Health and Social Care Bill
Baroness Armstrong of Hill Top Excerpts(13 years ago)
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Lord Warner
My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a source of grievance. It often goes with another grievance—one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs—the management costs—of local authorities. If one takes the two together—a meanness about meeting management costs and being treated unfairly on VAT—this is a barrier to entry.
I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government’s own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.
Baroness Armstrong of Hill Top
My Lords, I rise briefly to lend support to the amendment. I work with charities for the homeless and for children. If the Government’s ambition is to enable the NHS to work with the patient on the full pathway—rather than work being done in little bits by different organisations—then making the playing field level for the voluntary sector is absolutely critical to developing those pathways. In my experience, the voluntary organisation is frequently the glue in making sure that the pathway for the patient works for the patient.
I remind the Minister that when this works well there are often savings for the National Health Service. I have experienced that in homelessness, where we have been able to work with the PCT to get a community matron. That has reduced the number of expensive admissions to hospital and A&E for the most disadvantaged—the homeless. I have also seen that work well with, for example, children with disabilities and children who are very ill. They have been enabled to remain at home with the proper support instead of being frequently admitted to hospital.
It is to the advantage of the NHS that we get this right. What will the Government do to bring forward in the Bill comfort and encouragement for the voluntary sector? After the pause, that sector has been left with a rather large amount of confusion.
Baroness Barker
My Lords, for over 25 years I have worked either in or as a consultant to voluntary organisations. Consequently, my eyes lit up at the sight of an amendment that said VAT and charities. In my time, I have sat with wet towels around my head trying to figure out this, one of the most complicated subjects. I have attended seminar after seminar with the Inland Revenue at which people with bigger brains than me have come away with their heads reeling from trying to understand the issue of VAT and charities. It is infinitely more complicated for charities than it is for the private or public sectors. That is not new. As various people have said, this issue has been running for some considerable time.
I want to correct two impressions that might have been given inadvertently in the debate. First, there is the impression that there is a view in the charitable sector on this issue. There is not, because the issue effects different organisations disproportionately. While there may well be a consensus among hospices that it would be advantageous for them to make such a change, it may not be and indeed is not for other, smaller charities. That is the first thing.
Secondly, we have this new generation of social enterprises. These organisations are not charities but businesses. They are intended to be big players in the provision of services. The noble Lord, Lord Patel, has been clever here in not asking for the Government to take a particular step. He simply asks for a report on a subject that will fascinate some of us quite deeply. Were the Government to take on board the point that the noble Lord makes, apart from looking at a whole range of different charities—not just hospices—would they also consider the effect on social enterprises? I do not think that it is possible to come up with a set of legal proposals that relate simply to health and social care. By definition, they would have to go across the whole of public services. I hope that the noble Lord, Lord Patel, would accept that an exercise of this kind should do that.
Finally, be careful in the questions that you ask of HMRC. As someone who advised charities, I was always brought up never to ask a question of HMRC unless I was pretty confident that I would get back the answer that I wanted. This may be an answer that the hospices want but I would wish to be pretty clear that it worked for charities across the board. I simply finish by saying that if this subject were straightforward, it would have been sorted out a long time ago—but it is not and that is why it has not been.
Health and Social Care Bill
Baroness Armstrong of Hill Top Excerpts(13 years ago)
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Baroness Tyler of Enfield
My Lords, I, too, should like to speak in support of this raft of amendments which are all designed, to use the words of the noble Baroness, Lady Murphy, to give greater teeth to reducing health inequalities. We have already heard various statistics from a number of noble Lords and those for life expectancy are generally the most stark. The statistic that means the most to me relates to London, probably because that is where I live; namely, that the life expectancy of men ranges from 71 years in one ward in the London Borough of Haringey to 88 years in one ward in Kensington and Chelsea. That is a huge difference of 17 years. It is worth also pointing out that even within Kensington and Chelsea, there is a difference of nearly 12 years in life expectancy across different parts of the borough.
As many noble Lords have said, there is a whole range of reasons for this, including the social and the economic. It is one of the things that underline the critical need in our debates to put more focus on public health interventions. I also very much welcome the establishment and the role of Public Health England, and the fact that the public health function at a local level will sit with local authorities.
In discussing the need to strengthen these duties, it is important to recognise and welcome that having explicit duties placed for the first time on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups is a landmark, representing a major shift from the current position. There is something very significant about the whole raft of these NHS reforms.
