LORDS AMENDMENT (Hansard, 27 March 2003)

§ Baroness Andrews
My Lords, I beg to move that the House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35.
Subsection (4), which Amendment No. 35A removes, would delay the coming into effect of the part of the Bill that deals with delayed discharge payments until 30 days after the Secretary of State has determined that there are sufficient incentives within the system to prevent the NHS from discharging patients too early. Noble Lords will know that we had some problems with the amendment, because it does not fit with the main structure of the Bill. However, I understand the concerns of noble Lords, and the noble Baroness, who has been particularly concerned with this, that we have over-focused on social services and that there should be an explicit fairness between them and the NHS so that patients are not discharged too early, with all the consequences that brings.
Noble Lords are right to want to ensure that discharge follows proper procedures and is safe. We certainly do. The existing Commission for Health Improvement has a remit to monitor quality and to ensure that trusts provide a high standard of care. Clearly, they would not provide that standard of care if they discharged patients too early. I referred earlier in the debate to the successor body to CHI, which will be more independent of the department and will have a remit to monitor and report on patient experience and behaviour. The noble Baroness was very concerned that we should get away from data and statistics to look at real people and real hospitals. That monitoring will clearly cover aspects such as the patient's journey through hospital and discharge to another care setting. Noble Lords will recall that older people's services are the subject of a forthcoming Audit Commission study.
The National Centre for Health Outcomes Development is working with the department on improving data on readmissions. In the light of what the noble Earl said in our previous debate, that is very good news. We will certainly keep noble Lords up to date on that. It will help us discern when readmissions are caused by bad discharge factors and not, for example, by the epidemiology of the area, the demography or the high rate of chronic illness.
However, in response to concerns that the NHS may have got off lightly, we need to emphasise that strategic health authorities have a particular role to play through their performance management, because readmission rates are a specific performance indicator and therefore also have a direct effect on waiting times and access targets, which are all used to determine a trust's star rating. It is not in the interests of a trust to discharge patients too early and risk their being readmitted, because the impact on a trust's star rating carries with it a real financial penalty for trusts, in that access to 993 performance funds is limited to high-performing trusts. So, a trust with a high rate of readmissions risks losing access to extra funding and freedoms. A core discharge policy that led to readmissions could also lead to a trust failing its clinical audit.
Thirdly, the impact that high numbers of readmissions will have on the hospital's capacity acts as a disincentive to discharging patients too soon. If hospitals need to treat the same patient twice because they have come back as an emergency admission, they will have less capacity to treat patients on waiting lists. We are talking about enlightened self-interest as well as proper performance management.
It is essential to ensure that the system that we put in place is fair to patients and to social services and does not have any unintended consequences, such as causing a riot and readmissions. I believe that we have robust systems in place to prevent that occurring. Noble Lords will remember the commitment I made in our earlier discussion on Amendment No. 23, that we will issue guidance requiring social services to review the care package within two weeks of an older person returning to their home from hospital. This review will take place earlier if that person is particularly frail or vulnerable or living alone, which means that any problems can be picked up. As I said, this guidance will be issued under Section 7 of the Local Authority Social Services Act 1970. Councils will be under a duty to follow it.
The three-month period between October and December when reimbursement operates in shadow form also provides extra time for the NHS and social services to ensure that the new systems introduced by the Bill function properly and to make any necessary changes. I believe that the monitoring that will be carried out by the new inspection bodies, the two-week review of the care package, the period of shadow operating and the existing incentives on trusts to perform well are powerful enough to prevent the NHS from trying to cut corners in its discharge practice and will ensure that patients are protected when reimbursement is introduced.
This may be the last time that I shall speak with, as it were, any freedom on the Bill, so I conclude by saying that I am grateful to all noble Lords who have informed and illuminated the Bill and its impact on people leaving hospital in a vulnerable condition. It has been a robust but extremely positive and constructive debate. We are all agreed that the Bill is the better for it and it sends a strong powerful signal to those implementing the Bill that Parliament is fully behind it.
I also pay tribute to my noble friend Lord Hunt of Kings Heath who carried the Bill through four-fifths of its passage and responded with his usual commitment and intelligence—and slight scepticism at times—but always in good heart. At the end of the day there is absolutely no distance between us. As the noble Lord, Lord Clement-Jones, said, we have the common interest of the individual patient at heart. We very much hope that this Bill will make a material difference to their prospects when they leave hospital.
Moved, That the House do agree with the Commons in their Amendment No. 35A to Lords Amendment No. 35. —(Baroness Andrews.)

§ Baroness Barker
My Lords, I am sure with the minimum of three days I could get the hang of the procedure. I wish to ask the noble Baroness to clarify 995 something she said. She talked about the reassessment happening within two weeks of discharge from hospital. I understood from her comments on an earlier amendment that the period was two weeks after someone had returned to their own home from intermediate care or another form of care and not just from an acute hospital.
I was being flippant earlier on, but actually I believe that is one of the most important parts of the Bill. It is its underpinning and the determination of whether it works in the best interests of older people. I am extremely serious.
I wish to pay tribute to the noble Lord, Lord Hunt. He approached the Bill, as he did many others, with a wonderful mixture of conviction, scepticism, charm, tolerance and occasional bewilderment at the antics of these Benches, for which I thank him. I congratulate the noble Baroness on the way that way she has taken over so effectively.
Finally, I want to put my thanks on record to the Bill team. We have made contributions to this Bill which have been far more of the real world than some of those made in another place. I believe it has been a combined effort by us all to make an unworkable Bill much more workable.

§ Baroness Andrews
My Lords, in response to the noble Baroness's question, I said that we would look at both discharge from hospital and discharge from other forms of care. But all those matters will the subject of consultation. I am sure that the noble Baroness will be able to join in that process.

§ Earl Howe
My Lords, I join the noble Baroness, Lady Barker, in everything she said about the helpful and constructive approach adopted by the noble Lord, Lord Hunt, and the noble Baroness, Lady Andrews. I beg leave to withdraw the amendment.