Health and Social Care Bill

Debate between Baroness Armstrong of Hill Top and Lord Beecham

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.

Public Bodies Bill [HL]

Debate between Baroness Armstrong of Hill Top and Lord Beecham

Monday 29th November 2010 Lords Chamber

[Baroness Armstrong of Hill Top]

I support my noble friend Lord Liddle. He is much identified with the west of the north—if I may put it that way—whereas I am identified with the east coast, where we have rather a lot of snow at the moment as well as very particular problems.

I hope that the Minister will think a little more about the constitutional issues. In reality, the RDA in the north-east was not imposed from London. Way back in, I think, 1987 or 1988, my noble friend Lord Radice put forward in a Private Member’s Bill in the other place the idea of establishing a regional body in the north-east. There was much pressure at that time within the region for such a body to deal with economic matters and regeneration. At that stage, we were going through the end of ship-building in the north-east and—as I knew all too well—the closure of steelworks. We also knew that we were coming to the end of the coal-mining industry—thereby hangs a tale, but I shall not go there—so the body was created in the region but it also received the support of the then Conservative Government. The RDA in the north-east started in a totally different way from the other RDAs, as it was started through local enthusiasm and commitment to the region as a whole, which is a very small region in comparison to the rest of the country.

Amendment 16 deals with an important issue, given the fear in the north-east that some of the critical decisions will now go to the body that is to be chaired by the noble Lord, Lord Heseltine. The Government—and I shall make these arguments later as the Bill progresses—are making a huge mistake in the north-east. It is simply not true to say that people there want the RDA to be broken up. I listened carefully to the Minister last week when he said that the idea had come before the election from discussions that his party were involved in with business. In the north-east, that was not the message that business was giving. However, I shall say much more on that later.

In reality, the RDA in the north-east came from the locality, was acknowledged by the Minister’s party when it was previously in government and has continued and fitted into the structure and architecture that my party introduced after it came into government in 1997. There is great fear and anxiety about the new architecture but, whatever the architecture is, the north-east will work with it—even if we think it a mistake—because we want the best for the people and industry in the region. However, we wish to make sure that decisions—particularly on some of the bigger projects—stay local and are not taken into the national body that the noble Lord, Lord Heseltine, will chair. I hope that the Minister can give us that reassurance through these probing amendments.

[Lord Beecham]

My Lords, I, too, support the amendment moved by my noble friend Lord Liddle, and I associate myself with the remarks made by my noble friend Lady Armstrong. I, too, come from the east side of the region. Indeed, she spent the early part of her career in the ward that I now represent and she has obviously benefited greatly from that experience.

Today’s debate is quite significant in terms of the problems of the north-east. This morning, I read that Durham University Business School has produced a report for the soon-to-be-abolished One North East that suggests alarming implications for the region. The report refers to 50,000 jobs being lost in the near future, 20,000 of which will be in the private sector, with a loss of £2 billion to the regional economy over the next few years. The report has provoked the chairman of the development agency—a leading private sector businessman in the region who hails from Sunderland—to renew his criticism of the current trend of government policy. It is clear that he is very critical of the decision to abolish the agency and that the private sector in the region, for the most part, wishes the agency to continue. If the current policy is maintained, of course that will not happen.

In addition to those serious concerns, there is another issue that could be partly addressed by an amendment along the lines of Amendment 16, which seeks to require that,

“the ‘eligible person’ to which functions are transferred must be located within the region”.

I invite the Minister to agree that if Amendment 16 is accepted—and even if it is not—the same principle could be applied to the assets built up by the agency within the region. When I asked a Written Question about that recently, I received an answer that I would say was remarkable for its opacity if it were not, I am afraid, characteristic of most of the Written Answers that I and other noble Lords receive. Referring to the White Paper on local growth, the Written Answer stated:

“As set out in the White Paper … RDA assets and liabilities will be transferred or disposed of in line with a clear set of principles which include a key aim of achieving the best possible outcome for the region consistent with achieving value for the public purse”.—[Official Report, 22/11/10; col. WA 286.]

However, the White Paper states that the principal criteria will be,

“that a reasonable balance is reached as part of disposal/transfer between national deficit reduction, national policy aims and local ambitions/opportunity”.

In other words, the local element seems to be the back runner in that field of three considerations.

I hope that the Minister will give a clearer indication that the proceeds of any asset disposal—if assets are indeed to be disposed of, although they may well be better retained within the portfolio of agencies or other bodies that survive the abolition of the RDAs—should be directed to the region to which they have made a significant contribution over the years. The regions will be desperately in need of those, to judge by the report published by One North East today.