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Elderly Patients (Bed Allocation)

Volume 492: debated on Wednesday 20 May 2009

Motion made, and Question proposed, That the sitting be now adjourned.—(Mr. Blizzard.)

I am delighted to have secured this debate on the provision of primary care trust beds and the criteria relating to that. I am also delighted to appear under your chairmanship, Mr. Cook; you take a keen interest in these matters, so it is particularly appropriate that you are here today. I also welcome my Front-Bench colleague, my hon. Friend the Member for Eddisbury (Mr. O’Brien), the Minister and other hon. Members.

I have had a number of constituency cases concerning elderly and end-of-life care, but a recent personal interest has cast a different light on the subject. Some 1.3 million people are employed by the NHS, and I recognise the excellent care provided by staff, not just in Vale of York, but across the country. They deserve praise and recognition at every turn. Their level of care, commitment and dedication is outstanding; they are the true angels of the health service. Having said that, however, not all is well. Considerable changes have been brought in since 1997: the number of hospital beds has fallen; the role of community hospitals has been revised; and there is confusion about who is responsible for each bed, for agreeing the criteria for their allocation and for deciding who occupies them and for how long.

I shall explain my reasons for seeking this debate. I was fortunate enough to have a question on the provision of elderly care beds answered by the Minister of State, Department of Health, the hon. Member for Corby (Phil Hope). However, I had great difficulty understanding the purport of the response. It began:

“Primary care trusts work with local authority partners to commission high-quality care services from appropriate providers to meet local patient needs”.

However, it did not say who those providers are, so it would be helpful to hear today who is involved at each turn in securing that decision.

I then put it to that Minister that, in my view, PCTs have too much power and responsibility and that many of their members are not clinically qualified and yet are taking key decisions about a patient with a terminal illness, which can cause great distress to them, their family and their loved ones. He replied that the Government have

“an appropriate process for commissioning high-quality services locally. It is the responsibility of primary care trusts to undertake that function and, in the case of the care of elderly people, to do so, through beds in hospitals, beds in residential care and so on, in partnership with their local authorities.”—[Official Report, 12 May 2009; Vol. 492, c. 675.]

I want to focus on that area.

I shall address not the least of the changes to which I referred earlier. Since 1997-98, there has been a dramatic drop in the number of hospital beds, from 138,000, in 1997-98, to 121,780, in 2007-08. If people are spending less time in hospital after an operation, it can be a good thing, but within those statistics is a sub-figure for geriatric beds, the number of which has fallen from 30,200 to 20,700. That rings alarm bells. I hope that the Minister here today will explain where those beds have gone.

The Government want more people to end their lives in their own homes, and North Yorkshire is no exception. I support that, but many local authorities are reducing the number of places in council-provided care homes, which removes an element of choice, especially for those who cannot remain in their own homes, because, perhaps, they lack support or live in a very rural area where the provision of care is challenging. Over the next five, 10 or 15 years, sufficient care home places will not be available.

The role of community hospital has been revised. I understand that one change came in 2000 and another—possibly—in 2006-08. When I was first elected, it was generally understood that someone who was very seriously ill and likely to deteriorate and enter the end-of-life stage could end their days, over a prolonged period, in a community hospital. That understanding is no longer there. The confusion over the past eight years over the changing role of community hospitals is causing an element of concern and distress. Will the Minister explain how community hospitals fit into that?

On continuing healthcare, it was also my understanding that, once assessed, a patient would remain on that assessment for a prolonged period. That changed in September 2008: following six weeks on continuing health care, that category is now reassessed. Who makes those assessments? I understand that there is an assessor from the PCT and a social worker, but it is not clear who has the final say in each case and who can appeal. I hope to return to that point.

There is a lack of transparency and a clear understanding about the criteria for the allocation by PCTs of beds for the elderly, especially when a patient moves from an acute to a community hospital and when trying to vacate places in the latter over the long term. The way in which the criteria are applied is causing anxiety for patients and distress for families. This month, the Public Accounts Committee, dealing with terminally ill patients, reported:

“People who die in hospital are not always afforded the end of life care they deserve”.

It also concluded that patients are not always treated with “dignity” and “respect”. Patients sometimes have difficulty eating and drinking, which I found hurtful in my own experience. When a close member of the family makes themselves available to hydrate and feed the patient, that needs to be handled very sensitively. Those with such difficulties need particular care, and surely it is in the interests of the Government, the health service and the wider community that family members be encouraged to assist the patient in eating and drinking—hydrating and taking the right nutrition.

Over the past 10 years, the Government have engaged in various reorganisations of health care, but, somewhere along the line, have lost sight of the plight of elderly patients, in the view of the PAC. Clearly, this problem will not go away, but will increase, given that we are all living longer, owing to improved health care and scientific and medical advances, which obviously we all welcome. However, as part of the Government’s approach of meddling, the criteria for caring for the elderly in community hospitals have changed. I am finding it very difficult to get to the bottom of that change, and I would be very grateful if the Minister were to elaborate .

In addition to wanting to understand the process, both retrospectively and for the future, is the thrust of my hon. Friend’s anxiety that, in the absence of knowing who ultimately takes a decision, there is no sense of accountability or, indeed, opportunity to negotiate or review a decision, when it does not appear to have been taken on primarily clinical grounds?

There is a problem with both accountability and transparency. We need to know what the criteria are, who takes the decision and what the appeal mechanism is. A second concern is that decisions should be taken primarily on clinical need. I will elaborate on what I think about continuing health care assessment and why it is flawed. Thirdly, and perhaps most importantly, the system seems to be driven on a cost-efficiency basis. I do not think that we can put a price on health care. Someone who has had a good life and lived to a good age deserves to be given by the health service and the community both dignity and a “good death”. I am most grateful to my hon. Friend for allowing me to elaborate on those three points.

