decisions on care being taken inappropriately. In other words, the Bill runs the risk of producing exactly the opposite of what the Government claim it will produce.
§ Mr. Hinchliffe
The central thrust of Conservative party policy on the care of the elderly appears to involve more and more institutional care. On the hon. Gentleman's travels around Europe—I met him on a plane a few weeks ago—has he dropped in on Denmark, which has a similar proportion of elderly and very elderly people to this country, but no old people's homes at all?
§ Dr. Fox
That is a very useful point. Perhaps the hon. Gentleman and I would agree on one thing: for elderly patients, as for all other patients, the most important phrase is "appropriateness of care", which involves having a full range of provision. Some patients require and want long-term care in nursing or residential homes, 515 but that will not be available if the capacity decreases as quickly as it has in the past five years, and the Bill will do nothing to help.
The Bill will add substantially to the burdens on already hard-pressed local authorities. At least the Government are being consistent. Let us consider the list of obligations imposed without proper funding in recent years, starting with flooding. Emergency grants from central Government are not even remotely covering all the costs of recent floods, as millions of council tax payers are about to find out. The Homelessness Act 2002, passed during the previous parliamentary Session, imposed new burdens on local authorities to draw up new homelessness strategies. Air targets have been devised by Brussels and announced by the Minister for the Environment but are being funded by no one. Waste recycling will cost at least £55 million, and there are asylum costs, travel concessions and the huge burden of children's services, the costs of which fall on local government and accounted for 64 per cent. of the total overspend last year.
§ Dr. Fox
I have given way already and will do so again later.
There is no point in Ministers saying that they are giving more money to local authorities, because the rate at which they are piling on responsibilities is greater than the rate at which funding is being applied to local authorities to cope with Those responsibilities.
Most absurd of all, the Secretary of State said today that the Government have introduced the Bill because bed blocking is costing the NHS money and local government must play its part in sharing responsibility, but what are they proposing to do? They will fine the NHS £100 million and give the money to social services so that, when they fine them, they can give back the money. If that is not complete bureaucratic madness, I do not know what is. It can only help bureaucrats and produce paperchases; it will do nothing to help local government, hospitals or the patients themselves.
§ Rev. Martin Smyth (Belfast, South)
I appreciate the hon. Gentleman's giving way on that point because I was lost earlier when I heard that health service costs would he reduced. Is it not a fact that the procedures in the health service put up the costs, so if beds are vacated—for which we would be thankful—there will be more operations, more procedures and increased costs and therefore health service costs will not be reduced?
§ Dr. Fox
The hon. Gentleman may be right. It is certainly true that despite the increased amount of money that the Government have undoubtedly put into the NHS in real terms, the level of activity coming out is very much less than predicted. Funding has increased by almost 11 per cent. in real terms, but the level of activity is up by less than 2 per cent. Clearly, therefore, there is a huge amount of wastage.
It seems that Ministers are not yet content with the amount of costs that they are imposing on local government. When one asks local authorities how much 516 they think the scheme will cost, one finds that their estimate is a lot higher than that of the Secretary of State. The Association of London Government estimates that the cost to it alone will be £25 million a year. Buckinghamshire estimates that it will cost £2 million; Essex that it will cost £3 million; Cambridgeshire, £1.4 million; Surrey, between £6 million and £7 million; and Kent, £5.5 million. What are Ministers trying to do? Do they have any understanding of the real problems of local government in the real world? I shall now give way to the hon. Member for Milton Keynes, South-West (Dr. Starkey).
§ Dr. Starkey
I am grateful to the hon. Gentleman for at least demonstrating, unlike the hon. Member for West Chelmsford (Mr. Burns), that he notices women and realises that they are individuals, not clones. Is he suggesting that councils should not fulfil their current obligations unless they get additional money from Government? Why does he think that some councils can fulfil their obligations but not others? Does he not think that the councils bear some responsibility for that?
§ Dr. Fox
Of course, they are supposed to work in a partnership wherever possible. But the whole point of the debate is to examine whether the Bill will improve the working relationships between health and social services, or whether it will make them more difficult. As I pointed out to the Secretary of State, if he thinks that the Bill will improve the relationship, why is 30 per cent. of the entire Bill devoted to new bodies being introduced to resolve disputes which, as the Bill admits, do not currently exist? That is not an improvement in the working of the current system, which is what everybody would like.
Much of the Government's case has been based on their interpretation of the system in Sweden. On 18 April 2002, the Secretary of State made a statement in the House of Commons, announcing the Command Paper, "Delivering the NHS Plan", in which he said that the Government were impressed by the success in getting delayed discharges from hospitals down of the system in countries like Sweden and Denmark. Had the Secretary of State made a visit to examine the project? No, he had not. According to the Health Service Journal,the Government's decision to bring in cross-charging was taken without even consulting Gert Alaby, the architect of the Swedish model on which Mr. Wanless had placed so much emphasis—although it was also reported that Mr. Wanless had not met Mr. Alaby either. Yet the Department of Health said recently that there had been conversations with a "number of people" in Sweden.
If the Secretary of State or Mr. Wanless want to know about the problems in Sweden, they can ask the hon. Member for Ealing, North (Mr. Pound), who made a telling intervention in the Queen's Speech debate:May I point out some of the differences between that model and what we have been discussing today? In Sweden there was a two-year lead-in time before the proposals were implemented. In addition, local authorities had responsibility for a vast range of alternative provision, including direct commissioning of health care."—[Official Report,14 November 2002; Vol. 394, c. 231.]The hon. Gentleman seems to have a much greater grasp than the Secretary of State. Had the Government looked at the model, they would have found that Swedish local authorities are responsible for social care as well as hospital care, so they can affect patient flows into the 517 acute sector. That is not possible in our system, because the primary care trusts have discretion over the flow of patients into the hospitals, but local government is to be made financially liable for discharging—it will be punished for something over which it has absolutely no control. Where is the fairness in such a proposal? Do Ministers have any idea of the damage that they might be inflicting on the ground?
Several Labour Members, including the Secretary of State, have mentioned working relationships. The central proposal in the Bill risks undoing what has undoubtedly been a recent improvement in the NHS: the increased willingness of health and social care departments to work together. That still has a long way to go but, in the words of one Labour Member, "the direction of travel is positive when viewed as part of the complete patient journey," which in English means that things are getting a bit better on the ground. The real change that the Bill might introduce was well expressed by the British Medical Association, which fears that the plans will seriously damage working relationships:the BMA supports co-operation and improving co-ordination between health and social services to provide seamless high quality services for vulnerable patients who may be adversely affected by the barriers that exist between social services and the NHS. The proposal for fines has the potential to damage some of the good relationships that have evolved with the greater opportunities for joint working.It is not alone in that view. The Association of Directors of Social Services, the NHS Confederation and the Local Government Association made the following joint statement:Real progress has been made in forging partnerships between health and local government, including the particularly successful joint work to alleviate winter pressures.We would all welcome that. The statement continued:A recent Audit Commission report endorsed the successful partnerships already in place. We want to build on these to prevent unnecessary hospital admissions, reduce delayed discharges and provide integrated health and social care services. It would be a retrograde step if the current proposals undermined this trust and led to the development of adversarial relationships rather than cooperation between health and local government".
§ Dr. Fox
I will give way in a moment.
It is typical of the Government to believe that they know better than those on the front line who are already responsible for these services, and so like them to produce yet another one-size-fits-all blueprint designed in Whitehall against all the advice of those with hands-on experience.
§ Mr. Steinberg
I have some sympathy with what the hon. Gentleman says, although I do not necessarily agree with all his comments. What would he do to a social services department that receives money to use to unblock beds in hospitals but does not use that money accordingly? What sanctions would he use against authorities that do not use the money for the purpose for which it is given?
§ Dr. Fox
When we in the House talk about sanctions, I think we are in danger of believing that Whitehall 518 always knows best about resolving these problems. What has been happening on the ground—I am the first to admit that the approach has definitely improved—is an evolution of understanding between health and social care and an improvement in the working relationship. That is not universal, and the relationship still leaves a lot to be desired in some parts of the country, but it is improving. Why risk undermining all that by introducing a Bill that will set one part of the system against another? That cannot make any sense. When all those on the ground are saying that this is mistake, why are the Government pushing ahead with a proposal that can only lead to greater acrimony?
Under the proposals, local authorities will come under pressure as never before. The question we must ask is whether these changes will increase or decrease the probability of finding the most suitable care and type of placement for individual patients' needs. Alternatively, are the proposals likely to mean that, to avoid financial penalties, patients will be removed from hospital to the first available place, whether it is the right place or not? That is a major problem. Are we likely to see a repeat of some of the awful cases of inappropriate care being provided for elderly people? Elderly patients have a right to feel less secure under these changes—for the first time, they are being regarded in the system as a financial liability to be moved around for cost reasons.
The potential for perverse incentives as a result of the Bill is equally worrying. The hon. Member for Dartford (Dr. Stoate) raised the issue of the impact on general practitioners. Let me tell him one of the problems that the Bill will produce. GPs who are already finding it difficult to get their patients placed in a care home will come to understand something new: precedence will be given by local authorities to patients who are already in acute wards in a hospital. What will be the inevitable result? It will be the creation of a perverse incentive whereby GPs know that they are most likely to be able to get a patient into a care home by first getting them into an acute unit. That has the potential to cause more delayed discharges, by blocking more hospital beds, than we have at present. I am sure that that is not what the Government intend, but that will be the effect in the real world. It is the inevitable result of the Government not understanding how the system works in reality.
§ Mr. Roger Gale (North Thanet)
As the Secretary of State was unable or unwilling to answer this point, perhaps my hon. Friend can touch on it. The logical extension of what he is saying is that a problem that is already bad will be made worse. One of the principal causes of bed blocking is that families will not accept the provision that is being offered and want choice. How will that dispute be resolved within a three-day time limit? Will not beds be even more blocked as a result of what my hon. Friend describes?
§ Dr. Fox
As I said, there is the great possibility that things will deteriorate rather than improve as a result of the Bill. I am sure that Ministers do not intend it to have that effect, but that is what will happen, and it is the Bill, not the intention, that we are discussing. We have to take into account what we judge to be its effect on real patients in the real world, not what we think Ministers might want to happen.
519 The Bill leaves far too many questions unanswered. Those who followed the sad affair of the Government's creation of the care home crisis will be aware that there was much consensus on the Care Standards Act 2000, and that the damage came not from the contents of the Act itself, but from the ministerial regulations that were applied later on, which were recently subjected to a U-turn. Indeed, the Government's standard approach is to produce the merest skeleton of a Bill only to flesh it out later with mile upon mile of red tape and regulation. It is usually a sign that they are making it up as they go along.
The Bill falls neatly intro that category. Far too much of it depends on subsequent regulation to make it work and many of the important questions go unanswered. For example, who lays down the level of fines? The Secretary of State estimates that local authorities will be liable to pay a total of £100 million, but who sets the fine? How often will it be changed? Will there be an upper limit or will it be at the discretion of a future Secretary of State? Will fines apply if there is no appropriate bed, no other placement or no individual care available? Who will make those decisions? What will the Secretary of State do to determine who is, or is expected to become, a qualifying hospital patient? What procedures will be used and how does he justify such a ludicrous level of mismanagement when uses such achingly funny rhetoric about devolving power?
Then we have the problem of the dispute resolution mechanism. The disputes do not exist at the moment, but the Government admit that they will arise when the Bill is implemented. Three clauses out of 10 relate to the resolution of conflicts. Strategic health authorities are being established to steer the panels, which means that the NHS will be judge and jury in disputes between the NHS and local authorities. What sort of people will sit on the panels? What qualifications will they need? Most importantly, how much time and money will this nonsense divert from patient care into unnecessary, pointless and mindless bureaucratic squabbles?
§ Mr. Waterson
Is my hon. Friend aware of Age Concern's opinion that the Government's proposals may be in conflict with standard 2 of the national service framework for older people, which specifies that older people should be treated as individuals and enabled to make choices about their care?
§ Dr. Fox
I am sure that that is the correct approach. To be fair, I am not saying that the Government intend to do otherwise. Regardless of their intentions, however, the Bill could become another Dangerous Dogs Act 1991 and have the opposite effect of that intended. The Bill is a bad piece of legislation. Although it includes some good things that could command support on both sides of the House, they are totally outweighed by the dreadful provisions that I have outlined.
The Bill will not achieve its aims. It may well result in exactly the opposite. It is unfair to local government; it will divert time and effort away from patient care into bureaucratic games; it will create perverse incentives; and it will increase the risk of inappropriate care, especially for the elderly. It is part of the paperchase NHS created by the Government. It is about throughput not outcomes. It is about a "Never mind the quality, feel the width" health service. It punishes one group for the 520 failure of others over whom they have no control. Of all new Labour's crazy ideas, this is the craziest. I urge the House to oppose the Bill before untold damage is done.
§ Madam Deputy Speaker (Sylvia Heal)
Order. I remind hon. Members that Mr. Speaker has imposed a 10-minute limit on Back-Bench speeches.
§ Glenda Jackson (Hampstead and Highgate)
Setting aside the somewhat hysterical contribution of the hon. Member for Woodspring (Dr. Fox), I think it would be impossible to find anyone in the House or the country who would argue against the basis of the Government's proposal to have a national and properly integrated, multifaceted, high-quality service for older people. I do not think that anyone would argue with the Government's attempts to ensure that taxpayers' money earmarked for the provision of integrated social services for the elderly is spent. There can be no possible argument with the fact that the Government have their heart in the right place. They are clearly committed to ensuring that care for the elderly is not limited exclusively to residential care or nursing care, or to the practice of keeping elderly people in hospital long after their medical condition warrants a discharge.
Local authorities have been criticised for failing to spend the taxpayers' money that is accorded to them. That criticism could not, by the widest stretch of the imagination, be levelled against my local authority, Camden. It is not only council of the year, but a beacon authority for the care that it provides to elderly people. It has also more than spent the money that was earmarked by the Government for the provision of social services. It has exceeded the £30,876,000 given to it by more than £2 million. There is no doubt that the authority takes on board the thrust of the Government's policies, and not only in the provision of integrated services for the elderly. It is the first local authority to create an integrated mental health and social services trust. I pay tribute to the Government and my right hon. Friend the Secretary of State for ensuring that that was created.
Having been as polite as it is possible to be, I come to the difficult bit, which is to be critical of the Government. I would be less than honest if I did not say that it is my bounden duty to criticise aspects of their proposals. I am most critical of the idea that social services are exclusively responsible for ensuring that an elderly person does not remain in hospital longer than necessary. My constituency is part of an inner-London borough. Like other such boroughs, we have a suppliers' market for residential nursing home places. The homes charge and obtain higher fees for clients from the private sector. My local authority has received additional funding for the building care component, but there is still a desperate shortage of places, not least because patients in the two main teaching hospitals in the borough of Camden are not exclusively Camden residents. Social services departments outside Camden find places for their residents within my borough's boundaries because the treatment there is best suited to their needs.
521 There is another problem. It arises, curiously, from the fact that the Government have been hoisted on the petard of their own success. They listened to what hon. Members said about providing individuals with the ability and, indeed, the money to arrange their own domiciliary care. That has had an impact on local authorities, especially ones like Camden, because it removes the ability for authorities to block buy domiciliary care when elderly individuals return home.
Difficulties also arise in hospitals and medical teams when they have to determine whether an individual is ready to leave hospital. If they agree that someone can leave, the next problem is ensuring that that person can return to an independent and healthy life.
As I said, Camden has spent more than central Government gave it to provide integrated services for elderly people. It has increased the numbers of step-down beds and domiciliary beds and transformed some of its housing stock so that it can take people in wheelchairs, but there is still an element of bed blocking.
In some cases the failure to remove an elderly person from hospital has to do with limited capacity in occupational therapy. That point is anecdotal and I do not have figures to support it. As a Conservative Back Bencher said, there may be difficulties because the family disagree with what is proposed for their relative. It is not unusual for an elderly person to have no family or for the only person capable of caring for them to be as old and, in some instances, as frail as they are, so a return to home, even with a properly integrated programme of domiciliary care, may not be the best solution for that individual.
There seems to me to be gross inequity in the Government's proposals. I listened with interest to what the Secretary of State said about setting a ceiling of £100 million on the fines that may be imposed on local authorities and about taking that money out of the NHS. The fact remains, however, that local authority social services are not exclusively responsible for delayed discharges.
§ Dr. Andrew Murrison (Westbury)
The hon. Lady makes a good point with which I agree. Does she also agree that readmission is not exclusively the fault of hospitals? She referred to the multidisciplinary teams responsible for discharge delays, but they may also be responsible for high readmission rates, so it would be wholly wrong to fine hospitals for those rates, for the same reason that it would be wrong to fine social services departments.
§ Glenda Jackson
I hesitate to agree entirely with the hon. Gentleman that it is wholly wrong to impose fines because there are examples of best practice, certainly in hospitals. I know that some hospitals—not, I hasten to add, in my constituency—are dilatory in tackling these issues, and I am perfectly prepared to accept that some councils are less than good and do not spend the entire amount earmarked for social care for the elderly. However, we delude ourselves if we believe that the integrated, high quality care that we all want our elderly people to receive will be delivered by proposals that, in targeting bad councils, have a deleterious effect on local authorities that are committed to, and doing their best to deliver, those services.
522 I am concerned about the time afforded by the Government for consultation. There is an opportunity to reconsider the model on which the proposals have been based. I am not for one moment saying that they will not be effective, but this may not be the best model for achieving the aim to which the Government are clearly committed. There should be an opportunity for local authorities that are delivering high quality services and want to improve their delivery to make representations to the Government about the model that they would introduce. There are also justifiable concerns about the additional costs to local authorities, which are inherent in the Bill.
There is no uniformity among the many agencies responsible for ensuring that elderly people, once discharged from hospital, receive the care that is best for them. There are variations in practices and disagreements about which produces the best care. I am fully prepared to accept that the Government's heart is in the right place, but the basis of implementing their proposals is partnership, which means that the constituent partners who will eventually deliver these high quality services have at least to agree on the basics. It would be nice if they all had similar information technology, but they do not, so any attempt to track down the best person to provide a service among a wide range of service providers is time consuming. As we know, time equals money, so additional burdens may be placed on local authorities.
As I said, I strongly believe that the Government's heart is in the right place. We all want to see the highest quality services delivered, but I urge the Secretary of State to consider the points that will undoubtedly be made because there are dangers in the Bill, even though I will, of course, vote for its Second Reading.
§ Mr. Paul Burstow (Sutton and Cheam)
The Secretary of State told us that there is no magic wand to deal with delayed discharges, and I agree. The Bill is not a solution to that problem; it will simply exacerbate it and cause further problems in the NHS and the whole care system. The right hon. Gentleman's announcement of a £100 million sweetener will do nothing to remove the bitter taste of the Bill. The fact that that money is to be taken from the NHS, given to social services and then returned to the NHS is an admission that the Bill is fundamentally flawed because it is based on a crude market mechanism that does not reflect the complexities of the situation.
