Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Thornton]

I think that the noble Lord misheard me. I said that it was the first time that we had discussed this in the process of this Bill. I beg to move.

[Baroness Finlay of Llandaff]

My Lords, I shall speak especially to Amendments 10A, 10B and 11A, and address my remarks principally to Amendment 10A, whose aim is to avoid fragmentation and inequity through a loss of contiguous, coterminous and comprehensive area-based structures for healthcare resource allocation planning, commissioning and service co-ordination. The amendment would ensure that the sensible changes that were just agreed today over GP contracts for this year are carried forward into GP consortia arrangements. The Secretary of State, Andrew Lansley, himself discussed issues around area-based practice at the congress for the Royal College of General Practitioners last month, and had a fairly extensive and open discussion with the GPs there on this topic.

I move to the Bill as it stands. I hope that with some of the background discussions that have been happening, my amendment will not just be dismissed and will be quite seriously considered, because it might solve a problem.

In the Bill, the new commissioning consortia’s duty—

[Lord Mawhinney]

I am sorry, I may be the only person in the Committee who is thick enough not to understand what is going on, but I have to say that I do not. I asked the noble Baroness, Lady Thornton, to define something that she said she was in favour of, which was area-based entities, but she palmed that off on to the noble Baroness, Lady Finlay. I would be grateful if she would define what an area is. Is it a county, a city, a town or a village? Is it the north-east or the south-west? Who in the context of this Bill does she see as having responsibility for defining the area and addressing the issue in the area?

[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.

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[Baroness Tonge]

My Lords, most of the points I wanted to raise have already been raised so I will not repeat them. I congratulate the noble Baroness, Lady Finlay, on her comprehensive overview of her amendments. What concerns me most is those patients who fall through the net of the new general practice commissioning groups. If it is not area-based and there is not a primary care trust responsible for allocating those patients, where will people who do not speak English very well, asylum-seekers, the homeless, mentioned by the noble Baroness, and Travellers go? What about those patients whom I remember well, whom most GP practices did not want on their lists at all and who were rotated around general practices in order that they got medical treatment? What will happen to all those patients? There are many of them and some of them have severe disabilities and some are severely mentally ill. They fall into all sorts of groups. I am extremely concerned that without an area base or a responsibility on a PCT or a commissioning group to deal with patients in a particular geographical area, those patients will suffer hugely.

I want to make one final point. The other service that will suffer hugely is our accident and emergency departments, because if those people do not have GPs, that is where they will go. I was a casualty officer in central London for a whole year, once upon a time, and I virtually ran a general practice there then for patients who were unattached to general practices. That problem will increase, and I hope that the Minister will address that in his comments.

[Baroness Finlay of Llandaff]

My Lords, it may help the Committee if I explain how the GP contract is being renegotiated; I hope that I get this right. Instead of a GP contract covering a rigidly defined area, as now, there will be an outer ring as well. If patients move a bit further away but stay within that outer ring area, instead of being forced to change their GP, they will be able to remain with their current GP. Therefore, I think that the problem of choice, to which the noble Baroness, Lady Cumberlege, alluded, should in large part be solved by the negotiations that the Government have just had with GPs. There is of course a difficulty in defining any area but to date the areas have been defined by GPs, and they will still have to define the outer area or outer ring to which it is practical for them travel to carry out home visits and so on.

As I understand it, a decision has not yet been taken on what will happen with people who, like most of your Lordships, are classified as temporary residents. Many of us live a long way from here and, if we need to see a GP, we register as a temporary resident with one somewhere in Westminster. I am not sure how those arrangements will work in the future but they have served us reasonably well until now. The danger in relation to allocation relates precisely to those patients to whom the noble Baroness, Lady Tonge, referred—those who have been thrown off GP lists or cannot get themselves signed on to a GP list for whatever reason but still have healthcare needs. If those needs are not met, that will impact on the very social fabric of our society. I hope that I have clarified some of the points.

[Baroness Hussein-Ece]

I should like to ask a couple of questions to clarify where the debate is going. As my noble friend Lady Tonge said, for a number of years some groups have found it almost impossible to get a GP. It is almost a case of GPs selecting the people they want on their lists; it is an unwritten code. That is why asylum-seeking families, refugee families and others with very high needs will always find it difficult to get a GP, and I want to ask the noble Baroness, Lady Finlay, how her amendment will assist that.

Equally, as has already been mentioned, areas of high need have in my experience always been in inner cities, where it has been difficult for some people to register with a GP. We know that attendance at A&E departments has become extremely high in some areas—almost unsustainably so—and I want to ask how the amendment will address that too.

There are also families who are placed by local authorities in temporary accommodation in other areas. Currently, a local authority is responsible for such a family—for example, social services or family support may be involved with the children. However, if that family is placed in another borough way out of the catchment area, I am not sure who their GP will be. Perhaps the Minister can respond to that as well and say how that would work with a local authority having responsibility for a family placed well outside the area. Would that family still be able to get support by going on to a GP list in the new area? Would that connection be made? Over the years we have worked very hard to make sure that social care, healthcare and local authorities all work together in partnership. Perhaps we could have an explanation of how it is going to work when families with very high needs are spread around.

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[Baroness Finlay of Llandaff]

My Lords, I thank the Minister most sincerely. Apart from anything else, he has explained the BMA agreement far better than I did in my attempted few sentences. I hope that that has provided some reassurance to the House.

I am grateful to him for explaining the problem with the wording in Amendments 10B and 11A, and I accept that he has assured us of the totality of the Secretary of State’s duties overall in relation to the two proposed subsections. I thank him for explaining, in relation to the other amendment in this group, that the mandate set by the Secretary of State is one to which the Commissioning Board must have regard. That was precisely why I was concerned about also having “areas” because the Commissioning Board will be contracting with GPs themselves for their clinical services, which is separate from the role of the clinical commissioning group. So I have a little nagging doubt and that is why I put this right at the front of the Bill. I am sure we are going to return to the word “area” as we work our way through the Bill.

For the moment, however, I am grateful for the noble Earl’s explanations. I also thank all noble Lords who have contributed to the debate, particularly the noble Lord, Lord Warner, for what I think was a flash of brightness in the fog when he asked for a diagram that will set this out geographically for us. That will be most helpful.