National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013

Earl Howe Excerpts

Thursday 20th June 2013 Lords Chamber

Moved By

[Earl Howe]

That the draft order laid before the House on 22 April be approved.

Relevant document: 1st Report from the Joint Committee on Statutory Instruments.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, in 2009 we debated piloting direct payments for healthcare as part of the wider personal health budget pilot programme. Personal health budgets allow people to have choice and control over the care and support that they receive. A care plan is drawn up between individuals and their healthcare professionals, which is person-centred and designed to allow them to access care that works in the best way for them. It is already possible to offer personal health budgets where the money is held by the NHS or by a third party, but direct payments would allow personal health budgets to be held by the individual in the form of cash sent directly to their bank account, albeit one separate to their own personal funds.

Direct payments—and, indeed, personal health budgets more widely—are new to the NHS and we wanted the pilots to explore whether they would be beneficial. We wanted to find out which people and services were likely to benefit most and how we should implement them in order to get the best results. The pilot programme ran from 2009 to 2012 and I am delighted to report that the independent evaluation of that programme supports the wider use of direct payments in healthcare.

I will spend a few minutes talking about what the evaluation and the learning from the pilot programme tell us about direct payments for healthcare and personal health budgets more widely. The evaluation demonstrated that personal health budgets were most beneficial for people who had higher levels of health needs. In particular, it identified benefits to people with long-term physical or mental health conditions and disabilities who access the NHS most frequently. For these people, having real choice and control over how to manage their budget to meet their individual needs is a key factor in how they handle their own condition and improve their quality of life.

The most important element of our debate today is the discussion around whether we should take a step further and allow direct payments for healthcare as a new option for people who have or want personal health budgets, building on the success of the pilots. If the House agrees with the principle, secondary regulations, which will be laid before the Summer Recess, will set out the rules for the making of direct payments for healthcare.

The current debate focuses on direct payments for healthcare because this is the only part of the personal health budgets policy that requires legislative change. The other two ways to manage personal health budgets, where money is held by the NHS or alternatively by a third party, are currently lawful. However, direct payments for healthcare are a great deal more than money in lieu of NHS services. They are designed to allow people more flexibility and control over how their health needs are met.

The pilot programme showed that the success of direct payments for healthcare is dependent on good-quality, personal, holistic planning. The secondary regulations set out that individual care plans must be agreed before a direct payment can be approved. Importance is placed on the development of the plan being led by the individual or their carers, or a collaboration of both, using the right information and support. It should bring together their knowledge and experience of what works for them alongside clinical knowledge and expertise. The role that healthcare professionals play is still vital, but the conversation between the individual and specialists involved in their care should be a different, more real partnership.

So where does the NHS constitution fit into all this? It is vital, as we are absolutely clear that the budget must meet the full cost of the care and support agreed in the plan. NHS care provided through a direct payment for healthcare remains comprehensive care, free at the point of delivery, based on need rather than on ability to pay. This means no top-ups.

In the vast majority of cases, direct payments for healthcare will continue to be used on traditional care and support. However, a personal budget will give people the freedom to set arrangements that work for them. For example, people will be able to employ their own carers. In these circumstances, they will have greater control over who comes into their home, when they are scheduled to come and what tasks care staff perform. This can make a real difference to people’s lives and to their families’ lives by encouraging them to organise care that is more appropriate for their needs and the lifestyle they wish to lead. It is crucial to note, however, that direct payments for healthcare are not about new money; they simply allow people to use money already being spent on their care in a different way.

The NHS provides a huge range of care, support and treatment, and it would not be appropriate to include all NHS services in direct payments. Secondary regulations will set out what services should be excluded from a direct payment for healthcare. These will include, for instance, GP services, as we believe that disruption to the holistic care currently provided by a GP would be detrimental.

In addition, we do not think that it is appropriate to include the costs of unplanned care in a direct payment for healthcare. This would include things such as a visit to accident and emergency or admissions to hospital. However, it is important to point out that the evaluation of the pilot programme suggests that people with personal health budgets use secondary care services less. We are therefore confident that there is merit in giving people budgets to help them access care and support which works for them and prevents their unnecessary admission into hospital. Everyone will be able to reap the benefits as individuals will experience a more infrequent need for acute care and the overall cost of care for each individual will decrease, meaning an overall saving to the public purse.

Another area where we do not think that the use of direct payment for healthcare would add value is payment for medication. Deciding what medication an individual requires is a core responsibility of GPs and it should remain that way. This is currently dealt with using a two-stage process whereby a GP gives a prescription and pays for the cost of the medicine, and the individual then contributes with their prescription fee. We do not believe that direct payments should be used for either stage, or for any other area where NHS charges apply.