The Secretary of State told us that the proposed penalty system is based on one that was introduced 10 years ago in Sweden, but the penalties introduced there were only part of a much wider set of reforms to that country's care system and they were arrived at after a good deal of consultation and debate. They aimed to shift the centre of gravity in the Swedish care system out of the acute sector and into community care systems. That is not the aim of this proposal, which is grafted on to a system that includes a large amount of private and independent provision, whereas care in Sweden is largely provided by the state, through local govt. By contrast, in the UK, we have seen the NHS withdraw from long-term care, and a fragmented, unplanned set of arrangements put in its place.
523 Reading the report of the Health Committee's inquiry into delayed discharges earlier this year, I found that some of the most interesting hearings were those with the Department's officials. Their ideas do not appear to have got through to the Ministers framing the policy and the measures in this Bill. For example, the chief inspector of social services told the Committee in February:"Our concern about the over-75s is that delayed discharges here are a symptom that we need to do something about the totality of the system for older people. Actually just homing in on the issue of delayed discharges is concealing that there is a systems issue.It is a systems issue, yet the Bill provides a quick fix by introducing a single incentive that will have a series of consequences, many of which are not those intended by Ministers. It is certainly not a solution for the whole system.
§ Mr. Roger Williams (Brecon and Radnorshire)
The Bill deals with England and Wales, but both health and social services are devolved responsibilities, so I hoped that this would be enabling legislation within the spirit of the devolution settlement. In Wales, the Assembly already provides free care for six weeks after discharge from hospital. It would like, if it had the power, to provide free long-term care for the elderly, which it believes would prevent unnecessary admission to hospital and promote prompt discharge.
§ Mr. Burstow
My hon. Friend has made an important point about whether the Bill should apply equally to England and Wales. It is one thing for English Health Ministers to want to put the proposal into practice, but it is entirely different for it to apply automatically to Wales. I hope that as the Bill proceeds through the House, we will find a way for Wales to have discretion. Given the Government's commitment to devolution, I hope that the Bill will include powers to enable the Welsh Assembly to go as far as it wants in providing long-term care and making personal care free on the basis of an assessment of need.
§ Mr. Tom Clarke (Coatbridge and Chryston)
My interest in these matters derives from the fact that I introduced a measure as far back as 1986 covering the whole UK, so I am interested in seeing how the Bill progresses. Does the hon. Gentleman agree with the Secretary of State, who made an important point—not mentioned by the Opposition spokesman—when he said that of course we want to consult patients, their families and their advocates?
§ Mr. Burstow
The Bill does not stipulate the patient's right of consent to discharge arrangements. Nothing in the Bill stipulates the carer's right to be consulted about whether or not they wish to continue to take on a caring duty or, indeed, take it on in the first place. There have been representations from many organisations about the absence of those issues from the Bill. I hope that in Committee we can move beyond the vague promises that that will be dealt with in regulations to cast-iron commitments that it will be dealt with in the Bill.
The hon. Member for North Thanet (Mr. Gale) asked how consultation could be completed in three days. We have been told that the Government are satisfied that we 524 will have a partial assessment of someone's needs while they are in hospital. What on earth is that? How does it relate to the single assessment that the Government said would be in place from April this year? We now have the spectacle of the Government wanting to rush through discharges and implement an assessment procedure that does not include everyone who ought to be part of the process, shunting patients into an unsatisfactory interim provision and leaving them there too long.
§ Dr. Starkey
Does the hon. Gentleman accept that many local authorities, including my own, have already attempted to solve that problem by providing heavily supported, if I can so describe it, accommodation for patients who have been discharged—in my local authority's case, for up to six weeks—to give them time to decide whether they need to go into full-time residential care or go back home? Is that not better than leaving those patients in a hospital bed, which is unsuitable for elderly patients?
§ Mr. Burstow
It is better, but there will be a short decision-making process of three days to get someone out of hospital, which does not address their long-term care. We need a process that ensures that appropriate judgments are made. The hon. Lady must address the fact that the provision that her local authority has been able to make does not exist universally across the country, and is unlikely to come on-stream when the Bill is enacted. I want to try to explain why that is the case.
The Bill is all about treating symptoms, and does not tackle causes such as lack or loss of capacity upstream and downstream in our care system. Budget pressures have forced social services departments in the past 10, 15 or 20 years increasingly to ration access to care. Eligibility criteria have been drawn ever tighter as a result. Indeed, the Local Government Association says that two thirds of local authorities have narrowed their criteria still further in the past two years. They have done so by denying help to people with moderate needs or carers; by making people with high needs wait, often in their own home; and by setting limits on price, quantity and quality of care. In the past 20 years, social services departments have withdrawn home help services that offer domestic help and have concentrated care on the most disabled and dependent, in stark contrast to what is done in Sweden—the exemplar that the Government have chosen to use for the Bill. In Sweden, people still have home help services, which cover such activities as cleaning, shopping, outings, social contact and so on. The penalty system to be introduced by the Bill will undermine efforts to develop the preventive services that the hon. Member for Milton Keynes, South-West (Dr. Starkey) and many other Members believe should be widely available. Investment in prevention can postpone the onset of disablement, disability, illness and dependency, and has the biggest long-term impact on the problem of inappropriate admissions to hospital that result in delays in discharge.
It is not only upstream that there are capacity problems—there are serious capacity constraints downstream as well. We have serious staffing problems in the care system across the country, including a 15 per cent. vacancy rate for occupational therapists. Indeed, 40 per cent. of local authorities report severe difficulties in recruiting occupational therapists, who are key 525 players in facilitating a speedy discharge from hospital, enabling adaptations and changes in someone's property to be made quickly. If the OT is not there, who will do the assessments? That issue was considered by the Select Committee, but I do not think that it reached a final conclusion on how to progress the matter.
§ Mrs. Humble
The hon. Gentleman may not be aware that in Lancashire occupational therapists are employed by the health authority. If the OT is not there to provide a service, that is not social services' fault, but the fault of the health service. That complicates the situation.
§ Mr. Burstow
Basically, there are not enough OTs to go round. There is also the spectre of social services and the health service competing for a scarce resource. Until additional OTs are in place, we shall continue to have logjams in the system, as there is a fundamental lack of capacity. Those capacity constraints also apply to home care staff—the latest figures suggest that there is a 10 per cent. vacancy rate. We have serious problems recruiting such staff because they are low paid and undervalued. Unless we tackle that, we shall continue to have problems and will certainly not fulfil the Government's ambition to have more people cared for in their own homes.
Because of rationing, fewer people, as has been said, are receiving home care. The figure may be disputed, but 110,000 fewer home care packages are being delivered. Ministers say that that is because people are getting other services instead, such as meals on wheels, day care and so on. It is clear, however, that the figures for home care support have gone down. People who get such care, however, are getting it for more hours because they are more dependent. The Government's mantra is prevention. In practice, however, when they are judged on the figures, their emphasis is on dealing with crises and the most dependent people, and not prevention.
Capacity has also been lost in the care home sector, and is not being replaced by more care in people's own homes. The loss of 60,000 beds over the past five years has been mentioned but, more importantly, in the past three years closures have exceeded new registrations, which have been flatlining for at least three years.
§ Andy Burnham (Leigh)
The hon. Gentleman has just referred to the loss of 60,000 care home places, as mentioned by the Conservative spokesman, and also referred to the report by the Select Committee on Health on delayed discharges. Has he not seen the part of the report dealing with care home places, which suggests the loss is nothing like 60,000?
§ Mr. Burstow
I read that and the dissection of the Government's figures. The Committee was fair, and acknowledged that the figure of 19,000, which is regularly trotted out by Ministers, is probably more misleading than the figure of 60,000 cited in Laing and Buisson's report.
§ Mr. Burns
The hon. Gentleman is absolutely right, whatever Ministers may say. Before he is led astray by the hon. Member for Leigh (Andy Burnham), may I point out that there was not a unanimous decision by the 526 Health Committee on the number of beds lost? The report was actually rammed through by a majority of aspiring Labour Back Benchers.
§ Mr. Burstow
I am sure that the hon. Member for Leigh (Andy Burnham) is one of those aspiring Back Benchers.
I want to focus on the figures from Laing and Buisson's report for 2001, which give the net position—the gross figures have given cause for concern. In 2001, 107 new homes, amounting to 3.800 new beds, were registered. During that period, however, 828 homes closed with the loss of 16,600 beds. There is therefore a clear downward trend in the sector, which, in some parts of the country, has contributed to the problem of delayed charge.
The Minister told us in a statement in July that the Government aim to stimulate the care home market to get more care home beds back into the sector. They stated in their document that they want an extra 6,000 beds by 2006, the majority by 2004. I hope that the Minister can tell us how those beds are to be achieved, where they will be provided, and how the barriers posed by the development value of land will be overcome, given the investment costs and the risks involved, and given the fact that the rate of fees has still not gone up sufficiently to bring new players into the market. Why would anyone come into a market where the fee rates are unsustainably low? Work by the Joseph Rowntree Foundation clearly shows a shortfall in the resources going into the sector.
§ Dr. Stoate
The hon. Gentleman is generous in giving way yet again. He is exercised by the number of care beds in the system, and of course that is important, but is he aware of a recent national audit commissioned by the NHS executive, which found that 17 per cent. of elderly people living in nursing homes no longer needed nursing home care at all? Surely it is more important to make sure that the right people are in the right homes than to worry about the absolute number of beds, given that 17 per cent. of elderly people were apparently in the wrong place.
§ Mr. Burstow
The hon. Gentleman makes a self-evident but nevertheless valuable point. I am not arguing that care homes are good and anything else is irrelevant but that there is a fundamental problem of capacity, not just in care home places but in home care places. We need more investment upstream to ensure that we can postpone or prevent the onset of the disability and illness that result in admissions in the first place. That ought to be a key priority for investment, but I fear that it will be denied because of the penalties.
My hon. Friend the Member for Guildford (Sue Doughty) has drawn my attention to figures produced in Surrey. I understand that 225 people are experiencing delayed discharge from hospitals in the county, and 120 of them are believed to be the responsibility of the county. Of those 120, 30 are funded but no placement is available because of care home closures and the lack of capacity that I have described, and the other 90 are unfunded.
From next April, the building capacity grant about which the Government have spoken a great deal, and which has been paid for the past one and a half years, 527 comes to an end. That grant has been used to provide ongoing services, new care packages, the fees paid to care homes and for other purposes. Those are ongoing commitments that arise from a specific grant, and in future years they will have to be funded out of the 6 per cent. real-terms growth. However, the funding commitments that councils have already made will leave little of that new money available for new investment in new services.
I shall give an example from Kent county council, which received £2.12 million through that grant in 2001–02. In a full year, the council believes that the cost of its investments amounts to £6.5 million, but in 2002–03 its grant for building capacity was £4.7 million—a gap of £2 million. The gap continues to grow because the people for whom the council is providing services continue to need those services. Why will not the Minister confirm that the penalties system is simply designed to give the Treasury its pound of flesh for giving extra money to social services in the Budget this year? Even that extra money, welcome though it is, leaves social services behind the curve in terms of meeting demand and reducing rationing in the care system.
During the Select Committee hearings on delayed discharge, officials told the Committee that dementiais a principal cause of delayed discharge because of the complexity that having dementia plus a physical illness produces in terms of developing a good discharge plan.and that the latest figuressuggest that about 70 per cent. of people in nursing homes, not EMI homes but nursing homes, have a level of cognitive impairment that affects their mental function.There is not enough provision in this country, whether in people's own homes or in care homes, to provide a decent standard of care to people with dementia, and nothing that I have heard today suggests that that is to be addressed in the near future. In the national service framework for older people, the targets that have been set for dementia care do not require anything to be done until 2004.
The Bill undermines partnership arrangements. It is a recipe for conflict. As the hon. Member for Hampstead and Highgate (Glenda Jackson) said, it is wrong to blame social services as though delayed discharge were their sole responsibility. The Bill turns patients into commodities labelled as bringing in or losing money, depending on one's point of view. The wording of the Bill sounds like a fed-up parent mediating between two scrapping children. It is not surprising that the Local Government Association and the Association of Directors of Social Services oppose the Bill, but it might be surprising that the NHS Confederation does. Those are the managers who will have to live with the consequences of the Bill that the Government are trying to foist upon them.
Why do not the Government instead take forward the ideas suggested by the NHS Confederation for joint local protocols and building on existing partnerships? The Government say that they will aid partnership through the Bill, but it is a strange sort of partnership where one partner is given a stick with which to beat the other. That sounds more like domestic violence than relationship building.
The Bill ignores the patients' and carers' perspective. All the submissions from charities representing older people and carers that I have read oppose the penalty 528 system. The Bill as drafted makes patients the passive recipients of care, rather than active participants in their own care and recovery—
§ Mr. Hilton Dawson (Lancaster and Wyre)
So what does the patient stuck in NHS provision—it may be an older person or a person with a mental illness—do when, despite all the protocols and all the good intentions, nobody will help them move?
§ Mr. Burstow
Under the Bill, such people will not have access to advocacy services to help them with their discharge and they will not even be asked, because the Bill does not address their right to give consent to be discharged. It does not even address whether the carer should be consulted. Such considerations are absent from the Bill. We have the vague promise that the discharge workbook, which the Government have been promising for two years to update, will be updated. The hon. Gentleman should address his question to Ministers, not to me.
Why does the Bill make no provision for patient consent or for consulting carers? I hope that we can persuade the Government to do that in Committee. As Carers UK has documented in its report, "You can take him home now", 77 per cent. of carers said that they were not given a choice about taking on a caring responsibility. Carers UK also found that emergency readmissions had increased from 19 to 43 per cent. among the carers surveyed, and carers increasingly saw early discharge as the reason. Emergency readmissions have been increasing. The latest figures available show that 122,357 people experienced emergency readmissions, which is an 11 per cent. rise in two years. In its representations, the Royal College of Nursing points out that that is symptomatic of inappropriate discharges.
In the NHS plan, we were told that there would be an equivalent penalty system for emergency readmissions. What we have heard today is a watering-down of that, so there is no equivalence between emergency readmissions and delayed discharge. Instead, they are to be linked to star ratings and nothing else.
§ Mr. Burstow
I must make progress, so I will continue, if I may.
Standard 2 of the national service framework states that older people should receive care that meets their needs as individuals, and that the role of the N HS and social services departments is to enable people to make choices about their own care. The penalties will not facilitate that. Health care should be driven by the needs of patients, but the Bill puts tick-boxes and spreadsheets first. Ministerial obsession with delayed discharge is distorting priorities. Penalties to incentivise one part of the system will have knock-on effects.
What happens to the elderly person in their own home who is waiting for an assessment? What happens to their care? The Bill means that social services departments will be forced to prioritise the person in a hospital bed ahead of the person in their own home—a case of them being out of sight and out of mind, and certainly not being a priority when it comes to avoiding penalties. 529 The message that the Bill sends to the House and the country is that the Government are setting up a system that creates perverse incentives where the only way in which some people can get appropriate care and ensure that they are fast-tracked is through hospital admission.
§ Mr. Burstow
That is a very fair question. Indeed, we will be asking some questions about how the Secretary of State arrived at the £100 million figure that was mentioned today, which is very interesting and double the Liberal Democrats' estimate. We decided to adopt a conservative approach. The basis of the calculation was to use the most recently available delayed discharge figures and apply the rates differentially, based on £120 for London and the south-east and £100 everywhere else. We applied those levels to the figures that are provided on a regional basis, and that is how we produced our estimate. It is interesting that the Government's estimate is now twice as large. Perhaps that shows that they have figures that they have not yet made available that should be brought into the public domain.
§ Mr. Burstow
The hon. Gentleman asked his question and had his answer, so he cannot really expect me to give way again.
The Bill is fatally flawed and will create a blame game between the national health service and social services. It will distort priorities, leave people waiting still longer in their homes to get the care that they need and result in patients and carers being left out of the equation. Delayed discharges are a symptom of chronic under-investment not only by this Government, but over decades, and of the rationing of care. The Bill does nothing to address those underlying problems; if anything, it will make them worse. That is why the Liberal Democrats will vote against it.
§ Mr. David Hinchliffe (Wakefield)
When we debate a Bill on Second Reading, we basically debate its principles. I fundamentally disagree with the principles of this Bill, which I think is flawed and will ultimately prove damaging to many positive policies that the Government have promoted.
My hon. Friends on the Front Bench deserve congratulation on many of the initiatives that they have developed, such as joint working, community care, the flexibilities in the Health Act 1999, limited pooling of budgets and care trusts. They have introduced a range of initiatives that have genuinely improved joint working locally, as the hon. Member for Woodspring (Dr. Fox) said. However, I fear that the Bill is taking us in the other direction. I welcome the Government's increase in funding for local authority social services, but it is a belated recognition of the serious difficulties that many local councillors face.
530 The Select Committee on Health considered the figures for 2001–02 in its recent public expenditure inquiry. It is interesting to compare the real-terms growth of the national health service, at 9.4 per cent., with that of social services, which is 1.3 per cent. We are making assumptions about the Bill on the basis of the experience in that year and previous ones when that huge discrepancy existed in the funding of those two areas. An extra £100 million has been promised by the Secretary of State—it will be taken from health funding to go into social services—but the Health Committee estimated in its public expenditure inquiry, on the basis of the Government's figures, that local authorities are already spending £200 million more than their budget on social services in 2001–02. That puts his £100 million figure into context. Some 10 per cent. of English local authorities are spending more than their standard spending assessment levels.
It is fair to say that we have treated social services as a poor relation—a term that was used by the Secretary of State. We are now putting the boot into that poor relation and we need to think the matter through very carefully. As my right hon. Friend made his speech, one of my hon. Friends asked me, "Who thought this one up?" In trying to work out some of the measures in the Queen's Speech whose logic I cannot understand, having believed in Labour party health policy for my whole adult life, I have concluded that some adviser or civil servant has been rooting around in the cellars of Richmond house and found in a file some dusty papers that were prepared for a Tory Secretary of State 20-odd years ago. That is the only conclusion that I can draw on the logic of foundation hospitals.
The supposed logic behind the Bill is based on thinking that is completely outdated, because it is rooted in the social services environment of at least 20 years ago, when social services were direct providers of care and could offer care home places and accommodation under part III of the National Assistance Act 1948. I worked in social services for many years in the 1970s. I went to hospitals, saw patients who were deemed fit for discharge, assessed their suitability under part III, and could then arrange a direct placement under those provisions. That is no longer the case. The previous regime rapidly got rid of local authority direct care provision, and in answer to the Health Committee, the Government now describe the role of local authority social services as managing the private care market. The arena is now fundamentally different from the one in which I worked 20 years ago, when the thinking behind the Bill emerged.
I am concerned about being told that we are considering practice in Sweden. I have always had a great interest in Scandinavian social policy, as I think that Scandinavia is light years ahead of the UK, having been there a number of times. I also found out recently that the origins of the Hinchliffe family are Norse, so perhaps I am genetically programmed towards Scandinavian social policy. However, I know enough about Sweden—indeed, I shall be there on Sunday evening with one or two of my hon. Friends—to know that its health and social care system is fundamentally different. As other hon. Members have mentioned, the Swedish system is better resourced and Sweden has higher taxes and better services. There is also far less reliance on the private market, much greater direct 531 provision and different charging regimes. We are making the same mistake that Tory Front Benchers have made on several occasions—that of going to Timbuktu, plucking out an obscure policy and trying to apply it to the UK. That is a ludicrous thing to do because the systems are fundamentally different.
