Health and Social Care Bill

Baroness Pitkeathley Excerpts

Wednesday 12th October 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, I am going to be in a minority on these Benches by speaking in favour of the Bill, at least of one very small part of it, and that is Clauses 219 to 226 in Part 7 which create the Professional Standards Authority for Health and Social Care. I welcome the changes to the Council for Healthcare Regulatory Excellence, the organisation I currently chair. The changes provided by the Bill will bring in new regulatory options for the health and social care workforce through the accreditation of voluntary registers, new areas of oversight in statutory regulation across social work and new funding arrangements. I support this package of reforms because they keep the interests of patients, service users and the public at the heart of the system regulating healthcare workers in the UK and social workers in England.

These provisions reflect evolving thinking about right-touch regulation and proportionate protection of the public. Giving the Professional Standards Authority the power to accredit organisations which have voluntary registers of health and social care workers but are not statutorily regulated introduces a new, cost-effective and flexible option for improving patient safety and experience. I also support the reforms because they allow for greater integration of health and social care regulation through our oversight function of the renamed Health and Care Professions Council, and of course the CHRE will be renamed the Professional Standards Authority for Health and Social Care to reflect the broader scope of its work. Right-touch regulation promises less but better regulation, and I pay tribute to the nine health regulators and the staff of the General Social Care Council who have embraced the proposed changes, which are not necessarily easy for them to make in a professional and positive manner. That is the limit of my positive approach to this Bill.

I am a passionate devotee of the NHS. I grew up in the Channel Islands, where every visit to a doctor had to be paid for and where good health was, therefore, largely a function of your income. My grandmother was deaf because of neglected ear infections and my grandfather was killed in a road accident because he returned to manual work too soon after being in hospital for surgery, driven by the need to pay the bill. I owe my own life to the NHS through its intervention, pioneering surgery and medical expertise, and my continuing good health to the watchful eye the NHS keeps on me.

In addition, one of the great commitments of my working life has been about social care. It is too easy, as others have said, to overlook the fact that the Bill before us is about health and social care; and about enabling disadvantaged individuals, clients, carers and patients to speak for themselves and to contribute to policy formation. How I judge proposals for changes to health and social care, therefore, is simple: first, whether the new arrangements will lead to services that are more organised around individuals and more focused on patient need; and secondly, whether there will be more integration among the providers of care, whether health services, care services or indeed voluntary and privately provided service.

The emphasis placed on integration and collaboration by the Future Forum report was very welcome but I have yet to be convinced about how its proposals, as interpreted in the Bill, will lead to better integration across health and social care. As the Future Forum report reminded us, the provision of integrated services is rarely dependent on structural change:

“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”.

It is surely not hard to understand that since delivery of co-ordinated services depends on co-ordination between individuals, individuals are less likely to have the will to do something different when they are fearful about their own futures. This is not surprising, since the dedication and commitment of public sector workers is constantly undermined by some in our society and when they are worried about the service they love being dismantled and anxious about a future which seems to offer conflict between different types of vested interests instead of a focus on patient needs.

For the patients themselves, their fear and bewilderment is reflected in the huge number of communications that all your Lordships will have received. Is there anyone who really believes that the mantra of, “No decision about me without me” is going to be facilitated by the changes in the Bill? What patients want—and, I would strongly argue, what patients have a right to expect—are services across health and social care that are easily accessible, free from fears about affordability, and provide dignity, safety and peace of mind as well as treatment or cure. I pity any patient who is seeking those things in the mess the services now find themselves in. Patients always complain about the complexity of systems and about why one bit of the service does not seem to talk to another. The plethora of acronyms and layers with which they now have to contend is hardly going to help; and woe betide any patient who looks at the horrendous flow charts and diagrams of the new system.

I share with others the concerns that have been expressed about the lack of independence for HealthWatch, the potential conflicts of interest for local healthwatch organisations, the lack of proper transition arrangements between LINks and local healthwatch, and also the lack of real power for the health and well-being boards.

