Health and Social Care Bill

Lord Mawhinney Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Pitkeathley]

My Lords, I, too, will speak strongly in support of these amendments, to which I have added my name. In spite of my major misgivings about the content of the Bill when it was originally published, I remember being delighted by its title because it had “social care” up there with “health”. Did this mean, I thought to myself, that at long last health and social care were to be given equal status? At long last, was there to be a proper recognition that the patient experience of being ill, disabled or in need of care is an integrated one? The Bill was supposed to be about making the patient experience better—less confusing, and more effective and efficient from the point of view of the patient—so I was hopeful.

In more than 40 years of working at the margins of health and social care, I have seen two experiences constantly repeated. The first is of patients always being surprised, distressed and horrified by the lack of integration between health and social care. Since they cannot put their own needs into two separate boxes, they are surprised that the services seem to be provided in separate boxes. They are further distressed by having constantly to give their details and history to different people, having to undergo unnecessary repeat tests and yet still being left alone or reliant on their families to negotiate between the NHS, social care agencies and local authorities, not to mention voluntary and private sector providers.

The second experience which has been constant in my life is the seeming commitment of all those who work in the system to how important integration is to the delivery of proper patient-centred care. Indeed has anyone in your Lordships’ House or anywhere else ever heard any professional say that there are benefits to care which is not integrated? Yet that is what we continue to deliver and there seems little hope of the Bill in its current form rectifying and ensuring a joined-up approach. Indeed, I fear for the practice manager or the social worker who has to interpret the new diagrams of the system to an elderly and confused patient or client.

My noble friend quoted the Health Select Committee, which said:

“Although the Government has ‘signed up’ to the idea of integration, little action has taken place to date. The Committee does not believe the proposals in the Health and Social Care Bill will simplify the process”.

The committee further said that the reforms in the Bill were built on the hope that GPs, hospitals and local authorities will respond to payments for working together. These amendments are about more than hoping for the best. They make practical proposals, first, about defining integration which, as the Law Commission found, is not easy. It will surely not be difficult to agree, as the Law Commission did, around contributing to or promoting the well-being of the individual. That would cover not only health and social care but housing too. That separation, as your Lordships are well aware, has always been a problem.

The proposals about annual reporting and business planning to check progress are also very practical and taking into account the levels of integration in setting tariffs is also very important. It is of the utmost importance that we take the opportunity given by the Bill to move the reality of integration forward in a way which will make a radical difference. The benefits to the patient, the client and the carer are obvious but there are benefits to the community and society which are similarly significant, since integration clearly delivers more effective and efficient care. There is lots of research evidence about this. For example, Turning Point identified that for every £1 spent on integrating health, housing and social care, £2.65 was saved. This is not only better for patients but provides better value for money. What is not to like in these amendments? I hope the Government will accept them.

[Lord Mawhinney]

My Lords, it would be very courageous for anyone in your Lordships’ House to argue that there was no benefit to the patient in trying to have as integrated a service as possible. I am not that courageous. It is a good place to start. Having said that, I do not believe that these amendments are the answer or that they move forward the argument for integration. I searched through these proposed new clauses and I find no mention of any legal responsibility on the local authority, the social care agencies or anyone else. They are entirely directed to health bodies. That imbalance struck me as being a pretty poor starting point if you are genuinely interested in trying to produce integrated services.

Your Lordships will know that, even before the introduction of the Bill, there were various attempts to integrate services in various parts of the country. I happen to be a reasonably well-informed individual in respect of one of those attempts. It is one thing to say to the PCT, the cluster, or whatever is the latest development in that area that it has responsibilities to integrate with the local authority, just as it will be a different thing to say that a local commissioning group has to integrate with the local authority if some attempt is being made legally to define the role of the health component but there is no commensurate attempt to deal with the legal framework with regard to the providers of social care. I know of one example of attempted integration in this country that is foundering because the health component is seeking to shift its deficit on to the local authority. Sometimes the quality of those who serve in one is so different from the quality of those who serve in the other that no right-minded person who was dealing with his or her own money would invest in a partnership that was as skewed as those that exist up and down the country.

I started where I did because I do not wish to be interpreted as being against useful, appropriate and constructive forms of integrated provision. I have taken a view throughout the Bill that it ought to be for the benefit of the patient. It would be courageous to suggest that some appropriate form of integration would not be of benefit to the patient. However, these skewed and flawed amendments are not helpful and certainly do not beat a path to the future for the benefit of patients.

[Baroness Young of Old Scone]

My Lords, I rise to support Amendment 38C and to disagree violently with the noble Lord, Lord Mawhinney. I think that the importance of integration applies not just between health and social care but also within health services. We have to start somewhere, and the Bill before us gives us the opportunity—now, today—to start with the important new bodies that will come into existence on the health service side of the partnership. It is fundamental and vital that they are properly tasked with responsibility for integration. Let me explain why.

I hope that many noble Lords listened last week to the interesting and powerful “File on 4” programme on the dreadful condition, in terms of lack of integration, of our diabetes services. Diabetes is a long-term condition and those who have it require each year that about 15 essential and different services are clustered around them in an integrated way; otherwise they run a high risk of suffering premature death or horrific and expensive complications. I emphasise the word expensive because those complications can include kidney failure, blindness and amputation, which are hugely expensive for the National Health Service to treat and could, at the current rate of increase in diabetes, financially wreck the NHS. I hope that at least some noble Lords heard that programme because it demonstrated that integration between health and social care and within healthcare is vital for long-term conditions—not just for diabetes but for other long-term conditions as well.

This is a disputed figure, but it is thought that long-term conditions now take up somewhere between 60 and 70 per cent of the NHS budget. If the Bill is about the future provision of healthcare in this country and how healthcare needs to be joined up internally and with social care, it will have to address that 60 or 70 per cent of NHS expenditure that relates to long-term conditions. Therefore, it is pretty important that the new institutions of the NHS Commissioning Board, the clinical commissioning groups and Monitor are clearly now tasked—while we have the opportunity to influence them—with incorporating integration into their annual plans and with reporting annually on how they have got on with fulfilling this obligation and important duty. I do not think it is too much to ask; I think it is pretty important. I hope the Minister will agree.

Monitor will also have a crucial role in the development of tariffs. At the moment we have tariffs which, unless properly constructed, get in the way of integration: they form a barrier to putting together sensible packages of services. In a competitive environment, that will be even more so. It is fundamental that tariffs are constructed in a way that supports the important integration—and I am not going to apologise for repeating this—which if not delivered results in premature deaths and horrific complications. I hope that the Minister will take this point and support the amendment.