Health and Social Care Bill

Lord Davies of Stamford Excerpts

Wednesday 2nd November 2011 Lords Chamber

[The Archbishop of York]

My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State’s duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty—already provided for in the first two subsections—will not be carried out. Integrating the delivery of services will be important.

I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.

It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.

[Lord Davies of Stamford]

My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.

Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire—and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter—that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis—some old person who can no longer cope in some way—his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.

Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week—it is not an exceptional situation—to patients, their families and carers, who are the victims of it.

The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.

Sadly—I deeply regret this—the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice—the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.

I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, all the amendments in this group have the entirely laudable aim of improving the integration of services across health and social care and improving access to services. I agreed strongly with many of the messages which the noble Lord, Lord Warner, delivered in his excellent speech, and with so many of the powerful contributions from other noble Lords. The only person with whom I felt seriously out of sympathy was the noble Lord, Lord Davies of Stamford. I would simply say to him that the Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors to improve patient outcomes through far more co-ordinated working.

For example, the reformed system that this Bill will give form to—the provision of high-quality, efficient and fair services—represents the fundamental goals of the health and care service. This clause puts on to a statutory footing the three domains of quality identified by the noble Lord, Lord Darzi, in his next stage review: effectiveness, safety and experience. Every aspect of healthcare quality fits into the Darzi domains, and that is a tribute to the noble Lord’s work in co-producing the quality framework with patients and the professions, and it is also why the domains still provide the framework for quality.

In answer to my noble friend Lady Jolly, or at least to give her a partial answer, we seek to measure success in meeting these fundamental goals through the transparent accountability mechanisms of the outcomes frameworks for the NHS, public health and social care. Integration and access, though laudable objectives that I share with all those noble Lords who have spoken about them, are a means to this end. If integration and access help the NHS to meet the quality and fairness duties—and by fairness I mean reducing inequalities—then integration and access will need to be factored in to commissioners’ plans. Commissioning guidance will set out how best to achieve this based on the accredited evidence of what works best that NICE is developing in its quality standards and other guidance.

The point is often made that high-quality care must surely be integrated care. Integration is not an outcome, it is a possible feature of the process. Where it will improve outcomes and reduce inequalities, integration should most certainly happen, and this Bill provides for that. But we must not sacrifice outcomes for process. I thought the noble Baroness, Lady Armstrong, injected a welcome dose of reality on that theme borne out of her considerable experience, and although I did not fully agree with everything that the noble Baroness, Lady Wheeler, said, she also made some very sensible comments on that point. Indeed, the NHS Future Forum’s Phase 1 report highlights well the practical rather than legislative challenge of bringing about more integrated services for patients. I shall quote from its summary report, which states that,

“legislating or dictating for collaboration and integration can only take us so far. Formal structures are all too often presented as an excuse for fragmented care. 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”.

[Lord Davies of Stamford]

My Lords, I am most grateful to the noble Earl for giving way. Of course we all agree about the importance of the right values and behaviours. I know he did not like my questions, but perhaps he would answer at least two of them. First, what concrete, specific measure in this Bill, if any, addresses the perversities currently existing in the integration of social care and NHS care? Secondly, what about Northern Ireland? Why is the system that exists in Northern Ireland, where the provision of the two is entirely integrated, not suitable for England?

[Earl Howe]

My Lords, if the noble Lord will be patient, I will proceed and answer his questions at the end, as I normally do.

It was in recognition of these practical challenges that the Government asked both the NHS Future Forum and the King’s Fund, jointly with the Nuffield Trust, to provide further advice on the practicalities of achieving more integrated services around the needs of patients. We look forward to receiving their advice later this year. So we share entirely the intentions of noble Lords, and that is why Clauses 20 and 23 contain proposed new Sections 13M and 14Y to create duties for national and local commissioners to promote integration across health and social care—that is the first part of my answer to the noble Lord, Lord Davies.

New Section 13M creates an NHS Commissioning Board duty to promote integration. Rather than simply requiring the board to encourage clinical commissioning groups to work closely with local authorities, as under this amended duty, the board is required to promote integration by taking specific action to secure that services are provided in an integrated way where it considers that that would be beneficial to the people receiving those services. The duty requires the board to exercise its functions with a view to securing that health services, health and social care services and health and other health-related services are provided in an integrated way where it considers that this would either improve the quality of health services and the outcomes they achieve, or reduce inequalities in access to and outcomes from health services. By other health-related services, I mean services such as housing, which may have an effect on the health of individuals but are not health services or social care services.

This requirement would cover both integration between service types—for example, between health and social care—and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This would apply to all the board’s functions not just when exercising its commissioning functions, including when it exercises public health functions under arrangements with Public Health England.

The duty also requires the board to encourage clinical commissioning groups to enter into partnership arrangements with local authorities under Section 75 of the NHS Act 2006 where this would secure the provision of services in an integrated way, or that the provision of health services is integrated with the provision of health-related services or social care services. Proposed new Section 14Y creates a similar duty for local clinical commissioning groups.

The changes to the regulatory framework give Monitor a role in Clause 59 in relation to improvement in quality and fairness as well as efficiency.

The question then is: what actual risk exists of fragmentation at the national level? There is no such risk. Our outcomes frameworks span public health, the NHS and social care; the Secretary of State will aim to improve outcomes in all three components of the care system; NICE will provide quality standards across the whole patient pathway that will push for integrated care; and the care system, nationally as well as locally, will have to pay attention. The Secretary of State’s duties and his actions are, in other words, an embodiment of integration.

Our reforms are firmly focused on improving quality and outcomes for patients. We are not in the business of dictating the processes by which this improvement might be achieved, or trying to measure success in terms of whether a particular process has been put in place regardless of whether it actually delivers a good outcome for patients. I make no apology for that. We are of course committed to enabling and facilitating integration, but integration is neither a necessary nor a sufficient condition of a good outcome.

Perhaps more importantly, our reforms aim to encourage measurement and reporting throughout the system that will tell us whether it is achieving what we have said it should achieve. Accountability should finally have arrived at all levels in the system. Improvement should result and will be understood through the outcomes frameworks in terms of the actual outcomes achieved and those that matter most to patients, service users, their families and carers and the wider public.