Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Tuesday 22nd November 2011 Lords Chamber

Each of these criteria would admirably test any proposal, but any change meeting all three would have a powerful endorsement to be carried through. To accept changes that meet some but not all the criteria could result in the desired objectives not being met. I suggest that, with the criteria, commissioners will be able to judge whether the providers of choice will be able to collaborate to deliver co-ordinated, integrated care pathways.

[Baroness Tyler of Enfield]

My Lords, I will speak to Amendment 135CA in my name. We have already had a very interesting debate about what we mean by integration. Obviously, different people mean different things. The sense in which I will talk about integration is how we can encourage integrated care pathways for people who experience some of the worst inequalities in terms of access to healthcare.

Clause 20 states that the NHS Commissioning Board will encourage integrated working between clinical commissioning groups and local authorities. This is clearly welcome. However, it needs to go further. Those with the worst health outcomes often have the most complex needs and can often benefit most from integrated care. However, as is so often the case, disadvantaged groups can easily be overlooked in the overall system. The fundamental aim here is to ensure that integrated care pathways can be set up that specifically target those with the poorest health.

I will briefly explain why integrated care pathways are important for those with complex needs. A number of patient groups experience health inequalities. We all know about that, and heard about it in our previous debates. In their 2010 report, the Cabinet Office and the Department of Health identified a number of groups of people who have complex needs and as a result carry a disproportionate cost to the NHS. The report states that,

“socially excluded people often make chaotic and disproportionate use of health care services, and experience a range of barriers and issues relating to their access and quality of primary care”.

As we know, these groups include homeless people, people with mental health problems, people with drug and alcohol addictions and others.

I will give a specific example of why this is a very important issue. Homeless people have some of the poorest health outcomes in our communities. I will give noble Lords a couple of facts and figures. Eight in 10 homeless people have one or more physical health need. Seven in 10 have at least one mental health problem. Between 50 and 75 per cent of rough sleepers experience mental health disorders, including anxiety, depression, dementia and psychosis. Research by the Department of Health, again in 2010, estimated that the average age of death of a rough sleeper was between 40 and 44. I find that statistic shocking. Finally, the Department of Health estimated that this had a knock-on cost to the NHS that was four to eight times greater than that of a person in the general population.

As a result of these patients’ complex needs, barriers often exist that prevent them getting the treatment they need. Some services simply exclude them because they are deemed too difficult to deal with—too chaotic or complex. Evidence was found that one in 10 homeless people is refused access at primary care level. Integrated care pathways are crucial to provide personalised and accessible services that treat multiple problems at the same time.

I shall give a very brief example of how this can really make a difference in practice. The average age of homeless people dying while living in a St Mungo’s hostel is just over 40 years. Back in 2009 St Mungo’s began an intermediate care pilot at one of its hostels in south London. It was run by a full-time senior nurse and a health support worker. Together they worked with residents to help improve their health and well-being and particularly to prevent unnecessary admission to hospital. They also arranged appropriate discharge from hospital. As a result of this pilot there has been a marked increase in attendance at HIV services, chest clinics, dental appointments and mental health services. Calls to the London Ambulance Service have gone down by 13 per cent and hospital admissions by 40 per cent, which I think is a very significant figure.

This fits very much with the Government’s approach. Indeed, this amendment builds on the commitment to improve the health of the poorest the fastest, which has been part of these health reforms since the White Paper was published in 2010. It also builds on evidence presented by the NHS Future Forum, which stated:

“We need to move beyond arguing for integration to making it happen whilst also exploring the barriers. We would therefore expect to see the NHS Commissioning Board actively supporting the commissioning of integrated packages of care”.

In their response, the Government agreed that integration of commissioning health and social care should be the ambition for all local areas. The Government have made a number of welcome commitments to strengthen local development of pathways between health and social care providers, and we have heard about some of them this evening. They obviously see an important role for the NHS Commissioning Board working with senates and CCGs in taking this forward. Can the Minister explain how—in achieving better outcomes for those with the poorest health, as is required to reduce health inequalities—the aims of improving integrated working and the health of the poorest the fastest will be achieved in practice?

[Baroness Finlay of Llandaff]

My Lords, I have several amendments in this group. Amendment 203A has been spoken to fully by noble friend Lady Hollins, who has supported other amendments in this group. Amendment 135C would require a biannual report by the board to the Secretary of State on what has been done to promote integration. The other amendments are all designed to promote collaboration, decrease duplication and bring together primary and secondary care and public health and the diagnostic services to have better diagnosis and management of disease.

Integrated working allows patients and their carers to benefit from good primary care provided by GPs and others in the team, to have help and support provided by those working in social care, and to access early referral, appropriate investigation and treatment as required from specialist services. Good integrated care needs to see the patients and their experience in the context of their lives, social support, relationships, cultural experience, gender and a range of other factors. Bringing together an integrated social and clinical approach should include holistic plans for diagnosis, treatment, rehabilitation, support and long-term follow-up.

In their report Teams without Walls, the Royal College of Physicians, the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health highlighted the recommended use of patient pathways as the building blocks for services, with the right balance between prevention, early identification, assessment, intervention and, where necessary, long-term support. They also pointed out that this had implications for commissioners, providers and regulators of services. Multi-professional working with the patient at the centre of everything provides the opportunity for a wide range of professionals, including those outside an organisation, to monitor care delivery and challenge standards. This will help prevent trusts and professionals from becoming insular. Insular practices can result in negative cultures developing and poor standards becoming tolerated.

The clinical commissioning groups have quite a challenge facing them if they are really to commission and develop integrated as opposed to fragmented care. Much has been said on this already, and I will not repeat the points made by previous speakers. However, patient needs will be better met if we move to a tariff structure that better reflects clinical complexity. The Government’s response to the Future Forum report seems to recognise this, but the current tariff structure overcompensates for simpler conditions and consistently under-compensates for more complex and unpredictable areas of care. To encourage integrated working, consideration needs to be given to a system in which payments are received over a longer term and for the achievement of integration and good clinical outcomes. To do that, it will be crucial for Monitor and the Commissioning Board working closely with royal medical colleges and specialist societies to develop a tariff that will provide integrated care.