There may be concerns surrounding the proper or improper use of funds, or people’s needs not being met. In order to monitor this, there will be periodic reviews to ensure that the care and support being delivered are meeting the individual’s needs. In the case of direct payments for healthcare, these reviews will include a financial review to ensure that the money is being used appropriately. The details of what the review should entail will be set in the secondary regulations and explained to the individual as part of the care-planning process.

The evidence from the pilot programme suggests that people spend their money as set out in the individual care plan. What is more, they were happy to give money back if it was not needed. However, safeguards will be written into the secondary regulations to ensure that action can be taken where there is an excess that people are reticent to return, or where fraud has occurred.

In implementing direct payments for healthcare we are keen to ensure that integration between health and social care is taken into account. There are a few differences between direct payments for healthcare and direct payments provided by local authorities to fund social care. For example, the latter rely on means-testing, whereas direct payments for healthcare do not. Nevertheless, where possible the policy and regulations for direct payments for healthcare mirror those for social care. This will help to facilitate integration across health and social care. In future, it is intended that adults who have both health and social care needs could have a joint plan and budget.

I will now turn briefly to the issue of who should be able to have a direct payment for healthcare. We do not believe that such a payment would be appropriate for everyone who uses NHS services, or for all the services that an individual may use. The founding principle is that there needs to be a benefit from having a direct payment and that this should outweigh any additional costs. The evaluation suggests that those with higher health needs and inevitably larger budgets benefit most.

I make it clear that direct payments for healthcare will always be voluntary. No one will be forced to have one or be asked to take more control than they would find comfortable. However, where they add value and the individual is interested in using them, the right information and support should be made available so that people can make informed choices about how they wish to proceed. The need for information and support is intrinsic to this entire process, and this will be set out in the secondary regulations.

The pilot programme and the evaluation that followed provided evidence that the concept of direct payments for healthcare is beneficial and cost effective if properly implemented. Nevertheless, we accept that there is still much to learn and that we are only at the beginning of the journey. Therefore, it is important that direct payments for healthcare are introduced gradually and in a way that guarantees the sustainability of the programme. As of April 2014, people receiving NHS continuing healthcare will have a right to request a personal health budget and direct payments. It is thereafter anticipated that this progression, allowing more and more people the opportunity to have direct payments, will continue into 2015 and beyond.

In conclusion, I trust that I have demonstrated how the draft order removing the pilot scheme limitation will enable direct payments for healthcare to be made to patients using the NHS in England, and how secondary regulations will clearly set out the details of how they will be implemented. I commend the draft order to the House.

[Baroness Wheeler]

My Lords, I thank the Minister for his comprehensive explanation of the background and purpose of the order. We recognise that it is a technical amendment, but this is nevertheless a good opportunity to be updated by the Minister on the consultation on the extension of direct payments for healthcare and how the learning points from the pilots are to be translated into the revised regulations. Labour is fully supportive of extending personal health budgets, having pioneered them in social care through our personalisation and transformation of social care agenda, and set the ball rolling into 2009 on the PHB direct payments pilot.

It was also right to focus on exploring the use of PHBs and direct payments where people had the highest needs, such as those with long-term health and mental health conditions and who access the NHS most frequently. The pilot group covered CIPD, diabetes and long-term conditions, mental health and stroke and patients eligible for NHS continuing care. Labour was particularly concerned that PHBs do not stop at physical health but also include people with learning disabilities.

The national rollout target for PHBs to be extended to 56,000 people by April 2014 is challenging but is necessary to boost the take-up of PHBs across the country, as is the NHS mandate provision for every patient who will benefit to have the option of a PHB by 2015. Is the Minister confident that in the current circumstances, the resources will be available to support achieving these targets?

The pilot evaluation concluded that the majority of budget holders and their carers reported positive impacts of PHBs on patients—on health and well-being, care and other support arrangements for family members. As we know, PHBs have the potential to improve quality of life and satisfaction for both patients and carers, including psychological well-being. Helping patients design packages of care and support from clinicians, primary and secondary care and community health services also helps to provide joined-up integrated care, as the Minister pointed out, and in many instances has led to a reduction in the number of hospital visits. This is exactly where we need to be in terms of future service provision.

