(13 years, 1 month ago)
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Lord Warner
“(c) the clinical integration of the delivery of health and social care”
Lord Warner
My Lords, as they say in commercial television, welcome back after the break. In moving Amendment 12, I shall speak also to Amendments 16, 17, 182, 183 and 184 tabled in my name and those of other noble Lords. I have also added my name to Amendment 18 to which my noble friend Lord Rooker will speak—I hope. The theme of these amendments is that of giving greater prominence in the Bill to the issue of service integration not just within NHS services, but across the health and social care boundary. At the same time, I will try to give some clearer meaning to this term by offering a definition in Amendment 184. This is a very complex issue and it has not been helped, if I may say so, in some of the public discourse by the way that the term “integration” has been used in a wide variety of ways by different people.
I shall start with some remarks about integration and its relationship to competition, which has been the subject of quite a lot of debate around this Bill and NHS reform. In recent months, the term “integration” has been bandied about as a kind of panacea for the NHS in the challenges it faces, but with little clarity about what it means. The Future Forum put the issue of integration on the map in its report. Some of this affection for integration has grown because it has been seen as a useful term by opponents of competition. They have tried to make the argument stand up that somehow if you have integration of services, you cannot support competition because the two are incompatible. I do not believe that to be true. It is perfectly possible to have the right kind of integration within a competitive market. Kaiser Permanente, among others, has shown this to be the case in the United States. Indeed, it was the very competitiveness of that market which caused Kaiser to offer patients more clinical integration in order to survive and flourish in the marketplace. That integration was done on the basis of reducing the use of in-patient hospital services. It is worth noting that there are NHS-Kaiser Permanente partnerships in six areas of the NHS which are adapting lessons from Kaiser’s experience in the US to apply in this country.
Having got that off my chest, I turn now to the issue of how integration and competition can coexist and how we need to be clear on what we are talking about when we use the term “integration”. There is, I suggest, good and less good integration. Much so-called organisational integration is effectively mergers of providers with little benefit to patients and often involving a reduction in choice. We see this in integration horizontally across organisations of the same kind and vertically between community and hospital services. The former is often done to save costs and reduce competition, while the latter is too often a way of securing patients for in-patient services and maintaining hospital income. Some will disagree with that, but it is certainly a perspective we should think about. Organisational integrations of this kind have sometimes fallen foul of the competition and collaboration panel. They are to be viewed with a sceptical eye, although I accept that integrated commissioning can be a major benefit for patients.
The integration, however, that is likely to benefit patients the most, and the cost structure of the NHS the greatest, is integration that brings together the assessment and delivery of health and social care services at the point of assessment and delivery to the individual person. This is the type of integration we have attempted to define in Amendment 184. At a time when such a large part of the NHS’s work involves patients with long-term conditions, who often require social care as well as healthcare, this is the type of integration that NHS and social care organisations and personnel should be focused on, particularly those commissioning services. These commissioners need to look for a new breed of service integrators who can take responsibility for integrating services for individuals across the health and social care boundary or divide, depending on your perspective. The Conservative’s community care reforms of 20 years ago produced care managers as integrators of social care in a mixed economy of providers. We now need to apply the same thinking to the whole spectrum of health and social care, especially for those with long-term conditions.
None of this will be easy, but if the NHS is to meet the financial and other challenges it faces and reduce its dependence on expensive, often unsustainable and often inappropriate, acute hospital services, it must begin the process of improving service integration at the level of the individual and not just the organisation. It is important that we use the Bill to set a new direction of travel on service integration for both the NHS and the social care worlds. The word “integration” needs to move from a term of rhetorical flourish to a reality that benefits people at the local level.
Of course, simply putting words in a Bill will not on its own change things; they will need to be backed up by changes in the professional culture, the use of IT and the financial reimbursement system. Later in the Bill I shall move amendments to help integration in the areas of tariffs and the use and extension of an electronic patient record. In the mean time, I want to establish a bridgehead in the Bill with this group of amendments that give more prominence to integration and try to define it. My co-signatories will expand on some of the arguments.
I should make it clear that I do not regard the wording of these amendments as the last word on the subject. I am sure they could be improved and they may have consequences for other parts of this leviathan of a Bill that we have failed to spot. I also recognise that the Labour Government had integrated care organisation pilots and that the Department of Health and the King’s Fund are working on the issue of integrated care following the Future Forum report. It is no purpose of these amendments to pre-empt or damage that work. I and my co-signatories are seeking to establish today whether the Minister is up for amending the Bill to give more prominence, more precision and greater reality to the term “integration” to shape the future commissioning and provision of services in ways that will benefit patients. We will be glad to sit down with him and his officials to improve the wording of the amendments and their placement in the Bill. I beg to move.
Lord Patel
I support the amendments to which my name is attached. This is an important issue. As the noble Lord, Lord Warner, mentioned, at some of the seminars we heard the word “integration” used in different forms with no clear definition of what it meant.
Future Forum, of course, put integrated care at the heart of NHS reform, but who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider? What can clinical commissioning groups do to stimulate providers to work together to meet the needs of the patient?
As the noble Lord, Lord Warner, mentioned, integrated care takes many different forms and may involve whole populations; care for particular groups or people with the same diseases; and co-ordination of care for individual service users and carers.
