NHS Future Forum

Baroness Pitkeathley Excerpts

Thursday 15th September 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, like many noble Lords I have very personal feelings about any health Bill and have taken part in debates on many since I have been in your Lordships' House. Let us remember that the Bill that will shortly be considered by this House is the Health and Social Care Bill. I am grateful to my noble friend Lady Wheeler not only for securing this debate but for reminding us that at the moment there is precious little about social care in the Bill.

Social care has been one of the great commitments of my working life. The other has been about enabling disadvantaged individuals—clients, carers and patients—to speak up for themselves and to contribute to policy formation. How I judge proposals for change to health and social care services is therefore simple: will the new arrangements lead to services that are more organised around individuals and more integrated among all the providers of care, such as health services, carer services or voluntary and privately provided services? Therefore, I am delighted by the emphasis placed on integration and collaboration by the Future Forum report. I am not surprised, because calls for better integration always result from consultation with users, carers and the third sector, and the forum made excellent use of the networks of members from patient and user organisations.

I draw noble Lords’ attention to page 20 of the Future Forum report, which reminds us that the provision of integrated services is rarely dependent on structural change. It states:

“The reality is that the provision of integrated services around the needs of patients occurs when the right values and behaviours are allowed to prevail and there is the will to do something different”.

I will illustrate how we can do something different by telling noble Lords about Trevor. He is an Afro-Caribbean man in his 30s and a severely ill bipolar patient. He is treated by both health and social care services. He is an in-patient on many occasions. Staff try to get him to attend daycare when he is not in hospital so that his medication and behaviour can be monitored. Noble Lords will know that the average day care centre is not very suitable for a man like Trevor and he rarely attended, resulting in frequent breakdowns and hospital admissions. Last year staff decided to try a personal budget for Trevor. They worked with him to decide how it should be spent. He decided that he wanted karate lessons. For nine months he has been going to karate lessons almost every day in his local gym. He has become very good at karate, he is fit and stable and he has had no hospital admissions in that time. Moreover, when he is asked what benefit he has gained, Trevor says that he feels good and is a better father to his children.

Now this took place in one of the commissioning consortia pathfinder areas, but it is rare. We have not yet dealt with the problems caused by the mismatch in timing in the development of personal healthcare budgets and social care budgets. I fear that there will not be as many examples of such innovative practice as we need to see going forward.

Harry Cayton, writing in 2006 about patients as entrepreneurs, said that we got very near to enabling patients to have some real autonomy with personal budgets, but we stepped back from the brink as we were afraid of losing control and of what they might do with it. He said that we must not be afraid in the future. I am sure that that is absolutely right, but I fear that we are still afraid.

We still have the problem that commissioners may be focusing on the wrong problems. If you talk to a group of GPs, you will find that they are very clued up about the diagnosis and treatment of cardiovascular disease and even about its prevention. That was entirely appropriate when we had the worst record in Europe on cardiovascular disease, but the problems that face us now are not like that. They are about chronic illness and long-term care, and we still have a long way to go before we are innovative in that area.

The new amendments place a duty on local commissioning groups to consult health and well-being boards and HealthWatch is to ensure the involvement of patients and the public in policy and commissioning decisions. I worry that the plans for local healthwatch bodies have the potential to create conflicts of interest, as they are accountable to local authorities, the very bodies that commission and provide the services that HealthWatch is to monitor. Moreover, the consortia, as the noble Baroness, Lady Jolly, has reminded us, are under no obligation to abide by the views of the health and well-being boards, so I think there are some real questions about how much influence those boards can have. I very much endorse her call for them to have sharper teeth.

In addition, although some progress has been made toward coterminosity—that awful word—between consortia and local authorities, the populations for which consortia will be responsible will in fact be based on the practice lists, not on geographical boundaries, so there may be the sort of problems that those of us who have been around a long time have seen many times before of health and social care professionals trying to work across geographical and administrative boundaries.

My principal worry about the patient and public involvement issue is that all my experience shows that structural change does not bring about integration and collaboration, either within a service or across services; it is people and proper communication about the assessments of need and the point of view of the patient that bring that about. That was the example that I gave about Trevor.

However well intentioned the changes—and I am sure that they are well intentioned—that have been made as a result of the Future Forum’s work, have they really led to systems and structures that are in fact more complex and more difficult to find your way around, even for the professionals who work in them, let alone consumers when they are concerned and anxious? If you can ever find a flow chart about the new system—and they are pretty hard to find—they make your hair curl, as they look like one of those very elaborate electrical wiring diagrams. That is pretty difficult for any user, carer or patient to follow. I am concerned about the staff who are trying to administer such complex structures, anxious as they often are about their local position and jobs. They are anxious about the different paces at which different things are happening at local and national level, and I think that the complexity of the system will make that even worse.

I am also concerned about the mismatch that we now have in timing between a very major reorganisation of the NHS, in spite of promises that were once given about there being no such thing, and the very major reorganisation of the social care system as a result of the Dilnot commission, about which we still await government proposals. Will the NHS changes be set in stone by the time any decisions can be reached about social care?

I want to say a word about prevention. It is always a balancing act between quality and affordability. Services which prevent crises rather than intervene once crises have occurred are always vulnerable at times of financial restraint. How are commissioning boards going to see services that are not at present urgently needed but which are a good investment because they prevent crises developing? For example, I believe that some research about telecare shows that if you spend £1 now, it saves you £4 down the line. Will such investment be made?

I hope that the Minister will reiterate the Government’s commitment to prevention in heath and social care and will assure the House of their commitment to ensuring that social care is given equal status and importance with healthcare and that the reconvened Future Forum will have a clear programme of work and a timetable with regard to the integration of services. The temptation to focus social care on those with high needs and no means is very great. One of the ways of countering this short-sighted view is to remind ourselves that social care must achieve the same status as healthcare in future. In other words, it is not the province of the poor and feckless. It is in all our interests, and especially in the interests of commissioners, to ensure that it is understandable, which means that the current proposals are far too complicated. It must also be free from fear about affordability and provide dignity, safety and peace of mind. I remain to be convinced that the Bill that will shortly be before us will bring that vision closer.