Health and Social Care Bill

Debate between Baroness Williams of Crosby and Baroness Murphy

Monday 19th December 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, we on these Benches have strongly supported the many references to integration that have been made in Committee, and it is obviously central to the whole of the attempt to deal with the major problems that confront us all over the next few years. However, I completely agree with the noble Lord, Lord Warner, that it is not very clear what this is, other than a nice word. The more flesh that we can put on it, the better all round, and the clearer the position of local authorities will be.

Many local authorities have of course already delivered, on behalf of the primary care trusts, the kind of approach that the noble Lord, Lord Warner, has been advocating, but the situation has to go a great deal further. We are particularly attracted by his Amendment 336 because it is very clear and precise in what it suggests about the relationship between CCGs, particularly those who wish to devolve some of their responsibilities, or in some cases are unable to deliver on those responsibilities.

I would like to say, from these Benches, on behalf of my noble friend Lady Jolly and myself, is that it is crucial that at an early stage health and well-being boards are able to mount mechanisms for early decision-making. If a CCG is unable to meet part of its responsibilities—and that may happen at relatively short notice—it is critical that the health and well-being boards have structures within their own management which would enable them to deal with the issues rapidly. It would be no good at all if there is a long interregnum when services to patients are put at risk.

I would advocate, in addition to what the noble Lord, Lord Warner, has said, that the new health and well-being boards should make an early approach to seeing how they would deal with what might be, if not an emergency, at least the beginnings of an emergency in the particular aspect of what the CCGs are proposing to deliver.

[Baroness Murphy]

My Lords, I have added my name to these amendments. Like the noble Lord, Lord Warner, I have come back time and again to this issue of what we really mean by integration, and what it will mean for patients, clients, and people living in the community. It must be a seamless service. They do not mind, of course, where the services come from, but it has to be utterly without gaps. It has to operate 365 days a year, year after year after year, if it is to work.

It seems to me that these health and well-being boards have two huge areas that they will have to work in: the public health and well-being functions around housing, the health of children, and the education of children, for example; and the delivery of services. These two arms are quite difficult to meld together in any joint planning arrangements. The joint strategic needs assessment will try to produce these two focused blocs, but it is actually quite difficult. I am sure I am not the only alumnus, or graduate, or perhaps I should say survivor, of joint planning arrangements. I am even a survivor of a health action zone. I know how difficult it is, and how many hours of work go into properly well-functioning joint planning arrangements, which can commit funds. It takes hours of time and extraordinary leadership from health and local authorities to make them work properly.

I am not sure that I think these health and well-being boards are an inspiration, as the noble Baroness, Lady Cumberlege, does. They are a bit of an improvement on what went before, but to work properly they are going to have to work very hard locally to get it right, and get the structures right. I think it would help enormously if they were working towards something real. For me the real thing would be the integration of the working of health and social care, both at the patient level and at the public health and well-being end of the population. Our Amendment 336 provides one option for a way of working together—an option that local organisations might want to take up. It is an idea, and I am sure that we can think of many others that would also fit the bill. I want these boards to be real and their functions to be made practically useful on the ground, so I support these amendments.

Health and Social Care Bill

Debate between Baroness Williams of Crosby and Baroness Murphy

Tuesday 13th December 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, at this late hour I will keep the Committee only for a moment or two. I congratulate the noble Lord, Lord Warner, on a courageous, statesmanlike and important amendment. We all believe that there have to be huge changes in the NHS, those of us who support it very strongly just as much as those who are critical of it. The noble Lord has thoughtfully tried to produce a machinery of government that will enable some of these extremely difficult decisions to be made. Perhaps I may say without, I hope, offending anybody, that there are echoes here of what happened to the Governments of Greece and Italy—flatly refusing to look at the realities, refusing to change, and ending up with effectively a total loss of trust in the democratic system. I believe that this amendment is an attempt to try to get away from that and to begin to mobilise a much larger section of the public for the changes that have to be made. That can be done only through open debate and the willingness of politicians to get up and express the need for change and their support for it, not by hiding away and doing the popular thing when that is almost certain to bring about the destruction of the remaining health services in any effective way.

I congratulate the noble Lord and say that he is brave to have done this, and to point out rather harshly that we all have to learn that we cannot at one and the same time take part in Chase Farm demonstrations and Chase Farm decisions. What that means is that, inescapably, the Secretary of State has to be at the centre of this operation, unpleasant though it is, because—as most of those who have been in Government know—either you have to take unpleasant decisions or you have to resign. What you cannot do is dodge the issue by saying, “It is nothing to do with me”, because in the end that will not carry the public with you. It is the public we need to mobilise behind us.

[Baroness Murphy]

My Lords, I have added my name to this amendment because it fills in the hole in this Bill that I am still worried about. Clauses 95 and 96 contain good ways of intervening early in individual failures on quality and the financial governance of providers that will enable Monitor to get in and do the business it needs to do with individuals, but what we have not got are the mechanisms that will allow Monitor to address at an early stage failures that can be seen coming up in a local health economy.