Let me expand on the continuing health care assessment, which is the nub of the problem. In my mother’s case, 12 boxes had to be filled in. Even to a lay person, it was evident that she ticked a sufficient number of boxes, yet she was deemed to have failed the assessment. That obviously caused distress, but as I am capable of standing up for myself, I was able to argue our corner. However, that is not the case for a constituent of mine—I will not disclose her name, because I do not have permission—about whom I have been corresponding with the Department. The health care assessment form that she had to fill in ran to 23 boxes—23 different criteria that had to be met, many of which were obscure and opaque. It is very difficult for a lay person, particularly someone who is a close relative of the patient, to understand the assessment system. If someone is unable to eat, drink, take their medication and is in danger of falling, I would have thought that their condition was so transparent that they would tick all the boxes for continuing health care assessment. It is bewildering for a patient to have to tick 23 boxes for a primary care trust. Often, the options are not sufficiently well explained to the patient. If the case involves an elderly relative, the family need to understand the system to be able to explain it. If the patient is registered blind, profoundly deaf or is not able to read the form themselves, relatives will not make much progress in explaining to them the purport and the importance of the assessment.

Will the Minister explain who sets the criteria, who owns or has responsibility for the beds, and who, in each case, delivers the health care? Obviously, part of that is evident in the location of the bed—whether it is in an acute hospital, a community hospital or another place. Moreover, will the Minister explain who supervises the delivery of the treatment under the continuing health care assessment and does he think that supervision is adequate? I fear that there is evidence of systemic failure in the way in which the criteria of continuing health care assessment are defined. Where does one find the definition? Having seen two or three assessments from different primary care trusts, I understand that there is some fluidity in interpretation.

Community hospitals provide an excellent service. I am fortunate to have two in my constituency—Lambert hospital in Thirsk and St. Monica’s hospital in Easingwold—which provide excellent services close to the homes of local people. Many of the staff live locally and are well integrated in the community. Families, friends and loved ones are easily able to visit the hospitals and the patient can remain close to their own home in fairly familiar surroundings.

My understanding is that there have been significant changes to the role of community hospitals for patients over a six-week period—that arbitrary criterion seems to have been introduced in the past eight or nine years. I want to know why the changes have occurred, highlight the difficulties created by the new criteria and draw attention to the unfortunate results that they are producing locally in the care for the elderly.

It is true that funding for the NHS has risen consistently under both Labour and Conservative Governments since it was founded in 1948. Yet, while the Government have nearly doubled spending over the past few years, the number of beds has reduced overall. In particular, the number of beds available for the elderly has reduced by a larger proportion than any other beds. It looks as though money is being spent on management, bureaucracy, form-filling and pointless and endless reorganisations. We now have strategic health authorities. We had a primary care trust for the whole county—York and North Yorkshire—then four separate PCTs and now we have just one to cover the whole county. I am referring only to the PCTs. If we consider the ambulance service as well, we will see that the number of reorganisations throughout the NHS is bewildering. Surely it is the Government’s hope to ease the distress of elderly patients and restore their dignity by drawing attention to such issues.

In the time that I have been preparing for this debate—I am sure that the Minister is aware of this—the Public Accounts Committee has published a report on end-of-life care. Paragraph 2 is striking:

“People who die in hospital are not always afforded the end of life care they deserve, including effective pain management and being treated with dignity and respect.”

The report goes on to say that when

“someone is approaching the end of life it should not mean we abandon concern for their quality of life”.

Paragraph 3 states:

“Lack of co-ordination between health and social care services mean that peoples’ preferences for care are not always communicated effectively.”

That confirms the thrust of my earlier remarks. The report continues:

“People nearing the end of their life should be allocated a single health or social care professional contact to improve the co-ordination of care between services and providers.”

I know that it is the intention of the Government and the NHS to have a welcoming nurse for the patient when they are admitted to hospital. In my experience, and in the experiences of my constituents, that is not happening. Often even simple things are not done properly. For example, handovers at the beginning and end of each round are not as full as they should be, particularly when all beds are occupied. When a patient is admitted to hospital and given a terminal diagnosis, the GP should be informed of their condition. When that patient is discharged, a package on the continuing health care assessment is then given to their GP, but for the weeks or months that a patient is in hospital, GPs are kept out of the picture.

It is also wrong that an individual should see seven doctors in as many weeks. Continuity of care should mean, as far as possible, that a patient has a dedicated nurse and doctor—unless the doctor is on holiday or otherwise absent. I take some comfort from the PAC report.

The fourth conclusion states:

“There is a lack of education and training in basic end of life care.”

That is staggering. In the body of the report—paragraph 14 —the PAC states:

“A survey of doctors and nurses carried out by the National Audit Office found that only 29% of doctors and 18% of nurses had received any pre-registration training in end of life care.”

It is perhaps a good moment to pause and say that I am heavily related to the medical profession: my father was a GP; my brother is a practising GP; my uncle was a consultant surgeon; and we had two or three pharmacists in the family as well—I was never going to go into medical practice, because I do not do very well with the sight of blood. I have always understood that a good bedside manner is important for medical practitioners, and I am sure that for previous generations end-of-life care training was a priority, so what has changed? Staggeringly, less than 30 per cent. of doctors and 20 per cent. of nurses receive any pre-registration training, and they are the people to whom families and patients look to guide them through what is the most traumatic stage of life.

The PAC report goes on to state:

“Primary Care Trusts have limited understanding of the local demand for and the cost-effectiveness of their commissioning of end of life care services. Trusts should use the commissioning guidance provided…and benchmarking information provided by the National Audit Office, to assist them in allocating resources more effectively.”

I am sure that the Minister will want to consider that in the context of my earlier remarks.

The report continues:

“There is a risk that the additional”

money that the Government have

“committed to improving end of life care will not be used as intended.”

How does the Minister expect PCTs to account for how the additional money will be spent and how will information be fed back to the trusts to allow them to benchmark their performance in improving service quality?

The report states:

“There has been limited formal evaluation of the patient benefits associated with approaches intended to improve end of life care such as the Gold Standards Framework. The Department should”—

urgently—

“commission clinical evaluations to determine whether use of such approaches results directly in higher quality care.”

Will the Minister take this opportunity to comment on that?

