Health and Social Care Bill

Debate between Lord Walton of Detchant and Baroness Finlay of Llandaff

Wednesday 7th December 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I too support this amendment, although like the noble Lords, Lord Warner and Lord Turnberg, I would much prefer to see Clause 53 deleted from the Bill. Throughout my professional career I have been familiar with the expertise of the former Public Health Laboratory Service. It conducted research, carried out microbiological surveillance, protected the population of this country from epidemics and so on, looked after the safety of our water supplies, and indeed undertook a huge number of other activities. The noble Lord, Lord Turnberg, chaired that body with great ability and distinction.

I just do not understand the purpose of the Government in abolishing its successor, the Health Protection Agency, which has continued to follow that pattern and to supervise the work of laboratories across the country which were formerly part of the Public Health Laboratory Service. Again, it is difficult to understand what the purpose is of abolishing a body that has proved to be so effective, which continues to give excellent service and which, as other speakers have said, attracts external research funding. If it were to be absorbed into the Government under the Secretary of State, I believe that it would be less able to fulfil its functions and to carry out the distinguished research in which it has been involved over many years. For that reason, while I strongly support the proposal that Clause 53 should no longer stand part of the Bill, if—for the reasons that I hope can be explained by the noble Earl—the Government decide that that clause should remain, it is crucial that we have an amendment such as the one before us in order to preserve the activities of such a vital scientific institution.

[Baroness Finlay of Llandaff]

My Lords, I have added my name to Amendment 260, but I should like also to talk about the problem of abolishing the Health Protection Agency. I must declare an interest because at the moment my daughter is on a placement there and is most impressed by the work that she has seen. There will be a very specific problem for the Health Protection Agency if it is not completely independent, and that relates to Medical Research Council research funding. If the agency is part of the Department of Health, it will find it more difficult to secure MRC funding. That may also apply to Wellcome funding, but the problem will be particularly acute with regard to funding from the MRC, which is the highest rated funding that the agency can get.

Also, as has already been said, the agency is internationally renowned and recognised for the excellence of its work and looks set to bring in more work to the UK. It is now working with the World Health Organisation on disaster planning. In planning for new disasters that might take place, it is important that countries know what other countries are going to be doing. We have sea borders, but if there is a massive disaster in another country we cannot go to its assistance if we do not know how its systems work. The Health Protection Agency is the leading body in this work on behalf of the UK. It seems very short-sighted to do anything that would destabilise this organisation.

Health and Social Care Bill

Debate between Lord Walton of Detchant and Baroness Finlay of Llandaff

Monday 28th November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

I add my thanks for the Minister’s remarks. I look forward to seeing amendments which thread education and training through all parts of the Bill with duties on everybody at every level.

[Lord Walton of Detchant]

The Minister has completely taken the wind out of my sails. I had every intention of going at this hammer and tongs because all the medical organisations and all those involved in education and training are deeply concerned about the absence of detail in the Bill. The Minister has now reassured us greatly. We look forward earnestly and with keen anticipation to seeing what he proposes for the Report stage and hope that it will be adequate.

Health and Social Care Bill

Debate between Lord Walton of Detchant and Baroness Finlay of Llandaff

Wednesday 2nd November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

I would be grateful if the noble Lord would bear with me for a couple of minutes while I go through a few paragraphs and try to explain how this clause poses some problems, because I agree that it is pretty complicated.

The new commissioning consortias’ duty in the Bill is to arrange for health services provision that applies to those enrolled patients registered with them. This contrasts with primary care trusts, and the other structures that will be disbanded when the new structures come in, because the population of the consortia will be drawn from the patient lists of member general practices rather than from residents living within a defined geographical area. That means that as clinical commissioning groups they will have the freedom to choose who they take on to their registers, regardless of where they live. As a consequence, the population for which a clinical commissioning group is responsible may not include all individuals and families living in the local area, so may not represent an area-based population. However, it may have some people whose primary residence is a long way away but who decide to register with a GP because that is where they work and where they are during the week.

It has been suggested that individuals and families who are not enrolled within a local commissioning group’s general practitioners may not be covered and would therefore need to be covered by a small number of more centralised clinical commissioning groups, which will effectively mop up those individuals and families who lack membership within a local clinical commissioning group. I would therefore be grateful if the Minister could confirm the arrangements for those patients, such as people who are homeless, and who may for whatever reason not be on a particular general practitioner’s list. Can he also explain to the Committee how these patients will be allocated to receive primary medical care services since that allocation duty currently falls to primary care trusts, which will not be there in the future? The services will be designated from the commissioning board, which is at quite some distance from patients who do not have a GP and from individual GPs.

The combination of removing geographical responsibility for the provision of healthcare, together with the removal of practice boundaries, creates a number of risks: an inability to plan for local services; a risk of worsening health inequalities and social segregation; and fragmentation between social care and healthcare—the former being based on local authority boundaries and the latter then being based on a potentially England-wide catchment area, depending on who registered with a GP. Allocating resources based on the GP-registered list rather than any geographical population will mean that there would not be coterminosity with public health—or, importantly, with local authority services, which are responsible for much social care and for the safeguarding of children and vulnerable adults. A lot of those responsibilities for safeguarding held by a local authority relate to the geographical area of a local authority.