I have already experienced in the current regime how difficult it is for a regulator to get discussions going locally between trusts and local commissioners on how to address a local service failure. I well remember the whole of the Monitor board going down to the south-west—the trust will remain nameless—to address a failure of the local economy, to discuss it with the strategic health authority and to attempt to come to a conclusion and come up with a plan about how the local economy would solve the problem. The Minister has already mentioned bailouts. The solution was that the strategic health authority would give a bung, which it duly did and which sent the problem away. But in fact the problem did not go away because the local economy was still failing.

It is this early failure—where you can see that things are mounting up, that it is not going to work and that the sums are not going to add up—for which we need some mechanism. This is a clever scheme, but it may be too interventionist. It may be put into blocks which are too chunky to be inserted into the Bill as it is. But we need to address the problem of failure before it gets to the point of administration. As the noble Lord, Lord Warner, says, Monitor will not want to implement the failure regime and the administration regime until things have gone desperately awry. It should not implement the failure regime when the problem is an economy problem and not a trust problem. We need to have some reassurance that there will be some support for local people who are trying to tackle this in a meaningful way.

Health and Social Care Bill

Debate between Baroness Williams of Crosby and Baroness Murphy

Tuesday 22nd November 2011 Lords Chamber

[Baroness Williams of Crosby]

I listened very carefully to what the noble Baroness, Lady Murphy, said, and I broadly agree with it, with one slight exception. She said that she did not think that there were many examples around the world of particularly good integrated practice and then she mentioned that there had been considerably activity of this kind in some mental health trusts in the UK. I want to throw a slightly more cheerful note into what has been a slightly gloomy debate. As it happens, this morning, a Canadian doctor friend of mine brought to me the latest report of the Commonwealth of Massachusetts study on relationships between doctors and patients. It is a comparative study of 11 medical systems throughout the world. I shall not keep the Committee for long, but I will read a couple of the findings that date from November 2011. It was a major study of thousands of patients—more than 1,000 in Britain, a couple of thousand in the United States and so on—at the time that the report was put together at the end of 2009. I shall be very quick, but I think it is quite remarkable. In patient engagement in care management for chronic conditions, which is something we have been talking about a great deal when talking about integration, the country that comes out the best of the 11 is the United Kingdom. In shared decision-making with specialists, the first is Switzerland, the second—

[Baroness Murphy]

I am very well aware of the wonderfully heartening Commonwealth of Massachusetts report, but the point I was trying to make is that we are marvellous at health and social care integration in this country compared with many others. Having spent my life doing it, I am quite proud that we can say that we do it better than most. But my point is that if you want cost-effective purchasing of care systems that promote it, we cannot point to anywhere in the world where there are very good, efficient systems. Kaiser Permanente is a very restricted system for its employed clients in California. We do not have the systems that financially promote a drive towards those systems. It is not that we do not do it, but that we do it in spite of, not because of. However, the report is most heartening.

[Baroness Williams of Crosby]

I would not disagree with the noble Baroness on that issue. I agree with her, but I am trying to make a different point, which is that I think we have been left with, by sheer good fortune, if you like, a much better starting point for serious integration than many other health systems. It relates also to Amendment 203A, which was tabled by the noble Baronesses, Lady Hollins and Lady Finlay, about the role of competition, about which I am rather less confident than some others.

I shall mention two other findings from the report because it is a remarkable and impressive story. On the doctor/patient relationship, there was a question about how far patients felt that they had close relations with their doctors and the ability to speak to them and to discuss their cases with them. Once again, quite remarkably, the United Kingdom comes out second to Switzerland in the 11. To take a final and very surprising finding in this study, on medical, medication or lab test errors in the past two years, the figure for the United States was 22 per cent, for the Netherlands it was 20 per cent and for the United Kingdom it was 8 per cent. It is extraordinary that we so rarely blow our own trumpet in this country, and very occasionally, we should.

Health and Social Care Bill

Debate between Baroness Williams of Crosby and Baroness Murphy

Wednesday 2nd November 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, perhaps I may ask a couple of questions in this short debate and thank the noble Baroness, Lady Finlay, for her comprehensive presentation. This is a difficult area of the Bill. First, what happens with someone whose main residence is in one place but who is actually very dependent on out-of-hours care because of the nature of their job. There must be literally hundreds of thousands of commuters for whom the natural place they would like to go, due to the recollection of personal data and all the rest of it, would be the clinical commissioning group in their home area, but because they spend a great deal of time at work a long way away they will in fact depend on out-of-time services. I am troubled by the low quality of some of those services in comparison to what we might call mainstream NHS care.