Reference has been made to the Health Committee's recent inquiry into delayed discharges. I should like to quote from some of the evidence that we heard. Mike Leadbetter, the former president of the Association of Directors of Social Services, said that the measure was "a perverse incentive" and added:when you look further in Sweden, there is still the exact same number of delayed discharges in Sweden per population as there is in England.Dr. Gill Morgan, chief executive of the NHS Confederation, said:people do not believe it is an effective incentive and that in places which have worked hard to have good relationships it could bring contesting back rather than partnership … It could be counterproductive.Dr. Chris James of the NHS Alliance, speaking from a primary care viewpoint, said:If health fining social services is the Department's answer to facilitating partnership working, then we have a long way to go.Those are the people who will be doing the jobs, and John Ransford from the Local Government Association agreed with all those points. We got a clear thumbs down. My recollection is that we did not hear any support for the Bill apart from that of the Department of Health. Indeed, the support expressed by some of the officials whom we interviewed was muted, as they could envisage some of the likely problems.
As I indicated in my intervention on the Secretary of State, my concern is that many factors outside the control of social services result in delayed discharges. For example, why do we not fine home nurses for failure to arrange home nursing packages because that sometimes results in delayed discharges? To my knowledge, that is a factor. What about ambulance service failures? I have come across cases in which people cannot get transport to enable them to leave hospital, especially if they have to travel some distance. What about the failure of housing authorities to arrange appropriate accommodation for people who can no longer go back to their homes because they need ground-floor accommodation or some form of specialised sheltered housing? What about resistance from relatives? I have encountered cases in which relatives have said, "No, she's not coming out, because in our view she's not fit to do so." What should we do in such circumstances—fine the relatives? The Government do not seem to have considered that question.
§ Mr. Hinchliffe
No, because my time is limited. I fundamentally disagree with my hon. Friend's position on this matter, as he knows, although I have a lot of respect for him on many other issues.
What about choice? People may not want one care home. We have choice on one hand but contradiction at the heart of the measure. What about a private company's delay in supplying equipment required to 532 enable someone to leave hospital and be at home? Do we fine the private company the costs of the patient's remaining in hospital?
What about delays caused by the national health service's failure to admit people from social services establishments? Admitting them would create vacancies for people who want to leave hospital. I have come across that problem in what little remains of our part III accommodation. We cannot get people out because we cannot get people in. It is ludicrous to concentrate on one small part to resolve a big problem.
The Bill has not been thought through. Some of its provisions are vague. As has been said, the disputes procedure under the strategic health authority is not objective. Why should the strategic health authority, which is clearly in one camp, referee? It is not neutral, so there is no objectivity.
What about the period for social services assessment that regulations will establish? A set period for an assessment does not take account of the huge differences in the ability of social services departments in different parts of the country to recruit staff. Some London boroughs are desperately short of social services staff. Surely we must take that into account.
§ Mr. Hinchliffe
No. I can provide a solution. I am a moderniser and a radical. We should be bold and have common budgets. We should get rid of the boundaries between health and social care. One common budget is the way forward.
§ Sir George Young (North-West Hampshire)
The hon. Member for Wakefield (Mr. Hinchliffe) was the fifth speaker in the debate. So far, only the Secretary of State's speech has supported the principles of the Bill. The score is therefore 4–1; it will be 5–1 when I sit down.
In nearly 30 years in the House, I have seen many Bills. In a competitive field, the Bill that we are considering is one of the worst. It is divisive and mean-spirited and has no place in social care in the 21st century. It will poison the atmosphere between the two key organisations that should engage in a spirit of partnership to improve the quality of life of elderly people. Instead of joint incentives to co-operate, there will be a unilateral power to fine. At a stroke, the Bill destroys much of the language of seamless government, pooled decision making, joint budgets and integrated teams.
As the hon. Member for Wakefield said, even those who work for the NHS—the supposed beneficiary of the scheme—do not support the Bill. The NHS Confederation described it as a retrograde step. The Royal College of Nursingremains unconvinced that charging Social Services for delayed discharges from hospitals will lead to better discharge planning.533 Scarce funds that were voted for the care of elderly people will disappear into the maw of the NHS, possibly to be spent on other groups.
There will be yet more bureaucracy in a system that is buckling at the knees under paperwork. There will be perverse consequences as people find ways through and around the new rules. For example, care home providers may exert further pressure and increase prices when they know that the authority faces the threat of a fine, thereby diminishing the amount of care that can be bought.
We heard from one doctor today and another in the debate on the Queen's Speech what GPs will do. Those whose patients need access to a care home will have an incentive to admit them first to a hospital so that they reach the front of the queue. Social services departments will cut some of their preventive work to protect their budget from the fines for which the Bill provides, which will make elderly people more likely to end up in hospital.
The proposals might be tenable in an atmosphere where relationships had broken down, people were not working together and there was a refusal to co-operate. The previous Conservative Government were driven to introduce rate capping when the relationship between parts of local government and central Government had broken down. Nobody who follows health and social care matters could begin to argue that such an atmosphere prevails between health and social services. We simply have not reached that stage.
There is a temptation to consider the Bill from the viewpoint of the NHS or from that of social services departments, but the right place to start is the viewpoint of the client, customer or patient. He or she wants an overall package of reform or investment that supports independence at home when possible, and in residential or nursing care when it is not. Of course it is wrong for elderly people to stay in hospital for longer than necessary. They lose the living skills that they had before admission and they become exposed to hospital-acquired infection. There is therefore no dispute about objectives.
The reimbursement system, however, will place the patient and the carer in an untenable and often stressful position. Patients and the carers, who may already be distressed and disoriented, will become pawns in a professionally combative and hostile environment.
Patients want a continuum of care from a variety of institutions, provided in a spirit of partnership. They want the people on whom they depend to work together and not against each other. The sole focus on delayed discharge, which is one stage in the spectrum of care, will inhibit efforts to build on services that prevent hospital admissions and investment in longer-term solutions. It will not contribute to building up capacity in the care sector. The client will feel the tensions that the regime creates.
The regime that we are debating highlights publicly the contrast between Government rhetoric about the rights of carers and person-centred care and the lack of 534 individual protection that will result from the proposals. Kevin Terry of Age Concern expressed that well on 14 November. He said:The proposals for reimbursement are ill-conceived and, we believe, impractical.The proposal is one sided; only one partner will be fined. When the NHS fails to admit a patient for a hip replacement or other operation on a pre-determined date, it faces no fine, although the delay may impose financial costs on others. I recently received a letter from my NHS trust. An image intensifier had broken down and a constituent was consequently unable to receive treatment for back pain. The chief executive wrote:The piece of equipment … costs 100,000. A bid has been submitted to fund a replacement … a decision will not be known until later in the year … I will ensure you are kept informed as to when we hope to be able to progress with your treatment.My constituent and everyone else will not be treated until the local trust gets around to buying another intensifier. There are no penalties for the failure of the NHS to provide the quality of care that it should.
The explanatory notes give a further example of one-sidedness. Paragraph 31 states:If for some reason the patient is not discharged at this point, then the social services authority is not liable to make any further payment, as it is not responsible for any further delay.That is fair. However, if the social services department has reserved and paid for a bed in a home and the NHS fails to discharge the patient, the former will be out of pocket but receive no reimbursement from the latter.
As several speakers have pointed out, one key assumption underpins the Bill: a delayed discharge is the fault of social services. Many delays are caused by other factors such as self-funders awaiting the home of their choice, lack of community health services or a transfer to a specialist service in the NHS. The fault may lie with the housing department rather than the social services department. In many counties that have a two-tier authority, the housing authority is often at fault but the social services department will take the hit.
As the hon. Member for Wakefield said, the social services department is the under-resourced partner in the equation. It has not received the same increases as the NHS. Let us consider the extra resources that the Secretary of State mentioned. What the Chancellor has given through the comprehensive spending review the Deputy Prime Minister will remove through the redistribution of grant. Many counties have been promised the same grant in cash terms for next year as they received last year. That is no basis for further investment in education and social services.
In the south-east, despite all the investment that the Government mentioned in rehabilitation and community services and the good working relationship between the two departments, the overriding reason for delayed transfers is simply capacity. The problem has been exacerbated by inadequate funding in an environment of increasing demand for services for older people. Simply fining social services will not address the core problem. If the Government want faster progress, as I believe they do, the Department of Health ought to be giving positive assistance to Hampshire county council and other councils that want to expand the capacity of their nursing home sectors.
535 We need a holistic approach with incentives, not a narrow approach with fines. I am amazed that Labour Members who have sat on local authorities and who are close to these issues are letting their Government get away with this. If the Conservatives had introduced this measure, they would have walked all over us, complaining about internal markets and all the rest, yet they are not stopping their Government. I genuinely believe that this is a mistake, and I urge the Government, even at this late stage, to think again.
§ Mrs. Joan Humble (Blackpool, North and Fleetwood)
I agree with the many Members who have said that we can all applaud the aims of the Bill. No one wants to see elderly people unnecessarily delayed in hospital. Elderly people deserve to be cared for in the most appropriate setting, and we need to examine ways of ensuring that that is provided.
One of the other aims of the Bill is to establish better communication between health and social services departments. Of course that should happen; these are the two agencies that have responsibility for looking after the very vulnerable people in our communities. If I have a concern, however, it is about the manner in which the Bill sets about achieving those two aims. I am raising my concerns not from the point of view of the social services departments in my constituency, which could be subjected to substantial fines; in fact, quite the opposite. I cross my fingers when I say this, but my local hospital does not have a problem with delayed discharges.
I am always extremely sceptical about statistics, especially those relating to health and social services. I was shocked and amazed, last year, to see that my hon. Friend the Minister had said, in response to a written answer, that north-west Lancashire had a 10.6 per cent. delayed discharge rate, and that that compared with 4.2 per cent. in south Lancashire and 0.2 per cent. in east Lancashire. I wrote to the then chair of North West Lancashire health authority and received a reply that can be described only as a confusing analysis of how the statistics are arrived at. She wrote:The figure of 10.6%is a plan figure which is provided by the Authority's 2000/2001 Service and Financial Framework.She went on to describe how the figures were arrived at, but ended by saying:I am pleased to be able to reassure you that actual performance during the first two quarters of the 2000/2001 financial year is considerably below the plan figure in the Service and Financial Framework. Quarter One showed delayed discharges running at 8.9%, whilst in Quarter Two this number fell to 4.6%.Anyone looking at the original figure, however, would have thought that Lancashire had a problem. It clearly did not have a problem, and I knew that.
As well as writing to the health authority, I wrote to Lancashire county council's social services department and to Blackpool social services. They both wrote back to say that they did not have a problem, and that they were working well with the health authority and with the hospital. They commented, however, that the picture behind the delays that did occur was not a simple one. The reasons for delayed discharges included non-availability of a specialist service at a particular time—for example, assessments or continuing therapy from 536 health staff such as occupational therapists, who are employed by the health authority in Lancashire, or physiotherapists. In some instances, delayed discharges were also caused by a place not being immediately available in a patient's choice of residential or nursing home.
An analysis of the figures for delayed discharges shows that about 50 per cent. of them were due to a patient's choice of residential or nursing home not having a vacancy. I say that in the context of there not being a problem of availability of nursing home and care home beds in Lancashire; we have an over-provision. Patients are therefore waiting in hospital until a vacancy arises in their preferred home. That raises concerns for me about the choice directive. What will happen to patients in hospital who are saying, "I am ready to move, but I want to go to that home down the road, and no other." How will the choice directive be applied? How will that bed become unblocked? How will the person be moved? I hope that my hon. Friend the Minister will address the issue of consultation with patients and carers in this context. For example, if an individual had to make an interim move, they should be fully consulted and offered a reassurance that, should a vacancy arise in the home of their choice, they would be considered for it.
I carried out my inquiries a year ago, so I thought that I should also look at some more up-to-date figures to find out what is happening now. I contacted Blackpool primary care trust to find out the current position. Of the 163 delays recorded between 5 August and 17 November 2002, only 16–9.8 per cent.—were attributable to social services departments. If those delays attributable to patient or carer choice are removed from the statistics, the actual figure falls to 5.5 per cent. So social services cannot be blamed for the number of delayed discharges. The blame—if blame can be ascribed—lies either with the health authority or with the patients and their carers. In Lancashire last week, there were 27 cases of delayed discharge. Of those, 17 people were awaiting practical or other arrangements beyond the control of Lancashire social services. Those 17 people included five who were awaiting arrangements to be made by families, and, for three others, discharge from hospital was imminent at the time that the statistics were being collected. I am concerned, therefore, that social services are being blamed for this situation when, certainly in my own locality, they are not to blame.
Exciting initiatives are being introduced locally. Lancashire social services, for example, has introduced a new scheme involving named social workers. One of the problems is that it can be difficult to manage and link the social work team in the hospital, which does the discharge assessment as part of the multi-disciplinary team, with social workers in the community. So Lancashire has introduced a system in which, if someone known to social services goes into hospital, a named social worker who knows that individual and knows their care needs follows them through the hospital process and arranges their discharge into the community—an excellent initiative that could, and should, be replicated elsewhere.
I recognise, however, that not every part of the country is as fortunate as the Fylde coast. We have not only excellent collaboration between social services and 537 the health service but some very good health service units, including two new NHS rehabilitation units at Rossall in Fleetwood and Kincraig in Blackpool. The Minister of State, Department of Health, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), opened the Kincraig unit, and he will have seen the excellent work that the health staff do to help to rehabilitate elderly people and to provide the interim care to ensure that they can safely be discharged from hospital and settled in the community.
When I speak to some of my hon. Friends, however, they tell me that the situation is not the same elsewhere. I want to make one supportive comment to my hon. Friend the Minister. I understand the importance of standardising some of the procedures, learning from good practice and ensuring that examples of good practice in discharge procedures are replicated around the country, but I ask her to allow time for that good practice to be developed. I also urge her to defer the introduction of fines, which will be counter-productive in this context and will undermine the good practice that I have seen and that I would like to see developed elsewhere.
§ Mr. Andrew Lansley (South Cambridgeshire)
I am glad to follow the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble). I recall that, only recently, we lost the chief executive of Addenbrooke's NHS trust in my constituency to the Blackpool NHS trust—our loss is her gain. No doubt if she discusses the matter with him, he will describe circumstances in South Cambridgeshire regarding the availability of nursing and care home places very distinct from those that she described on the Fylde coast.
None the less, some of the arguments continue to apply, and they speak of the necessity for the Government not to attempt to construct a theoretical national argument, but to consider practical issues as they affect localities. As my right hon. Friend the Member for North-West Hampshire (Sir George Young) so eloquently spelled out, they must not address issues by attacking one point in the system instead of understanding the whole system.
Essentially, I have four points to make. The first, which my hon. Friend the Member for Woodspring (Dr. Fox) referred to from the Front Bench, is about partnerships and it has been echoed across the House. In 1997–98, the hon. Member for Wakefield (Mr. Hinchliffe) and I, as members of the Health Committee, considered the relationships between health and social services. We could see then the necessity of taking down the Berlin wall between the two and of building partnerships. That began to happen, particularly over winter pressures, and it has extended to become more effective. Although it has become much more effective in my constituency, the Bill is designed not only to recreate that Berlin wall, but to give those on one side of the wall the ammunition to fire at those on the other. That is wholly misplaced and the Government should simply consider the response of the social services directors, the Local Government Association, the NHS Confederation and all those who gave evidence 538 to the Health Committee. It will become obvious that those who are managing such partnerships do not regard the proposal as at all helpful in that process.
Secondly, on the question of uniformity, I want to make a distinctive point that I have not heard set out in detail. We might bandy around national figures on the loss of care home places, but, in practice, that loss occurs for different reasons and to a different extent in different parts of the country. The Government are fond of saying—indeed, I have heard the Prime Minister say it—that places such as South Cambridgeshire are losing some nursing and care home places because of the rise in property prices. If there is a rise in property prices that is leading to such a loss, it is happening in South Cambridgeshire as much as anywhere else in the country.
However, we are also losing nursing home places in South Cambridgeshire because they are being converted, for example, to provide mental health places, as more money can be earned from those. We are losing availability in nursing and care home places because of the change in care standards. I shall not rerun that argument from a previous Session, but it has had an impact and it has driven care home providers out of business. It would not have done so if Cambridgeshire's authority had been in a position to provide the fees necessary to meet their costs, but, as things stand, Cambridgeshire cannot meet those costs.
Cambridgeshire cannot even compete with authorities such as Hertfordshire. They receive the area cost adjustment, which is meant to reflect the additional cost of providing services in their area, but, in practice, those costs are exactly the same. If anything, they are, in some respects, less than those around Cambridge. Hertfordshire's response to its problems is to buy care home places in Cambridgeshire, which crowds out that possibility for Cambridgeshire social services.
In parenthesis, I am struck by how the Government are trying to rectify some difficulties associated with social services funding. Going back three or four years, they were, for political reasons, badging money as NHS money, which then had to be given to a health authority or an NHS trust to buy nursing and care home places and bail out a social services department that could not solve the problem. That is still happening in Cambridgeshire.
The Government have given us £2.3 million and the implication, of course, is that it can immediately purchase additional capacity. However, anybody who looks at markets will recognise that, as is true around Cambridgeshire, additional capacity simply cannot be bought if the price is below the cost of providing the service. Who will come into such a market and offer such a service?
So, £2 million of the £2.3 million provided has enabled Cambridgeshire to raise fees and to maintain provision rather than see it decline. The money has not added capacity so much as sustained it, even at current levels. If the Government are serious about building capacity, they must think hard about how much money is required to enable that to happen in parts of the country such as Cambridgeshire. Judging from what I have seen, I am not sure that £100 million is sufficient to make a substantial difference in building capacity in all those places across the country where the fees being paid are below the cost of provision.
539 If the Government are to go down that path, they must think hard about differentiating between impacts across the country. I shall not stand here and say that no local authorities are failing to meet their responsibilities. Some will be failing. Equally, however, others are performing well within the resources available to them. They are spending more than the social services standard spending assessment—that applies to almost all of them, including Cambridgeshire—and they are performing well in terms of the provision of home care packages.
The problems of delayed discharge involve, pre-eminently, the availability of care home places and, to an extent, the exercise of patient choice. In such circumstances, it is iniquitous to impose on an authority such as Cambridgeshire an additional fine that will drive the service further and further down.
My third point is that there is an alternative. As my right hon. Friend the Member for North-West Hampshire said, we need a more integrated system with incentives rather than penalties, which is what Cambridgeshire is setting out to achieve. A discharge planning team is being established, which will integrate health and social services and be managed by the primary care trust.