The phrase “have regard to” health inequalities for the clinical commissioning groups is not sufficient because we need to make sure that they act and behave to secure real improvements, which need to be in both access to NHS services and in outcomes. I want those CCGs to account publicly for their progress, not simply as part of normal accountability but as part of sharing good practice and workforce development, and in the training of NHS employees. It should become part of the everyday currency and language of the NHS, part of the DNA of the way in which the health service operates. I believe that this strengthening is necessary if the NHS reforms are to become a real game-changer for some of the most disadvantaged group in society—to borrow from the words of the public health White Paper, Improving the Health of the Poorest Fastest.
Perhaps I may give an example in relation to homeless people who experience some of the worst health inequalities of any group in society. They are more likely to die young, live with a long-term condition, have multiple health problems and have mental health or substance use issues. They are also far less likely to have regular contact with a GP or other health professional and are much more likely to access healthcare through A&E, which is inappropriate and, as we know, causes all sorts of problems for A&E departments. In short, they are the most likely to have very poor health and the least likely to benefit from what the NHS has to offer.
Of course, many services are needed to help homeless people to improve their outcomes, including housing, employment, family support and other things. But it is particularly important that the NHS is able to cater for the needs of these groups. Appropriate services are far more likely to be commissioned where clinical commissioning groups have a duty to take account of these health inequalities in their plans and reporting mechanisms and the standards to which they are held to account, and that they are ensuring that these arrangements are incentivised through the commissioning arrangements.
I very much support the principle of the amendments put forward and I look forward to hearing the Government giving an even stronger commitment to tackling health inequalities and to making this a key outcome of the overall package of reforms that we are discussing.
Baroness Armstrong of Hill Top
My Lords, I seek only to intervene briefly on this. The whole issue of how to tackle inequalities in health is an extremely complex and difficult one. When I was a Member of Parliament, I looked forward to receiving from the department reports on a regular basis on how inequalities had been addressed and how health had improved throughout the constituency. What was clear was that the more effective our public health interventions were, such as on reducing smoking, the more difficult it was to tackle inequalities. The people who automatically responded best to those interventions were those on higher wages, with better qualifications and who were likely to be in higher class groups than those in the poorest parts of the constituency. That could always be seen clearly in those reports. The amendments that support better information are very important because clinical commissioning groups in particular are not well placed instinctively to tackle inequalities. It is generally not part of the training of GPs to look at these issues and work out how to address them.
We have already discussed the second issue today, and it is important—the issue of access. Unless we open up access much more sharply to the disadvantaged we will not have a chance of addressing inequalities. The noble Baroness opposite talked about homelessness. I have discussed this issue with the Minister on a number of occasions, and I am not content that the Bill deals with it adequately. It is not fair to ask clinical commissioning groups to address this issue. Sometimes they will simply be too small to do so. Also, homeless people tend to be fairly mobile, so in London they will cross authority areas. From my experience in the north-east of England, a single PCT—or what will now be the smaller clinical commissioning groups—does not have the people available properly to offer the sort of services that are needed to open up access effectively to those who are not normally registered on a GP list.
I am also concerned that clinical commissioning groups may be responsible for areas with poor GP coverage and there will be a need to bring in salaried GPs. It will need someone other than a clinical commissioning group to address the issue of GP shortages—and it is always the poorest areas which have the poorest access to GPs. It is an issue that continues to have to be addressed time and time again. I was pleased when the last Government introduced many more salaried GPs, but we have to keep on top of that agenda.
I also support the amendments that look to the responsibilities of the NHS Commissioning Board. There will be occasions when the board has to come in specifically to address inequalities in a range of ways. I am not sure that it is really geared up to do that at the moment. But because I certainly do think that clinical commissioning groups are not going to be able to do this on their own, and indeed it would not be appropriate for them to address some areas of clinical commissioning, it is very important that the department, the Secretary of State and the Commissioning Board think about how they are going to do this effectively.
Baroness Hollins
My Lords, I particularly welcome the amendments which are designed to strengthen the duty to reduce health inequalities between people and communities, the emphasis here being on inequalities not between “the people of England”, but between individuals as well as groups. I draw attention to this because in 2008 the Department of Health drew up a policy on health inequalities, and I sat on the group which developed it. I was pleased when the document was published in June 2008 because it talked about the group that I am interested in, which is people with learning disabilities. I shall read out a short paragraph from the executive summary because it makes my point very nicely:
“Progress on health inequalities will be judged against how public services treat especially vulnerable groups. The recent Disability Rights Commission report made it clear that people with learning disabilities often receive a poorer level and quality of service from the NHS. If services and health outcomes are improving for people with learning disabilities, they are likely to be improving for other groups at risk of health inequalities”.