There is good evidence of the benefits of integrated care for whole populations and for older people. There is mixed evidence of its benefits for people with long-term conditions such as diabetes and for people with complex needs. I will return to that later. Of course, Kaiser Permanente is one of the good examples of managing integrated care for long-term conditions but there are not that many.
The commissioning groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. That includes advice on matters of contracting and procurement, outcomes and quality measures to include in contracts, and the tariffs and incentives to use. Work is also needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective care. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more co-ordinated, unplanned care when funding is tight. That will have to involve the providers.
Other factors that appear to support integrated care commissioning include robust performance management, sufficient time and resources from the provider side, and adequate investment in the main stages of the commissioning cycle, such as needs assessment, service design, contracting and tendering, and outcome-based evaluations. As management and resources shrink, there are obvious questions about whether clinical commissioners will have the necessary time and support to plan and contract for changed services in profound ways. To be more specific, there need to be resources at a national level to avoid commissioners at a local level reinventing the wheel many times over.
To turn briefly to long-term conditions, in the next decade the health and social care system will have to contend with an ageing population, increasing numbers of people with complex long-term conditions, budget constraints, increasingly sophisticated and expensive treatments, and rising expectations of what healthcare services should deliver. An integrated care approach to meeting these challenges—through better co-ordination of health and social care services, reducing the fragmentation or duplication of care—has the potential to improve support for the management of these complex needs.
Let me share a true story as an example of the issues here. Somebody approached me just before Second Reading of the health Bill. I mentioned this at one of the seminars and have since checked the authenticity, and visited the person in the hospital where care is currently provided. This person has insulin-dependent diabetes and was found to have an ulcer on the leg. He saw his GP who suggested that dressings would be required to try to heal the ulcer. During the process of that treatment, a specialist diabetic nurse who came in contact with the person suggested that they might be better getting advice from a specialist unit. While the GP suggested that the care provided was satisfactory, the person demanded to be referred to a hospital. By the time he got to the hospital, three of his toes were necrotic. They had to be removed last week. The patient needed an angiogram to decide whether the blood flow was satisfactory so as to put stents in so that he would not lose further parts of his limbs.
As we all know, it is crucial for diabetic patients to avoid certain complications. Good glycaemic control is required to manage that, so that their sight and renal functions do not deteriorate, their cardiovascular functions remain good and they also do not lose limbs because of necroticism. This shows the need for integrated care that requires the whole team to work together. For a start there need to be good records and IT that can transfer information between different carers, GPs, practice nurses, specialist nurses, and specialists in diabetes. There needs to be screening for eyes, kidneys, blood pressure, diet, cardiovascular disease and so on. Most importantly, there needs to be joint training for people who look after these patients, whether that is in the community or in specialist units.
If you are looking for good outcomes for patients, integrated care is what matters. It should be based on the journey of care—the patient pathway of care. That is what we need to establish. I hope, as the noble Lord, Lord Warner, said, that we can have further discussion to try to improve this Bill and see if we can deliver that.
Baroness Murphy
My Lords, this is a topic very close to my heart. The delivery of social care is almost wholly towards people with health problems; if you do not have a health problem, a disorder or disease, you will not be in receipt of social care. But we have always had this curious distinction between who delivers what. We have had these great silos whereby enormous amounts of spending in the health service would be better spent transferred to social care services. We have known that for years and years, but it has not really happened as fast as it should have done.
The commissioning and delivery of services has been almost wholly down these isolated silos. We have tried to chisel away at this over the years with joint trusts for delivery of services to children and other joint trusts for delivery of services to mental health, and so on. But for the mainstream older person coming through healthcare services, we have not had that integration very effectively, and we have therefore wasted money buying health services when we should have been buying social care services. So it is crucial that people get better cost-effective packages of care, which include the whole pathway.
It is also true that we have a system at the moment whereby in the past 20 years we have moved hundreds of thousands of seriously disabled older people out of NHS care into independent sector nursing homes and, in the beginning, local authority care homes and contracted private homes, leaving behind the teams of people—healthcare professionals, medics and nurses who used to care for them in hospitals—completely isolated back in the hospital. They are not delivering those community services that the independent sector nursing homes and local authority care homes so desperately need to provide—comprehensive health and social care service in residential care. It has always seemed extraordinary that we have allowed these silos to grow up, whereby the person sitting in the hospital, the consultant geriatrician or the psychogeriatrician, does not think that it is their business to provide a service for the wider community of patients in their patch. It seems extraordinary to me that we could have got ourselves into this position.
We need something to move back again to a situation in which people think epidemiologically about a community, about how the best services could be provided from vertically integrated care between hospital and community services—and of course that community care must start with what comes from primary care—but also fundamentally from what is commissioned from social care as part of the package. Perhaps we can get it in somewhere in this Bill that we need to do this. We all know about Kaiser Permanente and the examples of how it works in the States. It works very effectively when you can commission from a range of services across health and social care directly. That makes a great deal more sense than trying to narrow the trenches; a trench always pops up somewhere else when you chisel away at a trench between local authorities and NHS authorities. You do not need to do that if you are very clear about commissioning a package of services across the divide and across NHS primary care and social care. This is extraordinarily important as the population continues to age and, without it, we will not be able to generate that wonderful £20 billion of savings that we are always going on about. We will get better value for money if we contract across an integrated care pathway across health and social care.