I like to think that we can be constructive whenever possible, so I point out that an option for the Government is to take out of the hands of the social services departments alone the question whether patients should be discharged to care homes. That should be put in the hands of a discharge planning team that is independent of social services to the extent that it can buy the place and pass the cost to the local authority if one is available. That would take from any given local authority the excuse that it cannot find a place when, in reality, one is available. Of course, that would follow evaluation.
As I said to the Secretary of State, I am worried that a consequence of the proposal will be the undermining of patient choice. In particular, and as the Health Committee heard from Essex, local authorities are required to make urgent placements and interim placements that are far from the choice of the patients and even not necessarily what is clinically best for them.
Patients will be damaged. I have seen that, especially when those with Alzheimer's or dementia are moved from one place to another. The physical process of transferring such patients from one set of circumstances to another and from one environment to another can do immense damage. I recall that, in some cases, patients who were moved from a ward to a nursing or care home died. The home was of perfectly good quality, but it was not in the patient's interest to be transferred.
There is an alternative, and it involves providing some independence so that a local authority that is failing to deliver on its tasks cannot escape any financial responsibility for meeting patients' needs. If a team is working on those matters and if the NHS trust concerned and the PCT are part of that team, they have an incentive to ensure that patients are not taking up beds when they should be out of hospital. Those bodies can push, through the discharge planning team, for the transfer of patients.
On adding to perverse incentives, due to Cambridgeshire's circumstances and the nature of my area, we know that many care home providers, good as 540 they are and as much as they want to work with local authorities, will raise their fees if they think that my social services department will lose money—
§ 5 pm
§ Mr. Kevin Hughes (Doncaster, North)
We heard from the Secretary of State that the Bill's basic aim is to prevent delayed discharges from acute hospital beds. As we know, that affects older people in particular. Other Members produced, in effect, a regurgitation of the professional whinges and excuses for not doing anything to tackle the problem—notably the hon. Member for Sutton and Cheam (Mr. Burstow), who for some reason managed to make a 25-minute speech although he is only a Back Bencher like me. I cannot remember when we decided that there were two Opposition Front Benches.
We are all worried about people being kept in hospital longer than necessary. No one wants to be trapped in hospital when they do not need to be there, and that applies especially to elderly people. It is well known that the vast majority of older people prefer to be in their own homes. That was demonstrated to me very clearly earlier this year, when my mother needed emergency surgery. After the operation all she wanted to do was go home, even when she was still in the intensive care unit. The care she received in hospital was first-rate, but she wanted to go home nevertheless. I am glad to say that as soon as she was able to leave she was discharged.
My family and I remain very grateful to all the staff involved in my mother's operation and after-care at the Doncaster and Bassetlaw hospital. Had she lived in a different area, things might well have been different, as we know from some of the stories we have heard today. In Doncaster, however, social services, the primary care trusts and the Doncaster and Bassetlaw trusts operate robust arrangements to ensure that they work together to reduce delays. It is an excellent example of collaboration and co-operation between health and social care services, providing support and care for patients who do not need to be in hospital for medical reasons. Patients who require time and care to recover from illness or surgery may need intermediate care, with intensive rehabilitation support, before going home or into sheltered or residential accommodation. Some may need round-the-clock nursing care in a nursing home.
Most people want to be able to stay in their own homes, as I have said. Health and social services have crisis intervention teams to prevent the need for admission to hospital, or to ease patients back into their homes. In many cases involving elective surgery, they start considering what needs to be done after patients come out of hospital before the patients have been admitted. That is where some authorities go wrong.
Joint agency panels allocate residential places for those who can no longer stay at home. The overall approach is to ensure that as many of my constituents as possible are given the right health and social care support, when they need it. The key is joint working and partnership throughout the caring organisations, and commitment to securing the best for local people. There is also a joint equipment store, and occupational 541 therapists—of whom we have heard much today—employed by the NHS can assess and order equipment without the need for social services to agree to the ordering of each item, which means that delays are minimal. The provision in the Bill on liability for delayed discharge payments will certainly concentrate the minds of those who have not already started working together to reduce delays significantly.
For authorities such as Doncaster that have put considerable effort and resources into reducing delays, targets must not be seen to be unfair, and should take into account work already done. It would be perverse to set targets that are too high for those that have already started to act, while allowing those that have done nothing to benefit.
According to the House of Commons Library, the rate of delayed discharge in England as a whole is about 9.5 per cent. The rate in Northern and Yorkshire region is 6.5 per cent. Doncaster's average is only about 2.4 per cent. The worst rate this year peaked at 4 per cent. in September, probably owing to the actions of local private care homes, and fell to 1.9 per cent. in October.
All this demonstrates that where there is a will there is a way. Reducing delays have meant commitment across all services at the highest level, and proactive joint working has resulted in better outcomes for older people.
I do not agree with the British Medical Association and some Members that the plans for charging will seriously damage relations between the NHS and local authorities. Where we have the type of joint working that I have described, there should be no need for the charges. Of course, if some turn their faces against it, the BMA and Members may well have a point.
There are other ways of helping to reduce delayed discharge. In a recent report on the subject, the Health Committee rightly observed that telecare and telehealth systems had an increasing role to play in a modern health service, enabling people to stay in their own homes for longer. Tunstall, a locally based company seems to be at the cutting edge. For many years it has been providing telecare systems for a number of local authorities, giving a cover for 1.5 million older people throughout the country. Not only do such systems help older people to remain independent, but safe and secure in their own homes; the company is moving ahead, pioneering technology that can help to prevent hospital admission in the first place by monitoring vulnerable people at home. Following discharge the systems can monitor patients while they are at home, where they want to be. Blood pressure, blood oxygen levels, electrocardiograms, temperature and breathing rates can be monitored from centres, or even by a nurse on duty in the hospital ward. The benefits are obvious, and local authorities must start considering them.
The Bill's overriding intention is to get people out of hospital when they do not need to be there. It may well be, as the Select Committee said, a blunt instrument, but it tackles a problem that needs to be sorted out. Perhaps some need a blunt instrument to concentrate their minds-none more than the professional whingers Members have mentioned today.
542 The victims of this situation are older people, who deserve better than being stuck—trapped—in hospital unnecessarily. The victims are also those in pain who wait for a hospital bed that is blocked because no one thought about after-care before they were admitted or while they were having treatment. The Bill should put an end to local empire protection and professional elitism, and finally kill the syndrome in which everyone thinks someone else is dealing with a problem when in fact no one is doing a thing. I look forward to joining my right hon. and hon. Friends in the Lobby to support the Bill.
§ Madam Deputy Speaker
Order. Before I call the next speaker, I should explain that spokesmen for the second largest Opposition party are exempted from the time limit.
§ 5.9 pm
§ Mr. Nigel Waterson (Eastbourne)
You will doubtless forgive me, Madam Deputy Speaker, for not being drawn into any further comment on your ruling, which I know to be the case.
It is a pleasure, as always, to follow the hon. Member for Doncaster, North (Mr. Hughes). I hope that, at the end of my speech, he will let me know whether he considers me one of the "professional whingers" to whom he referred at some length.
§ Mr. Waterson
Well, there you go.
We all know when there is an intractable problem, because names and definitions keep changing. The phrase "bed blocking" used to be used, but I am told that that is no longer very politically correct. Then "bed blocking" became "delayed discharges," and now it is rather grandly called, "delayed transfers of care." Whatever it is called, it affects about 5,000 patients every day of each week of the year.
In my own constituency, as in many other parts of the country, there used to be great concern about so-called winter pressures and the associated problems. However, one of this Government's achievements—if that is the right word—is the creation of an all-year-round problem, at least in Eastbourne. They have created not only a list to get into my local hospital, but a list to get out, which reached an absolute peak of 149 blocked beds in June this year. So concerned am I about the issue that I have sought regular updates on that figure for a year or more. Although it has tended to fluctuate, until recently it has tended to fluctuate upwards.
What have this Government done? Typically, they have panicked, tabling a measure that will introduce the law of unintended consequences in spades. The proposal does not have a friend in the world, apart from the hon. Member for Doncaster, North, who seems to think that everybody else in the world is wrong and he is right. It would be difficult to point to any group, body or organisation involved in the consultation that considered the proposals a good idea—nor am I sure that the Swedes would accept fatherhood. Apart from the hon. Gentleman, nobody thinks it the right thing to 543 do, and nobody thinks that it will work. We have heard from Labour Back-Bench Members, and we have heard other excellent contributions from Conservative Members. Basically, the Government are introducing a bed tax to get themselves out of this problem.
I turn to the likely effect in my own area of East Sussex, and in Eastbourne in particular. The irony is that the Government are introducing the proposals in a great rush at precisely the moment when places such as Eastbourne are beginning to see the fruits of a working partnership between the health service and social services authorities. In recent times, since Conservatives took control of the county council, there have been some major steps forward in social services. Conservatives took over a waiting list of 800 people who were assessed for social services care, but who under the previous regime were not getting it. That waiting list has gone—all those people have been dealt with.
The county council, in partnership with East Sussex Hospitals NHS trust, has actually over-achieved its bed-blocking targets. As the trust said to me in a letter of only yesterday:The SSD Delayed Transfers PIP target has been overachieved so far to try and provide a buffer zone to assist with winter planning".The letter continues:It is pleasing to see that the total number of Delayed Transfers of Care has reduced from the peak that it reached in June of 149 to the present level of 62.
§ Mr. Waterson
The hon. Gentleman says, "Say thank you," but no thanks are due to this legislation, which will actually set the two organisations at each other's throats instead of enabling them to continue to work in close partnership.
We have already heard how the number of delayed discharges, although still too high, has fallen as a result of partnership working. Mr. David Archibald, the director of social services, wrote to me saying thatthe level of cross-charging could be as high as £2.5m.He points out that this sumwould have to come from existing budgets to older people. This sum equates to 240 residential or nursing placements, or 800 home care packages.As if that were not bad enough, as we all know, social services nationally are grossly underfunded—to the tune of at least £1 billion. That figure, or rather more, is the amount by which local authorities—the great majority of them—overspend their standard spending assessment.
We in East Sussex are told that the 6 per cent. increase over the next three years will be guaranteed, but that leaves aside the massive impact of the Government's proposal—already touched on by my right hon. Friend the Member for North-West Hampshire (Sir George Young)—to change the basis of local authority funding. In East Sussex, that could mean £44 million being taken straight out of the county council's budget in a worst-case scenario. Such a cut equates to the scrapping of nearly 2,500 elderly people's care. All this talk of a 6 per cent. increase is complete hokum, because of the massive effect—it is the financial equivalent of falling off a cliff—of such a cut in funding for authorities in the south-east such as mine.
544 There is also the question of the supply of suitable beds. For eight years, our county council was run—if that is not too ambitious a word—by the Liberal Democrats. Year after year, they paid the lowest rates per week to the private sector. No wonder so many homes have closed. As we have heard, some 66,000 care places nationally have gone since this Government came to power. To make matters worse, they insisted on keeping open wholly inadequate, county council run facilities that cost a great deal more than those in the private sector. My hon. Friend the Member for West Chelmsford (Mr. Burns) will remember responding to such debates when he was a Minister responsible for these issues. We have witnessed a run-down in basic provision. Where are these places to come from?
There is another, fundamental issue—the question of choice—that the Minister needs to deal with in her winding-up speech. Age Concern is extremely worried about this issue. It has drawn attention to standard 2 of the national service framework for older people, which states:NHS and social care services [should] treat older people as individuals and enable them to make choices about their own care.However, as has been pointed out several times by Members on both sides of the House, the reality is that elderly people, who are often confused and very unwell, will become a kind of commodity. They will become counters on a vast Monopoly board, being shoved backwards and forwards between authorities, with the prospect of the imposition of heavy fines if they are in the wrong place at the wrong time. Older people and their families deserve some say in where they are cared for and on what basis. Potentially, this ludicrous legislation carries a vast human cost. We have heard the concerns about emergency readmissions, which have already reached a record high. I suspect that they are bound to increase, as old people are shoved out of the door of their local hospital under the pressure of the Bill.
As Age Concern said in its letter to me, the Bill's penalties and provisionstake no account (and indeed make no mention) of the rights of older people".For that reason, and for the others that I have set out, it is clear that in a place such as East Sussex, the Bill's effects can only be destructive—not just of the choices and needs of the older people who we all profess to be looking after, but of the so far quite successful partnership between social services and the health authorities.
In another letter, the director of social services said that, of the current cases, 59 per cent.resulted from difficulty in making nursing and residential placements due to capacity issues in the market place.It is no earthly good the Government trying to make water run uphill—that is one of the Bill's effects—if the places are simply not available for the people whom we are trying to help.
§ Dr. Howard Stoate (Dartford)
I welcome this debate and the Government's determination to tackle what is, after all, a very difficult problem. On any given day, 5,000 people are awaiting discharge that has been delayed for one reason or another—a problem which is 545 having a significant detrimental effect on acute sector NHS care, and which, like road congestion, has finally reached the point at which something must be done.
Why are we in this situation, and what can be done about it? I have been in the health service for a long time. When I started out as a junior houseman, we worked in big Victorian hospitals with huge numbers of beds. Patients would be admitted through casualty, moved to a medical ward and then, if they were old enough, transferred to a geriatric ward or, if they showed any signs of mental instability, to a psychogeriatric ward, where they remained until the grim reaper decided that it was time to come and remove them, long after everyone else had forgotten where they were.
That unsatisfactory situation carried on for a long time. Now we have changed the regime completely, with modern hospitals providing high-tech treatment, and therefore much shorter stays. That works well, but it means a significant increase in throughput, with people who have received their high-tech care being quickly transferred elsewhere. It also means that many patients are discharged from hospital at an earlier stage of recovery, so it is essential that the facilities are there in the community or in their home for care to continue outside the hospital.
There is also now a much greater determination among patients to remain in their own homes as long as possible and to be transferred home after treatment as quickly as possible. Fortunately, there are now better facilities in the community to allow that to happen. When I was a junior doctor, it was difficult to set up care packages in people's homes.
The situation is strained in Dartford. According to a paper that I received just this morning from the Dartford and Gravesham NHS trust, there are currently 47 patients awaiting transfer, which constitutes about 12 per cent. of the hospital capacity, which is only just over 400. The trust says that there are enough care beds in the locality to deal with the local population, but because of the proximity of London a third of the beds are taken by patients from London whose authorities have much higher funding levels available for such care.
Recent changes in the inspection of care homes mean that older people with mental health problems are becoming more difficult to place. The ability of some patients to fund their care independently—they take up about a third of the available stock—also puts pressures on the beds available to social services. Six of the 14 nursing homes in the area are BUPA homes and charge more than the social service contract price, so top-ups are needed.
Patients with mental health care needs constitute a particular problem. Of the 47 patients awaiting transfer of care, 40 per cent. are waiting for EMI—elderly mentally infirm—places, which also puts great strain on the system.
§ Mr. Gale
As a Kent Member, I agree with much of what the hon. Gentleman is saying. He rightly highlighted the fact that inner-London boroughs are buying beds in Kent and blocking beds that are needed 546 by Kent social services to move people out of Kent hospitals. Will he ask the Minister to tell us how the Bill will even begin to address that problem?
§ Dr. Stoate
I thank the hon. Gentleman, but that is not quite the problem that I was talking about. I will come to that shortly when I refer to a constituency case.
The paper I received this morning points out that there are alternatives to nursing home care, and I am pleased to see that the acute trust is using much more sheltered accommodation with joint social services and health care team support. A community dementia team has been set up to allow people to receive care in their own homes, and that is certainly easing some of the pressure. The trust is working very hard indeed to make such alternatives available.
I want to talk about a constituent who was seen this morning by two of my constituency workers. He is quite a difficult case and his story highlights some of the problems. He has a rapidly evolving dementia and severe Parkinson's. I have a letter from his GP saying that he needs an EMI bed, but social services has said that it will not pay for EMI care but will pay only for nursing care and has put pressure on the GP to redesignate him accordingly. The GP has written to me in outrage, which is why I undertook to raise the case in the House.
Social services is prepared to pay £450 a week for my constituent's care, but not the £560 required for an EMI home—there is a place available—so he has now been languishing for many months in a bed in a community care NHS unit, quite inappropriately, as he does not want to be there, his family do not want him there and the NHS clearly does not want him there. For want of a top-up of £110 a week, he is occupying a bed in an NHS facility where his condition cannot be properly treated. As his condition deteriorates and his mental health care needs become ever greater, it is increasingly obvious to those caring for him that there is a problem.
The Bill will at least make discussions of such cases more realistic. They will take place more frequently, and we can hope for more appropriate care packages for different types of patients. However, if we introduce the reimbursement scheme by April 2003, it could cause problems and create pressure. What does the Minister think about that? Despite recent funding increases—£300 million earmarked for partnership in care last year—social services departments are still having problems with the effects of historical underfunding, so we need a period of pump priming to ensure that the capacity is in place before they face penalties. That will give them time to identify the services that they need to provide. For the proposals to work properly, we must have sufficient nursing home care beds, community facilities and home care packages in place.
We should not forget that early discharge is also a problem. If we ensure that hospitals are not put under pressure to send patients home or on to other facilities before they are fully ready, we will reduce the risk of the merry-go-round of patients being readmitted. We must ensure that step-down facilities are in place. I am pleased that a facility will be completed in Dartford and Gravesham by 2004 providing 60 step-down intermediate community beds, which will take enormous pressure off the social services and health departments. I would like to see such projects rolled out across the country.
547 We need a clear incentive for health care and social care services to work together to unblock delayed discharges, which are causing great misery for many of our constituents. At least the Government's proposals will get things moving, but they must recognise that procedures must be in place to allow the situation to improve before draconian penalties are imposed on already overstretched services.
The proposals will contribute greatly to improvements in care, provided that they are implemented in a way that allows social services to build up capacity in a measured way to unblock the problem.
§ Mrs. Patsy Calton (Cheadle)
I do not believe that there is anyone in the House who does not think that elderly people should get the best possible care and a streamlined service so that they are not kept in inappropriate conditions. The issue is whether the Bill will help to achieve that. I am surprised that it has been introduced at all. On 2 July, the Minister and I served on a Standing Committee distributing grants to social services departments across the country, in order to allow them to implement measures to reduce bed blocking or delayed discharge. On the face of it, three-star local authorities were being given rather more leeway and were allowed to spend the money as they liked. Authorities with one, two or no stars had to provide detailed proposals and to spend the money on reducing delayed discharge caused by bed blocking.
As I said at the time, the problem is that one-star local authorities sometimes have very good delayed discharged figures. In Stockport, where I used to be chair of social services, the health authority and social services did excellent work to prevent bed blocking. A parliamentary answer to question 43988 made it clear that Stockport's delayed discharge figure was already good.
Stockport is a one-star authority with a good record in that area. I noted that the Kensington, Chelsea and Westminster health authority—which covers the three-star boroughs of Kensington and Chelsea, and Westminster—had a 9.8 per cent. delayed discharge rate in the same period. That is five and a half times the Stockport rate. I asked at the time how authorities with other problems could spend on anything that they liked apart from delayed discharge work, whereas the place that had prioritised the issue that the Government claim to want to support was made to go through the hoops.
