Health and Social Care Bill

Lord Sentamu Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Turnberg]

My Lords, I rise to support these amendments. I agree with virtually everything that my noble friend Lord Warner has said. However, I disagreed with the assertion that Clause 2 may not be the right place for the measure. Clause 2 is headed “The Secretary of State’s duty as to improvement in quality of services”. If there is anywhere that needs improvement, it is in the integration of services. Therefore, I think this clause is the ideal place to insert the measure.

There is general agreement that the principle of seamless care—that is another term for integration, from the point of view I am talking about—for individual patients is a good one and we should support it. By that I mean the ease with which patients can move between one set of carers, hospitals, homes and social care and another. At the moment it does not seem to happen as well as it should in many places, so the Bill is, theoretically, a way in which we can stimulate the mechanism by which it can all happen. However, for integration of care between providers to happen with the minimum of disruption to the individual patient, we need to ensure that there is much more collaboration and consultation between them. It is not only between doctors, nurses and other carers that this collaboration is needed, but particularly across the divides between those funding and managing the different care streams. That is where these amendments can help.

At the moment, we have patients waiting for far too long, as we have heard, in an environment unsuited to their needs—elderly patients sitting in acute hospital beds waiting far too long to go home or into social care. A range of problems get in the way, such as a lack of planning, a lack of facilities, or closure at the weekend of offices where these arrangements should be made. To me, integrated care means the close working arrangements that allow not only the rapid and efficient transfer of patients but the ability to discuss the best course of treatment for a given patient. It means the ready consultation between different specialists, perhaps in different hospitals. It means different trusts, whereby patients can have access to the best treatment available.

I am reminded of the example of orthopaedic surgeons, some of whom specialised closely in hand surgery or re-do hip surgery—second operations on hips that have gone wrong the first time round. Those highly specialised orthopaedic surgeons are not available in every hospital. The ability of one group of orthopaedic surgeons to transfer a patient to the best care possible in another hospital should not be thwarted. We should not be putting any barriers to ready consultations and, if necessary, the transfer between hospitals of patients seeking the forms of treatment that are most relevant to them.

Of course, competition is seen as a driver to improving standards. However, let us be clear; there must be a balance between competition and integration, and between competition and collaboration. I am pleased that Monitor will, I believe, have a role in improving integrated care. I hope that we can persuade the commissioners and providers to support integration also. That is why I support these amendments.

[The Archbishop of York]

My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State’s duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty—already provided for in the first two subsections—will not be carried out. Integrating the delivery of services will be important.

I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.

It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.

[Lord Davies of Stamford]

My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.

Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire—and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter—that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis—some old person who can no longer cope in some way—his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.

Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week—it is not an exceptional situation—to patients, their families and carers, who are the victims of it.

The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.

Sadly—I deeply regret this—the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice—the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.

I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?