I do not know whether this is the right point to get this proposal in. Like the noble Lord, Lord Warner, I am sure that it should go somewhere and that we should have a real commitment in the Bill. If it is the right point, we can get people to translate this into the sort of unbundled tariff that we need to get the financial packages right and move away from the counterproductive system of payment by results. Unfortunately, that again tends to fossilise an old-fashioned way of doing things, which is too expensive. I give my full support to this amendment.
Baroness Pitkeathley
My Lords, my name is added to some of these amendments and I will add little to the eloquent speeches of my noble friend and of the noble Baroness and the noble Lord from the Cross Benches. I want to endorse only the important points of principle that they have set out. As someone who has spent a large part of a long working life at the margins or the crossover points between health and social care, I am only too well aware of what goes wrong if you do not have proper integration. It is very important, as the noble Lord, Lord Patel, reminded us, to come at this from the experience of the patient, the user and the carer. Their needs rarely come neatly packaged as health and social care; there is always crossover between them. That is especially true in the case of long-term illness but it is also a concern to those who have had an acute episode, especially in these days when people are discharged early from hospital but still need medical, nursing and social care at home.
Almost 40 years ago, I wrote a book called When I Went Home, a study of patients discharged from a local community hospital. One patient I interviewed said to me, “What I don’t understand is why they don’t talk to each other. Why did they discharge me without arranging it with my family—without even telling my family I was coming home—and why weren’t the services I needed at home all geared up for when I got there?”. I have lost count of the number of times that I have heard this story repeated over the years. Patients, users and carers do not understand different funding mechanisms, professional boundaries or sensitivities about exchanging information—and why should they? We have been saying for at least 40 years that we must improve integration. Let us for goodness’ sake use this reform as a means of achieving more commitment to integration, to which everyone pays such a lot of lip service but which in reality is still sadly lacking.
I must emphasise that we are at a point where not only do we risk not making integration better but where it could become worse if we do not really emphasise the importance of integration in this legislation. I am thinking of things such as the pressure on local authority budgets and on the voluntary sector, which is so often such an important part of an integrated care package. I am thinking of the mismatch in timing between the reforms in social care and those in the health service. I always think, too, that we should remember that it is people, not structures, who promote integration. Those currently employed in health and social care are working in a confused situation. They are often uncertain about their futures and their working relationships. They are therefore really not in a good place for cutting across professional boundaries and perhaps giving up some of their power to develop the flexible ways of working which are so necessary for integrated services. We owe it to them, as well as to the patients, users and carers, to be as explicit as possible about the importance of integration. I hope we will do that in this Bill.
Baroness Cumberlege
My Lords, I would like to make a contribution. I was very interested that the noble Lord, Lord Warner, said in his introduction that he felt that integration was sometimes used as a defence against competition. He cited Kaiser Permanente, as did the noble Lord, Lord Patel. Closer to home, I was really interested to see that Assura Cambridge—Assura is an independent company—was involved in an integrated care organisation. It was a pilot that was designed to improve the quality of end-of-life care locally and to ensure that 50 per cent of patients who knew they were dying would do so in a place of their choice. After five years, the aim is to increase this figure to 75 per cent.
Assura Cambridge, which is a partnership between Assura Medical and 16 GP practices in Cambridge, worked with a range of care providers to plan, co-ordinate and improve the delivery of care to patients in the last year of their lives. The project team was led by Assura Cambridge and included representatives—this is important because it shows real integration—from Cambridge University Hospitals NHS Foundation Trust, Cambridge Community Services, NHS Cambridge, which is the primary care trust, the Cambridge Association to Commission Health and the DoH integrated care organisation pilot team. This collaboration and partnership had a very simple system, which was to use “just in case” bags. The system was adopted to ensure that GPs had the appropriate medicines to hand for terminally ill patients in advance of their need. By taking this very simple step, the integrated care organisation was able to ensure that 87.5 per cent of deaths occurred in the patient’s usual residence or place of choice, compared to only 50 per cent of deaths without using the system.
In this case it was Assura Medical that acted as the glue to ensure that collaboration brought about an integrated solution, which has since exceeded the project’s aspiration. That is very interesting: it needed someone from outside the NHS to bring all these people together. When I talked to some of them, they said, “We haven’t got the time to do that. We just couldn’t fit all that together”. It was an outside organisation that was able to do that.
Recently I went to the Royal College of GPs’ annual conference in Manchester—no, I am sorry, Liverpool; I know there is a great difference between the two, but I have been travelling a lot recently. There was great debate about the ethical issue of GPs commissioning. The person promoting this was Professor Martin Marshall. He asked the audience of GPs—the place was packed—what the most frequent diagnosis that came through their surgery door was. As you might expect, the GPs mentioned coronary heart disease, diabetes and so on. Professor Marshall said, “No, it’s LIS”, and everyone looked very puzzled. He said, “Lost in the system”. I thought that was interesting. “Lost in the system” is the problem when we do not have integration.
It seems to me that integration happens on three levels, so maybe we have to define it more closely. The first is within community services. A GP said to me the other day, “District nursing—they’re the enemy”. When you start at that base, we have an awful lot of work to do just to get integration within the community. As the noble Lord, Lord Patel, said, you have to get the whole team to work, and to work beyond the team as well.