I suspected that there were other anomalies to be found, but the Minister at the time did not answer the question. Less than five months ago, it was all right to allow social services departments with three stars to spend the money as they wished, even though their delayed discharge figures were comparatively high, but now the Secretary of State has apparently changed his mind. How come? Have not the extra grant payments worked? Does the Minister know? Has there been any monitoring? Why has the Secretary of State changed his mind since July?
The Secretary of State said that the needs of the older person always came first. They did not appear to do so in July. The Bill has aroused almost universal condemnation. It uses coercion just when local authorities and health authorities are beginning to adopt best practice. It is likely to worsen and not improve the situation for patients.
548 Various hon. Members have mentioned Age Concern's worries. The right hon. Member for North-West Hampshire (Sir George Young) quoted that organisation's view that the proposals were "ill conceived and impractical". Age Concern says that the Bill makes no reference to older people's rights, and it is especially worried about matters to do with consent and advocacy. It has stated that the proposalsdo not treat older people as active participants in the provision of caring services, because they take no account (and indeed make no mention) of the rights of older people—for example, the Bill does not mention the need for consent of the patient at all stages of the process of discharge, or of the appeal rights of patients in relation to disputes between the NHS and the local authority.The Bill is likely to damage existing beneficial arrangements developing between health departments and social care departments. Age Concern was also worried about premature discharge and noted:Concentrating on delayed discharge and imposing penalties for this one aspect will not nurture the joint working (between health and social care providers) that is happening at the moment, and could lead to premature discharge and inappropriate placement decisions.Age Concern was also worried that the proposals would put even greater pressure on families than exists already.
The Royal College of Nursing's observations have been mentioned by various hon. Members. The RCN made it clear that it was keen to support efforts to improve discharge planning, but thata system that penalises one part of the care sector could threaten or diminish partnership working.The RCN said that fines would lead to the further stigmatisation of older people as "problems", and added that even the timing of consultant ward rounds could lead to delayed discharge. It also said—and I believe that this is very important—that nurses, who are very highly trained these days, should be given the authority in appropriate circumstances to arrange and allow discharge.
Mention has also been made of Carers UK, which is concerned that core discharge procedures are likely to get worse. It stated thatfrom 1999 to 2001, readmissions of the patient within two months of being discharged nearly doubled from 19 per cent. to 43 per cent.Therefore, when the emphasis is put on delayed and premature discharge, readmissions go up. It added thatthe proportion of carers who felt early discharge was at fault rose correspondingly from 23 per cent. in 1999 to 45 per cent.Carers UK also said that77 per cent. of carers said that they were not given a choice about taking on caring responsibilities.Carers are not being consulted. Carers UK said thatthe proportion of carers being consulted fell from 1998 to 2001 so that nearly four out of 10 carers were not consulted.That is during this Government's time in office. Carers UK also said thatthe proportion of carers who said their views and ideas were not taken into account rose from 36 per cent. in 1998 to 45 per cent. in 2001—nearly half of all carers providing substantial care … Only half of the carers were told about the sorts of care that would be needed upon discharge … 43 per cent. of carers said they were not given sufficient help on return home.549 The truth is that there is insufficient capacity in the community. That problem is felt not just in my constituency but right across the country. We can do all that we can to return people home, but if the care assistants and workers—and especially the trained ones—do not exist to meet their needs, the circumstances of those people will not improve. The Bill, with its half-baked and counter-productive measures, will not solve that problem.
§ Mrs. Calton
Wait for it, I have a minute left. The NHS Confederation has also made it clear that positive incentives have an important role to play. It believes that fining could undermine existing local partnerships. It is also worried about administrative costs. Where is the money going to go? How will it be redistributed?
As many hon. Members have said, the start date of April 2003 is too early. The Government are going to wait until 2003 to find out the results achieved by the money that has been spent this year. They should wait at least until then, and then give notice of how they intend to act.
§ Ms Joan Walley (Stoke-on-Trent, North)
A great deal has been said already and I shall not go over it, save to note that the concern in my constituency about how we deal with community care and ensure that the resources are there when they are needed has not changed in the 15 years for which I have been a Member of this House.
One thing that has changed is that the underfunding that may exist now is nowhere near as great as in the years of the previous Conservative Government. However, we must make sure that the legislative time available to the House—and the additional funding made available by my right hon. Friend the Chancellor of the Exchequer—is used to the best effect. We must make sure that the provision is there when constituents need it.
In that respect, I question whether so much time and energy should be devoted to the Bill just now. I accept that sometimes one needs to wield a bit of a stick to make people do what is needed, but the carrot-and-stick approach is also needed.
Is my hon. Friend the Minister satisfied that the extra money that is provided for care in the community is enough? I would be a lot happier debating the Bill if we knew what the local government settlement would he and what extra money would be given to Staffordshire and Stoke-on-Trent social services. I accept that we have had an additional 6 per cent., which we would never have had under the Conservative Government, but we need to ensure that we are getting the extra money that will allow our social services to do what we expect them to do.
§ Ms Walley
I am sorry, I do not have time.
550 On bed blocking, as of this week, there are 48 people on delayed discharge in the North Staffordshire royal infirmary. If those people were not in those beds, that acute hospital would have beds for people who are desperate to get the NHS service that they need. So I have no doubt that the Government are right in making sure that we do not spend money on highly specialised services in our acute hospitals for people who no longer need that expert specialist medical treatment. We must put all our energies into finding a solution to get those people back from hospital into their home and the community, back into intermediate care or even into the long-stay beds provided by the Combined Healthcare NHS Trust, which, itself, has patients who cannot be discharged because of the lack of appropriate community facilities.
A constituent of mine has written to me consistently over 15 years imploring me to make sure that the Government do what is needed regarding dementia services. I have spent a great deal of time making the case to Staffordshire county council that it should give money or land to Claybourne, a specialist place for people with dementia, which is run admirably by Methodist Homes for the Aged. It is of great concern to me that hardly any of my constituents can be placed in Claybourne now that the land has been acquired and this wonderful facility has been built, open and even extended. Not as many as my constituents who should go there can go because the local social services cannot afford the cost of moving them. That means that although people in other parts of the country where social services have additional money can go to Claybourne, my constituents cannot. That is a source of genuine concern.
Let us by all means have a Bill that will penalise local authorities that do not comply with the standard required, but let us make sure that there are minimum standards of service. Wheelchairs should be provided to the community where they are needed. Let us make sure that we have occupational therapists. Let us make sure that people are not being kept in hospital for want £20 for a handrail. I accept that we have to ensure that social services should be fulfilling those functions but in reality that is still not happening. I would rather look at ways of postponing the Bill until such time as we can do a proper audit and be certain that what should be happening is indeed happening.
We hear a lot about the need for modernisation, and I embrace that. The Edwards report on north Staffordshire has led to the award of extra money to oversee extra resources for care in the community and to deal with the need to transfer that funding from its traditional target of long-stay beds to care in the community. However, the implementation of the Edwards report is still not subject to full accountability. Until we have that, I feel that we cannot simply depend on a piece of legislation that will penalise and fine. If my hon. Friend can give me an assurance that the Bill will not only impose such disciplines, but ensure that the local social services are properly funded, able to respond to changes and accountable, perhaps we can look forward to making sure that our elderly people are not left at the mercy of a system in which they are sent from pillar to post and do not get the services that they need.
§ Dr. Andrew Murrison (Westbury)
The Labour Front Bench is struggling somewhat for support, even from its own Back Benchers. Far be it from me to offer any comfort, but may I point out that in February this year I introduced a ten-minute Bill? I wanted to call it the bed block Bill because I thought it sounded rather catchy. Unfortunately, the private Bills office had other ideas and it was downgraded to the Waiting Time for Discharge from Hospital Bill, which did not convey quite the meaning that I wanted. As is the way with ten-minute Bills, it ran into the sand, but in April, Ministers and Mr. Wanless appeared to be thinking along somewhat similar lines and subsequently produced the Bill before us.
I would not like to be considered a professional whinger, in the words of the hon. Member for Doncaster, North (Mr. Hughes) and although I would like to be fairly positive about some of the ideas that the Government are putting forward, I will explain why I think that the devil is in the detail, why the measure is doomed to fail and why it will not be attracting my support.
I note that the Government have consulted very widely on the Bill, which is good, and have had 270 responses. The Department of Health tells us that there was a wide spectrum of responses but did not say that there was much in the way of support for the measure from those 270 respondees. It would be interesting to hear in the winding-up speech who, among those 270, were positive about the measure. The soundings that I have taken in my constituency have been uniformly hostile.
There has been some recent improvement in the bed-blocking figures, and we need to give due credit to all who have worked hard to achieve that, but problems remain and winter is upon us. A London consultant recently told me that patients in his ward regularly have to spend the night on a mattress on the floor. That is a damning indictment of our health service in the 21st century. Those of us with first-hand experience as patients know full well that being on a hospital ward is an unsettling experience, whether or not we have a bed. For elderly or vulnerable people, that would be a gross understatement, and the experience would not be therapeutic.
We also know that the longer people are in hospital, the greater their chance of succumbing to hospital-acquired illness. Long stays mean unnecessary medicalisation of people's problems and the demotivation of valuable NHS staff. It is a classic lose-lose situation.
Despite the small measures to resolve the imbalance between the social services and the NHS announced today, I believe that there is a deficit between the two sectors. That is historic and I believe that we should be supporting what might be described as the less ritzy part of care. Traditionally we support those medical specialties that produce obliging targets and outputs. They focus strongly on cardiology and surgery in general, when we should perhaps be looking more closely at areas of care that could arguably produce more in terms of health care and outcome for people for every pound spent. To that extent, I welcome the Secretary of State's announcement that he is 552 transferring £100 million from the NHS to social services. It will be interesting to see whether that funding is sustained when the Bill comes into effect.
Much of the devil in the detail to which I referred is contained in the explanatory notes accompanying the Bill. I was left rather puzzled as to what qualified as a qualifying hospital under the definitions in the Bill. I am not entirely sure whether Ministers know either. For example, I have previously asked Ministers what they mean by "intermediate care" because they are often less precise than they should be. I am certainly confused about what it means in the Bill. Will an elderly person in a community hospital who is under the care of a consultant be a qualifying patient in a qualifying hospital for the purposes of the legislation?
Although there is little mention of primary care trusts, community hospitals and GPs in the Bill, the explanatory notes on clause 4 come close to that in the reference to care of an "interim nature" pending fuller social services assessment. That worries me as it could mean that a patient is discharged before a fully comprehensive package is in place. A fully comprehensive package involves primary care and I am amazed that a community care Bill can so obviously neglect primary care trusts.
Cross-charging rates are to be set by regulation. The consultation document suggested £100 a day except in London and the south-east, where the rate will be £120. That is a substantial differential and it implies that social care in the south-west is substantially less expensive than it is in the south-east. As I represent a Wiltshire constituency where we constantly make comparisons with the largesse that is heaped across the border on Hampshire, I shall be interested in any evidence that the Minister can provide to back up the assertion that social care in Wiltshire is less expensive than it is in Hampshire.
The measure's most obvious perverse incentive hardly needs restating. As a GP, I should he far more inclined to seek admission to an acute unit if I thought that it was the best, or only, way to obtain the social care that my patient needed. That would both encourage bed blocking and make it difficult for people who were not admitted to hospital—they would be for ever at the bottom of the pile.
A more subtle perversity occurs to me, as it may have done to other hon. Members: the relative disadvantage that would be introduced for emergency surgical and medical patients compared with those whose admission is anticipated in advance. Those potentially disadvantaged patients tend to be older and frailer than those considered well enough for elective surgery. Those who are less well would thus be disadvantaged by the Bill, because those who are well enough for elective surgery would, by definition, be relatively fit. I should be grateful if the Minister could consider that point.
Clause 2 restates Ministers' obsession with cold surgery. In his opening remarks, the Secretary of State said that Opposition Members had an obsession with the acute sector, which seems to be the pot calling the kettle black. There is no doubt that Ministers are obsessed with cold surgery—patients undergoing elective procedures. Such patients can expect their package to be arranged well in advance of those admitted as emergencies, yet it is arguable that prompt 553 reintroduction into the community may be of greater benefit to those who have recovered or are recovering from an acute illness, not least if they are older. I am concerned about the paradox that the least well will be disadvantaged.
Readmission rates are rising, and hasty discharge may be one of the causes. However, it is a fallacy to suppose that that is the province of one sector or another. It is not only the shortcomings of hospitals that cause increases in readmission rates. The problems lie also in primary care and social care, so fining hospitals is plain daft. Furthermore, health care staff will resent the implication that their actions should be dictated by the possibility that their hospital might be fined.
The regulatory impact assessment glosses over the burden that the measure is likely to place on carers—either by design or default. We must recognise that social service providers lean heavily on informal carers. Without them, our system would crumble.
There are several cracks in the RIA. The major costs in our health care system are up front, so if capacity is increased, as the Bill is presumably designed to do, which is welcome, there will be a great increase in costs as more surgical operations are carried out. There is no indication that Ministers have fully grasped that point. I shall be interested in their comments on the greater upfront costs that will undoubtedly result from the Bill.
§ Mr. Paul Truswell (Pudsey)
Before I join my hon. Friend the Member for Wakefield (Mr. Hinchliffe) in the Labour Back-Bench naughty corner by incurring the wrath of my equally hon. Friend the Member for Doncaster, North (Mr. Hughes), I want to say two things. First, no one doubts the commitment of the Government Front-Bench team to addressing this often difficult and deep-seated problem. Secondly, the Government's record on investment in the NHS and social services knocks that of their predecessor into a cocked hat.
The current situation is not, as Opposition Members try to suggest, the fault of the Labour Government. The roots of the problem go back not a few years but at least a decade. Opposition Members show their customary collective amnesia. Their hand-wringing makes me think that they must belong to the Uriah Heep appreciation society.
I shall remind the House of the background. In the late 1980s and in the 1990s, the Conservative Government's mantra was clear: public provision bad, private provision good. We all remember how funding was skewed so that people going into independent sector accommodation commanded more resources from the then Department of Health and Social Security than those going into local authority homes. We all remember the explosion in the number of private sector residential and nursing homes. We all remember the massive loss of care beds in the NHS and the closure of local authority homes, or their transfer to trusts, voluntary sector organisations or similar creative arrangements.
Of course that could not be sustained, so when the resources originally vested in the DHSS were transferred to cash-strapped local authorities, which 554 were then systematically starved of cash—unless they happened to be Westminster or Wandsworth—the die was cast. The Labour Government inherited a major problem and it has developed into a crisis.
As a solution, however, the Bill is at best premature and at worst could destabilise the care system for older people, as some Members have already pointed out. There are several key points in the case against the Bill and I base them on my observations over many years as a councillor, a chair of social services, an MP and someone whose parents will undoubtedly require care in the near future.
The issue of choice has been referred to over and over again. Older people, or their friends, relatives or advocates, want a place in a particular home and they are reluctant to leave hospital until it is secure.
There are funding problems. Leeds spends over £18 million more than its standard spending assessment on social services, a situation that is unlikely to change as a result of the local government finance review. The authority has not been able to pay nursing homes as much as they say they need to stay in business. About 200 beds have been lost during the past couple of years. However, following an independent report commissioned from PricewaterhouseCoopers, Leeds has increased payments by about 10 per cent. or more, which will, hopefully, check that loss of beds. Only time will tell. The 6 per cent. growth in real terms plus any further funding from the Government will not achieve an immediate improvement in that long-term funding problem. It cannot instantly ensure that a build-up to appropriate levels of community care services is achieved.
Other Members have referred to key issues such as the recruitment of specialist staff and said that blame is shared equally among various agencies. I am not sure that blame is the right word, although we seem to have used it a lot in the debate. The Bill is premature and unhelpful.
Capacity has been affected by the fact that some homes have closed because owners—often with an eye to shareholders—have chosen to realise a capital asset for housing or other uses.
My fear is that, as many hon. Members have rightly said, the Bill will lead older people to be pressured, albeit subtly, to leave hospital prematurely. They may have to undergo unnecessary extra moves between hospital and their eventual place of residence. For some people, those additional moves will require the commissioning of step-down facilities in the independent sector. In Leeds, as in so many other places, there is already little surplus capacity in nursing homes, and further use of spare capacity for step-down or interim placements may exacerbate the situation.
Leeds is trying to resolve the issue by creating the spare capacity in hospital wards that would then be transferred to a primary care trust. That capacity would not be designated as acute and, I hope, not counted against the measurements that would fall foul of the Bill. In the longer run, that resource could be decommissioned as better alternative community-based facilities were created, but that needs time, and the Bill is premature and unhelpful in that respect as well.
555 The Association of Directors of Social Services has understandably expressed concern that some independent sector providers may seek to take advantage of the pressure on social services departments imposed by the Bill to increase charges.
The penalty payments will, I understand, go to the hospital trust. As far as I am aware, there is no requirement to ring-fence that money for older people's services. The resources available for the care of older people will be absorbed into the general acute sector, thereby reversing a trend that everyone is trying to achieve. At the very least, if the Bill comes into effect, the Minister should consider ensuring that any penalties go to the PCTs, so that they can be recycled into the care of older people.
As other hon. Members have said, hospitals may accelerate discharge procedures to put pressure on social services or reap the benefits of the Bill. Many hospital trusts—Leeds is no exception—run considerable deficits, and there is a danger that they will take advantage of any possible income flows and view them as very welcome news. Any use of interim step-down facilities will require proper medical cover and GPs may be reluctant to take on such work. I am not aware that any guidance or funding has been offered to PCTs to cover that issue.
In Leeds, there is a very good working partnership—other hon. Members have referred to similar circumstances—and a will to ensure that patients are not detained unnecessarily in hospital. Delayed discharges run at about 2 to 4 per cent. per annum, mostly because of considerations involving choice, and I understand that that percentage compares favourably with national figures. That percentage represents 50 to 75 older people.
There is a huge problem, and it needs big answers. The Government are already beginning to provide those answers through the extra funding that they have made available, but I hope that the Minister will not reply by saying that we are at our best when we are at our boldest, because those words were no doubt uttered by George Armstrong Custer immediately before the battle of the Little Bighorn. I cannot help but fear that the Bill—well intentioned though it is—represents perhaps the wrong battle in the wrong place at the wrong time.
§ 6.3 pm
§ Dr. Richard Taylor (Wyre Forest)
I start from the same premise as most hon. Members who have spoken this afternoon: the Government are trying to tackle the problem of delayed discharges, which is exactly the right problem to tackle when we consider not only the financial implications but the quality of life of those elderly people towards the end of their days who are losing a few of their precious days in hospital. However, I am delighted to follow the right hon. Member for North-West Hampshire (Sir George Young) and the hon. Member for Wakefield (Mr. Hinchliffe), who did not mince their words. It gives me a great deal of pleasure also not to mince my words: this is the wrong Bill doing the wrong thing at the wrong time, and one cannot get away from that.