The report goes into some detail about the importance of measuring the improvement in health inequalities for particularly vulnerable groups. That is a good measure to measure progress in the NHS.
Health and Social Care Bill
Baroness Armstrong of Hill Top Excerpts(13 years ago)
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Baroness Armstrong of Hill Top
I intervene to dispel the view that it has always been even and equal for private and non-private patients in the NHS. When I was an Opposition Member of Parliament, before the 1997 election, the largest complaint that I had, which I had regularly, surgery after surgery, was from people who had some serious condition. They had eventually got in to see the consultant, frequently having had to wait a long time. Then they were told, “Yes, you need an operation but the waiting list is 18, 20 or 24 months. However, if you come in to see me next week in my private practice, I can do the operation in two weeks’ time”. People found that offensive.
That is why, during the passage of the Bill on foundation trusts, there was outrage on the Back Benches that we were going to revert to the situation where it seemed not to matter whether people were public or private patients.. That came because Back-Benchers insisted that they did not want to return to the old system.
I am actually in favour of varying the cap and the noble Lords who tabled the amendment actually had the right idea. But for us to pretend in this House that there was once a glorious age where everyone was treated equally is quite honestly offensive to all those people who knew that they were getting a poor service and were not getting adequate access to the healthcare they needed and had the right to receive.
Lord Patel
I rise briefly to comment on this amendment. As far as declaring an interest is concerned, I have not seen private patients because my contracts were such that academics did not do private practice. I have a family member who is a consultant. My daughter is a consultant at the Marsden where I hear there is a high percentage of private patients. I have no idea whether she does private practice or not. I have not seen any benefits of it. Maybe they will come.
However, I remember when I was a student and was training in King Edward VII Hospital in Windsor, in Ascot and other places there were private wings in the same hospital. Yes, the care provided was equal for NHS and private patients. However, one difference today is that NHS patients now receive quite a significant part of their care provided by doctors in training. If we are to ask for equality in how patients are looked after, we must say not only that those patients in private wings cannot jump the queue but that there must be the same quality of care provided by all the medical staff who work in the NHS.
I have one other question, which I would like to put to the noble Lord, Lord Phillips of Sudbury. How would we manage his amendment when there are to be qualified providers, which might provide care not only for NHS patients but for private patients under their own terms and conditions? How would we manage those qualified providers to ensure that they behave in the same way in dealing with NHS patients?
Earl Howe
The noble Lord, Lord Hunt, should be a little bit careful before he comes to this Committee and speaks as though it were Second Reading and as though he were not chairman of the Heart of England trust, which I do not doubt has a goodly number of private patients in its midst. He should bear in mind that it was the last Labour Government who introduced private sector involvement into the NHS in 2007; the independent sector was paid on average 11 per cent more than the NHS price.
Earl Howe
I am sorry, but I am going to finish. The private sector was paid £250 million for operations that never happened. I have a very interesting quote here:
“The private sector puts its capacity into the NHS for the benefit of NHS patients, which I think most people in this country would celebrate”.—[Official Report, Commons, 15/5/07; col. 250WH.]
That is a quote from none other than Andy Burnham. It is absolute hypocrisy on the part of the noble Lord, Lord Hunt, to introduce matters to this amendment that have nothing to do with my noble friend’s point. My noble friend’s point was quite separate from the point that the noble Lord was talking about.
Health and Social Care Bill
Baroness Armstrong of Hill Top Excerpts(13 years ago)
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Baroness Armstrong of Hill Top
My Lords, it is particularly apt that I follow the speech of my noble friend because, in supporting these amendments, I wanted to relate a little of my experience as the Social Exclusion Minister who came in and tried to learn from all the other things that we had done in government—and what we had missed and needed to come back to. One of the issues that we came back to that is particularly apposite to the amendments related to people who do not fit into any category, who are the most vulnerable and who turn up at different places to try to get a service. No service treats them as an individual who has several problems.
