Health and Social Care Bill

Baroness Murphy Excerpts

Monday 5th December 2011 Lords Chamber

Like my noble friend I hope that this will not be pressed to a vote because the Government need to do some thinking and should be able to do it between now and Report. Ultimately, that depends on the reaction to what he says and whether we can have some hope that these issues will now be thought through and modifications made if necessary before we come back to this.

[Baroness Murphy]

My Lords, apart from the postgraduate dean amendments, the rest of the amendments in this group in effect fall into the category that one might call “Stop the Bill, I want to get off”. They would all fundamentally change the Bill; they would ruin it. None of them is a serious proposition. You cannot go from one system to another without radical change, but the arguments that I have heard about these amendments seem to be the same arguments that I have heard about preventing any change in the National Health Service.

The noble Lord, Lord Hunt of Kings Heath, says, “No, we can’t do it now because it’s too expensive and we have to save £20 billion”. I suggest that it is not the £20 billion that we need to worry about; it is the increased costs that will continue to accrue through the changing demographics and changing technology over the next 20 to 30 years. If we continue to use the same direct management system, with its intermediate and many tiered system that we have used for the past 50 to 60 years, we will never address the challenges. All we will do is have a meagre, minor, reduced NHS of the same sort that we have now. We will have less and will not adapt and create something better. I am very much in favour of moving away from the direct management system with its so-called intermediate tiers, which I have served on as best I could over many years, to an independent regulator system where the providers at least are freed up and the commissioners, with the clinicians in charge, have the freedom to think about what they need to shape this service.

I agree with the noble Lord, Lord Newton, that the transition pathway in certain areas still needs to be clearly set out. We have had a clear indication of how that will work. Nevertheless, it is not all finalised. At this stage in the passage of a Bill, my experience is that things are put into place. That was certainly so in 1990 with the working on the patients’ transition and the other transitions that were put into place by the Labour Party. There were arguments in this Chamber and the other place about the fact that everything was being set up. Proleptic appointments and the transition of structures were being made—heavens, it would have been improper if they were not. The fact that some of these changes are happening is very helpful.

The centred primary care trusts and strategic health authorities have been mentioned before. Is it not strange that two to three years ago nobody could wait to get rid of them because they were not performing very well? I agree that they have improved. Nevertheless they have not proved to be that helpful structurally, as they have become extremely bureaucratic and have not performed as well as we had hoped. To the noble Lord, Lord Rea, I would say that the speech made by the noble Earl some time ago could be repeated word for word today because there will be no private commissioning. There will be public sector commissioning that is supported in some instances only by the expertise of the private sector, which the noble Lord, Lord Warner, said is often very useful in these circumstances. I hope that the noble Earl will be able to reassure him about that.

It seems to me that if we want to create a new system—which I think we must, because the NHS cannot continue as it is at the moment—we will need some very serious structural changes. We need to progress and move on as quickly as we are doing now to get the SHAs and PCTs out of the way in an orderly fashion and to get the new structures for a new sort of regulated system in place.

Health and Social Care Bill

Baroness Murphy Excerpts

Monday 5th December 2011 Lords Chamber

[Baroness Meacher]

I apologise to the Committee and to the Minister for not being present in these debates. However, I cannot resist supporting the noble Baroness, Lady Barker, on this issue, which, as the Minister knows, we debated at length when the Labour Party was in government. I, for one, strongly supported the idea that people leaving hospital should not be put under a community treatment order, most particularly if they are no threat to others, are competent, can give consent and can make rational judgments. Large numbers of people under community treatment orders suffer with depression and the only persons at any risk at any time are themselves. At a time when we so strongly support the principle of autonomy and the right to some control over medical treatment in general, it feels completely inconsistent to throw all those principles away in this one area and say, “No, doctor knows best. Whatever you say and however competent you may be, you have no right to make a decision about the treatment”.

Having said that, I understand Ministers feeling very concerned about having the same principles apply if someone might—if they become unwell again—be a real, serious and major risk to other people. Therefore, my plea to the Minister is that he gives serious consideration at least to those who are no risk to anyone else, because the noble Baroness, Lady Barker, is right to say that while these provisions are on the statute book it is almost impossible for doctors not to impose these community treatment orders or for them then to rescind them because, if something goes wrong, they will be in the most appalling trouble. I will say no more but I wanted to add a strong voice to the comments of the noble Baroness, Lady Barker.

[Baroness Murphy]

My Lords, it will be no surprise for you to hear me say that I support all the amendments in this group. I do not really understand the need for the change in Section 117 on aftercare provisions. I am not quite sure what the tidying up is about or what the matter is with the existing arrangements. They are complicated to deliver but nevertheless seem to be utterly essential in the way in which they are currently framed. I would need to be convinced that there was some serious reason for changing them, as they apparently will be in the Bill.

As I understand it, we did not struggle with the provisions on independent mental health advocates during the proceedings on the 2007 Bill. While it is thought that parents could take the place of advocates in negotiating treatment, the proposals for independent mental health advocates for children are important in adding to the quality of services, and I support that.