The report also states:

“Some 70% of independent hospices have only one year contracts with the NHS and for 97% the funding they receive does not cover fully the costs of the NHS services they provide.”

That we are so dependent on hospices, as voluntary organisations, to provide end-of-life care will set many alarm bells ringing.

The report concludes:

“More people could be supported to die in their homes or in a care home if there was a more responsive system for providing the equipment and support services needed.”

On that, I return to the continuing health care assessment. Will the Minister explain how rapidly the equipment can be put in someone’s home? How close are we to the provision of 24-hour care in the home and are there big differences between the level of care that can be provided by two adjoining PCTs, for example, between the North Yorkshire and York PCT and the County Durham PCT? The report states:

“The Department should review how requests for equipment and other assistance that support people to remain in their homes are handled, and identify ways of improving the speed and flexibility of the provision of such services.”

I welcome this opportunity to set out my concerns. I hope that the Minister realises that my constituent’s mother died in January, and that now, in May, she is still chasing the PCT, which does not cover my constituency. That situation has caused enormous human distress. I hope the Minister elaborates, so that I can go back and explain to my constituents how the continuing health care assessment works, who in the PCT is responsible for taking such decisions and what the appeal mechanism is. Will he satisfy me that when the PCT takes such decisions, it does so on the basis of clinical need, and that the matter should not be seen, as it currently is, as a tick-box exercise for those who are approaching their final days?

The most worrying thing that emerges from the debate is the lack of education and training of professionals in basic end-of-life care, and the fact that people who die in hospital are not always afforded the end-of-life care, dignity and respect, effective management, hydration and nutrition that they deserve. If I achieve anything through this debate, I want to see a single professional contact and perhaps a review of the system for the allocation of beds by PCTs. I am most grateful to have had the opportunity to discuss this matter today.

I am grateful to you, Mr. Cook, for allowing me to say a few words, and I congratulate the hon. Member for Vale of York (Miss McIntosh), both on bringing to the House a subject of growing importance, and on dealing with it in a sensitive and thoughtful way.

Care of the elderly is a measure of the civilisation of our society. When people are at the end of their lives, it is a stressful time for them and their families, and they require a lot of dignity and respect. I declare an interest: my son is a consultant neurosurgeon who treats some of the hon. Lady’s constituents at the neurosurgical centre in Hull and he often allocates beds for elderly people.

In January this year, Help the Aged, which is merging with Age Concern to make a single charity that will lobby on behalf of elderly people, and the British Geriatrics Society, produced a report in which they highlighted the fact that almost half the doctors who specialise in health care for the elderly think that the NHS is institutionally ageist. That is a worrying statistic, and I will say more about it.

First, we should put this debate in context. In the past decade, the Government have increased by a phenomenal amount the resources going into health care, on which they are to be warmly congratulated and for which they should be thanked. I am sure that whoever forms the next Government will continue that process but, unfortunately, the outcomes in the health service are not perceived to have increased or improved at the same rate, never more so than in relation to this matter, probably because people are living longer, which is a blessing. The average life span is about 83 years for ladies, and 78 years for men—I am hoping that the next Government will allow sex changes on the NHS because when I am 77, I intend to go for a sex change. More seriously, the demands for care are growing consistently and will continue to do so.

The hon. Lady made the valid point that there are insufficient beds, but the really important point is patient choice. It is not so much a matter of how many beds there are in any one part of the system, but of ensuring that there is the right number of beds in each part of the system, however many that is. There are different ways of caring for people when they are elderly or terminally ill, and it is important to ensure that there are sufficient beds in each part of the system to care for them, and to enable them to have choice between acute hospitals, community hospitals, the hospice service, nursing homes and family care at home. Different people will make different choices as to how they want to spend their last weeks, months and years.

I will focus on hospices, because the number of hospice beds determines how many beds will be needed in the NHS. I am grateful to the Government for the funding of the adult hospice sector—much more so than for the funding of the children’s hospice sector, which is a different matter. The Government are funding the sector generously, but we must ensure that hospices remain essentially voluntary organisations funded by charitable donations, as that is their ethos and character, which is a good thing. However, we must also ensure that any care given by hospices that displaces care that would otherwise have to be given by the national health care service, and would thus involve providing beds, is properly funded. The NHS and the Government must continue to work with hospice centres to develop a proper service agreement under which the care provided by hospices is funded by the NHS, so that hospices can continue to provide service and increase service to meet demand. I know that the Minister is sympathetic.

The right hon. Lady—excuse me, the hon. Lady; she should be a right hon. Lady—made some excellent points on nursing homes, but the problem with nursing homes is the formula for deciding how much a family must pay in top-up fees for the bed provided. I am aware of one case involving a lady who had a stroke eight years ago and has not said a word since. She is doubly incontinent and cannot speak, stand, eat or support herself sitting up, yet her family must pay several hundred pounds a month in top-up fees for what is obviously nursing care, which traditionally would have been provided in a long-term hospital bed. Eight years after the stroke, the family is having great difficulty paying the top-up fee. The lady was reassessed recently, but the family must still pay just over £106 a week in top-up fees. That is not good enough.

The Government are short-changing not only families but themselves, as the situation means that people stay in hospitals because they are not happy to move to homes. The Government are missing a trick. If they were a little more generous, and ensured that social services were more generous in assessing the nursing care element, we could get more people into residential homes where they would have society and a better quality of life and would be nearer their families. All in all, that would be a good deal for the individual and for the public purse.

On care at home by the family, there are some wonderful, heroic families who care for loved ones at the end of their life. They can do so only because of the fantastic support that they are given by Macmillan nurses, who take a lot of pressure off the NHS to provide beds in hospitals. We must never lose an opportunity both to congratulate Macmillan nurses on what they do and to promote their activities.

I have probably said enough, so I will end by quoting Help the Aged and the British Geriatrics Society, which said that the NHS must

“stop being service-led and become people-centred”,

and must do it soon. I know that the Minister is doing all that he can to move in that direction.

Right hon. and hon. Members will see that there are 57 minutes left before we must move on to our next topic for debate. As we have three Members who wish to make winding-up speeches, I expect each speaker to take no more than 18 minutes.