With GPs potentially competing for patients across the whole country there could be fragmentation, especially if someone registers near their place of work as when they are ill they are likely either to be at home or to return home, which may be many miles away. They may need services at home, particularly medical and nursing care, if the condition is sufficiently serious to require them. Yet the GP with whom they are registered for primary medical services would then be at a distance that would make home visiting impossible.

In April of this year the Health Select Committee emphasised the importance of aligning care to geographical boundaries, making this point:

“Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities”.

To paraphrase that, I hope that my amendment is in line with the recommendation of the Health Select Committee.

The local authority will take over many functions of current PCTs, especially over safeguarding, as I said. This is important, particularly for children who are unable to transfer their own care. Different children from the same family who are at particular risk and on an at-risk register will potentially be registered in different places by abusive parents who deliberately want to ensure that they limit, or almost exclude themselves from, surveillance. I am sure I do not need to remind the House that the tragedy of Baby P was an example of a parent who avoided surveillance and, tragically, avoided it far too effectively.

The other difficulty is that there are families who have very complex lifestyles, with different members registered at different distances, particularly if they are mobile families. This will make it very hard to obtain an overall picture of the health, education and safeguarding services if these are not coterminous. Where local authority, education authority and health provision are coterminous, there is a much better chance of a good transfer of important data on the welfare of these children who are at risk.

Public health is a major and very welcome focus of the Government. This amendment is also necessary to ensure that the NHS will adequately address those issues of health improvement such as smoking cessation, screening for disease, immunisation and so on, where treating people as a population rather than a collection of separate individuals is more effective. Public health can achieve optimal population health outcomes only if there are area-based organisational structures and frameworks in the health system. That becomes particularly important in more rural areas, as it ensures optimising efficiency, accountability and effectively integrated care.

The amendment also supports the Secretary of State’s responsibility for issues of health protection, such as the control of an epidemic of infectious disease. Such an epidemic cannot be dealt with just by treating individuals. It requires an area-based approach, using vaccinations, population monitoring and so on to ensure disease containment. Additionally, without coterminous working of health and local authority, planning of capacity becomes harder.

General practice can certainly do much to improve its quality of service in some areas, particularly access to primary care through extended hours, out-of-hours coverage of the population and decreasing the dangers that are encountered with the lone-worker GP who does not have contact with other colleagues. General practice could go towards federated models of practice; that is not incompatible with the spirit of this amendment. However, all these improvements need geographical areas to function properly and drive up quality of care.

Epidemiological research has been a strength of the UK, building on registers of a precisely defined denominator of patients, categorised by age, sex and so on, and known to be living in a particular environment. Weakening it by multiple registration will break the link of geography with health and may impede the aim of driving up quality. It will certainly impede our ability to carry out effective quality-based research on improving health in the future.

Another area that I want to address briefly is that of the medical examiners in relation to coronial jurisdictions. Their work depends on them being geographically area-based and seeing the death certificates of all the general practitioners within that area as they come through. There is a concern that if there is wide fragmentation it may be more difficult to pick up trends that should not be there.

Amendments 10B and 11A seek to delete “or” and insert “and” to make subsection (1) of proposed new Section 1A of the 2006 Act refer to the prevention, diagnosis and treatment of illness, and then go on to public health. I suggest that these amendments are logical as they would ensure that the Secretary of State has a duty to improve all three of those aspects in relation to illness. The measure also emphasises the importance of public health in conjunction with the prevention, diagnosis and treatment of illness. I stress that “illness” includes both mental and physical illness.

[Lord Walton of Detchant]

My Lords, my noble friend has, as always, been extraordinarily persuasive in her detailed argument in support of her Amendment 10A. I apologise to her and to the Committee for not having discussed it in detail with her beforehand. The intention underlying the amendment is in every way admirable. Amendment 10B, to which she spoke more briefly, deserves a great deal of attention and would greatly improve Clause 2 of the Bill. My only concern with her remarks about area-based populations relates to the definition that would be attached to the clause. New Section 1A(1), as inserted by Clause 2, is defective in my opinion in that it refers to,

“securing continuous improvement in the quality of services provided to individuals”.

The provision of services in the National Health Service does not relate simply to the treatment and improvement of the health of individuals. As the term “public health” implies, it deals also with the improvement of the health of communities. After all, public health doctors were called community physicians until quite recently. In many ways I would have preferred to see the clause include, after the word “individuals”, “and/or communities” to make that position entirely clear. I warmly support the principles underlying my noble friend’s amendment but the wording requires a little attention as throughout my professional career I have been very familiar with the hazards that arise in attempting to draft and redraft documents in committees, large and small. I do believe that this matter needs to be given attention by the Minister.