The major thrust of my support relates to the amendment in the names of the noble Baroness, Lady Barker, and other noble Lords. It is my fervent belief that one day we will look back in this House and be horrified at how we structure our mental health legislation. The fact that we do not have legislation on capacity-based decision-making seems to be a terrible tragedy and is extraordinary, given that we see in Scotland that it is perfectly capable of being implemented safely. We should be at the forefront of developing legislation that destigmatises mental health services and allows people to make their own decisions about treatment.

We will have to wait a long time for that, but this amendment focuses on something that many of us predicted would be overused, and I regret to say that it is all too obvious that it is being overused for the wrong people. Yes, there are some people for whom community treatment orders should be used, but if we had legislation for capacity-based community treatment orders we would still be able to implement them safely. I strongly support the noble Baroness’s amendment.

[Baroness Hollins]

My Lords, I support these amendments. I was president of the Royal College of Psychiatrists when the Mental Health Bill was passing through this House and I remember listening to and reading the debates with great interest. I know that noble Lords on the government Benches, including the noble Earl the Minister, at the time very much supported capacity-based legislation. It works well in Scotland, but what was anticipated here would happen has happened—far too many people are subject to community treatment orders who know what they are doing and are no risk to themselves or to others. It would be good if it were possible in this Bill to make a change on this issue that made sense.

Health and Social Care Bill

Baroness Murphy Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Cotter]

I shall speak to Amendment 81B, to follow on from what the noble Lord, Lord Hunt, said. Brevity will be my watchword, of course, because we do not wish to drag out proceedings. This is a particularly important amendment, referring as it does to commissioning for rare conditions. There are many such rare conditions that people suffer from, but I refer particularly to one called arthrogryposis, which my wife has suffered from from birth to today. As with many people who have struggled with a rare condition from childhood to the age she is now, it has been difficult to get not just treatment but diagnosis. She was originally not diagnosed with this condition, which is associated with the nervous system and the muscles and mobility. Throughout her life she had the difficulty of being misdiagnosed, and then when she was diagnosed she had difficulty getting treatment. I welcome the amendment for that reason.

Many people have that struggle to get the treatment that they need appropriately in their area. For example, we recently went to Birmingham, where they have done some research work. It is so important to get research work done for rare conditions, to establish where they came from and whether people were born with them. I so much welcome—as my wife and others with her condition will welcome, as well as those with other conditions of various sorts—the fact that we are drawing attention to the need for commissioning for rare conditions. You could say that only a small proportion of the public has each rare condition but, when you add all the rare conditions together, there is quite a proportion of people with those problems.

I draw to a close on that basis and hope that the Minister will consider this very carefully, as we and many other people have had experience of rare conditions, with the difficulty of diagnosis and treatment and of getting it recognised throughout their lives.

[Baroness Murphy]

My Lords, this is an interesting group of amendments about how prescriptive the powers and duties should be for CCGs and about dividing up who should do what between the groups and the board. We have to be careful about how prescriptive we want to be, because it may vary in different areas according to the board’s confidence in the ability of groups to commission. However, I take the point that there are some fundamental principles which we would like to see in each of these groups. That was why I added my name to the amendment tabled by the noble Lord, Lord Warner, and others, about the need to strengthen the co-ordination of health and social care. This is fundamental to the care of so many people. In my view it is a requirement, not an option, that it should be in the forefront of commissioners’ minds.

I am sympathetic to the amendments on special conditions and rare conditions, but—coming back to what the noble Lord, Lord Warner, said—the areas where we need most improvement include everyday, ordinary, complex multiple conditions of older people and simple but common surgical emergencies. It is the ordinary, everyday things that we need—ensuring that we have the right commissioning groups at the right level and that they concentrate on these broad responsibilities relating to the population.

I support the question that underlines Amendment 82, in the names of the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath. This is about how agreement will be made between health and well-being boards and the commissioning intentions. We need some understanding of the ground rules which will underpin those negotiations. My experience of negotiating contracts in the NHS is that they can be an awful long time in coming and being finalised unless you have some clear ground rules. I wonder how far the Government have got in thinking about that.

I wish to speak to Amendment 178 on behalf of the noble Earl, Lord Sandwich, and the noble Lord, Lord Mancroft, neither of whom are in their place today. This again is about clinical commissioning groups’ awareness. Amendment 178 is a plea that commissioning groups should take into account—particularly into financial account—what is already being provided for voluntary organisations. Often these provide a more cost-effective and responsive service to client groups. In the noble Lords’ minds particularly were services for those who misuse drugs or alcohol, but there are also services in mental health or in specially targeted support and rehabilitation for specific ethnic groups. For example, a support worker from the same ethnic community can be so vital in establishing mutual trust and compliance with a care plan.

I very much hope that commissioning groups will take into account what is already being provided when they commission. Of course, I understand that alcohol and drug misuse services will be commissioned largely by local authorities. This is entirely positive because they often have a greater understanding of the involvement of voluntary organisations in being able to contribute to a wider service than the NHS often does. Nevertheless, this is an important amendment.