In addition, although some progress has been made towards coterminosity between consortia and local authorities, the populations for whom consortia will be responsible will be based on practice lists not geographical boundaries; so there may be all sorts of problems such as we have seen many times before with health and social care professionals trying to work across geographical and administrative boundaries, as the noble Lord, Lord Beecham, has warned us.

However, my principal worry about the patient and public involvement issue—I repeat—is that all my experience shows that structural change does not bring about integration and collaboration, either within a service or across services. It is people and proper communication about the assessment of needs from the point of view of the patient that bring that about. The well intentioned changes that have been made as a result of the Future Forum work have actually led to systems and structures that are more complex and difficult to find your way around—even for the professionals who work in them, let alone the consumers.

We always—not only in these difficult times—have to face a balancing act between quality and affordability. Much mention has been made in this long debate of competition. Some say it drives up quality, and that may be true for some services. I can only say that in a lifetime of working in health and social care, I have seen very few commercial interests competing to provide preventive services or services for those with dementia or with a mental disability. Those have been left to the voluntary and community sector, who will scarcely be able to compete on a level playing field with the giant commercial interests currently circling our NHS. Unlike the voluntary and community sector, which has always subsidised these services, I doubt they would be circling unless there were some prospect of profit.

Anyone who has ever run an organisation knows you have to build a consensus if you want to bring about change—otherwise you spend too much energy fighting the change instead of facilitating it. However pressing the need for change in the NHS—and I have heard no noble Lord in this long debate argue against the need for change—the Government have utterly failed to build that consensus. All the communications we have received, and the large petition that I understand has been received today, are ample evidence of that. For the sake of patients and professionals—and the NHS which is so loved by us all—I hope that the amendment tabled by the noble Lord, Lord Owen, if carried, would give more time for building that vital consensus.

NHS Future Forum

Baroness Pitkeathley Excerpts

Thursday 15th September 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, like many noble Lords I have very personal feelings about any health Bill and have taken part in debates on many since I have been in your Lordships' House. Let us remember that the Bill that will shortly be considered by this House is the Health and Social Care Bill. I am grateful to my noble friend Lady Wheeler not only for securing this debate but for reminding us that at the moment there is precious little about social care in the Bill.

Social care has been one of the great commitments of my working life. The other has been about enabling disadvantaged individuals—clients, carers and patients—to speak up for themselves and to contribute to policy formation. How I judge proposals for change to health and social care services is therefore simple: will the new arrangements lead to services that are more organised around individuals and more integrated among all the providers of care, such as health services, carer services or voluntary and privately provided services? Therefore, I am delighted by the emphasis placed on integration and collaboration by the Future Forum report. I am not surprised, because calls for better integration always result from consultation with users, carers and the third sector, and the forum made excellent use of the networks of members from patient and user organisations.

I draw noble Lords’ attention to page 20 of the Future Forum report, which reminds us that the provision of integrated services is rarely dependent on structural change. It states:

“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”.

I will illustrate how we can do something different by telling noble Lords about Trevor. He is an Afro-Caribbean man in his 30s and a severely ill bipolar patient. He is treated by both health and social care services. He is an in-patient on many occasions. Staff try to get him to attend daycare when he is not in hospital so that his medication and behaviour can be monitored. Noble Lords will know that the average day care centre is not very suitable for a man like Trevor and he rarely attended, resulting in frequent breakdowns and hospital admissions. Last year staff decided to try a personal budget for Trevor. They worked with him to decide how it should be spent. He decided that he wanted karate lessons. For nine months he has been going to karate lessons almost every day in his local gym. He has become very good at karate, he is fit and stable and he has had no hospital admissions in that time. Moreover, when he is asked what benefit he has gained, Trevor says that he feels good and is a better father to his children.