Most of these people have mental and physical health problems and probably have an addiction. They are probably difficult to deal with and are likely to get aggressive because they know that they are not getting the response they need to help them move forward. We set up some pilot projects which I now work with as chair of the Cyrenians in the north-east—a charity which took up one of those pilots and extended it. The pilot is paid for now by Newcastle City Council and the PCT, which is much bigger than the subsequent clinical commissioning groups will be. I was not sure whether I should raise this matter in the previous group of amendments or in this one, but I do not want to keep having to rise to speak because there are issues here that the Government need to address. I chose these amendments because they relate to the Secretary of State, the national Commissioning Board, and the clinical commissioning groups.
Some things will have to cross those boundaries and be paid attention to by more than just a clinical commissioning group on its own, because the people we are talking about do not remain in one place. Sometimes there are insufficient of them in one place for a clinical commissioning group to take account of what they are going to need. We have people who go round and find the most disadvantaged and the most dispossessed—the ones who are not fitting in anywhere. We use ex-clients to go and find them. Most of the money comes from the local authority.
We persuaded the PCT to appoint a community matron with whom we work and to whom we send those people. She is then able to assess their physical and mental health needs. This has substantially reduced in-patient care, and because we have a different system we can show that fewer people end up in A&E and are then admitted to hospital. Such an arrangement can save money but is also able to provide interventions at an earlier stage—and that was what attracted me about the amendments, because they relate to prevention, diagnosis and treatment.
However, we do not work just with the homeless; we also have three projects for addicts. One of them is a 12-step, 12-week day-centre programme. The programme is fairly tough and the addicts have to be abstinent. We pay for that with money from three PCTs which were so enthusiastic about the work and what it was producing that they are now funding another centre for addiction, where we take in on a residential basis mothers and their children to seek to prevent the children going into care—because that was what was happening. We still have a small problem with the acute providers because sometimes when a family was going to come to us the providers had increased the methadone rather than helped the mothers to come off the methadone. We use the recovery method rather than methadone.
I hope that the Committee can see that these are complex cases, with complex interventions that are aimed at preventing more difficult interventions later.
I cannot see one clinical commissioning group commissioning any of this work, because it will be too expensive and there will not be a sufficient body of people to justify the work and money that it would need to put in. That is why, in the new architecture, the Government need to think how they will respond to those more complex problems, where the voluntary sector is coming up with more innovative solutions, but they need also to deal properly with what is often called dual diagnosis—I think it is often triple and quadruple diagnosis—where people have more than one problem. We need to bring the different groupings together to make sure that the needs of that individual or that family are addressed in a holistic way. It is important to recognise that more than a physical illness is brought to the table, as it were, in those cases. At least the amendment acknowledges that both physical and mental illness must be addressed.
We will get a complex architecture under the Bill, and it will be all too easy for people to fall back through the cracks within that architecture and for there not to be a holistic approach. The next set of amendments, which talk about integration, are also important, and I will come back to them, but the Government need to think again about how to address those complex issues in a way that allows the whole person in that patient to be addressed in a more effective way than we are often able to do at the moment.
Baroness Masham of Ilton
My Lords, I first want to ask a quick question to my noble friend Lady Hollins or the Minister. Would the words physical and mental include those people who have a drug and/or an alcohol problem? Would addiction come under “mental”? I do not want those people to fall through the net, as was said by the previous speaker.
Health and Social Care Bill
Baroness Armstrong of Hill Top Excerpts(13 years ago)
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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.
Mental Health: Children in Local Authority Care
Baroness Armstrong of Hill Top Excerpts(13 years, 6 months ago)
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Earl Howe
My noble friend is absolutely right. She will know that minority-ethnic groups appear to be overrepresented in the looked-after population. Around 3 per cent of the child population of Great Britain is from black, black British or mixed groups, but 8 per cent of looked-after children are black and 7 per cent are from mixed groups. She is right that there is a problem. She is also right that early intervention is key. There is a strong emphasis on public mental health in the mental health strategy. The good foundations are down to early intervention, as I mentioned, and we are clear that this is a priority for the Government.
Baroness Armstrong of Hill Top
The Minister will be aware from recent research that an integrated budget actually makes sure that looked-after children and other vulnerable groups are more effectively responded to. Is he confident that the current confusion in the health service about the future and what the priorities should be is not preventing good work being developed in this area, because practitioners do not know what they should be doing?
