Health and Social Care Bill

Baroness Armstrong of Hill Top Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

I want to intervene briefly. I support much of what my noble friend Lord Warner said in his opening speech. There are some things on which we need to tread carefully. Integration is critical, but it can become a phrase that is used but is not backed up by good practice. We have to be sure that we introduce or develop integration in ways that improve the outcome for patients. I serve as a non-executive on an acute trust in the north-east of England, the County Durham and Darlington NHS Foundation Trust. It has just merged with, or taken over—I am never very sure—the community trust. The Government have been encouraging this throughout the country. There are mergers and a coming together of community services and acute services. In some places, the community services are joining the mental health trusts and so on and so forth. We have been very conscious throughout that process that in the private sector the majority of mergers do not succeed. Very often that has been shown to be a problem in the health service. That is not a good idea. When we are looking at integration, we have to be very aware of what outcome we want. We should not just say, “If we bring all this together, it’s bound to save money and it’s bound to be a better service”. It will end up that way only if it is exceptionally well planned, if the outcomes are worked out and are absolutely clear to people, and if we do it not just because it is the fashion of the day, or because the Government are asking for it to happen, or because the words are used in the Bill.

I entirely agree with my noble friend Lord Warner. This should not be used as a means of excluding or cutting out competition. One of the best examples of integrated care that I have seen was when I was Minister dealing with social exclusion and had the real privilege of going to Preston. I was able to give £1 million to the local mental health voluntary organisation. It was working with people with learning difficulties who were trying to make sense of individual budgets. It was inspirational to meet the individuals who had been part of that development, which had been co-ordinated by the voluntary organisation—I think it was Mencap. It offered and provided one person to work with the patient, the client or whatever label you want to put on them. That person’s job was to help the client negotiate their way through all the different organisations from which they needed care and to work out more effectively what they needed.

I spoke to one young woman who had been living at home with her father. He was very concerned because she was becoming housebound, obese and more mentally ill, and she also had learning difficulties. Technically, every agency was working with her but nothing was actually happening to change her experience of life and her ability to get out and contribute, as well as her ability to find the right way through the organisations. She talked to me at great length with incredible enthusiasm and took me round the places that she now had contact with. She was volunteering in a group for severely disabled children, where she was simply holding someone’s hand, being there and being a friend throughout the process. She told me she had reduced the number of hours of care she needed because she did not have time for it because she was so busy. She was busy being active as a volunteer in a whole range of things because the care she needed was now properly integrated and she had an advocate to help her work through the myriad of different things that she wanted; for example, where she needed particular drugs or care because of some physical illnesses. I was able to see true integration, with incredible enthusiasm from the patient, but it needed to be negotiated by the voluntary organisation. They were then able to get a pattern of care—a pathway, as we now call it—that made sense to her, that reduced her dependence on carers and professional intervention, but which worked for her. She was simply one example.

I also think that the integration of care for children is really not as good as it should be. I have seen some examples of where it works brilliantly and others where it simply does not work at all for some of our most disabled and disadvantaged children. Again, we can do it better. Integration is absolutely where it should be but it will have to be organised in different ways for different types and groups of patients. There will need to be people who can help negotiate the way through the pathway.

My experience in the County Durham and Darlington NHS Foundation Trust is that you have to be absolutely clear about what your outcomes will be. However you organise the different pathways and different coming together in groups—we are in the middle of doing that at the moment—there needs to be clarity about what you are trying to do in enabling the individual who is the concern of the local authority, the acute trust and the community trust. Someone has to negotiate that pathway with them, and that will frequently be someone who is not embedded in any of those areas of responsibility, although it may be someone from there. There will have to be different ways of doing it.

The Government are going to have a very difficult job in making absolutely sure that integration is working for the patients rather than simply saying, “Well, we are doing yet another reorganisation which we hope will save money”. My experience is that if that is all people think of at the beginning, it does not work, it saves no money and it becomes increasingly frustrating for the person whose care it is supposed to improve.

I went to see someone in a community hospital that I have a lot of experience of. It is a fabulous place that traditionally takes patients from a number of different areas. The local authority recommends people, the GPs recommend people, and of course the acute trust recommends people it wants to get out of acute care and into the community hospital. Trying to get that knowledge and understanding into the acute trust, now that it technically runs the hospital, is quite difficult. It rings up at the beginning of the day and asks how many beds the hospital has. The hospital might say four, and the trust rings again at the end of the day and says that it needs those four beds. The community hospital matron might say that the GPs have taken two of them and the local authority has taken another, so the beds are no longer there for the acute trust.

We need to make sure that we get integration right and recognise that we have to get the best and not simply use integration as a term that will cover everything.

[Lord Beecham]

My Lords, the hour is late and I will not speak for long, but I want to address one issue in this very important debate from the perspective of local government, in which I have so far spent two-thirds of my life. The issue is social care services, which are referred to in so many of the amendments.

This is partly a question of definition. What do we mean by social care? Do we mean the services provided by adults’ services departments, or do we take a broader view, such as the position of children’s services, which were split away from social services departments, having first been integrated after the Seebohm report in the early 1970s? I have had and continue to have misgivings about that separation, but I take it that, for the purposes of these amendments, we should look at children’s services as well as adults’ services in relation to social care.

As the noble Baroness, Lady Masham, has pointed out, there is also a housing aspect, which needs to be taken into account. That, of course, is a function of all principal councils. It is not a function of county councils, which are basically responsible for adults’ services and children’s services. It is, however, a function of district councils, and their role in relation to this provision also needs to be looked at.

There is also the issue of finance and budgets. The National Health Service benefited enormously from investment by the previous Government. There was very much greater investment in that than in social care, so there are questions about how the funding of integrated care between local government and health is to go forward. Perhaps when he replies the Minister will comment on the experience of community budgeting, which in some cases has been looked at, to see how that can be developed. If it has not been sufficiently piloted, perhaps he will indicate whether the Government will consider using that mechanism for community budgets to pilot further integration along those lines. The Government should also bear in the mind the impact of their proposals for the reform of welfare and the benefits system on the position of people requiring social care.

The noble Baronesses, Lady Cumberlege and Lady Armstrong, mentioned personal budgets, which clearly have considerable potential in the promotion and use of integrated care and for avoiding the cost-shunting that sometimes occurs. There is clearly a requirement for the kind of support to which the noble Baroness, Lady Armstrong, referred in helping people to navigate their way through that system and to maximise the efficiencies that can be obtained from it.

Therefore, while I certainly support the first of these amendments, I think we need to be clear about what we are looking to integrate beyond simply adults’ services.

In that context, finally, in relation to role of the health and well-being board, there is the responsibility of producing joint strategic needs assessments. It is not clear to me—perhaps we will debate this issue later—the extent to which those boards will be able to redirect the provision of services as opposed to providing an assessment and being consulted on the commissioning that clinical commissioning groups will carry out.