Thank you, Mr. Cook. I will take nothing like 18 minutes, to the relief of right hon. and hon. Members. I congratulate the hon. Member for Vale of York (Miss McIntosh) on securing this debate, and on her persistence on the issue. At the end of last week, I had the pleasure of walking through her constituency, which was enjoyable. I did the Ebor way as part of my training for the 126-mile challenge that I am supposed to be finishing this weekend. When I got to my own constituency, the weather changed somewhat, and it became rather less pleasurable. I am sporting an enormous blister on my left foot, which is something of a challenge.

The issue that we are debating is enormously important, and the hon. Lady is right to raise it. To echo the comments that have already been made, I think that all of us appreciate the wonderful work done in the NHS and in many care homes to look after our older people and ensure that they have the care and dignity that they deserve. That is not always the case, but a lot of wonderful work goes on, and it is important to recognise that.

Older people are the largest single demographic using NHS services. Despite that fact, the NHS is all too often not geared to the needs of older people. That lies at the heart of some of the problems that we often discuss in debates attended by the right hon. and hon. Members here today, who have a particular interest in the needs and rights of older people in health and community care.

The age of 60 is no longer old. People of 60 are still running marathons; I ran one a few weeks ago alongside people in their 60s, their 70s and even, amazingly, their 80s. Yet in the health service, people who reach 60 are suddenly regarded as older, or “elderly”, to use the term in the title of this debate. We must face the fact that despite attempts to counter the problem with measures such as the Equality Bill, which is going through Parliament, institutional ageism still exists within our health services, to echo the point made by the hon. Member for Castle Point (Bob Spink). That is simply not acceptable. All too often, older people’s needs are not met in hospital. Adequate provision is not made for conditions that are particularly, although not exclusively, related to older people, such as incontinence. That is a huge part of the problem.

We are all aware that funding for the NHS is a concern. The simple reality is that savings will have to be made in this difficult economic climate. The Budget estimates that those savings need to be about 3 per cent., or £10.5 billion, and that £500 million of savings have already been made. My first point to the Minister—and I am sure that we would all agree—is that the needs of older people, which I am afraid are not always met, as we heard from the hon. Member for Vale of York, must not be seen as an easy place to make further efficiency savings.

The Budget says that savings will be made partly by reducing the length of stay of people in hospital. Where clinically appropriate, that is something that we all support, but there is a concern about older people who are not necessarily so ill that they need to be in hospital but whose communities lack the facilities to deal with their needs. They may be simply too weak to live at home and cope alone, and I am afraid that they do not get the care that they need through local authorities to be able to do so. All too often, an unfortunate cycle arises. Older people are discharged from hospital back to their home, yet without the care and support that they need, they simply deteriorate, become ill again and are readmitted. The situation costs the health service huge amounts of money, because we are not dealing with people in a way that enables them to carry on without the need to go into hospital.

Primary care trusts’ funding is weighted by the number of older people in their area. We would therefore expect areas with more elderly people to have better care provision, but I do not think that the figures bear that out. One problem—this is a debate that we have had on many subjects—is that there is no ring-fencing. Surely, if there is a failure across the country to address the problem of dealing with older people who are not ill enough to be in hospital but clearly need a higher level of support, there must be some way to ensure that money is spent where it is needed.

Although this debate is about older people, my simple point is that whether or not people should be in a hospital or community hospital should be judged on their individual needs, regardless of age. Having said that, account must be taken of the particular situation that older people are in. Clinical judgments must take account of what will happen if the person is discharged from hospital. Too often, older people do not receive sufficient care in the community to prevent them from becoming ill again and returning to hospital. Although they are important, PCT criteria will continue to mask the problem until we break that cycle. There must be a principle of providing proper support in the community.

Emergency admissions of older people have risen in recent years, and that costs money. It is not ideal to keep older people in hospital for any length of time. They face particular problem such as being more susceptible to health care-acquired infections, and that will continue until there is more investment in community care and a better system of care funding up and down the country. That is what it boils down to.

On the other side of coin, we must look at the problem of bed blocking. Department of Health figures show that during one week in March 2008, some 2,232 people across the country suffered a delayed discharge from hospital. Beds are being used that need not be used if care in the community was adequate. The issue is not only about cost, but about people of all ages being unable to get the hospital beds that they need.

The hon. Member for Vale of York mentioned the end-of-life strategy, but that does not wholly relate to the subject of this debate, because many older people who go in and out of hospital are not at the end of their lives. We can and should enable such people to carry on living full lives for many years. However, end-of-life care is a particular issue for older people. As the hon. Lady said, about 40 per cent. of people who die in hospital do not have medical needs and therefore do not need to be there. A strong preference for dying at home was shown in the Public Accounts Committee report that she quoted. Despite that, 60 per cent. of deaths occur in acute hospitals. In many cases, the person has no clinical need to be there. Only 18 per cent. of people die at home.

Interestingly, the figures on the proportion of people who die in acute hospitals across different PCTs range from 46 to 77 per cent. In some parts of the country, more than three quarters of people die in hospital. As I have said, 40 per cent. of people who die in hospital do not have medical needs and so do not have to be there. We are therefore failing on both counts.

To echo the hon. Member for Castle Point, it is impossible not to mention the fact that the Government have invested heavily in the NHS. They are to be commended on that investment. At the end of the Government’s life, which is approaching, they will be able to say that they have put a lot of emphasis on the NHS. They can present that as a success. Nevertheless, the system of care for older people in this country is an acute and abject failure for this Government. Tony Blair infamously said that he did not want to live in a country in which people had to sell their homes to pay for care. Despite that, the Government have done precious little to address the system of care funding.

People have no idea what they are entitled to. In fact, they are entitled to very little unless they sell their house and drain a large amount from their savings, or they already live in poverty and so qualify for certain benefits. We do not have the national system of entitlement for older people that we need. I wait with interest to hear both the Conservative and Government policies for the next election. We have stuck our neck above the parapet with the Liberal Democrat minimum care entitlement policy, which states that every older person in this country should have some entitlement to care. I look forward to the debate on how much people should be entitled to if we go down that road. It pretty much follows the Wanless model. If people know that they have an entitlement, they can plan and have some security in older age.