Now this took place in one of the commissioning consortia pathfinder areas, but it is rare. We have not yet dealt with the problems caused by the mismatch in timing in the development of personal healthcare budgets and social care budgets. I fear that there will not be as many examples of such innovative practice as we need to see going forward.

Harry Cayton, writing in 2006 about patients as entrepreneurs, said that we got very near to enabling patients to have some real autonomy with personal budgets, but we stepped back from the brink as we were afraid of losing control and of what they might do with it. He said that we must not be afraid in the future. I am sure that that is absolutely right, but I fear that we are still afraid.

We still have the problem that commissioners may be focusing on the wrong problems. If you talk to a group of GPs, you will find that they are very clued up about the diagnosis and treatment of cardiovascular disease and even about its prevention. That was entirely appropriate when we had the worst record in Europe on cardiovascular disease, but the problems that face us now are not like that. They are about chronic illness and long-term care, and we still have a long way to go before we are innovative in that area.

The new amendments place a duty on local commissioning groups to consult health and well-being boards and HealthWatch is to ensure the involvement of patients and the public in policy and commissioning decisions. I worry that the plans for local healthwatch bodies have the potential to create conflicts of interest, as they are accountable to local authorities, the very bodies that commission and provide the services that HealthWatch is to monitor. Moreover, the consortia, as the noble Baroness, Lady Jolly, has reminded us, are under no obligation to abide by the views of the health and well-being boards, so I think there are some real questions about how much influence those boards can have. I very much endorse her call for them to have sharper teeth.

In addition, although some progress has been made toward coterminosity—that awful word—between consortia and local authorities, the populations for which consortia will be responsible will in fact be based on the practice lists, not on geographical boundaries, so there may be the sort of problems that those of us who have been around a long time have seen many times before of health and social care professionals trying to work across geographical and administrative boundaries.

My principal worry about the patient and public involvement issue is that all my experience shows that structural change does not bring about integration and collaboration, either within a service or across services; it is people and proper communication about the assessments of need and the point of view of the patient that bring that about. That was the example that I gave about Trevor.

However well intentioned the changes—and I am sure that they are well intentioned—that have been made as a result of the Future Forum’s work, have they really led to systems and structures that are in fact more complex and more difficult to find your way around, even for the professionals who work in them, let alone consumers when they are concerned and anxious? If you can ever find a flow chart about the new system—and they are pretty hard to find—they make your hair curl, as they look like one of those very elaborate electrical wiring diagrams. That is pretty difficult for any user, carer or patient to follow. I am concerned about the staff who are trying to administer such complex structures, anxious as they often are about their local position and jobs. They are anxious about the different paces at which different things are happening at local and national level, and I think that the complexity of the system will make that even worse.

I am also concerned about the mismatch that we now have in timing between a very major reorganisation of the NHS, in spite of promises that were once given about there being no such thing, and the very major reorganisation of the social care system as a result of the Dilnot commission, about which we still await government proposals. Will the NHS changes be set in stone by the time any decisions can be reached about social care?

I want to say a word about prevention. It is always a balancing act between quality and affordability. Services which prevent crises rather than intervene once crises have occurred are always vulnerable at times of financial restraint. How are commissioning boards going to see services that are not at present urgently needed but which are a good investment because they prevent crises developing? For example, I believe that some research about telecare shows that if you spend £1 now, it saves you £4 down the line. Will such investment be made?

I hope that the Minister will reiterate the Government’s commitment to prevention in heath and social care and will assure the House of their commitment to ensuring that social care is given equal status and importance with healthcare and that the reconvened Future Forum will have a clear programme of work and a timetable with regard to the integration of services. The temptation to focus social care on those with high needs and no means is very great. One of the ways of countering this short-sighted view is to remind ourselves that social care must achieve the same status as healthcare in future. In other words, it is not the province of the poor and feckless. It is in all our interests, and especially in the interests of commissioners, to ensure that it is understandable, which means that the current proposals are far too complicated. It must also be free from fear about affordability and provide dignity, safety and peace of mind. I remain to be convinced that the Bill that will shortly be before us will bring that vision closer.

