Health Bill [HL]

I rise to add my tuppenceworth to this debate. I very much support the amendments but, at the same time, I support direct payments. We have tended to forget that, at the moment, the NHS Act prevents any direct payments, which has meant no choice at all of people such as community physiotherapists, community occupational therapists and community chiropodists. My own service—I declare an interest as a supporter of that which I proposed—took over the scheme from Kent into a scheme in Lewisham and integrated it into our dementia services. We also successfully used the scheme of direct payments from Lewisham Borough Council, which was at first a great anxiety for social services. Again and again, I heard arguments from professionals in social care services about why direct payments would not work and why mentally ill people and their families would not be able to use this scheme directly. This proposal will create the same sort of anxieties. The arguments that will be used will be similar to the ones proposed by the noble Lord, Lord Campbell-Savours. For example, should we allow people to buy their own toenail-clipping service? That is one of the huge arguments in services for the care of the elderly. You have to have a dedicated chiropodist doing an assessment who then comes along, looks at your toenails and allocates you so many minutes of toenail cutting. Most elderly people say, "I just want someone to come along and cut my toenails every month". I am glad that the Minister agrees about that point. There are opportunities to reduce costs from some of the areas that are currently organised for us. Audiology, optical services of various sorts, chiropody, community physiotherapy and other services would benefit from this sort of approach, where cost allocations by senior managers or middle-grade managers in the NHS make it very difficult for people to get the services that they need. Community speech therapy is another example. There will be arguments about this, especially if direct payments are coming from patients going outside the NHS or to another team. I have seen huge arguments between the great edifice of Barts and the London NHS Trust and community health services in Hackney about who should be allowed to look at feet and do minor podiatry operations because of the movement of one tiny budget from a hospital to a community service. I see this proposal as a positive thing and a bit of a Trojan horse to drive into areas of competition which, in community health services, have been pretty well non-existent. I also take the point about individuals and I remind the noble Lord, Lord Warner, that there was tremendous support from the case managers in Kent for the handling of individual care budgets in the same way that there had to be in the Lewisham scheme, but that was the joy of watching case managers actually develop the skills. Enormous skill in case management will still be required to handle these cases properly and for case managers to learn a lot more about employment law, contracts and so forth with which they are not very familiar at the moment in the NHS. I strongly support this at the same time as wanting to see some of these amendments reflected in our overall scheme for the direct payment pilots that are so important.