I have done a bit of work with maternity services. This is the next tier up—integration between community and hospitals. One of the things that we have tried very hard to do is to get midwives to have caseloads, so that they are there when the woman is pregnant, looking after her. They will perform the delivery, which will not necessarily be at home—it can be in hospital—and then do the postnatal care. It is brilliant. It is what women want and it provides continuity and integration. Try getting that to work—it is very difficult, because of the territories; hospitals often do not want the community midwives to come in, on to their territory, and perform the delivery. Integration happens in some places but it is very hard to roll out. That is the second tier—the hospital and community tier.
Lord Turnberg
My Lords, I rise to support these amendments. I agree with virtually everything that my noble friend Lord Warner has said. However, I disagreed with the assertion that Clause 2 may not be the right place for the measure. Clause 2 is headed “The Secretary of State’s duty as to improvement in quality of services”. If there is anywhere that needs improvement, it is in the integration of services. Therefore, I think this clause is the ideal place to insert the measure.
There is general agreement that the principle of seamless care—that is another term for integration, from the point of view I am talking about—for individual patients is a good one and we should support it. By that I mean the ease with which patients can move between one set of carers, hospitals, homes and social care and another. At the moment it does not seem to happen as well as it should in many places, so the Bill is, theoretically, a way in which we can stimulate the mechanism by which it can all happen. However, for integration of care between providers to happen with the minimum of disruption to the individual patient, we need to ensure that there is much more collaboration and consultation between them. It is not only between doctors, nurses and other carers that this collaboration is needed, but particularly across the divides between those funding and managing the different care streams. That is where these amendments can help.
At the moment, we have patients waiting for far too long, as we have heard, in an environment unsuited to their needs—elderly patients sitting in acute hospital beds waiting far too long to go home or into social care. A range of problems get in the way, such as a lack of planning, a lack of facilities, or closure at the weekend of offices where these arrangements should be made. To me, integrated care means the close working arrangements that allow not only the rapid and efficient transfer of patients but the ability to discuss the best course of treatment for a given patient. It means the ready consultation between different specialists, perhaps in different hospitals. It means different trusts, whereby patients can have access to the best treatment available.
I am reminded of the example of orthopaedic surgeons, some of whom specialised closely in hand surgery or re-do hip surgery—second operations on hips that have gone wrong the first time round. Those highly specialised orthopaedic surgeons are not available in every hospital. The ability of one group of orthopaedic surgeons to transfer a patient to the best care possible in another hospital should not be thwarted. We should not be putting any barriers to ready consultations and, if necessary, the transfer between hospitals of patients seeking the forms of treatment that are most relevant to them.
Of course, competition is seen as a driver to improving standards. However, let us be clear; there must be a balance between competition and integration, and between competition and collaboration. I am pleased that Monitor will, I believe, have a role in improving integrated care. I hope that we can persuade the commissioners and providers to support integration also. That is why I support these amendments.
The Archbishop of York
My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State’s duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty—already provided for in the first two subsections—will not be carried out. Integrating the delivery of services will be important.
I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.
It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.
Lord Davies of Stamford
My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.
Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire—and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter—that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis—some old person who can no longer cope in some way—his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.
Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week—it is not an exceptional situation—to patients, their families and carers, who are the victims of it.
The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.
Sadly—I deeply regret this—the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice—the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.
I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?
Baroness Jolly
My Lords, I think it is entirely appropriate that integration is included in the Secretary of State’s duty with regard to the improvement of the quality of services. I do not think that anything can improve services more than making them patient-centred, and it is the whole business of integration that will make services focus on the patient. Therefore, we welcome the language. Again, I do not know whether it is in the right place but we welcome the fact that it is there, as well as the definition.
Integration is critical. We have heard about the savings that we need to make, and integrating care is cost-effective as well as being good for patients. I want to talk briefly about social care and the community, and about how the community care too. I come from the south-west, so I will also mention Torbay, which is the jewel in the crown in our neck of the woods. The thing that has worked in Torbay was that when PCTs were set up, the local council decided that, working with the area health board, it did not want a PCT, it wanted to have a care trust. The key to the whole thing was having not only shared governance but a shared budget. There was only one pot of money to fight over and all decisions were made by councillors, non-execs and the executive round the same table. So, in Torbay care is totally integrated.
In Plymouth there is another small integration pilot going on in the DGH whereby many patients from Cornwall go over the border to the acute hospital. Somewhere in the region of a quarter of Cornish patients do not go to Truro; they go to Plymouth. Discharge has historically been a huge problem—bed blocking, Friday afternoons, all the usual sorts of things. It was a joint appointment between the PCT and social services. A social work team was put into the hospital and they liaised with all the right people when discharge was coming along. There was liaison with patients, carers, GPs, social services, care homes, domiciliary, district nurses—the whole thing—to make sure that when the patient was ready to leave the acute service they went to their next port of call and everything was all teed up ready for them to go on. That was effective. It saved time and it was much better for the patient.
I return to the amendments. There is a whole series of interesting additions which are all to be outcomes—but outcomes need measuring. So how do we measure, and what are the indicators for the effectiveness of integration of services, or the equitable provision of care, or the safety of the service? These are good things to achieve and aspire towards but I am not sure how they will be measured. I would like some clarification from the Minister as a general point. Some of the outcomes from the original Bill were added to. How will the success or otherwise of achieving these outcomes be measured and how will it be reported?
Lord Kakkar
My Lords, the noble Earl, in his thoughtful introduction of the Bill on Second Reading, identified the challenges that face all mature healthcare systems such as our own in terms of the changing population demographics, with an older population, more chronic disease and the need to improve clinical outcomes through integration of the new technology innovations and pathways of providing care.