NHS: Cost-effectiveness

Baroness Pitkeathley Excerpts

Monday 12th September 2011 Lords Chamber

[Earl Howe]

My Lords, the department takes its cue from NICE. I am sure that my noble friend will agree that exercise is never irrelevant to the question of obesity. I think that my noble friend's difficulty centres on how relevant it is in relation to reducing calorie intake. No doubt the debate on that will continue.

[Baroness Pitkeathley]

My Lords, does the noble Earl agree that no system of health, particularly with an ageing population, can be effective and efficient unless we also provide the best possible social care to link with it?

[Earl Howe]

I agree with the noble Baroness. One of the aims of our reforms is to integrate health and social care in a much more seamless way. There is another element to our reforms, which may have escaped noble Lords' notice. It is our wish to bear down on health inequalities in a much more systematic way than we have done hitherto. Both health and social care have a part to play in that.

NHS: Medical Records

Baroness Pitkeathley Excerpts

Wednesday 7th September 2011 Lords Chamber

[Earl Howe]

This is a commitment that we have made. We fully support the concept of patients having full access to their medical records online. A great deal of work is going on at the moment to make sure that the protocols are sound, because clearly the one thing one does not want is for the wrong people to access the wrong patient data. If we can achieve that and do it in a simple way, we shall roll the programme out as soon as we can.

[Baroness Pitkeathley]

I take on board what the noble Earl says about engaging local commitment and the failure that there has been in that so far, but does he agree that one of the most important things about local commitment is that different localities may have different systems? As far as the patient is concerned, it is absolutely essential that the systems can talk to each other. How will that be ensured if we go down the local route?

[Earl Howe]

The noble Baroness makes a very good point. I said that the top-down approach to local service provision has not worked when it has come to local service provider systems. We think that local requirements are best judged and best met by decisions being taken locally but that does not mean that they will be left on their own. There will be the necessary support from the centre wherever needed. She is again right that the key will be that these local systems must be interoperable.

Reform of Social Care

Baroness Pitkeathley Excerpts

Monday 4th July 2011 Lords Chamber

[Earl Howe]

My Lords, this area was not overlooked by the commission. Indeed, the commission has made a specific recommendation as regards the cap on costs, which it believes should be, as a generality, somewhere between £25,000 and £50,000, although it has come down in favour of a £35,000 figure. That figure is lower for those who require long-term care at a much earlier age. The noble and learned Lord is right that this area should not be neglected, and I am sure will not be neglected.

[Baroness Pitkeathley]

My Lords, does the Minister agree that although the sum of £2 billion mentioned by Andrew Dilnot may strike fear into the heart of the Treasury at a time of financial constraints, it is a puny sum when you compare it with the £119 billion contributed by the main providers of care—the family carers? Therefore, I am sure he agrees that the support offered to family carers in the report is extremely welcome. Will he reconfirm the Government’s commitment to continuing to work with the stakeholder groups, as the Dilnot commission has so admirably done, particularly as the advice and information service for families is developed as we go forward?

[Earl Howe]

My Lords, I cannot stand here and claim that an additional £2 billion is a trivial amount of money; it clearly is not. That is why it was made clear in the Statement that we need to make some difficult decisions over priorities in public spending. As regards carers, for whom the noble Baroness has done so much in her career, I am sure she will accept from me that we recognise the value and contribution that carers make. We recently published Recognised, Valued and Supported: Next Steps for the Carers Strategy, which announced an additional £400 million over four years for PCTs to pool with local authorities to provide carers’ breaks. In our carers strategy we indicated that assumptions should not be made about who will provide care and to what extent. There has been a 21 per cent increase in the number of carers receiving information. We want to see greater flexibility and portability of assessments for carers. The agenda in this area is proceeding and we shall not forget it amidst the concerns over funding. It is every bit as important as getting the funding system for paid residential long-term care right.