We believe that our policy would go a long way towards stopping the cycle of people being discharged from hospital without adequate provision, getting ill again and blocking hospital beds unnecessarily. In the limited time that remains for them, how do the Government propose to deal with that problem, which they have not dealt with so far? There is a dual challenge and it is not easy to solve. Will the Minister give us some idea of how the Government intend to deal with it? Until this important challenge is addressed, we will not meet the needs of older people in our country, and everyone would agree that that is not acceptable.

In this House, we often speak of our constituents’ experiences and of our professional experiences. It is rare that hon. Members draw on their personal experiences when advocating for others. I congratulate my hon. Friend the Member for Vale of York (Miss McIntosh) on securing this important debate. By speaking up for her constituents, she has spoken for all our constituents. I pay tribute to her candour and courage in relating her recent experiences as a caring daughter to her mother.

My hon. Friend’s speech was shot through with a sense of the quality of our NHS. She stated that our focus on care and what we mean by care defines how civilised we are as a society. I agree that whenever we discuss these matters, we must repeat our admiration and support for all the care workers and professionals in the NHS. That is a personal matter for me because my wife is an NHS-trained nurse—she has specialised in caring for the elderly and more recently has become a hospice nurse. My hon. Friend’s comments are apposite to the aim we all share of providing the best possible care for people throughout their lives, and particularly as they approach the end of their lives. She is right that nurses tend to be the apex of that consideration.

The case that my hon. Friend described raises serious questions about the reality of local policies. The complexity of allocating beds to elderly patients reflects the complexities of morbidity and mortality as age progresses. Allocation is linked to issues such as cancer, palliative care, and intermediate and continuing care policies. Issues of quality are also linked to the bed, once it has been allocated, particularly in relation to the Government’s dignity in care agenda.

In the wake of the Staffordshire general hospital case, we must discuss bed provision in hospitals. One of the Healthcare Commission’s criticisms was about insufficient beds. In 2007-08, the number of NHS beds was cut by 4 per cent.—6,722 beds—and in the past three years, as the NHS has struggled to recover from deficits, the number of beds has been cut by 11 per cent., or 20,699. It is important to emphasise the point that my hon. Friend made, citing a further statistic, about the disproportionately negative effect that that has had on geriatric beds and elderly people. Bed occupancy is still too high, running at more than 95 per cent. in some trusts.

I recognise, however, that bed cuts are a crude measure. Better care should lead to a reduction in beds, but it is not clear that the relationship is organic, as is testified by the Government’s recent failure to bring superbugs adequately under control, to deliver on single-sex wards, to provide isolation beds or to prevent the tragedy at Stafford. Sir George Alberti makes telling comments in his review of Stafford, noting that there are serious problems around bed management. Of the emergency admissions unit, he says:

“There are officially 37 beds in the unit but this has been increased to 49. The layout is poor and there are insufficient nurses, particularly to manage the extra number of beds.”

That point emphasises that there must be proper staff resources for the number of beds in place. It also has ramifications for the dignity agenda. Will the Minister confirm how many hospitals are operating beds, or wards with beds, in excess of their official capacity? If he cannot do that immediately, will he ask his officials to grant that information by writing letters to hon. Members who have attended the debate?

Alberti also recommended that patients should be reviewed at 11 o’clock every morning, seven days a week, to see whether they could be discharged. It is important that bed blocking is avoided, but the reverse is also true, and patients must not be turfed out of their bed for anything other than clinical reasons—my hon. Friend the Member for Vale of York argued that point emphatically. Will the Minister explain what safeguards are in place? If it cannot be demonstrated that the only criterion, or the overwhelming priority criterion, is clinical, the only other default position, which might be addressed under the term “administration” or “efficiency”, would, at the end of the day, be a cost consideration. That seems completely inappropriate if we want to give people the best possible care, particularly as they approach the end of their life.

There is a more important issue, and I thought it rather strange that the Alberti report did not address this. It is clinically critical, particularly for good nursing—it has certainly been proven to be best practice since time immemorial—to start discharge planning the moment a patient arrives in a bed. That applies even when the patient appears to be moving towards the end of their life, or when it is too early to determine whether there will be an opportunity to discharge them or whether they are approaching the end of their life, in which case consideration should be given to whether that will be in hospital or whether the patient will be given a choice about where to die.

My hon. Friend is examining this issue very thoroughly, but the concept of early discharge when a patient has been in a new situation for only one day or one week causes the most distress. How can we handle that more sensitively, rather than making the patient feel unwelcome when they have been there for only a short time?

My hon. Friend’s question helps to make this point clear. We must ensure that the emphasis is right. Early discharge should occur only on clinical grounds—in that sense, it is not early, but appropriate. Early discharge is never really justified because, if it is early, it is happening before it would be considered appropriate on clinical grounds. Perhaps her intervention will help me to clarify that I am arguing not for early discharge, but for a process of discharge planning that starts as soon as a patient arrives in a bed. That is good clinical practice, because part of getting patients as well as possible is looking at how that can be achieved in the shortest possible time with the maximum possible care and dignity. That is especially important where there is high capacity utilisation of beds, the numbers of which are reducing, particularly for elderly patients in acute and hospital settings.

Not only are bed numbers reducing, but there is a real lack of intermediate care beds, as has been debated by Front Benchers before. In Winsford, in my constituency, a former care home was converted into Elmhurst intermediate care centre, which opened recently. That NHS asset had been lying redundant for far too long—many of us campaigned and argued about it—and eventually the local NHS hospitals trust, which covers Leyton hospital and the Victoria infirmary in Northwich, decided to convert it into a 30-bed intermediate and rehabilitation care centre to provide around-the-clock NHS care outside the hospital setting. I have visited it, of course, and met the staff, management and patients, and it was encouraging to see the progress that patients were making, and that they were receiving great care and were very enthusiastic about the centre.