In trying to understand how those important objectives will be achieved by the Bill we need to try to identify potential strategies. One of the most important is to ensure that the health service focuses on integrated care in the future. We know from quite a lot of important experience around the world that integrated care has the opportunity to improve clinical outcomes. We have heard of the patient with diabetes that the noble Lord, Lord Patel, described who ended up with the potentially unnecessary amputation of toes. Integrated care could have improved the clinical outcome in that case by avoiding a deterioration of the patient. Careful supervision in the community and the appropriate integration of different specialties and disciplines could have avoided that outcome. We know that integrated care has the opportunity to drive improved patient experience. We have heard about the potential for integrated care to improve patient safety. The example given by the noble Baroness, Lady Cumberlege, of the remarks made by Martin Marshall with regard to “lost in the system” puts patients at great risk, and the importance of integrated care and enhancing patient safety should not be neglected.
We also know that integrated care can achieve the important objective of taking our system towards a value-based healthcare system where, in addition to improving all the good clinical outcomes and improvement in experience and safety, the healthcare system can also deliver better value and ensure that the vital resources available and devoted by Government to the provision of healthcare can be used most effectively. Therefore, I strongly support the amendments that speak to the need to emphasise in the Bill the importance of integration.
The Bill has the important purpose of ensuring that a legal framework exists for driving forward future provision of the National Health Service, and also provides an important opportunity to set a vision and ensure that those ultimately responsible for implementation have an appropriate focus at the outset and can design the service moving forward in such a way that it achieves the objectives and meets the challenges that the noble Earl set at Second Reading. To ensure that there is a focus on integration is a very important objective. It will help achieve those important challenges. Failure to emphasise integration would run the serious risk of losing the opportunity to drive forward the improvements in healthcare and in the utilisation of resources that the health service desperately needs.
Baroness Barker
My Lords, the noble Baroness, Lady Pitkeathley, mentioned that she wrote a book 40 years ago. I wish I had written a book about the experiences of older people in various parts of the healthcare system. Many noble Lords talked about integration at different levels. My view is that integration just within acute hospitals will be ever more complex in future because they will be treating many people with dementia. The treatment of people with dementia in different parts of acute hospitals is a growing scandal. It poses a challenge to health professionals of all kinds, many of whom have never bothered to think about the issue of dementia. They will have to think about it for their own specialisms in future.
I have taken part in this sort of debate many times and come to the conclusion that the debate rests on a single factor: information. It is the sharing and availability of information and data about outcomes. Everything else is secondary. The previous time we had a serious discussion about this was when we discussed the proposals of the noble Lord, Lord Darzi. Some of what he achieved, in particular in improving stroke care in London, rested on the willingness and ability of people just in different parts of the NHS—let us not be too ambitious—to share information. I ask the Minister what the department has learned since the passage of the legislation of the noble Lord, Lord Darzi, about the crucial issue of sharing information about patients and their treatments, and other data on outcomes. Until we address that issue, and until health professionals feel able to maintain client confidentiality while sharing information just with other professionals, everything else will be redundant: we will never crack any of this until we get that right. Therefore, I ask the Minister how the department’s thinking was influenced in the preparation of the Bill by what the noble Lord, Lord Darzi, achieved.
Baroness Masham of Ilton
My Lords, integration has been said to be important and I agree. I agree also how important specialised nurses are to those with long-term conditions such as diabetes, stroke, epilepsy, Parkinson's, tuberculosis, spinal injuries, many neurological conditions, rheumatoid arthritis and many more conditions. Specialist nurses should not be cut. They are the vital link between primary and secondary care. Pain control should be included in integration. Nothing so far has been said about it. Last night, I was at a presentation about rheumatoid arthritis, and it was stressed that pain control is important.
Integration means much more with long-term conditions. Occupational therapists are employed by local authorities to adapt houses. What is going to happen in the new regime to the wheelchair service? Who is going to look after that? What about housing for those with serious disabilities? What happens now? If there is no suitable housing, patients stay in hospital far too long. Professionals should all be working together.
Baroness Armstrong of Hill Top
I want to intervene briefly. I support much of what my noble friend Lord Warner said in his opening speech. There are some things on which we need to tread carefully. Integration is critical, but it can become a phrase that is used but is not backed up by good practice. We have to be sure that we introduce or develop integration in ways that improve the outcome for patients. I serve as a non-executive on an acute trust in the north-east of England, the County Durham and Darlington NHS Foundation Trust. It has just merged with, or taken over—I am never very sure—the community trust. The Government have been encouraging this throughout the country. There are mergers and a coming together of community services and acute services. In some places, the community services are joining the mental health trusts and so on and so forth. We have been very conscious throughout that process that in the private sector the majority of mergers do not succeed. Very often that has been shown to be a problem in the health service. That is not a good idea. When we are looking at integration, we have to be very aware of what outcome we want. We should not just say, “If we bring all this together, it’s bound to save money and it’s bound to be a better service”. It will end up that way only if it is exceptionally well planned, if the outcomes are worked out and are absolutely clear to people, and if we do it not just because it is the fashion of the day, or because the Government are asking for it to happen, or because the words are used in the Bill.