Health: Multiple Sclerosis

Baroness Pitkeathley Excerpts

Tuesday 7th June 2011 Lords Chamber

[Earl Howe]

My noble friend makes an important point. The guide that I have just referred to in answering the noble Lord, Lord Walton, emphasises the important role of specialist nurses in the care of patients with neurological conditions. However, the key in the future will be better commissioning at a local level joined with better workforce planning at a provider level. If those charged with training and workforce planning tap into the commissioning plans that commissioning consortia determine, we will have a genuinely joined-up system that is also informed by the patient’s point of view.

[Baroness Pitkeathley]

My Lords, does the guide to which the Minister referred have anything to say about keeping records? MS patients, their families and carers always report that because it is an illness with long periods of remission—sometimes lasting years—the difficulty of keeping the records up to date causes them distress.

[Earl Howe]

The noble Baroness makes a very important point, and she is right. I will have to check whether the guide refers to that issue. I would be surprised if it did not. However, the central point that she makes is quite correct. The key to this, as so often, is good communication between those providing care at every stage of the care pathway. Sometimes, unfortunately, that breaks down.

Health: Hospital-acquired Infection

Baroness Pitkeathley Excerpts

Tuesday 7th June 2011 Lords Chamber

[Earl Howe]

The noble Baroness is quite right that delayed discharge poses a risk, not only in terms of infection but in terms of mobility and other issues that affect the elderly. We are clear that if this problem is to be eased, further funding is required at local authority level, which is why we have made available up to £1 billion over the period of the spending review to ensure that the issue is addressed.

[Baroness Pitkeathley]

I declare an interest as a recoverer from MRSA. Is the Minister making any assessment of the effectiveness of preventive measures, such as hand sanitisers and making sure that doctors do not wear ties, which droop in wounds, and so on?

[Earl Howe]

My Lords, the noble Baroness will know that a code of practice was issued some time ago, which the CQC uses to ensure that the registration requirements of a provider have been complied with. It is clear that the decline in numbers of hospital-acquired infections has coincided with the issue of that guidance. We believe that it has made a material difference. I am not aware that there has yet been systematic evidence-gathering of whether the guidance has had an effect, but it appears that it has.

NHS: Standards of Care and Commissioning

Baroness Pitkeathley Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, I thank my noble friend Lord Turnberg and declare two interests as chair of the Specialised Healthcare Alliance and as chair of the Council for Healthcare Regulatory Excellence.

However devoted we are to the NHS—I speak as one who owes her life to it—we must acknowledge that there are still far too many instances where it falls short. No one could fail to be shocked by the ombudsman’s report to which many noble Lords have referred. The universal standards which we all wish to see, of a compassionate and skilled service, are by no means universal as yet. The dismissive attitudes and indifference to deplorable standards encountered in all too many instances must be addressed and, as far as possible, eliminated. I say “as far as possible” because, as a regulator of healthcare, I know only too well that it is not possible for any form of regulation to bear on every safety or quality concern. We are dependent on the quality of the professionals delivering the service and we must judge this always from the experience of the patient and his or her family.

When we think about commissioning as being about improving health outcomes and reducing health inequalities, let us never forget what that means from the patient’s point of view. Most will have absolutely no idea what “improving health outcomes” means. They only know that they want to be treated safely, with dignity and compassion, and have timely and effective treatment. In all the discussions we are currently having about the reform of commissioning, I am often struck by how remote those discussions seem from the actual experience of patients. The test that we must apply is whether it is better for them, not whether it is better for the Secretary of State, the commissioning board and GP consortia.

It is also striking how removed our discussions are from the facts around patients’ experience, which are not linear but confused and complicated—a mixture of services from health, social care, housing, the voluntary sector and their own families. This complication of experience is little recognised, even now when some of us have been trying for 30 years to get it recognised. The question we have to ask is: will the new commissioning arrangements deliver that recognition? We do not know.