Such an approach is appropriate for rehabilitation, mainly for elderly people, not all of whom will go home. It provides an opportunity to avoid what seems to happen most of the time, when there is an emergency of trying to find a bed for continuing or later care, but the family are not ready. It gives people time to prepare and offers the patient a chance not only to recover medically, but to regain some of the confidence that is often lost as a result of a medical procedure. That work among Mid Cheshire Hospitals NHS foundation trust, the Central and Eastern Cheshire primary care trust—my hon. Friend made a key point about PCT involvement and who has true accountability—and Cheshire East Community Health shows how powerful it can be to work outside silos. We need much more of that kind of provision through the allocation of resources across the NHS. However, there must be a consideration of accountability and the question about who should ultimately take decisions on provision and allocation.

The elderly who are allocated beds are often receiving palliation. I am in no way suggesting that the state should try to usurp the fantastic work done by volunteers and professionals throughout the country in the hospice sector—no doubt the Minister will discuss the actions that the Government have taken on end-of-life care. The “End of Life Care Strategy” was published last July, although it was twice delayed. The headlines were about moving care away from hospices and into homes, and about various initiatives on the quality and continuity of care. That is an appropriate trend. St. Luke’s hospice in Winsford, with which I am very familiar, has a limited number of beds, but an awful lot of the best care can be given by finding ways of extending the great expertise within the hospice into homes and communities and into supporting the families and volunteers who can give people the dignity and, above all, care that they need.

There have been missed opportunities on moving towards an outcome-focused model of care in relation to what is described as a “good death”. Progress is demonstrated by the fact that we now talk about “good death” in Westminster debates. One has to track back only a few years to see when politicians were not using such phrases, in the same way that they sought never to be photographed when visiting prisons because they were concerned about the image that might be created. We are now talking openly about this, which shows important progress on debates about this sector, and we are refusing to withdraw from the issues that need to be tackled.

We need to continue to press the Government to consider delivering a tariff for palliative care, which has formed part of the debate about the future funding of hospices. In his previous role, the Prime Minister promised that, by April 2006, charities would not be subsidised by the taxpayer, yet that continues to happen in hospices across the length and breadth of the country, which is why the tariff would be a great step forward.

It is telling that the Darzi review, out of which the final iteration of the “End of Life Care Strategy” arose, mentioned palliative care only once. My hon. Friend made some important points that we need to bear in mind about not only the quality of end-of-life care, but training in it—as I said, I have a specific reason to be aware of how important that training is. Furthermore, none of the strategic health authority reports mention dignity as a key part of end-of-life care. Dignity does not just mean giving someone the option to die in a place of their choosing; it means receiving good care in that place and retaining the respect of self and others in the final days of life.

The Minister and I are unlikely to agree on my next point, which was also raised by my hon. Friend. I believe—I have been pressing this matter for a while—that the biggest scandal surrounding dignity in care has been malnutrition. Figures that I uncovered through parliamentary questions earlier this year revealed that in 2007—the last year for which figures are available—malnutrition killed 242 people in NHS hospitals. That marks a 20 per cent. increase in the number of people dying from malnutrition in hospitals since 1997. Conversely, the number of people dying in care homes from malnutrition has halved.

The regional increases were as big as 50 per cent. in the east midlands and 30 per cent. in the north-west and south-east. In fact, since 1997, 2,656 people have died from malnutrition in England, with the poorest performing regions being the west midlands, where 380 people have died from malnutrition in hospital, and the south-east, where 348 people have died. That is simply not good enough. I urge the Minister not to dispute the statistics, which is what happened during one of our first exchanges about the situation, but to recognise that, whatever his understanding of the statistical base, we need to get to grips with the problem. Such things are avoidable and can be corrected by giving nurses the chance to continue to offer the type of care that they would like to deliver, rather than deflecting them away from ensuring that nourishment is given.

Moreover, it is important to pick up my hon. Friend’s point about the care context of anybody who is moving towards the end of life or is in a very vulnerable and disabled state. It is important that care professionals encourage family members and other supporters to help with nutrition arrangements, because delivering nutrition is often quite boring and takes an awful lot of time. Nutrition is absolutely vital. It is ultimately one of the great tests of care for any trained nurse—they are, above all, motivated to care.

Finally, I shall mention continuing care, which has been a continuous bugbear for the Government. It is a complex issue because it sits at the interface between health and social care. Countless councils will testify that it is in relation to continuing care that PCTs first shed responsibilities in times of financial difficulties, because they know that the means-tested social care system might pick up the person and the tab. In June 2007, London Councils revealed that 13 boroughs had to provide £15 million to cover services heretofore provided by PCTs.

I hope that the Minister will address the serious concerns raised—I am sure that he will try to do so—particularly in relation to the number of beds in the NHS, and the issues of palliative care and dignity within that. It is increasingly clear that the failures of local health chiefs are not primarily to blame; it is the systemic failure of an ill-thought policy. We need to rethink that and show some leadership. Above all, we need to present patients—particularly as they approach the end of life—their families and those who really care the chance not only to make choices, but to get the care and dignity that they need. There should be accountability for the decisions made and those decisions should be taken on the basis of providing the best care, and according to clinical criteria, instead of people simply being offered what can be afforded because, at a time when someone needs to focus on care and dignity, they least wish to be confronted with purely financial choices.

I congratulate the hon. Member for Vale of York (Miss McIntosh) on securing the debate. Care for the elderly and for people at the end of life affects us all—whether it is for ourselves or the ones we love. I express my deepest sympathy, and that of the Secretary of State, to the hon. Lady on the recent loss of her mother. I am grateful not only for the general comments she made about the excellent work being done by NHS staff up and down the country, but for her praise for the doctors and nurses at Darlington Memorial hospital and at Richardson hospital. I add my thanks to them and to the thousands of others who work tirelessly to give their patients the best possible health care in an atmosphere of dignity and respect—especially for those who have reached the end of their lives.

