Health and Social Care Bill

Baroness Whitaker Excerpts

Thursday 8th March 2012 Lords Chamber

[Lord Ramsbotham]

My Lords, I shall be brief. First, I pay tribute to the noble Earl, Lord Howe, and thank him very much for his letter on this subject. I declare an interest as chairman of the All-Party Group on Speech and Language Difficulties. We have been campaigning in many Bills—education, welfare and justice—to make certain that every child is properly assessed not just for learning disabilities but for learning difficulties and particularly to enable every child to engage with the education system. The Minister has assured me that health visitors are being trained by speech and language therapists to enable that to be done. I hope very much that this will soon be the norm throughout the United Kingdom. Therefore, Amendments 238A, 238B, 238C, 238D and 238E add a little more to the debate that we had at earlier stages of the Bill.

In particular, I am anxious to make certain, if we possibly can, that the variability in commissioning between local areas is reviewed. In her recent report, the communications commissioner, Jean Gross, stated that there was considerable variety and that she expected to find such commissioning in only 70 per cent of local areas. This is unfortunate. I do not think it is right that there should be a postcode lottery in assessing our children’s ability to engage with education.

I introduce the words “allied health professional” in Amendment 238B because the allied health professionals have responsibility for liaising between the primary and secondary sectors and therefore cover a wide number of disciplines. I include the words “education or children’s services” in Amendments 238C, 238D and 238E in order to make certain that those services, along with the NHS and local government, are properly represented in ensuring that this opportunity is available to every child throughout the United Kingdom.

I appreciate that it may not seem appropriate to make these amendments to the Bill. However, I hope that the Minister will be able to assure me that these points will be made in instructions that go out about the health and well-being boards, the joint strategic boards and so on, even if they are not included in the Bill. I beg to move.

[Baroness Whitaker]

My Lords, in supporting the noble Lord, Lord Ramsbotham, I have very little to add, which I imagine will be welcome to noble Lords at this hour. He has really said it all extremely comprehensively but I would just add that, if the Bill cannot provide the framework that these amendments would ensure, particularly in respect of integration of the education services, children in particular will suffer. I briefly remind noble Lords that speech and language deficits are among the most common disabilities in childhood. They affect significant numbers, who will lose out on education, employment and relationships as a result. I hope that the noble Earl will be able to provide the reassurances that we seek.

[Baroness Massey of Darwen]

My Lords, I shall speak to Amendments 238AZA and 238CA, which concern integration of services. Integration is a word that is used very often in the Bill.

My amendments would require all health and well-being boards to take a local lead on integrating health-related services with health and social care. General duties to promote such integration are held by the NHS Commissioning Board and clinical commissioning groups. The amendments would ensure that health and well-being boards also played their part.

Integration of the planning and delivery of health and social care with health-related services is crucial for improving the health and well-being of local populations. Evidence and experience show that health and care services can be made more effective, efficient and accessible when integrated with wider support services. The Bill references this network of support as “health-related” services. This covers a wide range of provision that contributes to children’s and adults’ health and well-being. The National Children’s Bureau, the National Housing Federation, St Mungo’s and Homeless Link have come together to call for a clear role for health and well-being boards and they support close integrated working between health-related services and health and social care. This is clearly an issue that has implications across all sectors—health, education, children, housing and employment.

As the Bill stands, clinical commissioning groups and the NHS Commissioning Board will have a general duty to promote integration of health services with health-related services, as well as with social care. Health and well-being boards’ duties to support close working and partnership arrangements are limited to health and social care, with only a power to encourage close working with health-related services.

I am concerned that, without the support of their local partners through health and well-being boards, the NHS will struggle to deliver on this wider integration agenda. As health and well-being boards will be the key forums for local partnership working, they should have duties in this regard; for example, with children and young people. Schools and colleges, children's centres and youth services are vital settings for delivering health outcomes. The national evaluation of Sure Start found that a child with access to a children's centre—formerly Sure Start—had more immunisations and fewer accidents than young children living in other areas. School health initiatives have had a positive impact on health and behaviour among pupils.

Evidence suggests that health, social care, education, early childhood, youth and other services are not always working in partnership to secure good health outcomes for children and young people. The Marmot review identified a lack of consistent partnership working between such bodies as a barrier to delivery. Similarly, the Kennedy review highlighted the fact that the requisite links between the NHS, social care, education and the criminal justice services to support children and young people are not always made. This report recommended that local partnerships, covering all services for children, should have a duty to ensure that local organisations work together. Close working between local partners is particularly vital for children with complex needs, such as disabled or looked-after children, who need co-ordinated interventions from a range of services.