The regulatory impact assessment, which all hon. Members have probably seen, states that there are really only two options: do nothing, or introduce a 556 reimbursement scheme. The most obvious solution of all—looking at the whole system—has been missed, but the Health Committee has done the work on that. I should like to make four points. I think that they all come from the Health Committee report; I do not think that I have included any of my own.
The first and most important point is to avoid inappropriate admissions. The latest figures show that about one in seven patients do not need to be admitted to hospital, and there are already ways to avoid that. Many places have multi-agency response teams—MARS teams—that GPs can call out to patients' homes to work out alternative methods of coping with them other than sending them to hospital.
One of my daughters is a nurse-consultant in intermediate care. Her job is to go into the casualty department and medical assessment unit of a very large hospital to sort out patients' care at home, if possible.
I must, of course, refer to hospital reconfigurations. I am delighted to hear that a Government paper is coming out, recognising that reconfigurations that take assessment centres away from the local population have to be reconsidered.
The second crucial point from the Health Committee report is that a named person should be responsible for co-ordination of all stages of the patient's journey right from the moment of admission—before then in the case of elective admissions—and up to and beyond discharge. My PCT has a discharge co-ordinator who goes round all the hospitals that the trust uses. In addition to such co-ordinators, named people who are responsible for each patient would make a huge difference.
The third point, which has been made already, is that it is absolutely crucial to consult patients and carers. They must be involved, not just as an afterthought, but right at the beginning. If discharge planning starts early, a logical conclusion can be reached. Is step-down care needed? If so, is it available? Can the patient get home? Are adaptations and other aids needed? Such planning has to start at the beginning.
In their response to the Health Committee report, the Government agreed with most of those points, but then seemed to put them all on the back burner. They said several times that they would introduce the system of reimbursement, but, as I have said, that focuses entirely on the wrong end of the process.
I congratulate the Government on revising the hospital discharge workbook, and I hope that the new one will come very soon and that it will produce a radical overhaul of the whole process of hospital discharge. I welcome the change agent team and the Modernisation Agency. A lot of good things are going on, but this approach is completely wrong.
In his introductory remarks, the Secretary of State said that partnerships were the key, and several speakers have said exactly the same. I cannot see how the Government can argue that the proposal improves partnerships. It sets one side of the equation against the other. One can blame the other, and thus avoid paying. The Secretary of State says that £100 million can go from the NHS back to social services to make up for the fine, which proves to me that he has suddenly realised that the proposal is mad.
557 I will conclude my remarks, as I know that many other Members wish to speak. The Bill is wrong and should he thrown out. Like the right hon. Member for North-West Hampshire (Sir George Young), I have been counting speeches, and I think that the score is about 12–3. I wish that the Bill, which should be in the interest of patients throughout the country but not in the interest of political parties, could have been subjected to a free vote or decided on the number of speeches rather than a whipped vote, which, I fear, will automatically see it through.
§ Andy Burnham (Leigh)
It is a pleasure to follow the hon. Member for Wyre Forest (Dr. Taylor). I do not know whether the right hon. Member for North-West Hampshire (Sir George Young) is still keeping score, but I can tell both Members that I am about to pull a goal back. My speech will not be without observations of my own, having worked on the Health Committee report and taken a great interest in it.
The speech of the hon. Member for Woodspring (Dr. Fox) was high on conjecture and hypothetical situations but, other than what seems to be the Conservatives' policy of pumping money into care homes, contained no solutions to the issue of delayed discharges or bridging the divide between health and social services. If keeping care home places open is their overriding priority, they are sadly mistaken. That is no policy.
Conservative Front Benchers are not alone in not having answers on this subject. I worked briefly in the NHS, and I lost track of the number of seminars and workshops that I attended on bridging the divide between health and social services. Many good ideas and examples of good practice were discussed, but good practice only produces incremental change. There are huge problems in this area, however, which the system has failed to put right. My hon. Friend the Member for Doncaster, North (Mr. Hughes) referred to the need to concentrate minds, which is absolutely right. The system is not currently working for patients and families. I do not have all the answers, but the system needs to be made to work better and more quickly for those people than it does at present.
Opposition Members seem to be defending the current system. They seem to be saying that everything is fine as it is, but it is not good enough. We need to address that. Attacking these proposals should not be used as an excuse for saying that nothing should be done. The right hon. Member for North-West Hampshire referred to stress and tense situations in hospital, which are hallmarks of the current system. That is doing no good to patients or families.
In all the discussion about structures and processes, it is easy to lose sight of some of the purposes of the Bill. There are probably two clear objectives. One is to give elderly people in particular more appropriate treatment when they need it, to get them through the system and to get them back home, which is the important point. The second is to free up hospital beds so that more patients can be treated across the NHS. That problem has 558 bedevilled the NHS, and we must get better at bearing down on blocked bed days, as they are called. Five thousand beds are currently blocked at any one time.
§ Laura Moffatt (Crawley)
Is my hon. Friend aware that, despite all the good practice and all the hard work of many social services and acute trusts, when my acute trust began this work a year ago we had 70 delayed transfers of care and that this week we have 70 delayed transfers of care?
§ Andy Burnham
My hon. Friend is absolutely right. When minds are focused on this problem, and people start to bear down on the bureaucratic process that exists, it is amazing how the system can be made to work better. We should all bear that in mind.
As I said, the report found that there are 5,000 blocked bed days at any one time. It is important for hon. Members to consider the evidence that the Department gave as to why those beds are currently blocked: 22.2 per cent. are awaiting an assessment of care needs; 21.9 per cent. are awaiting a funding package to be agreed; 20.4 per cent. are awaiting a care home placement; 11.5 per cent. are awaiting further NHS care; and 6.7 per cent. are awaiting a domiciliary package of adaptations and equipment. Nobody can tell me, based on those figures, that there are not areas in which we can start to reduce delays in the system. Why are 22.2 per cent. waiting for an assessment of care needs? There must be things that can be done to bear down on that.
The report also mentioned our visit to the United States, to which, I think, my hon. Member for Wakefield (Mr. Hinchliffe) referred. On the United States system, the report clearly states:We were left in no doubt that this systemof financial incentiveswas very effective in reducing hospital stays.We visited a health maintenance organisation called Tufts Health Plan, which told us something extraordinary. The day its patients go into hospital for a planned admission, the builders move into their homes to adapt them so that they can leave hospital as soon as their care is complete. None of our constituents would recognise that experience. It is an example of good planning. There is no reason why it could not be done here, but our system does not place pressure on people to make them think that they have to do that good planning and deliver better services.
There are two reasons why the United States system works. The first is that the financial incentives are part of the process. They move people through the system and out of hospital quickly. The Bill tries to replicate part of that in our system. The second reason is that there is one budget and therefore only one person deciding how to get someone home as quickly as possible. On that matter, I bow to the experience of my hon. Friend the Member for Wakefield. In some ways, I am under his spell on the Committee. The Government should give careful consideration to a single budget as a way of getting people through the system more quickly. That is the ideal. It cuts away the possibility of squabbles about who is responsible or where the fault lies. We are more likely to get people through the system quickly with one budget and one objective than with a system of financial incentives or penalties.
559 It will be a shame if the Bill halts the move towards single budgets in health and social services departments. I do not want that to happen.
§ Mr. Dawson
I do not disagree entirely with my hon. Friend, but structural change is not the whole answer. Wherever there is a structure, there is a boundary, and other functions would be left out of a joint health and social care body. Surely it is our systems and values that are important. We must aim for the ultimate principle, which is to wrap services around the people.
§ Andy Burnham
My hon. Friend is right. People are the most important consideration. They do not mind whether the health department or the social services department provides their care. They do not care about the divides, which we have to break down. I favour a move to single pooled budgets. Having said that, the proposed system is the fall-back option. If people do not go down the collaborative route, another system has to be in place that will work for patients. It might be one or the other, but I hope that the Government will not rule out the good examples of joint working.
I echo what the hon. Member for Sutton and Cheam (Mr. Burstow) said about the readiness of the system to cope with the proposed changes. My local authority is a member of the special interest group of municipal authorities. We vehemently argue that we have been underfunded for years, especially in social services. One symptom of that is a severe lack of occupational therapists, which other hon. Members have mentioned. The health service and the local authority in Wigan employs occupational therapists, but the health service often takes them from the local authority, which struggles to keep them. I gather that there is a national shortage of occupational therapists and that there are 5,000 training places every year. The Government have to consider that problem if we are to achieve the ideal of getting people back home as quickly as possible.
The system is not able to adapt homes quickly enough. There is a 10 to 13 month wait in Wigan for an assessment for a stair lift. There are many former miners and people who suffer from industrial disease in my constituency. That is a hell of a wait for a home to be made adequate. That person could easily pitch up at hospital again before the changes are made.
Finally, will the Government consider the range of services and appropriate accommodation available in the community? Like my hon. Friend the Member for Wakefield, I believe that the choices available to people are not good enough, and my great hope is that the Bill will diminish the reliance on institutional care, in both residential and nursing settings. For people who are stuck in hospital for too long and who become institutionalised, hospital care becomes a pathway to residential care when, if they had been expedited through the system, that option may not have been the most suitable.
I should like to echo a point made by my hon. Friend the Member for Doncaster, North: why cannot we use social services resources to put better equipment in people's homes? When the Select Committee visited West Yorkshire, we saw people doing self-testing at home and sending their results to remote centres to identify any emerging health problems that may require 560 hospital admission. We should consider how we can concentrate resources on the point of entry to the system, rather than always thinking about how to cope with people when they need care. We should concentrate on getting to the point at which people do not need care, or, if they do, on ensuring that it is much later in life. If this system can keep people out of hospital in the first place, it can only be welcomed.
§ Mr. David Amess (Southend, West)
I wholeheartedly agree with the speeches made by my right hon. Friend the Member for North-West Hampshire (Sir G. Young), my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) and, yes, the hon. Member for Wakefield (Mr. Hinchliffe).
Thank goodness I do not have to stand up and make fawning speeches about the Government, so I can wholeheartedly say that this is a lousy Bill from an absolutely rotten Government. They should be ashamed that they are introducing it in the House. Some weeks ago, the Secretary of State gave evidence to the Health Committee, and I challenged him about consultants' contracts. I asked him whether he would take on the consultants and said that, if so, he must be mad. After a lot of waffle, which we also heard in his speech this afternoon, he said that he would not, and I judged him to be sane. I am now reconsidering.
These will be dark days for the Labour party and the Government. The economy is on the slide, and the Government will need all the friends that they can get. Having listened carefully to all the speeches today, I think that they are rapidly running out of friends among Back Benchers. The Bill is the ultimate case of buck passing, and, as we have heard, no one is in favour of it. There is a long list of people who have condemned the Bill.
What Member would say that it is terrific to have people stuck in hospital beds when they should be returned to their own home or admitted to a residential home? Of course Members of Parliament think that it is shocking. Who wants to stay in a hospital and catch MRSA? Every Member wants to do something about bed blocking, but the Government do not seem to understand that this ridiculous Bill, which they are trying to persuade the House to accept, will not solve the problem. In fact, it will make it much worse.
In part 2, the Secretary of State has had the cheek to take powers to allow him to remove, in circumstances set out in regulations, the power of local authorities to charge for certain community care services. That will do huge damage to local authority budgets, and authorities throughout the country are already struggling to meet the demands on them.
The Government should have listened to the Health Committee. We all know that, sadly, the House is not quite the force that it used to be, but Select Committees certainly provide a good means of challenging the Executive. Members of the Health Committee worked hard to prepare the report. We made 37 recommendations, and went to America and Canada. If the Government had listened to our recommendations, they would not be in a mess. For instance, we said:There are real risks that perverse incentives will be created that will undermine partnerships that have taken time to develop and foster an unproductive culture of buck-passing and mutual blame 561 between health and social care. We agree that appropriate incentives have a role to play, but we would also urge the development of positive incentives that reward good practice, rather than any precipitate and over-zealous emphasis on penalties.We went on:We are concerned that the focus on tackling delayed discharges, entirely laudable in itself, could lead to an intensification of pressures to discharge patients too quickly, with inadequate preparation, and in situations that could intensify the demands on their carers. This has the potential to trigger a rise in readmission rates. Premature discharge leading to readmission is clearly stressful and in many cases harmful for the patient, and is also wasteful of resources. High levels of unplanned admission are likely to be a marker for poor practice.As another member of the Select Committee, the hon. Member for Wyre Forest (Dr. Taylor), said, the Government should have looked at our key eighth recommendation that a dedicated person look after the individual before they were admitted to hospital and while they were there. Afterwards, that person would make sure that they were given proper care and support.
In my constituency, there is a huge number of elderly people. If you want to live longer, come to Southend, West. In February, a local resident will celebrate her 109th birthday. She lives in a bungalow on her own, and recently I had the privilege of having a cup of tea with her. She is truly remarkable, but many other people are admitted to hospital with no relatives or loved ones to support them. It is thus not just a question of dereliction of duty by social services.
Will the Government look at the Warm Homes and Energy Conservation Act 2000 that I had the privilege of steering through the House? That measure would deal with bed blocking, as it tackles the important issue of fuel poverty. All hon. Members know that this winter a huge number of elderly people will be readmitted to hospital. Cold, damp homes are associated with premature mortality, physical and mental illness and impaired quality of life. They aggravate a wide range of medical conditions, increase suffering and make it harder to care for vulnerable people at home, thus adding to the burdens on the NHS. Those burdens are seen, as I have said, in growing waiting lists for admissions and bed blocking. No doubt, there will be another crisis this winter. National Energy Action believes that the Government should look carefully at recommendations that winter taskforces in primary care trusts should produce a local plan to deal with that problem, thus increasing awareness of the links between housing and health, identifying households at risk, and making referrals to fuel poverty programmes and good-quality energy advice.
Next week, members of the Health Committee will visit Sweden and the Netherlands. Although we are looking at sexual health, I have decided that I shall make it my business to find out how the Swedish model is working. According to one director of social services, the introduction of a programme of penalties in Sweden resulted in a two-year build-up, after which time all the accommodation was made available. It is crazy and disastrous that residential and nursing homes throughout the country are closing because of the onerous duties placed upon them by the Care Standards Act 2000.
This is a rotten Bill and I plead with the Government at the eleventh hour to drop it.
§ Mr. Simon Burns (West Chelmsford)
I am not sure whether the Minister needs reminding of the saying that success has many fathers, but failure is an orphan. If one considers the majority of responses to the Bill, it is clear that it is an orphan. The overwhelming view of the Bill has been unfavourable, to say the least. That Labour stalwart, Sir Jeremy Beecham, the chairman of the Local Government Association, has urged Ministers to abandon the Bill. The NHS Confederation and the Association of Directors of Social Services have both condemned the proposals in the Bill. Age Concern has described the Bill as "ill-conceived and impractical".
The British Medical Association has voiced its opposition. Help the Aged is opposed to the imposition of fines, and says that the Government should concentrate their efforts on securing the long-term future of social services. Kent county council, acting as a spokesperson for a group of county councils that will be adversely affected, called the proposals "gravely flawed".
During the debate, speaker after speaker has condemned the proposals, particularly in part 1. I congratulate my right hon. Friend the Member for North-West Hampshire (Sir George Young) on an elegant and lucid speech in which he highlighted the fundamental flaws in the Government's approach, as outlined in part 1. I also congratulate my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), who presented a compelling argument about the impact that the Bill will have on partnerships. My hon. Friend the Member for Eastbourne (Mr. Waterson) highlighted the problems in his constituency, the way in which the NHS and local authorities have been working closely together, and the damage that the Bill will do to that relationship. Those sentiments were echoed by my hon. Friend the Member for Westbury (Dr. Murrison). My hon. Friend the Member for Southend, West (Mr. Amess), in a typically robust speech, left us in no doubt of his opposition to the Bill.
It is not solely Conservative Members who are opposed to the Bill. I know that the House always listens carefully and with respect to the views of the hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Health Committee, who in the course of his comments made it plain that he was against part 1 and thought that it was wrong. The hon. Member for Hampstead and Highgate (Glenda Jackson), who, to be fair, said that she would not vote against the Bill, was critical of certain aspects of it, as was the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble), who urged the postponement of the fines. She was chairman of social services in Lancashire before coming to the House.
The hon. Member for Stoke-on-Trent, North (Ms Walley) was lukewarm in her support. Some of the comments of the hon. Member for Pudsey (Mr. Truswell) may have been unpalatable to me, but the thrust of his powerful message was that the Government had got it wrong in part 1. Looking round the Chamber during the speech of the Secretary of State, it was interesting to see a number of other hon. Members expressing their support through their body language and their sedentary comments. I caution them about being over-enthusiastic in support of the Bill.
563 I caution in particular the hon. Member for Colne Valley (Kali Mountford). If I were her, I would check what her social services department thinks of the Bill. During the afternoon, my office had an opportunity to speak to the director of social services of Kirklees council who, among other things, made three comments on the Bill: first, that it is not the right way to tackle the problem; secondly, that it is totally wrong and not good for partnership work; and thirdly, that it will rebuild a Berlin wall between health and social services. I understand that hon. Members in the Kirklees local authority area are meeting the social services department tomorrow to discuss the implications of the Bill. The hon. Lady might be interested to hear the department's views in that meeting.
§ Kali Mountford
I am grateful to the hon. Gentleman for giving way. I am surprised but not alarmed about his telephone call, despite his office having said merely that it was from the House of Commons; the fact that it was his office had to be wheedled out of it. I called the department at 4.30 today, after his call had been made, and it said that it was perfectly happy with the Bill and that working relationships and partnerships were the way forward, and commended such arrangements to other authorities as the best way of making the Bill work.
§ Mr. Burns
I am grateful for that contribution, but I would be fascinated to know to whom the hon. Lady spoke in the social services department. If she spoke to the director of social services, Mr. Philip Cotterill, it would seem most extraordinary that his views on the Bill should have so radically changed in the course of a maximum of 90 minutes.
The role of the Health Committee is very interesting. Many hon. Members have mentioned the report that was published in July, and it has been interesting to hear in the debate the hon. Members from the governing party who were members of the Committee. The hon. Member for Leigh (Andy Burnham) gave us the benefit of an interesting speech in which he reassured my hon. Friends that he was going to redress the balance by speaking in support of the Government's proposals after an overwhelming number of Labour MPs had spoken in opposition to them. He is perfectly entitled to take that position and I do not criticise him for doing so, but I wonder—I shall leave this in the air merely as a matter of wondering—how he squares the support that he expressed for the fining system set out in part 1 with recommendation 33 in the Committee's report. I remember the discussions that we had in formulating the report, so I wonder how he squares his undying support for what the Secretary of State is doing with two parts of that recommendation, which states:There are real risks that perverse incentives"—that is, fines—will be created that will undermine partnerships that have taken time to develop, and foster an unproductive culture of buck passing and mutual blame between health and social care.The recommendation goes on to state:we would also urge the development of positive incentives"—as opposed to fines—that reward good practice, rather than any precipitate and overzealous emphasis on penalties.564 Again, that is very different from what the Government are now recommending.
§ Mr. Burns
No, because there is not much time.
The greatest flaw in the legislation is that, ironically, it will not achieve the aims that it seeks to promote. Simplistically to believe that the panacea for solving problems of delayed discharge is fining social services departments demonstrates a total lack of understanding of the problem.