Earl Howe
My Lords, I see the Government's proposals for local health and well-being boards as absolutely key to the effective integration of services and working across boundaries. The noble Baroness will know that the NICE and SCIE guidance that I mentioned is all about how better agencies and services should work together to produce the best results. We have a big opportunity in the Government's reform proposals to do the very thing that she is seeking.
Homelessness: Tuberculosis
Baroness Armstrong of Hill Top Excerpts(13 years, 8 months ago)
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Earl Howe
My noble friend puts her finger on a key difficulty with this group of people, who are often very difficult to keep track of. I heard of one case where a patient required 800 interventions, sometimes with the police involved. Clearly a lot of effort has to go into this group. However, it is possible, if the patient is willing, to register that person with a GP. The challenge is whether they actually return to complete their treatment, which of course extends over many months.
Baroness Armstrong of Hill Top
My Lords, I ought to declare an interest in that I chair the Cyrenians in the north-east. We have been working on a programme that has been identifying and keeping contact with these most vulnerable and disaffected people and we have reduced the number who have become, as they are called, “frequent flyers”. However, does the noble Lord acknowledge that there simply is not a straightforward system in the National Health Service to deal with people who do not have a fixed address and do not have regular contact with a particular locality or GP? Is it not about time that we looked at this much more holistically? There are some good individual examples around the country, but there is no guarantee that we will intervene sufficiently early to stop what is now known, which is that most people who sleep rough will be dead long before they are 50.
Earl Howe
My Lords, I was very interested to hear about the noble Baroness’s experiences in the north-east and I would like to hear more. The points that she raises lie behind our intention in the Health and Social Care Bill to make GP consortia responsible not just for the patients on the GP lists but for all the population in the local area. The health and well-being boards, which we propose should be set up at local authority level, will bring together all the relevant stakeholders to look at how the health needs of an area can best be met and prioritised.
Healthcare
Baroness Armstrong of Hill Top Excerpts(14 years ago)
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Baroness Armstrong of Hill Top
My Lords, I rise with some trepidation, following that. I congratulate the noble Lord opposite on this debate. I declare an interest. I have only just become a member of the board of County Durham and Darlington Foundation Trust as a non-executive. I claim no knowledge or benefit from that for this debate, however.
I have been delighted to see that the Government—and the Conservative Party, before the election—have really discovered how much the National Health Service is valued by the British people. We have that to thank for their commitment to the National Health Service during the election, and to ring-fencing the money for it. However, as we are now discovering, that ring-fencing has lots of problems within it. The rounding-up of figures, which all Governments do, means that the annual increase will be 0.1 per cent. In fact, it is a little less than that, but that is the rounded-up figure. We all know that that will give the National Health Service incredible challenges. I want to ask the Minister some questions arising from that settlement and the ideas in the White Paper.
The financial challenge is significant. What does the Minister think the number of redundancies within the National Health Service will be this year and next? How will those redundancies be funded? There are rumours that the funding for redundancies will come from some of the money put into the service to control demand—for example, in accident and emergency, by encouraging more people to be referred, and refer themselves, to urgent care centres. However, there are also rumours that some funding may come from budgets that are about trying to get healthcare to the most vulnerable, such as the homeless, who are frequently not on a GP’s list.
I know that many Members welcome the abolition of targets. I am amused to hear them now called “objectives”, but that is another matter; I am determined not to be cynical. When I was a directly elected Member of Parliament the main concern expressed to me by constituents about the National Health Service was, “I have been to see the doctor and been told that I can have the operation in about 18 months to two years. I could go next week if I was private”, with all the horror, anger and shame of that. That has not happened over the past five years. How many NHS patients does the Minister think will be waiting six months for orthopaedic surgery in February 2012? Does he think it will be 10, 100 or 1,000? I know that Ministers think carefully before they make any decisions. The decision to abolish the targets means that the Government must have estimated what effect that will have. I want them to share that thinking with us.
Inevitably, the change to the regime that the Minister envisages in the White Paper clearly means that some NHS hospitals will fail. How many does the Minister think will have failed by April 2013?
Finally, on parliamentary accountability, the Government are going to create the largest quango we have known in this country. That will take it outside direct questioning by Parliament. How is Parliament going to hold to account the decisions and actions of the NHS when, in fact, the money will be spent by the largest quango, the commissioning board? Who will appoint the chair? Can the Minister assure us, now that the appointments commission is to be abolished, that it will be an impartial appointment? Will it be done before the appointments commission is abolished?