Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Tuesday 6th March 2012 Lords Chamber

[Lord Patel]

My Lords, I support the amendment. The noble Lord, Lord Warner, and the noble Baroness, Lady Williams of Crosby, have said all that needs to be said. I had my name to Amendment 217. To relieve the anxiety—if they had any—of the noble Lord, Lord Warner, and the Minister, I will not move that amendment either. I strongly support Amendment 196ZA.

[Baroness Murphy]

My Lords, I also add my support to the very practical solution given in Amendments 196ZA, 214G and 217 that will provide Monitor with a mechanism to deal with future, upcoming failure and intervene early. That is very practical. I hope that it will be attractive to the opposition Benches because, in part, it deals with their anxieties about special administration orders. None of us wanted to see those special administration orders used early. We want them as a very rare fallback position, and to use them maybe once in a decade not once a year. If there were a mechanism like this one, enabling a practical way of targeting and getting local commissioners to address local failure, we could avoid some of the draconian measures that it is necessary to have in the Bill but which none of us wants to see used frequently. I hope that the solution will commend itself to the opposition as addressing their concerns about this regime.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Wednesday 29th February 2012 Lords Chamber

[Baroness Murphy]

My Lords, the noble Baroness, Lady Cumberlege, expressed what we psychiatrists call a transient situational emotion of delight.

[Lord Patel]

That is a serious mental condition.

[Baroness Murphy]

Just as she was delighted at having her amendment accepted, I too am delighted that the Minister has expressed the fact that the Government will accept this amendment. I beg to move.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Wednesday 29th February 2012 Lords Chamber

[Baroness Murphy]

I will respond briefly to that. We all have tremendous sympathy with the fact that very many rare conditions are not currently commissioned to the standard that we would wish. It is also true, by the way, that many ordinary conditions are not commissioned to the standard of service across health and social care which we think would be best for the patients. That is undoubtedly true, but we would not necessarily fix that by having a special focus on the way we say where it is going to be commissioned. What we need are specialists in each of those rare conditions’ groups to be consulted, to ask patients and their relatives about how they should be commissioned, and some professional advice about the epidemiology of it.

Noble Lords should remember that the national Commissioning Board has the ability in this Bill to use, for example, the good offices of their local offices that will regionally be able to ensure that clinical commissioning groups can come together to commission properly for rare conditions. That is already happening around the country, and that is more likely to be a way forward than this particular statutory amendment. I am not saying that those rare conditions do not need some focus and better commissioning: they certainly do.

[Lord Patel]

My Lords, my name is on Amendment 96. I feel we might be running the risk of missing the important point in a rush to say whether this amendment should be tested. I would very much like the Minister to accept that there is an issue to be addressed here: it is on how the commissioning would be carried out for patients with less common conditions and rare diseases. The Bill is not clear, hence this debate and the amendments put forward by my noble friend Lady Finlay, previously in relation to commissioning boards and now in relation to commissioning groups.

This amendment alludes to the duties of the commissioning group,

“to ensure the provision of services for patients with less common conditions”.

Small commissioning groups may not be able to ensure the provision and may well have to co-operate with other commissioning groups. The direction may well actually have to come from the national Commissioning Board.

The noble Lord, Lord Walton of Detchant, referred to the funding issue. There has to be some pool funding from the national funding pool because the commissioning group may not be able to afford the large amount of money required for treating those people. I am familiar with that, because I was involved in setting up the process for handling it in Scotland. I ask the Minister to accept that there is a lacuna here of how commissioning for rare diseases would be done. He needs to reassure us that it will be robustly done, with clear leadership and responsibility. I hope that he will be able to do that.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Monday 27th February 2012 Lords Chamber

[Baroness Murphy]

My Lords, I will interject here with regard to my amendment to Schedule 4, tabled as Amendment 148B in the supplementary hymn sheet. First of all, I thank the Minister very much for the discussions that I had with him and the Bill team last week. As a result, I tabled this amendment. Unfortunately, I omitted to let the Whips’ Office know that it was to be discussed with Amendment 42, otherwise they could have been tabled together.

As I understand it, the important thing about this amendment is that it addresses the issues that we have just spent another hour discussing of how in practice you get money flowing from health to social care, and how you promote integration of services through some practical mechanisms on the ground. Over the last 60 years, there has been too much money held in the NHS—I say this as a health service person—when it should have been better transferred in to social care services to support people with long-term conditions. It has been extremely difficult to get mechanisms that work well. The importance of this is that we do not have to have it repeated in the mandate, which was in the amendment tabled by the noble Lord, Lord Warner. I was very supportive of that, but it is much more flexible to have it as the Secretary of State’s direction. It also covers wider organisations than adult social care, although we expect that to be the main route to which the Secretary of State would wish to ask for moneys to be transferred. My amendment is slightly superior in that respect to the amendment proposed by the noble Lord, Lord Warner. However, it does not address the most important issue that the noble Lord brought up in the first part of our amendment—that of the reconfiguration of services and how you can prepare and work towards dealing with issues around failing organisations and services. I know that, as the noble Lord said, the Minister has been looking at that issue and may be able to come back to us with some mechanisms for that—but on this one I wish to speak in support of my Amendment 148B, which addresses the Secretary of State’s direction in Schedule 4.

[Lord Patel]

My Lords, I have added my name under that of the noble Lord, Lord Warner, and I would also have supported Amendment 148B under the name of the noble Baroness, Lady Murphy, if I had not been in India at the same time—not, I hasten to add, with the noble Lord, Lord Warner.