Most reasonable people would endorse the policy intention and goal of delivering improvements to the system to ensure better, more timely and safe discharge from hospital, but to hijack the Swedish system, completely misunderstand it and simply produce a negative policy of imposing fines on social services departments is a missed opportunity. I tell the Secretary of State that that approach is ultimately bound to fail. It is beyond argument that for vulnerable people, and older people in particular, to remain in hospital longer than necessary is potentially a danger to health and is grossly unfair and an utter waste of NHS resources, but to pray in aid the Swedish system without understanding the differences and the fact that it is now having to be amended to pick up on the unintended problems that it has created is not the best way to proceed.
The Government have failed to accept the inherent crisis in care for the elderly. Without redressing the problem of the loss of 60,000 beds, the closure of 2,000 homes and the decrease in the number of households that receive domiciliary care by almost 100,000, delayed discharge cannot be tackled satisfactorily.
The burden of prospective fines is hanging over social services departments like the sword of Damocles. It is an ominous and current threat. Regardless of the success of individual departments in reaching their specific targets for reducing delayed discharge, fines are to be distributed with zest. There has been much speculation recently about the financial burden that the fines will place on local authorities. Many authorities have expressed their grave anxiety about the detrimental effect of fines on them from next year.
The Liberal Democrats, the arbiters of financial prudence since the Chancellor finally divorced Prudence, claim that the estimated national cost is £50 million. The hon. Member for Sutton and Cheam (Mr. Burstow) kindly explained in an intervention that he had concocted those figures on the back of an envelope. Although it grieves me to tell him, their sums are wrong. Unlike the Liberal Democrats, who use a piece of paper and the back of a cigarette packet with a clipboard thrown in to calculate a combination or two of figures before announcing a figure that they believe to be newsworthy, I have spent my time more scientifically and productively. In the past week, I have canvassed as many local authorities with social services departments as possible.
The figures that I was given are significantly higher than those that the hon. Gentleman produced at the beginning of the week. London alone estimates a penalty figure of approximately £25 million. That is in line with the figures that the hon. Member for Ealing, 565 North (Mr. Pound) provided during the debate on the Queen's Speech when he opposed the proposals and claimed that they would cost Ealing, North about £2.2 million.
Let us consider the shire counties. Their estimates were £2 million for Buckinghamshire; £6 million to £7 million for Surrey; £1.5 million for Cambridgeshire; £3.9 million for my county of Essex; £2.5 million for East Sussex; and £8 million to £10 million for Hampshire.
In order not to leave anyone out, I also spoke to social services departments in the Health Ministers' constituencies. In case they do not already know, I shall enlighten them about the way in which the proposals will affect them. Worcestershire, which covers the constituency of the hon. Member for Redditch (Jacqui Smith), believes that the financial burden will be approximately £1.8 million. The local authority of the right hon. Member for Barrow and Furness (Mr. Hutton) estimates it at £2.74 million. The local authority of the hon. Member for Salford (Ms Blears) believes that the cost will be around £1 million, and the local authority of the hon. Member for Tottenham (Mr. Lammy) estimates the financial burden as between £500,000 and £750,000.
While I enlighten Ministers about the way in which their perverse proposals will affect their areas, it would be unfair if I did not draw attention to the financial burden that the proposals will place on the local authority that covers the Prime Minister's constituency. It has been estimated as approximately £1.4 million.
Just over half the local authorities that I managed to speak to reckoned that the financial burden would be £76 million. Let us project that upwards to the total: the Local Government Association figures estimate a cost of about £180 million, which also highlights the impact statement figures. That is probably about right. What does that mean? The Secretary of State suggests that he will rob Peter to pay Paul and shift £100 million from the Department of Health to the Department for Work and Pensions. That is ludicrous.
The policy should be abandoned before it does more damage. More help should be given to try to remove positively the problem of delayed discharge rather than introducing some crackpot and punitive scheme that almost nobody likes except the most diehard new Labour stalwarts. It is absolutely crazy and it will cause grave problems for the working and further development of partnerships. It will also do nothing to deal with the problems of admissions and readmissions to hospitals. It will distort operational priorities, create pressure for premature discharges, and discourage social service co-operation with care planning procedures in hospital settings.
For those reasons, I urge my right hon. and hon. Friends to join me in the Division Lobby tonight to vote an emphatic no to a policy and a Bill that are woolly and wrong-headed and that are bound, in the end, to fail, but not before they have done tremendous damage to what has been achieved in the working partnerships between health and social services.
§ The Minister of State, Department of Health (Jacqui Smith)
We have had a good debate today. I certainly welcome the constructive suggestions made by some hon. Members about what more we can do to ensure that our older people get the right care at the right time and in the right place. Unfortunately, however, I cannot say the same about the contributions from the Opposition Front Bench. The hon. Members for Woodspring (Dr. Fox) and for West Chelmsford (Mr. Burns) failed noticeably to focus on the needs of older people, had no practical suggestions for improvement, and seemed to see their sole role as the champions of local government. I have to say that that is a bit rich, coming from the people who brought us the poll tax, rate-capping and a stream of central controls on local councils, but who now feign to believe in freedoms for local government.
Let us return to the real issue in the Bill. The existing system means that 5,000 people are currently stuck in hospital when they would be better served outside. This Government's investments in community alternatives and better working between social services and health have made all the difference. The hon. Member for Southend, West (Mr. Amess), in a strident contribution, said that all hon. Members wanted to tackle delayed discharge, but when his party left government, delayed discharges stood at around 6,985. By September 2002, that figure had been reduced by more than one third. That is because social services have been able to build up alternatives to hospital, more care homes have been commissioned, and there are higher fees, more home care provision, and more community equipment.
The way that we have achieved this, through ring-fenced funding and top-down central monitoring, is not sustainable. Extra money has gone to areas in which the problem is worst, rewarding failure with extra resources. As my hon. Friend the Member for Doncaster, North (Mr. Hughes) rightly said, we now need a system that rewards success. Throughout the NHS, we will build systems to ensure that money flows through ward activity to ensure faster, better-quality care. The Bill will enable us to do that across the health and social services divide.
I was a little disappointed by the suggestion that no one supported the Bill, and a bit surprised at the approach of the hon. Members for Westbury (Dr. Murrison) and for Wyre Forest (Dr. Taylor). The hon. Member for Westbury actually introduced a ten-minute Bill earlier this year which he said would facilitate a model based on the Swedish approach to delayed discharge, which he termed a "hugely successful innovation". I do not know whether it is because he has ambitions that he has subsequently changed his mind, but it is very disappointing none the less.
My hon. Friends the Members for Hampstead and Highgate (Glenda Jackson) and for Blackpool, North and Fleetwood (Mrs. Humble) and the right hon. Member for North-West Hampshire (Sir George Young) expressed concerns about responsibility in relation to delayed discharge. There are two elements to 567 this question. First, I want to reassure hon. Members that the Bill states clearly, in clause 4(4)(b), that a charge would be due only ifit has not been possible to discharge the patient because, and only because, the local authority has not made available for the patient a community care service which it decided under section 3(3)(b)"—that is the assessment—to make available for him".[Interruption.] For those hon. Members who clearly have not read the Bill, let me explain what that means. It means that if someone is a self-funder, or is waiting for an element of NHS care, and that is the reason for the discharge being delayed, the social services department will not be charged. That is fair and reasonable.
The second element, however, is that several people—and, I am afraid, some local authorities—are trying to argue themselves out of responsibilities that rightly lie with social services departments, such as assessing needs and commissioning or providing adequate alternatives. My hon. Friend the Member for Milton Keynes, South-West (Dr. Starkey) rightly challenged the hon. Member for Woodspring on whether his argument is that local authorities should not meet their responsibilities. That is what it appeared to be. The Bill will not impose extra responsibilities on local government, but we expect local government to shoulder those responsibilities for vulnerable older people that it already has.
Unlike the Conservatives, we have recognised our responsibility as a Government to fund the necessary developments. It has been claimed throughout the debate that there is not enough capacity in the care home sector for the Bill to work. There are clearly capacity issues in parts of the country, which is why our spending review made available resources for an increase in care home places. However, as my right hon. Friend the Secretary of State told the House on 14 November,we will … have a problem if we think that the only way of caring for older people is placing them in … care homes."—[Official Report, 14 November 2002; Vol. 394, c. 178.]That is not how the majority of people want to be cared for. Most want to be able to return to their own homes, which is why we are providing the funding for local authorities to increase capacity across services for older people.
Once again today, we heard calls for more money from Opposition Members, including the right hon. Member for North-West Hampshire, and the hon. Members for South Cambridgeshire (Mr. Lansley) and for Eastbourne (Mr. Waterson), whose authorities received from the building care capacity grant £7.5 million, £3.2 million and £3.8 million respectively. Of course, they refused to vote for all that money when they were given the opportunity.
The Bill will provide the incentive for local authorities to use that funding to produce a range of services—not only care home packages, but interim and intermediate care involving the provision outlined by my hon. Friend the Member for Dartford (Dr. Stoate), such as step-down facilities, extra sheltered housing, home adaptation services and different home care packages. Only through the provision of such a range of services will older people get the choices they deserve in relation to the care that they receive.
568 The important point is that there is a difference between how authorities, including those that face the same pressures, handle their responsibilities. As my hon. Friend the Member for Doncaster, North pointed out, using the approach that I have outlined, a difference is being made to the lives of people in Doncaster, North. For example, Croydon—part of the south-east that also faces pressures—has made a significant difference in respect of delayed discharges. The Bill will ensure that local authorities take responsibility, with the additional resources, for making the differences that will allow older people to get out of hospital when they need to.
My hon. Friend the Member for Leigh (Andy Burnham) outlined the particular constraint around staff and occupational therapists in particular, so I am sure he is pleased that, under this Government, there has been a 36 per cent. increase in occupational therapists in training. He is right: part of the capacity constraint is to ensure that we have the work force in place.
Several Members, including my hon. Friend the Member for Wakefield (Mr. Hinchliffe), concentrated on choice, among other things. Some have argued that the Bill will lead to patients having less choice regarding the services that they receive on discharge and that they will be pressured by local authorities to accept the first available placement. I believe that the opposite is true: the proposals will put the patient firmly at the centre of care and they should increase the choice available to older people. As we know from our experience with the building capacity grant, those councils that have achieved progress on delayed discharge have invested the money innovatively and in a range of services.
The Bill will increase choice in other ways, such as that of staying at home rather than going into hospital in the first place. Preventing people from going into hospital when they could be better cared for with support in their own homes is a key way to reduce delays, and sensible councils will invest in services that enable older people to exercise that choice.
Some Members raised the direction on choice, which exists to enable people to exercise choice when selecting a care home. The direction on choice does not mean that a patient has a right to occupy an acute bed indefinitely when others may be in much greater need. Even if someone is waiting for a place in the home of his or her choice to become available, that person should not be subjected to an inappropriate delay in an acute bed if he or she no longer requires acute hospital care, not least because that is not good for older people themselves. Councils need to invest in services such as step-down and interim care, or to provide intensive home care services so that patients can move to a more homely environment in the meantime.
Some Members expressed concern about consent and advocacy. Let me reassure them that nothing in the Bill removes the current practice or law on consent and advocacy. Many areas have very good advocacy services, and are involved in discharge planning. There is no reason for that to change. In fact, the Government are ensuring that advocacy is available for patients throughout the health service.
569 Concerns have also been expressed about care, but I think my right hon. Friend the Secretary of State dealt with them. Several Members mentioned damage to partnership. Of course good working relationships exist in many areas, but partnership must be judged on the basis of what it produces. There must be more to the outcomes of partnership than simply a good set of minutes. If partnership is delivering, it will be the way in which to avoid reimbursement charges; but partnership depends on clarity about roles and responsibilities.
Whatever the good intentions locally, the current system rewards buck-passing. An older person stuck in hospital is paid for by the hospital, even if that person is the responsibility of social services. We propose that the social services budget should pay for the older person's care when it becomes the responsibility of social services. Essentially, this will be a payment for looking after the patient.
The Bill will clarify the roles and responsibilities of the various agencies. It will assist partnership. Most important, it will prevent older people from being caught in the middle of disputes.
The Bill will ensure that the needs of the patient are put first, not the needs of the NHS or local government. Delayed discharges are bad for older people, worrying for their families and carers, frustrating for patients waiting for treatment and wasteful of taxpayers' money. Each older person trapped in hospital is an argument for change, and each is a demonstration that the current system is not working. As my right hon. Friend made clear, the mark of any civilised society is the way in which it treats its senior citizens. The mark of an effective health and social care system is that it ensures choice, access, independence and quality of care for our older people.
The national service framework for older people is bringing health and social services together, and raising standards of care for older people. In July, my right hon. Friend announced a £1 billion package leading to faster assessment, more places in care homes and sheltered housing, more intermediate care services, and more support for older people wanting to live at home and their carers. Today we have responded to local government concerns about capacity by announcing that, in addition to the increases in social services funding, from next April we will transfer money from the NHS to enable social services departments to fulfil their responsibilities. This is a whole-system commitment to tackling delayed discharges.
Not only has the extra funding been opposed by the Conservative party; today Conservative Members have also opposed the reforms to make it work. We know that the extra money we are providing for our health and social services brings with it a responsibility for us all—a responsibility to ensure that it makes a difference. The Bill ensures that services needed to promote independence will be provided free. It places new duties on the NHS to work with local authorities. It rewards social services departments that live up to their responsibilities. Most important, it puts the needs of vulnerable people, not organisations, at the centre of the system. I commend it to the House.
