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.