I merely wish to speak about reconfiguring hospital services. It is quite clear that in the long term demographic changes and the shifting burden of disease require a fundamental shift away from acute care in hospitals to supporting people with long-term conditions in the community. The recent financial pressures and shortages among some parts of the workforce and the need to improve quality and safety mean that changes to hospital services in some parts of the country are already a necessity. The Government have argued that service change should be locally led. In Committee, the Minister stated that,

“we should be cautious about any process that would significantly weaken both local commissioner autonomy and public engagement”.—[Official Report, 13/12/11; col. 1271.]

I agree that clinicians and local communities must be fully engaged in the process of service change. However, local involvement and strategic leadership are not mutually exclusive. For example, the reorganisation of the successful stroke services in London proceeded with strong support from clinicians and the public. It is not clear how strategic reconfigurations of specialist services will be led. Again in Committee, the Minister stressed that the NHS Commissioning Board,

“will be able to support clinical commissioning groups by providing support and advising on the possible effects of larger changes”.—[Official Report, 22/11/11; col. 1046.]

A recently released paper outlining the design of the NHS Commissioning Board confirmed that involvement in large-scale reconfigurations will be one of the functions of the four regional sectors that will be established as part of the board. But I am not too sure whether the NHS Commissioning Board has the necessary capacity or experience to do that. The lack of clear responsibility for driving forward strategic reconfigurations of services is the most significant omission from the Bill. We need a clearer explanation about how these reconfigurations will be taken forward under the new arrangements, otherwise the risk is that the NHS will not be equipped to meet one of the bigger challenges, as is necessary to reconfigure some of the acute services.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Monday 19th December 2011 Lords Chamber

[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.

[Lord Patel]

My Lords, I have my name on these amendments. Of course, we have had an opportunity to discuss integrated care at length at other times. However, I agree that integrated care and the delivery of it is one of the key challenges in the Bill. I agree with what the noble Lord, Lord Warner, said. To a patient, integrated care is the care they need: primary care, secondary care, social care and care in the community.

What leverages will there be for the commissioners to promote the integration of health and social care? They will have the budget, but what other incentives will they have? There is some evidence that contracting of provision of care to a population, particularly the elderly, the frail and those with complex diseases, will require much more care but also use more resources and services. It is not only value for money, but improved patient experience and patient outcomes. How will the commissioners be encouraged to do this? Does the Minister think that three separate outcomes frameworks in health, social care and prevention will help or hinder integration of care? There is also an issue about who will lead this change, if we think that this is the key challenge in the Bill. I agree that putting a clear definition of what we mean by integration, or what a patient means by integration, into the Bill will give a clear message to all those who commission and deliver the care, to know exactly what they have to do.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Wednesday 30th November 2011 Lords Chamber

[Baroness Murphy]

I do not disagree with the noble Lord, Lord Warner. It is absolutely true that there is a balance and that size is important. Nevertheless, at the moment we are going back to a size that is approximately the same as the old district health authorities that we had between 1983 and 1992. They survived for quite a long time—

[Lord Patel]

Too small.

[Baroness Murphy]

I agree; they were too small. However, if you want to get that balance and that advantage of the clinical commissioning, it seems that, with a different sort of central support, it would be possible. With some local responses and reconfiguring of commissioning groups and the old PCTs, it can work. I do not feel quite as depressed about the clinical commissioning groups as other people.

Health and Social Care Bill

Debate between Lord Patel and Baroness Murphy

Monday 14th November 2011 Lords Chamber

[Baroness Murphy]

My Lords, I must confess that when I first read about clinical senates, I thought, “This is a great solution”. But what is the question? The problem came home to me very much when visiting the New York mental health commissioning services and seeing the great difference in their approach. Mental health is commissioned by the public purse for a largely public service everywhere in the world, so it is a good way of looking at how people commission differently in different places. The big difference between New York’s system of commissioning mental health services and ours was that they had clinical specialists involved on a day-to-day basis who could never be second-guessed by the provider system. That is because they were recognised experts who usually had run a service themselves and were very respected nationally or locally. They were incorporated into the commissioning group. The same was true of public surgical services, public health services, and so on. That was very impressive.

Therefore, when I heard about clinical senates, I thought that this could be the way to provide that kind of serious expertise from a region to clinical commissioning groups. However, it does not seem to be developing quite that way. The noble Lord, Lord Hunt of Kings Heath, is very optimistic, with a slightly grandiose idea of what these clinical senates might do. I would love to share his optimism but I remember those dreadful regional medical advisory groups. I know that the noble Baroness, Lady Emerton, will remember them, because we dealt with the same clinical regional advisory group for the south-east Thames. They were dire; they were the lowest common denominator of time-serving BMA—No, I am going to be very careful now. I do not want to be too rude, but on the whole, they were not the edifying cutting edge of specialties.

[Lord Patel]

Psychiatry.

[Baroness Murphy]

Even the psychiatrists were not. I can remember this group of people being pretty darn useless. You would send up a proposal; they would look at it; they did not like it because it was not in their best interests as a specialty and they would send it back again. I can see that my colleague, the noble Baroness, Lady Emerton, agrees with my every word.

I am a little concerned about what these people are going to do. Will they provide cutting-edge, evidence-based expertise of the best kind to local commissioners? Will they be a talking shop? Will they be a regional medical advisory group?