Question put, That the amendment be made:—
§ The House divided: Ayes 136, Noes 238.572
|Division No. 11]||[6:59 pm|
|Ainsworth, Peter (E Surrey)||Lansley, Andrew|
|Amess, David||Lewis, Dr. Julian (New Forest E)|
|Arbuthnot, rh James||Liddell-Grainger, Ian|
|Atkinson, David (Bour'mth E)||Lidington, David|
|Atkinson, Peter (Hexham)||Lilley, rh Peter|
|Baldry, Tony||Llwyd, Elfyn|
|Barker, Gregory||Luff, Peter (M-Worcs)|
|Baron, John (Billericay)||McIntosh, Miss Anne|
|Beith, rh A. J.||MacKay, rh Andrew|
|Bellingham, Henry||Maclean, rh David|
|Blunt, Crispin||McLoughlin, Patrick|
|Boswell, Tim||Malins, Humfrey|
|Brady, Graham||Maples, John|
|Brake, Tom (Carshalton)||Mawhinney, rh Sir Brian|
|Brazier, Julian||Mercer, Patrick|
|Brooke, Mrs Annette L||Moss, Malcolm|
|Browning, Mrs Angela||Murrison, Dr. Andrew|
|Bruce, Malcolm||Norman, Archie|
|Burnett, John||Oaten, Mark (Winchester)|
|Burns, Simon||Öpik, Lembit|
|Burnside, David||Osborne, George (Tatton)|
|Burstow, Paul||Ottaway, Richard|
|Burt, Alistair||Paterson, Owen|
|Calton, Mrs Patsy||Prisk, Mark (Hertford)|
|Cash, William||Pugh, Dr. John|
|Chidgey, David||Randall, John|
|Chope, Christopher||Reid, Alan (Argyll & Bute)|
|Clappison, James||Rendel, David|
|Clarke, rh Kenneth (Rushcliffe)||Robathan, Andrew|
|Clifton-Brown, Geoffrey||Robertson, Hugh (Faversham &|
|Conway, Derek||Robertson, Laurence (Tewk'b'ry)|
|Cormack, Sir Patrick||Robinson, Peter (Belfast E)|
|Curry, rh David||Rosindell, Andrew|
|Davey, Edward (Kingston)||Ruffley, David|
|Djanogly, Jonathan||Russell, Bob (Colchester)|
|Duncan, Alan (Rutland)||Selous, Andrew|
|Evans, Nigel||Shephard, rh Mrs Gillian|
|Fabricant, Michael||Shepherd, Richard|
|Fallon, Michael||Simpson, Keith (M-Norfolk)|
|Field, Mark (Cities of London &||Soames, Nicholas|
|Westminster)||Spicer, Sir Michael|
|Forth, rh Eric||Spring, Richard|
|Foster, Don (Bath)||Stanley, rh Sir John|
|Fox, Dr. Liam||Steen, Anthony|
|Francois, Mark||Stunell, Andrew|
|Gale, Roger (N Thanet)||Swayne, Desmond|
|Garnier, hon. Edward||Swire, Hugo (E Devon)|
|Gibb, Nick (Bognor Regis)||Syms, Robert|
|Gidley, Sandra||Tapsell, Sir Peter|
|Gillan, Mrs Cheryl||Taylor, Ian (Esher)|
|Gray, James (N Wilts)||Taylor, John (Solihull)|
|Grayling, Chris||Taylor, Dr. Richard (Wyre F)|
|Greenway, John||Taylor, Sir Teddy|
|Grieve, Dominic||Tonge, Dr. Jenny|
|Gummer, rh John||Trend, Michael|
|Hammond, Philip||Turner, Andrew (Isle of Wight)|
|Hayes, John (S Holland)||Tyrie, Andrew|
|Heald, Oliver||Whittingdale, John|
|Heath, David||Wiggin, Bill|
|Hendry, Charles||Wilkinson, John|
|Hogg, rh Douglas||Williams, Hywel (Caernarfon)|
|Horam, John (Orpington)||Williams, Roger (Brecon)|
|Howard, rh Michael||Willis, Phil|
|Hunter, Andrew||Wilshire, David|
|Jack, rh Michael||Young, rh Sir George|
|Keetch, Paul||Younger-Ross, Richard|
|Key, Robert (Salisbury)|
|Kirkbride, Miss Julie||Tellers for the Ayes:|
|Knight, rh Greg (E Yorkshire)||Mr. Mark Hoban and|
|Lait, Mrs Jacqui||Angela Watkinson|
|Adams, Irene (Paisley N)||Foster, Michael Jabez (Hastings &|
|Ainsworth, Bob (Cov'try NE)||Rye)|
|Allen, Graham||Gapes, Mike (Ilford S)|
|Anderson, Janet (Rossendale &||Gardiner, Barry|
|Darwen)||George, rh Bruce (Walsall S)|
|Armstrong, rh Ms Hilary||Gerrard, Neil|
|Atherton, Ms Candy||Gibson, Dr. Ian|
|Atkins, Charlotte||Gilroy, Linda|
|Austin, John||Godsiff, Roger|
|Bailey, Adrian||Goggins, Paul|
|Banks, Tony||Griffiths, Jane (Reading E)|
|Barnes, Harry||Griffiths, Nigel (Edinburgh S)|
|Barron, rh Kevin||Grogan, John|
|Battle, John||Hall, Mike (Weaver Vale)|
|Beard, Nigel||Hall, Patrick (Bedford)|
|Benn, Hilary||Hamilton, David (Midlothian)|
|Bennett, Andrew||Hamilton, Fabian (Leeds NE)|
|Benton, Joe (Bootle)||Harris, Tom (Glasgow Cathcart)|
|Berry, Roger||Henderson, Ivan (Harwich)|
|Betts, Clive||Hendrick, Mark|
|Blears, Ms Hazel||Hepburn, Stephen|
|Blizzard, Bob||Heppell, John|
|Bradley, Peter (The Wrekin)||Hesford, Stephen|
|Bradshaw, Ben||Heyes, David|
|Buck, Ms Karen||Hill, Keith (Streatham)|
|Burden, Richard||Hoon, rh Geoffrey|
|Burnham, Andy||Hope, Phil (Corby)|
|Byers, rh Stephen||Hopkins, Kelvin|
|Cairns, David||Howarth, rh Alan (Newport E)|
|Campbell, Mrs Anne (C'bridge)||Howarth, George (Knowsley N &|
|Campbell, Ronnie (Blyth V)||Sefton E)|
|Casale, Roger||Hughes, Kevin (Doncaster N)|
|Caton, Martin||Humble, Mrs Joan|
|Cawsey, Ian (Brigg)||Hurst, Alan (Braintree)|
|Challen, Colin||Hutton, rh John|
|Chapman, Ben (Wirral S)||Iddon, Dr. Brian|
|Clapham, Michael||Illsley, Eric|
|Clark, Mrs Helen (Peterborough)||Ingram, rh Adam|
|Clarke, rh Tom (Coatbridge &||Jackson, Glenda (Hampstead &|
|Clarke, Tony (Northampton S)||Jackson, Helen (Hillsborough)|
|Clelland, David||Jamieson, David|
|Clwyd, Ann (Cynon V)||Jenkins, Brian|
|Clwyd, Ann (Cynon V)||Johnson, Alan (Hull W)|
|Coffey, Ms Ann||Johnson, Miss Melanie (Welwyn|
|Coleman, Iain||Jones, Helen (Warrington N)|
|Colman, Tony||Jones, Martyn (Clwyd S)|
|Cousins, Jim||Joyce, Eric (Falkirk W)|
|Cranston, hon. Ross||Keeble, Ms Sally|
|Crausby, David||Keen, Alan (Feltham)|
|Cruddas, Jon||Keen, Ann (Brentford)|
|Cryer, John (Hornchurch)||Kemp, Fraser|
|Cunningham, Jim (Coventry S)||Khabra, Piara S.|
|Davey, Valerie (Bristol W)||Kidney, David|
|Davidson, Ian||Kilfoyle, Peter|
|Davis, rh Terry (B'ham Hodge H)||Ladyman, Dr. Stephen|
|Dawson, Hilton||Lammy, David|
|Dean, Mrs Janet||Laxton, Bob (Derby N)|
|Dhanda, Parmjit||Lazarowicz, Mark|
|Dismore, Andrew||Lepper, David|
|Dowd, Jim (Lewisham W)||Leslie, Christopher|
|Drown, Ms Julia||Levitt, Tom (High Peak)|
|Eagle, Angela (Wallasey)||Lewis, Ivan (Bury S)|
|Ellman, Mrs Louise||Linton, Martin|
|Ennis, Jeff (Barnsley E)||Lloyd, Tony (Manchester C)|
|Etherington, Bill||Love, Andrew|
|Farrelly, Paul||Luke, Iain (Dundee E)|
|Field, rh Frank (Birkenhead)||Lyons, John (Strathkelvin)|
|Fisher, Mark||McAvoy, Thomas|
|Fitzpatrick, Jim||McCartney, rh Ian|
|Flint, Caroline||McDonagh, Siobhain|
|Follett, Barbara||MacDonald, Calum|
|Foster, rh Derek||MacDougall, John|
|Foster, Michael (Worcester)||McGuire, Mrs Anne|
|McIsaac, Shona||Ruddock, Joan|
|McKechin, Ann||Russell, Ms Christine (City of|
|MacShane, Denis||Ryan, Joan (Enfield N)|
|McWalter, Tony||Sarwar, Mohammad|
|McWilliam, John||Savidge, Malcolm|
|Mahmood, Khalid||Sawford, Phil|
|Mallaber, Judy||Sedgemore, Brian|
|Mann, John (Bassetlaw)||Sheerman, Barry|
|Marris, Rob (Wolverh'ton SW)||Sheridan, Jim|
|Marsden, Gordon (Blackpool S)||Shipley, Ms Debra|
|Marshall, Jim (Leicester S)||Short, rh Clare|
|Merron, Gillian||Simon, Siôn (B'ham Erdington)|
|Milburn, rh Alan||Singh, Marsha|
|Miller, Andrew||Skinner, Dennis|
|Moffatt, Laura||Smith, rh Andrew (Oxford E)|
|Morgan, Julie||Smith, Jacqui (Redditch)|
|Mountford, Kali||Smith, John (Glamorgan)|
|Mullin, Chris||Soley, Clive|
|Murphy, Denis (Wansbeck)||Spellar, rh John|
|Murphy, Jim (Eastwood)||Squire, Rachel|
|Naysmith, Dr. Doug||Steinberg, Gerry|
|O'Bripn Mike (N Warks)||Stevenson, George|
|O'Hara, Edward||Stewart, Ian (Eccles)|
|Olner, Bill||Stinchcombe, Paul|
|Osborne, Sandra (Ayr)||Stoate, Dr. Howard|
|Palmer Dr Nick||Sutcliffe, Gerry|
|Perham, Linda||Taylor, Dari (Stockton S)|
|Picking, Anne||Todd, Mark (S Derbyshire)|
|Pickthall, Colin||Trickett, Jon|
|Pike, Peter (Burnley)||Turner, Dr. Desmond (Brighton Kemptown)|
|Plaskitt, James||Turner, Neil (Wigan)|
|Pollard, Kerry||Twigg, Derek (Halton)|
|Pond, Chris (Gravesham)||Twigg, Stephen (Enfield)|
|Prentice, Ms Bridget (Lewisham||Tynan, Bill (Hamilton S)|
|E)||Walley, Ms Joan|
|Prentice, Gordon (Pendle)||Wareing, Robert N.|
|Prescott, rh John||Watts, David|
|Primarolo, rh Dawn||White, Brian|
|Prosser, Gwyn||Wicks, Malcolm|
|Purchase, Ken||Wills, Michael|
|Rapson, Syd (Portsmouth N)||Winnick, David|
|Raynsford, rh Nick||Woolas, Phil|
|Reed, Andy (Loughborough)||Worthington, Tony|
|Reid, rh Dr. John (Hamilton N &||Wray, James (Glasgow|
|Robertson, John (Glasgow||Wright, Anthony D. (Gt|
|Robinson, Geoffrey (Coventry NW)||Wright, Tony (Cannock)|
|Roche, Mrs Barbara||Tellers for the Noes:|
|Rooney, Terry||Mr. Nick Ainger and|
|Ross, Ernie (Dundee W)||Mr. Ivor Caplin|
§ Question accordingly negatived.
Main Question put forthwith, pursuant to Standing Order No. 62 (Amendment on second or third Reading).
The House divided: Ayes 237, Noes 135.575
|Division No. 12]||[7:11 pm|
|Adams, Irene (Paisley N)||Battle, John|
|Ainsworth, Bob (Cov'try NE)||Beard, Nigel|
|Allen, Graham||Benn, Hilary|
|Anderson, Janet (Rossendale &||Bennett, Andrew|
|Darwen)||Benton, Joe (Bootle)|
|Armstrong, rh Ms Hilary||Berry, Roger|
|Atherton, Ms Candy||Betts, Clive|
|Atkins, Charlotte||Blears, Ms Hazel|
|Austin, John||Blizzard, Bob|
|Bailey, Adrian||Bradley, Peter (The Wrekin)|
|Banks, Tony||Bradshaw, Ben|
|Barnes, Harry||Buck, Ms Karen|
|Barron, rh Kevin||Burden, Richard|
|Burnham, Andy||Howarth, George (Knowsley N &|
|Byers, rh Stephen||Sefton E)|
|Cairns, David||Hughes, Kevin (Doncaster N)|
|Campbell, Mrs Anne (C'bridge)||Humble, Mrs Joan|
|Campbell, Ronnie (Blyth V)||Hurst, Alan (Braintree)|
|Casale, Roger||Hutton, rh John|
|Caton, Martin||Iddon, Dr. Brian|
|Cawsey, Ian (Brigg)||Illsley, Eric|
|Challen, Colin||Jackson, Glenda (Hampstead &|
|Chapman, Ben (Wirral S)||Highgate)|
|Clapham, Michael||Jackson, Helen (Hillsborough)|
|Clark, Mrs Helen (Peterborough)||Jamieson, David|
|Clarke, rh Tom (Coatbridge &||Jenkins, Brian|
|Chryston)||Johnson, Alan (Hull W)|
|Clarke, Tony (Northampton S)||Johnson, Miss Melanie (Welwyn|
|Clwyd, Ann (Cynon V)||Jones, Helen (Warrington N)|
|Coffey, Ms Ann||Jones, Martyn (Clwyd S)|
|Cohen, Harry||Joyce, Eric (Falkirk W)|
|Coleman, Iain||Keeble, Ms Sally|
|Colman, Tony||Keen, Alan (Feltham)|
|Cousins, Jim||Keen, Ann (Brentford)|
|Cranston, hon. Ross||Kemp, Fraser|
|Crausby, David||Khabra, Piara S.|
|Cruddas, Jon||Kidney, David|
|Cryer, John (Hornchurch)||Kilfoyle, Peter|
|Cunningham, Jim (Coventry S)||Ladyman, Dr. Stephen|
|Davey, Valerie (Bristol W)||Lammy, David|
|Davidson, Ian||Laxton, Bob (Derby N)|
|Davis, rh Terry (B'ham Hodge H)||Lazarowicz, Mark|
|Dawson, Hilton||Lepper, David|
|Dean, Mrs Janet||Leslie, Christopher|
|Dhanda, Parmjit||Levitt, Tom (High Peak)|
|Dismore, Andrew||Lewis, Ivan (Bury S)|
|Dowd, Jim (Lewisham W)||Linton, Martin|
|Drown, Ms Julia||Lloyd, Tony (Manchester C)|
|Ellman, Mrs Louise||Love, Andrew|
|Ennis, Jeff (Barnsley E)||Luke, Iain (Dundee E)|
|Etherington, Bill||Lyons, John (Strathkelvin)|
|Farrelly, Paul||McAvoy, Thomas|
|Field, rh Frank (Birkenhead)||McCartney, rh Ian|
|Fisher, Mark||McDonagh, Siobhain|
|Fitzpatrick, Jim||MacDonald, Calum|
|Flint, Caroline||MacDougall, John|
|Follett, Barbara||McGuire, Mrs Anne|
|Foster, rh Derek||McIsaac, Shona|
|Foster, Michael (Worcester)||McKechin, Ann|
|Foster, Michael Jabez (Hastings &||Mackinlay, Andrew|
|Gapes, Mike (Ilford S)||McWalter, Tony|
|Gardiner, Barry||McWilliam, John|
|George, rh Bruce (Walsall S)||Mahmood, Khalid|
|Gerrard, Neil||Mallaber, Judy|
|Gibson, Dr. Ian||Mann, John (Bassetlaw)|
|Gilroy, Linda||Marris, Rob (Wolverh'ton SW)|
|Godsiff, Roger||Marsden, Gordon (Blackpool S)|
|Goggins, Paul||Marshall, Jim (Leicester S)|
|Griffiths, Jane (Reading E)||Merron, Gillian|
|Griffiths, Nigel (Edinburgh S)||Milburn, rh Alan|
|Grogan, John||Miller, Andrew|
|Hall, Mike (Weaver Vale)||Moffatt, Laura|
|Hall, Patrick (Bedford)||Morgan, Julie|
|Hamilton, David (Midlothian)||Mountford, Kali|
|Hamilton, Fabian (Leeds NE)||Mullin, Chris|
|Harris, Tom (Glasgow Cathcart)||Murphy, Denis (Wansbeck)|
|Henderson, Ivan (Harwich)||Murphy, Jim (Eastwood)|
|Hendrick, Mark||Naysmith, Dr. Doug|
|Hepburn, Stephen||O'Brien, Mike (N Warks)|
|Heppell, John||O'Hara, Edward|
|Hesford, Stephen||Olner, Bill|
|Heyes, David||Osborne, Sandra (Ayr)|
|Hill, Keith (Streatham)||Palmer, Dr. Nick|
|Hoon, rh Geoffrey||Perham, Linda|
|Hope, Phil (Corby)||Picking, Anne|
|Hopkins, Kelvin||Pickthall, Colin|
|Howarth, rh Alan (Newport E)||Pike, Peter (Burnley)|
|Plaskitt, James||Smith, Jacqui (Redditch)|
|Pollard, Kerry||Smith, John (Glamorgan)|
|Pond, Chris (Gravesham)||Soley, Clive|
|Prentice, Ms Bridget (Lewisham||Spellar, rh John|
|Prentice, Gordon (Pendle)||Steinberg, Gerry|
|Prescott, rh John||Stevenson, George|
|Primarolo, rh Dawn||Stewart, Ian (Eccles)|
|Prosser, Gwyn||Stinchcombe, Paul|
|Purchase, Ken||Stoate, Dr. Howard|
|Rapson, Syd (Portsmouth N)||Sutcliffe, Gerry|
|Raynsford, rh Nick||Taylor, Dari (Stockton S)|
|Reed, Andy (Loughborough)||Todd, Mark (S Derbyshire)|
|Robertson, John (Glasgow||Trickett, Jon|
|Anniesland)||Turner, Dr. Desmond (Brighton|
|Robinson, Geoffrey (Coventry||Kemptown)|
|NW)||Turner, Neil (Wigan)|
|Roche, Mrs Barbara||Twigg, Derek (Halton)|
|Rooney, Terry||Twigg, Stephen (Enfield)|
|Ross, Ernie (Dundee W)||Tynan, Bill (Hamilton S)|
|Ruddock, Joan||Walley, Ms Joan|
|Russell, Ms Christine (City of||Wareing, Robert N.|
|Ryan, Joan (Enfield N)||White, Brian|
|Sarwar, Mohammad||Wicks, Malcolm|
|Savidge, Malcolm||Wills, Michael|
|Sawford, Phil||Winnick, David|
|Sedgemore, Brian||Woolas, Phil|
|Sheerman, Barry||Worthington, Tony|
|Sheridan, Jim||Wray, James (Glasgow|
|Shipley, Ms Debra||Baillieston)|
|Short, rh Clare||Wright, Anthony D. (Gt|
|Simon, Siôn (B'ham Erdington)||Yarmouth)|
|Singh, Marsha||Wright, Tony (Cannock)|
|Smith, rh Andrew (Oxford E)||Tellers for the Ayes:|
|Smith, rh Chris (Islington S &||Mr. Nick Ainger and|
|Finsbury)||Mr. Ivor Caplin|
|Ainsworth, Peter (E Surrey)||Djanogly, Jonathan|
|Amess, David||Evans, Nigel|
|Arbuthnot, rh James||Fabricant, Michael|
|Atkinson, David (Bour'mth E)||Fallon, Michael|
|Atkinson, Peter (Hexham)||Field, Mark (Cities of London &|
|Barker, Gregory||Forth, rh Eric|
|Baron, John (Billericay)||Foster, Don (Bath)|
|Beith, rh A. J.||Fox, Dr. Liam|
|Bellingham, Henry||Francois, Mark|
|Blunt, Crispin||Gale, Roger (N Thanet)|
|Boswell, Tim||Garnier, hon. Edward|
|Brady, Graham||Gibb, Nick (Bognor Regis)|
|Brake, Tom (Carshalton)||Gidley, Sandra|
|Brazier, Julian||Gillan, Mrs Cheryl|
|Brooke, Mrs Annette L||Gray, James (N Wilts)|
|Browning, Mrs Angela||Grayling, Chris|
|Bruce, Malcolm||Greenway, John|
|Burnett, John||Grieve, Dominic|
|Burns, Simon||Gummer, rh John|
|Burnside, David||Hammond, Philip|
|Burstow, Paul||Hayes, John (S Holland)|
|Burt, Alistair||Heald, Oliver|
|Cable, Dr. Vincent||Heath, David|
|Calton, Mrs Patsy||Hendry, Charles|
|Cash, William||Hogg, rh Douglas|
|Chidgey, David||Horam, John (Orpington)|
|Chope, Christopher||Hunter, Andrew|
|Clappison, James||Jack, rh Michael|
|Clarke, rh Kenneth (Rushcliffe)||Keetch, Paul|
|Clifton-Brown, Geoffrey||Key, Robert (Salisbury)|
|Collins, Tim||Kirkbride, Miss Julie|
|Conway, Derek||Knight, rh Greg (E Yorkshire)|
|Cormack, Sir Patrick||Lait, Mrs Jacqui|
|Curry, rh David||Lansley, Andrew|
|Davey, Edward (Kingston)||Lewis, Dr. Julian (New Forest E)|
|Liddell-Grainger, Ian||Shephard, rh Mrs Gillian|
|Lidington, David||Shepherd, Richard|
|Lilley, rh Peter||Simpson, Keith (M-Norfolk)|
|Llwyd, Elfyn||Soames, Nicholas|
|Luff, Peter (M-Worcs)||Spicer, Sir Michael|
|McIntosh, Miss Anne||Spring, Richard|
|MacKay, rh Andrew||Stanley, rh Sir John|
|Maclean, rh David||Steen, Anthony|
|McLoughlin, Patrick||Stunell, Andrew|
|Malins, Humfrey||Swayne, Desmond|
|Mawhinney, rh Sir Brian||Swire, Hugo (E Devon)|
|Mercer, Patrick||Syms, Robert|
|Moss, Malcolm||Tapsell, Sir Peter|
|Murrison, Dr. Andrew||Taylor, Ian (Esher)|
|Norman, Archie||Taylor, John (Solihull)|
|Oaten, Mark (Winchester)||Taylor, Dr. Richard (Wyre F)|
|Öpik, Lembit||Taylor, Sir Teddy|
|Osborne, George (Tatton)||Tonge, Dr. Jenny|
|Ottaway, Richard||Trend, Michael|
|Paterson, Owen||Turner, Andrew (Isle of Wight)|
|Prisk, Mark (Hertford)||Whittingdale, John|
|Pugh, Dr. John||Wiggin, Bill|
|Randall, John||Wilkinson, John|
|Reid, Alan (Argyll & Bute)||Williams, Hywel (Caernarfon)|
|Rendel, David||Williams, Roger (Brecon)|
|Robathan, Andrew||Willis, Phil|
|Robertson, Hugh (Faversham &||Wilshire, David|
|M-Kent)||Yeo, Tim (S Suffolk)|
|Robertson, Laurence (Tewk'b'ry)||Young, rh Sir George|
|Robinson, Peter (Belfast E)||Younger-Ross, Richard|
|Ruffley, David||Tellers for the Noes:|
|Russell, Bob (Colchester)||Mr. Mark Hoban and|
|Selous, Andrew||Angela Watkinson|
§ Question accordingly agreed to.
Bill accordingly read a Second time.