I would also like to say—the hon. Lady might have already done this and I hope she will forgive me if she has done so—that if she would like to discuss her case with her primary care trust in more detail, I would be happy to facilitate that. I would also be happy to ensure that such a meeting is facilitated in relation to the case of one of her constituents that she mentioned. From what she says, her constituent has been having trouble getting to the bottom of some of the decisions made about the care of her relative.

The hon. Lady raised a number of issues that I will come to in turn: the criteria for allocating beds by PCTs; the funds available for that purpose; how the NHS deals with elderly patients, and the issue of community hospital beds. Decisions about overall service provision for all aspects of health care are made locally by the PCTs that work with the local community and clinicians. PCTs commission the services that they think they need to improve the health care of their populations. With local authorities, PCTs undertake regular local strategic assessments to understand their current and future health needs. They then commission the most appropriate services from a range of providers to meet those needs. As we have heard, those providers might be a hospital, care home, hospice or any other appropriate provider. They are then responsible for delivering the agreed level of service. Specific decisions, for example about bed numbers, will be made to best fulfil contractual obligations and provide the highest possible quality of care.

The hon. Lady raised the overall national decline in geriatric beds. Yes, that has been the case, but there are many more places for older people that are funded by the NHS—both in care homes and in their own homes supported by care home packages. I am sure that she will appreciate that individual decisions about the discharge of a patient can be complex and can involve a range of clinical and social factors. There will always be some difficult borderline cases, and a judgment needs to be made about the best way forward. The patient might return home with a care package, such as regular nursing care, or there might be a move into full-time residential care. Whatever the decision, it should be made in consultation with the patient and their family. Decisions also need to be kept under review, because people’s circumstances and condition can quickly change.

Individual decisions about treatment and discharge must be taken in the best medical interests of the patient by clinical professionals and for no other reason or by any other person. Although the PCT commissions services, including beds, it should play no part in the individual allocation of those beds. The hon. Lady asked a number of questions about what sort of criteria are considered when such decisions are made, and she had a list in relation to her own case. A few issues—they might seem obvious to hon. Members, but they are important—are behaviour, cognition, nutrition, psychological needs, mobility, drugs and medication, skin condition and any other significant needs.

The hon. Lady also asked to what extent patients’ or relatives’ views are taken into account. The national framework for continuing health care sets out the expectation that patients should be at the centre of decision making. They should be supported so that they can be actively involved in those decisions and relatives should be involved, too. She asked who makes the final decision on discharge. If there is some sort of dispute or disagreement, the final decision is made by the multidisciplinary team and the consultant in discussion with the family.

The hon. Lady did not ask this question, but thinking about this debate, I asked my officials whether there might be circumstances in which the wishes of a patient or a relative could be overridden. The answer I received is that the patient’s wishes are at the centre of the decision-making process, but the clinical well-being and needs of the patient may mean that it is not possible to meet them. For example, a patient might desperately want to go home, but the clinicians may decide that they would not be able to look after themselves, and do not have the necessary support at home to do so. In some exceptional circumstances, there will be a need for a clinical override.

I know that systems are in place and that guidance has been given, but they are simply not working. I cite a case that arose a week ago. A constituent from Canvey island was taken to Southend hospital, then discharged to a nursing home in Southend without the family’s permission or knowledge. She was not cared for properly at the nursing home, she did not take food, and she ended up back in Southend hospital. The family wanted very much for her to be moved back to Canvey island, where there are places in residential and nursing homes where she could receive care. I hope that that will now take place, but the system is not working.

The hon. Gentleman raises an individual case. As I indicated in my remarks, some decisions are difficult and some are borderline. In a service as big as the NHS, which deals with many people every day of the year, decisions will, unfortunately, occasionally be made which perhaps are not correct.

What is important is that if patients or their relatives believe that a decision is wrong, they come forward and make that clear to the people who made the decision. They need to appeal and take the matter up with the PCT. I would invite the hon. Gentleman, if he has not already done so, to raise the case with the PCT.

The problem has been sorted, perhaps with the hon. Gentleman’s help. His help should not have been required to sort it, but we are all human beings, and mistakes can be made. What is important is that if they are made, they are rectified as quickly as possible to the satisfaction of patients and their families.

I am grateful for the thoroughness with which the Minister is responding. He mentioned the number of beds, but has not yet touched on the change in the role of community hospitals and the length of time that patients can stay in them, or the point, which was touched on by the hon. Member for Leeds, North-West (Greg Mulholland), about patients who are taken out of hospital, put into a care home or their own home, then readmitted in a short time as an emergency case. The Minister has also not dealt with my remarks about the thrust of Government policy to close council-run care homes. There was a consultation, which I believe has concluded. The perverse effect will be less patient choice, because there will be fewer care home beds in local authority control.

I was about to address those points, and I still have a bit of time to do so. However, if at the end of my remarks the hon. Lady feels that there are questions that I have not addressed, I would be happy to write to her about them.

The hon. Lady specifically asked how rapidly equipment could be put into someone’s home to facilitate their return home. I am advised that it can take several days, and that it depends on how long the occupational therapist takes to do the assessment. If specialist equipment is required, it could take longer.

The hon. Lady highlighted what she believes to be possible differences in policies and quality of care between PCTs. The national continuing health care framework is designed to ensure consistency across all PCTs. However, we recognise that there are still variations, and my Department is working hard to try to remove them. The national service framework for older people sets out the standard of care that all PCTs should provide, and therefore quality should be more consistent across all PCTs. We are working hard to ensure that that is the case.

The hon. Lady asked why general practitioners were not routinely informed. GPs are not normally involved or informed when a patient is in hospital. However, they should be informed as part of the normal discharge process, and they should also be invited to become involved in continuing care decision making, although attendance may depend on the GP’s availability at any given time.

The hon. Lady asked about training for NHS staff in end-of-life care. Additional funding has been found for training the work force in end-of-life needs and has been given to all strategic health authorities for the financial year 2009-10. She made a point about the rules changing in her community hospitals. I hope that she will forgive me, but I have not been able to get an answer on that in the time that we have had available during the debate, but I will write to her and hopefully provide the answer that she requires.

