Health and Social Care Bill

Lord Collins of Highbury Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Collins of Highbury]

My Lords, I am very aware that my contribution has been eagerly awaited by all noble Lords who are still here. As the 85th speaker, and the last tonight, I suspect that it is not its content but its end that is desired most. Therefore, I promise not to go on too long.

After reading hundreds of e-mails from both users and providers of the NHS, and having listened carefully to the debate so far, I remain of the view that was ably expressed by my noble friend Lady Thornton this morning when she said that in making these top-down changes to our NHS, this coalition Government have no mandate, no evidence and no support. Like many in this House, I do not want a health service that stands still. I was, and remain, a keen supporter of the health policies of the last Labour Government which, as my noble friend Lord Warner reminded us, were identified in our manifestos in 2001 and 2005, and on which we won.

The change agenda then was to deliver the best outcomes for the patient and best value for taxpayers. I fear that the changes proposed in this Bill, despite what the Minister states, will not improve care for the patient and will be extremely costly to taxpayers. The worthy aims expressed by the Minister are not the issue. As we have heard many times throughout this debate, the aims can be achieved without a major high-risk, high-cost reorganisation of the NHS.

My fear—I think that this is shared by many—is that ideology drives the promoters of the Bill. It is an ideology that sees a competitive free market as the way to deliver healthcare efficiently. As the noble Lord, Lord Owen, said, this is not a model supported by the British public. I do not often find myself agreeing with the noble Lord, but I thought that he was spot on when he explained why the NHS had so much support from the British public: it is because, in the distribution of resources, it is fair.

For me, modernisation of the health service was, and is, about addressing unacceptable variation in standards; inequality; lack of integration—vertically and horizontally; the fixation with acute care rather than better primary care; and more investment in prevention and public health.

My real concern is that I do not see this Bill as being helpful in addressing these key issues. In fact, I see a Bill that will cause fragmentation rather than integration. It is in this context that I wish to raise three specific issues, which I hope to address further in the event that my noble friend’s amendment is not carried tomorrow.

First, on public health, while I accept and agree that the transfer of public health functions to local authorities creates the potential for better alignment with other responsibilities and other issues—we have heard mention in the debate of housing, environment and education—that will not happen unless directors of public health are in a position to shape policy in these areas. I along with many others fear that the Government’s response to the NHS Future Forum offers no further clarity over the role, status and work of directors of public health.

Secondly, on HIV and the role of prevention and treatment, the House of Lords Select Committee report on HIV in the UK, chaired by the noble Lord, Lord Fowler, identified that more than a quarter of those infected have not been diagnosed and are unaware of their condition. This affects the individual concerned and spreads the disease further. Better testing must be a priority. The committee proposed routine testing for all new patients at GP surgeries and general medical admissions beginning in areas where the prevalence of HIV is highest. It also proposed the legalisation and regulation of home testing.

Spending on prevention is seriously inadequate. HIV is entirely preventable, but the latest figures show that the Government spent only £2.9 million on national prevention programmes, compared with £762 million on treatment. My concern with the Bill is the disconnect in planning between prevention and treatment, plus the strong probability that public health budgets will be severely limited, leading to even further underfunded prevention campaigns. There needs to be better investment in evidence-based HIV prevention work to prevent the treatment bill rising even further.

I turn finally to diabetes. The noble Earl the Minister knows that, last week in the debate on non-communicable diseases, I “came out” as a type 2 diabetic. My condition has been caused, as I am repeatedly reminded in the media and even by some noble Lords in the House, by my bad lifestyle as a former smoker and a person who eats too much—that is fair enough. However, as a result of NHS provision, I am now very much aware that diabetes is a complex and lifelong condition.

My regular testing and treatment, comprising GP surgery, podiatry clinic, retinal screening, specialist eye clinic and dietician, is a perfect example of a pathway of services where primary, secondary and community healthcare and social care are integrated around my needs. My early diagnosis and this integrated pathway of care will keep me free of the worst and most costly consequences of this disease.

Although the amended Bill requires the NHS Commissioning Board and clinical commissioning groups to promote integration, Diabetes UK, which has given me excellent support, proposes that to strengthen this vital duty the NHS Commissioning Board and clinical commissioning groups must report annually on how they are fulfilling their duty to promote integration.

The Government have stated that they are committed to the principle of “no decision about me without me” and there is substantial evidence about the benefits of patient involvement on health outcomes, something that I know only too well.

Diabetes UK believes that the Bill should be further improved by defining the involvement of individual patients and their carers in decisions relating to their own care and treatment. In addition, collective patient, patient organisation and carer expertise must be central to commissioning decisions and service design through the introduction of an overarching principle of co-design in the commissioning of care pathways.

It is essential that this collective experience and knowledge is used in the design and commissioning decisions to gain the benefit of the experiences of a wide range of patients, not simply a small number of individuals. The Secretary of State for Health has said that,

“integration around the needs of patients trumps other issues, including the application of competition rules”,

yet it is not clear from the Bill that that is the case. The Bill has been amended with a duty laid on Monitor to exercise its function to enable services to be provided in an integrated way. However, the balance still appears to be in favour of competition over integration.

One big concern for me is that the need to demonstrate that competition requirements have not been infringed will drive elements of the diabetes care pathway to be opened to competition and will be fragmented. It will not be the joined-up treatment and understanding of the podiatrist knowing what the dietician is advising. It will break the trust between elements of the pathway over time. I understand from Diabetes UK that there are discussions currently about the possibility of integrated pathways being commissioned rather than individual parts of the pathway. But it is suggested that this could happen only if the whole pathway was subject to competition. Diabetes UK believes that this is impracticable and so do I, and I urge the noble Earl in his reply to outline clearly how integrated pathways will be commissioned.

Debate adjourned until tomorrow.

House adjourned at 12.23 am.