I entirely agree with my noble friend Lord Warner. This should not be used as a means of excluding or cutting out competition. One of the best examples of integrated care that I have seen was when I was Minister dealing with social exclusion and had the real privilege of going to Preston. I was able to give £1 million to the local mental health voluntary organisation. It was working with people with learning difficulties who were trying to make sense of individual budgets. It was inspirational to meet the individuals who had been part of that development, which had been co-ordinated by the voluntary organisation—I think it was Mencap. It offered and provided one person to work with the patient, the client or whatever label you want to put on them. That person’s job was to help the client negotiate their way through all the different organisations from which they needed care and to work out more effectively what they needed.
I spoke to one young woman who had been living at home with her father. He was very concerned because she was becoming housebound, obese and more mentally ill, and she also had learning difficulties. Technically, every agency was working with her but nothing was actually happening to change her experience of life and her ability to get out and contribute, as well as her ability to find the right way through the organisations. She talked to me at great length with incredible enthusiasm and took me round the places that she now had contact with. She was volunteering in a group for severely disabled children, where she was simply holding someone’s hand, being there and being a friend throughout the process. She told me she had reduced the number of hours of care she needed because she did not have time for it because she was so busy. She was busy being active as a volunteer in a whole range of things because the care she needed was now properly integrated and she had an advocate to help her work through the myriad of different things that she wanted; for example, where she needed particular drugs or care because of some physical illnesses. I was able to see true integration, with incredible enthusiasm from the patient, but it needed to be negotiated by the voluntary organisation. They were then able to get a pattern of care—a pathway, as we now call it—that made sense to her, that reduced her dependence on carers and professional intervention, but which worked for her. She was simply one example.
I also think that the integration of care for children is really not as good as it should be. I have seen some examples of where it works brilliantly and others where it simply does not work at all for some of our most disabled and disadvantaged children. Again, we can do it better. Integration is absolutely where it should be but it will have to be organised in different ways for different types and groups of patients. There will need to be people who can help negotiate the way through the pathway.
My experience in the County Durham and Darlington NHS Foundation Trust is that you have to be absolutely clear about what your outcomes will be. However you organise the different pathways and different coming together in groups—we are in the middle of doing that at the moment—there needs to be clarity about what you are trying to do in enabling the individual who is the concern of the local authority, the acute trust and the community trust. Someone has to negotiate that pathway with them, and that will frequently be someone who is not embedded in any of those areas of responsibility, although it may be someone from there. There will have to be different ways of doing it.
The Government are going to have a very difficult job in making absolutely sure that integration is working for the patients rather than simply saying, “Well, we are doing yet another reorganisation which we hope will save money”. My experience is that if that is all people think of at the beginning, it does not work, it saves no money and it becomes increasingly frustrating for the person whose care it is supposed to improve.
I went to see someone in a community hospital that I have a lot of experience of. It is a fabulous place that traditionally takes patients from a number of different areas. The local authority recommends people, the GPs recommend people, and of course the acute trust recommends people it wants to get out of acute care and into the community hospital. Trying to get that knowledge and understanding into the acute trust, now that it technically runs the hospital, is quite difficult. It rings up at the beginning of the day and asks how many beds the hospital has. The hospital might say four, and the trust rings again at the end of the day and says that it needs those four beds. The community hospital matron might say that the GPs have taken two of them and the local authority has taken another, so the beds are no longer there for the acute trust.
We need to make sure that we get integration right and recognise that we have to get the best and not simply use integration as a term that will cover everything.
Lord Beecham
My Lords, the hour is late and I will not speak for long, but I want to address one issue in this very important debate from the perspective of local government, in which I have so far spent two-thirds of my life. The issue is social care services, which are referred to in so many of the amendments.
This is partly a question of definition. What do we mean by social care? Do we mean the services provided by adults’ services departments, or do we take a broader view, such as the position of children’s services, which were split away from social services departments, having first been integrated after the Seebohm report in the early 1970s? I have had and continue to have misgivings about that separation, but I take it that, for the purposes of these amendments, we should look at children’s services as well as adults’ services in relation to social care.
As the noble Baroness, Lady Masham, has pointed out, there is also a housing aspect, which needs to be taken into account. That, of course, is a function of all principal councils. It is not a function of county councils, which are basically responsible for adults’ services and children’s services. It is, however, a function of district councils, and their role in relation to this provision also needs to be looked at.
There is also the issue of finance and budgets. The National Health Service benefited enormously from investment by the previous Government. There was very much greater investment in that than in social care, so there are questions about how the funding of integrated care between local government and health is to go forward. Perhaps when he replies the Minister will comment on the experience of community budgeting, which in some cases has been looked at, to see how that can be developed. If it has not been sufficiently piloted, perhaps he will indicate whether the Government will consider using that mechanism for community budgets to pilot further integration along those lines. The Government should also bear in the mind the impact of their proposals for the reform of welfare and the benefits system on the position of people requiring social care.
The noble Baronesses, Lady Cumberlege and Lady Armstrong, mentioned personal budgets, which clearly have considerable potential in the promotion and use of integrated care and for avoiding the cost-shunting that sometimes occurs. There is clearly a requirement for the kind of support to which the noble Baroness, Lady Armstrong, referred in helping people to navigate their way through that system and to maximise the efficiencies that can be obtained from it.
Therefore, while I certainly support the first of these amendments, I think we need to be clear about what we are looking to integrate beyond simply adults’ services.