I am grateful to the Minister for allowing me to make this point. My understanding is that the Government changed the role of community hospitals across the piece, not just in the Vale of York. It used to be possible to receive long-term end-of-life care in community hospitals, particularly in areas that had hospice facilities in such hospitals or did not have hospice facilities. My understanding is that it was Government policy that made the change nationally, not just in one specific constituency.

If the hon. Lady will forgive me, I will have to write to her with clarification. My understanding is that the policy in the particular hospital where her mother was staying is not to keep patients long term. I will have to write with clarification, if she will allow me to do so.

The hon. Member for Leeds, North-West (Greg Mulholland) raised the issue of delayed transfers. We acknowledge that they have been a problem in the past and still are a problem, but the number of delayed transfers has fallen dramatically since 2001. In 2007-08, there were 2,235 delayed discharges from 85,119 acute care beds, equating to 2.6 per cent. of all occupied acute care beds. That was down from more than 7,000 in 2001, so there has been a dramatic fall. However, I accept that we still have more to do, and we will work hard to ensure that we build on the progress that has been made in recent years.

I would like to make a few more general remarks about issues that have been raised by hon. Members, and explain what the Government are doing to improve the quality of care generally for older people. The transforming community services programme supports the NHS in delivering the commitment that we made in “NHS Next Stage Review: Our vision for primary and community care” to create modern, responsive community services of a consistently high standard. The programme seeks to improve the amount of information available about services, patient outcomes, quality and the overall patient experience. It also supports new models of service delivery as PCT provision is separated from PCT commissioning.

Many elderly people enjoy good health in their later years, but that is not always the case. A central objective for all NHS providers is to build care around the needs of each individual. That personalised care planning approach is the same for everyone, including the elderly. For a patient with a long-term condition, personalised care planning that is tailored around their lifestyle and aspirations provides them and their carers with information and self-management advice to help them to learn about their condition, and find out how best to manage it and how it will affect their life.

Most hon. Members will acknowledge that many people die well. At the end of their lives, they are cared for with dignity and respect, surrounded by their family and friends in an environment in which they feel comfortable and safe. They experience care that is well co-ordinated, holistic and ethical with regard to their personal beliefs and preferences.

I spoke about nutrition, and my hon. Friend the Member for Eddisbury spoke eloquently about malnutrition, which is a concern for those who provide personal and health care. People go into nursing and the caring professions—I include carers in this as well—because they want to care for patients, regardless of their age. I was shocked by the figures that my hon. Friend gave: there is obviously an increasing problem with malnutrition. I hope that the Minister will take that on board. I was staggered by the fact that the Secretary of State was not aware of initiatives such as those undertaken by the National Patient Safety Agency, as well as the nutrition now programme, which incorporates hydration. This is obviously an area of policy on which the Government must focus.

The hon. Lady is right. It is an important area of Government policy on which we place great priority. I do not want to rehearse my disagreements with the hon. Member for Eddisbury (Mr. O'Brien) over his interpretation of the statistics, but basically we are talking about episodes of care within a hospital. Often, if an elderly patient goes into hospital to be treated for some acute problem or other, their initial episode of care in that hospital is not registered as malnutrition and, although there may be underlying malnutrition as well, the acute problem facing that patient is registered. Of course, by the end of their stay in hospital we all hope that the initial, main reason for their being admitted to hospital has been resolved. Often, their last episode of care in hospital is for the underlying malnutrition, which was already there. The statistics make it look as if people are becoming malnourished in hospital, but that is not so. We have had discussed this matter at length, both in Select Committees and in other arenas, and I do not intend to spend a lot of time going over it again.

As I was saying, I think that most people would accept that many people die well and are able to exercise choice in relation to where they are cared for and where they die. I accept, however, that not enough people experience a death like this. The Government are committed to improving end-of-life care for everyone. As hon. Members have acknowledged, we have developed an end-of-life care strategy specifically to meet the needs of people for whom end-of-life care is not as good as it could or should be. That strategy, published last July, set a clear direction for the future development of services and showed how we can deliver high-quality, responsive services across all settings for all patients and their carers, irrespective of their condition or circumstance.

The measures set out in the end-of-life care strategy are based on what interested parties, stakeholders and others told us what they thought was needed to bring about real improvements in end-of-life care. Included in those measures is provision, first of all, for all patients and carers to have individual care plans recording their preferences and the choices they would like to make, which should be reviewed as the patient’s condition develops and which should be available to everyone who has a legitimate reason to see them, including out-of-hours and emergency care services.

We are investing an additional £286 million in end-of-life services in the two years to 2011, which will more than meet the commitment on funding that we made in our 2005 election manifesto. Much of this additional funding will go directly to primary care trusts, which will, of course, retain the prime responsibility for commissioning services locally.

The hon. Lady and the hon. Member for Eddisbury, the Conservative spokesman, also mentioned the importance of recognising generally that we had better wake up to the challenges presented by our ageing population. There are more people in this country aged over 65 than there are under 16. In the past couple of years, the carers and stroke strategies and, more recently, the dignity, dementia and end-of-life strategies have aimed at starting to improve the care for our most vulnerable older people. We will soon publish our Green Paper, which will look at the sort of care system we want in the longer term. The hon. Member for Leeds, North-West is absolutely right: as a society and a country, we are not unique in the developed world in facing an enormous challenge and some difficult decisions to take about how collectively we decide to fund people’s long-term care. I hope that, when the Green Paper is published, we can have a good, open debate that may lead us to the sort of all-party consensus that we managed to achieve on the future of our pensions policy.

If I have not answered satisfactorily any specific question asked by the hon. Lady, I assure her that I will write to her. If necessary, the Minister of State, Department of Health, my hon. Friend the Member for Corby (Phil Hope), will write to her on issues that fall under his area of responsibility. Treating the elderly with dignity and respect when they fall ill and come to the end of their lives is about much more than strategies and objectives: it is about what makes a decent society. In this country we can be proud that the NHS is there to help everyone, regardless of their wealth or background, but we can always do better.

Sitting suspended.