The second question is perhaps easily answered. Can the Minister say something about the relationship of both new structures to NHS Direct? I am not clear as to whose responsibility NHS Direct will be. Will it continue as a kind of separate freewheeling service or be linked to a clinical commissioning group; and, if so, at which end of the spectrum would it be linked?

[Baroness Murphy]

My Lords, I am particularly concerned about the area-based issue because, like many people, I have been banging on for years about the importance of coterminosity between health and social services. However, my experience over the years has been that that has not made much difference to the co-ordination of care between health and social care.

I want to raise a point about the new arrangements. I understand that we are trying to move away from the old RAWP funding formulation, which has always been deeply unsatisfactory and open to political manipulation, to the funding of real groups of patient populations on a risk-assessment base. To achieve that, there is no doubt in my mind that you must have real people on real lists, whether or not that clinical commissioning group has a responsibility to provide for a population within the group. You must be able to work towards a funding solution for those clinical commissioning groups that reflects real need and moves away from the old area-based populations.

I think that that may be the response I would give the noble Baroness, Lady Finlay. I did not really understand the brief amendments in this group that were not specifically related to this question so I address my issues to that.

Academies Bill [HL]

Debate between Baroness Williams of Crosby and Baroness Murphy

Wednesday 23rd June 2010 Lords Chamber

[Baroness Williams of Crosby]

Foundation schools, both Anglican and Catholic, are allowed to appoint a majority of governors, and those schools in turn have the right to be admissions authorities for their own schools if they are voluntary aided. It is a very important power that currently exists. It is not clear from the Bill—perhaps the Minister can tell us—whether the foundation retains the right to appoint a majority of governors. Does it retain the right, if it is a voluntary aided school, to be involved in the admissions process? Can he tell us broadly whether that situation is expected to continue?

[Baroness Murphy]

I support the amendments in the name of the noble Baroness, Lady Massey, and of the noble Lord, Lord Lucas, although he has not yet spoken to them. I also support the amendment of the noble Baronesses, Lady Walmsley, Lady Garden and Lady Sharp.

We have not yet addressed this fundamental problem relating to faith schools. My questions at Second Reading about the status of faith schools, and the Government’s approach to encouraging the development of faith schools, have not been responded to. Does the Minister have the teeniest anxiety that a quarter of academies are presently faith schools and that the Bill will encourage more?

I shall recount a tale of two schools. I am delighted to see the noble Lord, Lord MacGregor, in his place, because I am going to talk about Brockdish primary school. He and I are probably the only two people in this Chamber who know where Brockdish is. It is my local school, serving the entire community of Brockdish. It is a Church of England school that has received an outstanding report and will be in the running to become an academy. It is an extraordinarily good school. I love it dearly and hope very much that it does become one, for all those reasons.

It was established in 1843 in the parish workhouse for the children of paupers. The curriculum then was the Catechism and the Ten Commandments for half the day. In the other half of the day, when they were not at work—they had to do some work in the fields as well—they did the three Rs. That was 160 years ago. During the past 160 years, the curriculum at Brockdish Church of England Voluntary Controlled Primary School has changed dramatically. As it is the only school in the village, it is entirely inclusive. If you ask people in Brockdish about the school, they will say that they do not really think of it as a religious school. Its teachers come from all faiths or none; it has a non-denominational assembly; and it gives the most brilliant education.

However, according the Bill as far as I understand it, the school has two choices when it becomes an academy. The first is that it could become more religious and more faith-based, which would be an imposition on our local community. The Minister looks puzzled. The school might have to stay with the religious denomination which it has adopted historically but from which it has gradually been moving away. Under the Bill it would have to stay like that and would have no option to become a more generalist school. There would be no choice for those of us who live in the community because the other schools are too far away. It is our local school. It is a good one and we would like it to stay as it is.

Now take the case of the Ebrahim Academy in Whitechapel, an academy school for boys. It is highly selective and employs only male Islamic teachers. The school day is, again, just like 160 years ago in Brockdish primary school, divided into two sections. The school day begins with Tahfeez, which is reciting the Koran and getting the pronunciation right, which takes up half the day. Then the national curriculum takes up the second half of the day. It is a state-funded, tax-funded madrassah for the Islamic faith.

Perhaps that is an extreme example, but there are many such faith schools. I stress that I have no objection to Sunday schools—I was a Sunday school teacher. Noble Lords might be amazed to hear it, but it is possible to deliver good Sunday school teaching without any faith whatever. I suspect that it is like the approach of the noble Lord, Lord Baker, to Anglicanism. It was possible for me to do that and I enjoyed it greatly.

I have no objection to families teaching their faith in their own time and making sure that every child has an understanding of all religions. But is the Minister not the teeniest, weeniest bit worried about the creation of more faith schools under the freedoms that we are providing today? What reassurances can he give to those of us who do not like these divisive, incohesive schools that they will not further separate a divided community?