In that context, finally, in relation to role of the health and well-being board, there is the responsibility of producing joint strategic needs assessments. It is not clear to me—perhaps we will debate this issue later—the extent to which those boards will be able to redirect the provision of services as opposed to providing an assessment and being consulted on the commissioning that clinical commissioning groups will carry out.
Baroness Wheeler
My Lords, the hour is indeed late and I have done my best to cut back on bits of my speech. On behalf of the opposition Front Bench, I commend these amendments for beginning the process of retipping the balance of the Bill from its current predominance of measures dealing with NHS structures, governance and competition. Today’s amendments start to explore ways of addressing in the Bill the need for the NHS, public health and social and community care to work together to achieve improvements in quality of services in diagnosing and treating patients. Integration is a means for achieving this and is not an end in itself.
It is worth reminding ourselves of the recent warning from Chris Ham, chief executive of the King’s Fund, of the very real risk in the Bill of integrated care being,
“a sideshow involving small-scale pilots, with competition the main game in town”.
He also said:
“If the Government is serious in its endorsement on the Future Forum's advocacy of integrated care, it must demonstrate its commitment by putting the best civil service brains on the case and ensuring that the mandate given to the NHS Commissioning Board has the promotion of integrated care at its heart”.
We are certainly not at that stage yet, as the contributions in this debate have demonstrated.
The Bill offers the opportunity for the promotion and enabling of integration to be embedded into the work of the Secretary of State, the NHS Commissioning Board, clinical commissioning groups, health and well-being boards and Monitor, and further amendments throughout the Bill will allow for debate and development of these areas. The Royal College of Physicians has referred to these bodies needing to have, under the Bill, an explicit duty of mutual co-operation and collaboration, and this should be the aim. The Secretary of State, the Commissioning Board and Monitor all need to ensure that national policy promotes, not just enables, the supporting context for integration.
We support working towards a strategic definition of integration that encompasses the NHS, public health and social and community care. Nuffield, the King’s Fund, National Voices and the Local Government Association are all undertaking comprehensive work on producing clearer definitions, so there is no shortage of expertise in this area. Our hope is that this work will help lead us to a more coherent approach and ensure that current provisions in the Bill can be strengthened. As we know, the Future Forum is currently consulting on what now turn out to be the non-legislative steps that can be undertaken. But whatever recommendations it comes up with need to be in the context of a Bill which provides the strategic context, framework and direction. The National Voices key principles of integration have much to commend them in taking this work forward.
Amendment 18A has a particular focus on integrating public health with local authorities. We strongly support the proposed role for local authorities for public health and this amendment would help to address fears of some public health professionals that this might lead to public health becoming divorced from the NHS. Amendments 182 to 184 look to clinical commissioning groups having particular regard for outcomes which show “effectiveness and integration” and integrating “assessment and delivery” by those who provide health and social care services. CCGs need to demonstrate that their commissioning plans address the physical health, mental health and social care needs of their local population under the joint strategic needs assessment.
In this regard, one of the major ways of promoting integration will, as many noble Lords pointed out at Second Reading and today, be by strengthening the powers of health and well-being boards. We strongly support giving health and well-being boards the power to sign off the commissioning plans of CCGs and will be supporting amendments to achieve this later in the Bill. If health and well-being boards own the health and well-being strategy, they must also own the plans to deliver it.
Finally, at the beginning of the debate on how we use legislation to promote integration of services and care, as a carer myself perhaps I may endorse noble Lords who have underlined the importance of this issue to carers. Carers, particularly of people with long-term conditions, oversee care packages across the NHS, local authority social care, the independent agency and provider sector and the voluntary sector. Carers are often the principal players in organising the care package and the ones who fight to hold it together. Hours can be spent going over the same information for different parts of the system or ensuring that one part of the system is aware of decisions and developments, and any possible knock-on effects, taken in other parts of the system involved in the care pathway. Joined-up support is the key enabler for people with severe disabilities or long-term health conditions to remain at home and it is crucial that the Bill gets this important issue right.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, all the amendments in this group have the entirely laudable aim of improving the integration of services across health and social care and improving access to services. I agreed strongly with many of the messages which the noble Lord, Lord Warner, delivered in his excellent speech, and with so many of the powerful contributions from other noble Lords. The only person with whom I felt seriously out of sympathy was the noble Lord, Lord Davies of Stamford. I would simply say to him that the Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors to improve patient outcomes through far more co-ordinated working.
For example, the reformed system that this Bill will give form to—the provision of high-quality, efficient and fair services—represents the fundamental goals of the health and care service. This clause puts on to a statutory footing the three domains of quality identified by the noble Lord, Lord Darzi, in his next stage review: effectiveness, safety and experience. Every aspect of healthcare quality fits into the Darzi domains, and that is a tribute to the noble Lord’s work in co-producing the quality framework with patients and the professions, and it is also why the domains still provide the framework for quality.
In answer to my noble friend Lady Jolly, or at least to give her a partial answer, we seek to measure success in meeting these fundamental goals through the transparent accountability mechanisms of the outcomes frameworks for the NHS, public health and social care. Integration and access, though laudable objectives that I share with all those noble Lords who have spoken about them, are a means to this end. If integration and access help the NHS to meet the quality and fairness duties—and by fairness I mean reducing inequalities—then integration and access will need to be factored in to commissioners’ plans. Commissioning guidance will set out how best to achieve this based on the accredited evidence of what works best that NICE is developing in its quality standards and other guidance.