What we do know is that every bit of research ever done about changing institutional structures shows that only a part, and usually a small part, of the objectives are achieved, and the bigger the upheaval, the fewer of those objectives are achieved. Since we are largely dependent for quality outcomes on the skill, commitment and—let us not be afraid to use the word—dedication of our staff, how are we to maximise those and provide them with the support they so urgently need when, for the next two years at the very least, their energy will be directed towards the change itself in the form of applying for their own jobs, learning to work with a new set of partners and so on? Also, the history of co-operation between GPs and social services does not fill me with hope, while the lack of co-terminosity between consortia and local authorities is certainly not going to be helpful.

We know that the commissioning board will issue guidance on commissioning to the consortia, but when is this to happen? Do we not risk a mismatch in timing? Some of the consortia are already willing to go ahead and are following their own rules in the absence of any from the commissioning board. I hope that the Minister will be able to comment on this. Also, from the patient’s point of view, we need a great deal more clarity about what will happen when GP consortia refuse to commission a service that a patient requires. Where is the accountability?

As to the voluntary sector, for so long the provider of good preventive care and services, we hear a great deal about organisations being encouraged to take on a greater share in providing public services and for the commissioners to recognise this. If we are serious about pushing power as close to individuals as possible and for citizens and communities to define the priorities and expectations of public services like the NHS, as the big society concept suggests we should, it is certainly important for the voluntary sector to be involved. However, many organisations are having their funding savagely cut, and more than half of them say they are going to have to cut staff in the next three months. Given that, I doubt their capacity.

Herbal Medicines

Baroness Pitkeathley Excerpts

Thursday 13th January 2011 Lords Chamber

[Earl Howe]

My Lords, again I think that the House is well aware of the noble Lord’s views, which I know are sincerely held, although personally I regret his comments about the Prince of Wales. However, I am sure that, with regard to herbal medicines, he will be aware that there is an international trade in sometimes poor-quality, unregulated and unlicensed herbal preparations. Some of these have been found to contain banned substances, heavy metals or pharmaceutical ingredients or substances from outside the UK that may not be subject to any form of regulation at all, so there is a public safety issue.

[Baroness Pitkeathley]

My Lords, does the noble Earl agree that, while statutory regulation has its place, regulation in healthcare and anything else should always be proportionate? Would he therefore endorse the concept of light-touch regulation, which is promoted by the Council for Healthcare Regulatory Excellence? I declare an interest as its chair.

[Earl Howe]

My Lords, I pay tribute to the noble Baroness for the work that she does and I entirely endorse the approach to regulation that she has outlined. Certainly, we need to adopt a targeted, risk-based approach to regulation.

Autism

Baroness Pitkeathley Excerpts

Tuesday 7th December 2010 Lords Chamber

[Earl Howe]

My Lords, I am very grateful to my noble friend for raising that issue. I can reassure her that under Section 47(1) of the National Health Service and Community Care Act 1990 local authorities have a duty to assess a person who may be in need of community care services. This duty applies to people with autism. The revised Fair Access to Care Services guidance already makes it clear that an assessment of eligibility for care services cannot be denied on the grounds of a person’s IQ. We intend to reiterate this very clearly in the autism statutory guidance.

[Baroness Pitkeathley]

My Lords, does the Minister agree that delivering the vision for people with autism and their families is, in many cases, dependent on local authority resources? Has he any anxiety about that, especially as many of the services are delivered in the voluntary and community sector, which is already reporting major cuts to its grants?

[Earl Howe]

My Lords, clearly, local government grants will come under pressure over the coming years. To my mind, that makes it even more important that decisions about priorities are taken at a local level and the joint strategic needs assessment is, of course, the tool which will enable local authorities to decide on their priorities locally.