Improving people's health is rarely achieved by clinical interventions alone, but is dependent on the wider determinants of health; for example, housing support acts as a health intervention and can help people to improve their well-being, manage their health better and prevent the need for more acute services. A lack of good housing can also be a major determinant of poor health: eight out of 10 homeless people have one or more physical health needs and seven out of 10 have at least one mental health problem. The average age of death of a rough sleeper is estimated to be 40 to 44 years.

I chair the National Treatment Agency for Substance Misuse and I am well aware that, in tackling drug and alcohol use, we also need to tackle the social issues such as housing, employment and education. The Marmot review, Fair Society, Healthy Lives, noted that,

“this link between social conditions and health is not a footnote to the ‘real’ concerns with health … it should become the main focus”.

The role of health and well-being boards in promoting integration across local services was debated in Committee on 19 December. The Government acknowledged the role that housing, schools and other services might play in promoting health and well-being.

However, in response to separate amendments aimed at strengthening the role of health and well-being boards in engaging and working with specific health-related services, the noble Earl, Lord Howe, responded:

“we want to avoid being overprescriptive. On the other hand, we are clear about what best practice looks like, and … we have provided for statutory guidance”.—[Official Report, 19/12/11; col. 1542.]

The relevant statutory guidance has been published in draft form by the Department of Health. Although it makes broad references to vulnerable groups and wider services like housing, there are no clear expectations for how, when and where this integration could take place or which client groups or needs would particularly benefit from this. The Bill offers opportunities to integrate services beyond traditional primary and secondary care to reach across initiatives to improve lives. These amendments would ensure such opportunities will be taken by local partners. I look forward to the Minister’s response and hope that he can give me some reassurance.

--- Later in debate ---

[Baroness Whitaker]

I am sorry to interrupt the noble Earl, but before he moves off our amendments, I did not actually hear the words “education services” in his helpful remarks. Could he explain how they will come in?

[Earl Howe]

I was going to come on to that in replying to the noble Earl, Lord Listowel. If the noble Baroness will bear with me, I hope that I will cover the point.

Amendment 238A would require local authorities and CCGs to specifically consult relevant health professionals when preparing the JSNA. As I have said before, in preparing the JSNA and joint strategy, local authorities and CCGs will be under a duty, which the health and well-being boards will discharge, to involve people who live or work in the area. In practice this could well include health professionals. Indeed, I thought that the noble Baroness, Lady Finlay, made a powerful point in this regard, and I do feel that we are broadly accepting the spirit of the amendment.

In relation to Amendment 238AZA in the name of the noble Baroness, Lady Massey, and the noble Earl, Lord Listowel, I should like to reassure both of them that the health and well-being strategy will be a shared, overarching response addressing the health and social care needs of an area identified through the JSNA. In the joint strategy, the board will be able to consider how the commissioning of wider health-related services could be more closely integrated with health and social care commissioning. For example, the board could consider whether and how housing, education or local authority leisure services could affect health and, if they do, how commissioning could be more closely integrated with the commissioning of health and social care services. The model we have chosen for health and well-being boards is designed to enable those wider conversations to take place, and in answer specifically to the noble Earl, Lord Listowel, I genuinely believe that the arrangements in the Bill afford a much better chance of us having joined-up thinking and joined-up services than we have had before. Clinical commissioners will be best placed to work in the interests of children, especially when this requires working with other professionals. There are strong duties on commissioners as to promoting integration, as the noble Earl will be aware.

On Amendment 238H, in the name of the noble Lord, Lord Beecham, we believe that health and well-being boards will provide an opportunity to build strong relationships with an open culture of peer-to-peer challenge. The JSNA and joint strategy will provide all members with a common understanding of local needs and priorities. However, giving boards a power of veto over commissioning plans would undoubtedly undermine that relationship. I am afraid that we are firmly against that idea.

We are in agreement on that matter with the Future Forum and the Local Government Association, both of which recognise that placing a duty on CCGs to agree commissioning plans with the health and well-being boards would confuse lines of accountability and be unworkable—confusing and unworkable were the words of the Future Forum. CCGs are ultimately responsible for their budgets and to give the health and well-being boards the right to make decisions that might incur costs for commissioners without taking responsibility for expenditure would be wrong.

I hope that I have been able to reassure noble Lords adequately—although I know that I will not have reassured the noble Lord, Lord Beecham—and they feel able not to press their amendments.

Finally, I should like to speak to the government amendment in this group, Amendment 239, which is a minor technical amendment in relation to Clause 195. The purpose of this amendment is to clarify that a local authority may delegate any functions exercisable by it to the health and well-being board. I hope that it will receive the support of the House.