As a member—like many Members on all sides of both Houses—of the Westminster Health Forum, I recently chaired a specialist conference on PHBs which was attended by staff, providers and practitioners from across health and social care. The forum conferences are a valuable exchange between experts and staff on the ground including, in this case, those who are part of the multidisciplinary teams supporting and delivering PHBs. There was strong support for PHBs but it is clear, as the Minister said, that we are still very much in a learning process about their development. As usual, as you would expect, there were many questions and answers about some of the implementation, monitoring, accountability and evaluation issues.

I should like to finish by asking the Minister three questions on the issues that arose. First, there were widespread concerns at the conference that the evidence on the impact and effect of PHBs needed to be sharpened up in the future evaluation process. The pilot evaluation showed that there did not appear to be an impact on health status per se. Can the Minister explain whether there are plans in the rollout to assess possible measurements of health improvements, although of course we recognise that these can be hard to achieve in long-term health conditions?

Secondly, a number of GPs at the conference spoke about the challenge of getting wider GP buy-in to PHBs. Can the Minister update the House on discussions with the Royal College of GPs and the BMA on addressing this important issue? The college’s guidance on PHBs was especially commended by conference participants.

Finally, there was widespread concern about how PHBs will be taken forward by commissioners, health professionals and service users. Can the Minister update the House on advice planned or issued by the Department of Health in this respect?

[Earl Howe]

My Lords, this is most definitely one area of policy where all sides of the House are at one and I am grateful to the noble Baroness for her comments. She is right that the pioneering work on social care budgets was carried out during the previous Administration and gave us—and her own Government in 2009—sufficient confidence to institute these pilots for healthcare. I am pleased that she is as gratified as I am that the pilots have been a success, although as I emphasised earlier, we still need to feel our way in rolling them out.

The noble Baroness mentioned specifically people with learning disabilities and I agree with what she said. Although the number of people with learning disabilities involved in the pilot was small, it is clear from their stories that people with learning disabilities and their families benefited from the flexibility and control offered by personal health budgets. As the final report on Winterbourne View identified, personal health budgets have the potential to improve commissioning for people with complex needs and challenging behaviour. Many people in out of area placements, or who are at risk of such placements, are funded entirely through NHS continuing healthcare or have some NHS funding. These groups could be offered personal health budgets as the basis for a person-centred approach, meaning that they could have more control over where they live and the care they can access. It is that kind of intangible benefit—the noble Baroness asked about health benefits—that is very difficult to capture metrically, but it is nevertheless an important factor.

The noble Baroness asked me about resources and whether they will be available. As I mentioned earlier, personal health budgets are not about new money, they are about using existing money more effectively. Funding for budgets will need to be found from within normal NHS allocations and how that is done will be a decision for local CCGs. The personal health budget toolkit contains learning from the pilot programme on this and more information will become available during the early rollout phase as Going Further Faster sites consider sustainability issues. NHS England will be publishing guidance to help CCGs consider how to introduce direct payments for healthcare and personal health budgets on a local level in a sustainable way.

In answer to the noble Baroness’s question about health outcomes, it might be helpful to run through some of the findings from the pilots, which I think show that we can hold our heads up and say that they benefit people. First, we are clear that personal health budgets are cost-effective. They improve or maintain outcomes and reduce costs or are cost-neutral. These results are particularly true for people eligible for NHS continuing healthcare and people with mental health problems. When personal health budgets are implemented so that the person has choice over services and how they receive the budget, the cost-effectiveness increases. People can choose to meet their needs in different ways through lower-cost interventions, for example by training their personal assistants to carry out some health tasks, such as changing dressings. This means that people’s needs can still be met but in a different way, and perhaps in a way which is less stressful for them.

Personal health budgets also clearly resulted in an increase in the quality of life. The study found that effects were greater when people had budgets of more than £1,000, and this generally applies to people who have higher levels of health need, as I mentioned earlier. People benefited more from personal health budgets when there were fewer restrictions in place around what they could spend the money on and how they received the budget—that is, having a choice of a direct payment, a third-party budget or a notional budget. I hope that that is helpful to the noble Baroness in answer to her question.

In answer to the noble Baroness’s further question, I can tell her that the review will include a review of whether the budget is meeting the individual’s needs. That is clearly an important factor. We need to make sure not only that the money is adequate but that the plan itself and the money that goes with it are in step with each other. As regards the Royal College of General Practitioners and wider GP buy-in to personal health budgets, we have been very careful to engage with the royal college at all stages. We met them in conference last week to discuss their role going forward. It is important, as the noble Baroness stressed, that we engage GPs in this process, and I hope that we can continue that active co-operation with them.

Motion agreed.