The point is often made that high-quality care must surely be integrated care. Integration is not an outcome, it is a possible feature of the process. Where it will improve outcomes and reduce inequalities, integration should most certainly happen, and this Bill provides for that. But we must not sacrifice outcomes for process. I thought the noble Baroness, Lady Armstrong, injected a welcome dose of reality on that theme borne out of her considerable experience, and although I did not fully agree with everything that the noble Baroness, Lady Wheeler, said, she also made some very sensible comments on that point. Indeed, the NHS Future Forum’s Phase 1 report highlights well the practical rather than legislative challenge of bringing about more integrated services for patients. I shall quote from its summary report, which states that,
“legislating or dictating for collaboration and integration can only take us so far. Formal structures are all too often presented as an excuse for fragmented care. The reality is that the provision of integrated services around the needs of patients occurs when the right values and behaviours are allowed to prevail and there is the will to do something different”.
Lord Davies of Stamford
My Lords, I am most grateful to the noble Earl for giving way. Of course we all agree about the importance of the right values and behaviours. I know he did not like my questions, but perhaps he would answer at least two of them. First, what concrete, specific measure in this Bill, if any, addresses the perversities currently existing in the integration of social care and NHS care? Secondly, what about Northern Ireland? Why is the system that exists in Northern Ireland, where the provision of the two is entirely integrated, not suitable for England?
Earl Howe
My Lords, if the noble Lord will be patient, I will proceed and answer his questions at the end, as I normally do.
It was in recognition of these practical challenges that the Government asked both the NHS Future Forum and the King’s Fund, jointly with the Nuffield Trust, to provide further advice on the practicalities of achieving more integrated services around the needs of patients. We look forward to receiving their advice later this year. So we share entirely the intentions of noble Lords, and that is why Clauses 20 and 23 contain proposed new Sections 13M and 14Y to create duties for national and local commissioners to promote integration across health and social care—that is the first part of my answer to the noble Lord, Lord Davies.
New Section 13M creates an NHS Commissioning Board duty to promote integration. Rather than simply requiring the board to encourage clinical commissioning groups to work closely with local authorities, as under this amended duty, the board is required to promote integration by taking specific action to secure that services are provided in an integrated way where it considers that that would be beneficial to the people receiving those services. The duty requires the board to exercise its functions with a view to securing that health services, health and social care services and health and other health-related services are provided in an integrated way where it considers that this would either improve the quality of health services and the outcomes they achieve, or reduce inequalities in access to and outcomes from health services. By other health-related services, I mean services such as housing, which may have an effect on the health of individuals but are not health services or social care services.
This requirement would cover both integration between service types—for example, between health and social care—and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This would apply to all the board’s functions not just when exercising its commissioning functions, including when it exercises public health functions under arrangements with Public Health England.
The duty also requires the board to encourage clinical commissioning groups to enter into partnership arrangements with local authorities under Section 75 of the NHS Act 2006 where this would secure the provision of services in an integrated way, or that the provision of health services is integrated with the provision of health-related services or social care services. Proposed new Section 14Y creates a similar duty for local clinical commissioning groups.
The changes to the regulatory framework give Monitor a role in Clause 59 in relation to improvement in quality and fairness as well as efficiency.
The question then is: what actual risk exists of fragmentation at the national level? There is no such risk. Our outcomes frameworks span public health, the NHS and social care; the Secretary of State will aim to improve outcomes in all three components of the care system; NICE will provide quality standards across the whole patient pathway that will push for integrated care; and the care system, nationally as well as locally, will have to pay attention. The Secretary of State’s duties and his actions are, in other words, an embodiment of integration.
Our reforms are firmly focused on improving quality and outcomes for patients. We are not in the business of dictating the processes by which this improvement might be achieved, or trying to measure success in terms of whether a particular process has been put in place regardless of whether it actually delivers a good outcome for patients. I make no apology for that. We are of course committed to enabling and facilitating integration, but integration is neither a necessary nor a sufficient condition of a good outcome.
Perhaps more importantly, our reforms aim to encourage measurement and reporting throughout the system that will tell us whether it is achieving what we have said it should achieve. Accountability should finally have arrived at all levels in the system. Improvement should result and will be understood through the outcomes frameworks in terms of the actual outcomes achieved and those that matter most to patients, service users, their families and carers and the wider public.
Lord Warner
My Lords, this has been a good debate. The hour is late but I want to make a couple of points in response to the noble Earl. There is probably a fundamental difference between him and me and, I suspect, other Members on this side of the Committee about whether integration and access are just bits of process and whether we should focus entirely on outcomes. I say gently to the noble Earl that the public care about some of those processes. That is why we had targets for access; they care about access and integration. The outcomes framework will not adequately measure either of those areas, which are of public concern. Indeed, they are important contributors to good outcomes. Therefore, we probably have a philosophical difference of view over how we approach those issues.
I do not want to go over this ground tonight. However, we must look at the Bill to see whether it can give stronger signals to professionals and the culture in which they operate about the importance of integration, not just within healthcare but across the boundary between healthcare and social care. I hear what the noble Earl says but, looking at the Bill, I do not believe that the Bill goes far enough in changing that culture. I will certainly talk to some of these outside experts with a number of colleagues to see if we can come back with some amendments. I am happy to talk to the noble Earl about that with my colleagues before Report stage. I hope we can convince him that we can strengthen the Bill in this area. With that, I beg leave to withdraw the amendment.