Health Bill [HL]

I shall speak to two amendments: Amendment 57, which I tabled, and Amendment 54. In speaking to Amendment 57, I should point out that this comes from the UNISON stable. As I have said before, I have a non-pecuniary relationship with UNISON. Its concern should be heard during a Bill’s proceedings, particularly on the viability of services, which to some extent was my case when we considered maternity services. UNISON is very much in the front line when it comes to the implementation of the Bill in the sense that many of its members will be affected by it. That does not mean that it is bad, but we have to be sensitive about what we are doing, particularly in relation to the interests of staff. The union is concerned that the impact of the proposals on staff, such as workforce planning or accountability when a patient embarks on a course of treatment that conflicts with professional opinion, has not been sufficiently considered. The union is keen to have proper assurances that staff will be properly protected and supported when dealing with a patient using direct payments. I am sure that the Committee is well aware of the implications of what might happen, and of the circumstances. As in social care services, while some will use their budgets to opt out of generic health services, those who cannot or choose not to do so will be left with a service that perhaps no longer has the vital critical mass of service users to make it viable. The union believes that these complex questions have not been satisfactorily addressed, and continues to be concerned that although the NHS is based on the principle of universal service, direct payments could fundamentally undermine that. My noble friend will know that the unions are following the proceedings of the Bill very closely because thousands of their members will be affected. It does not mean that the union is totally opposed in every way to the principle of direct payments, but it has considerable reservations about how they might operate in particular areas. I hope that my noble friend will deal with some of those concerns as we proceed. Amendment 54 would, ""ensure that appropriate training and guidance is provided for patients and (if different) payees to manage their direct payments and to safeguard effectively against potential abuse"." In the excellent document that my noble friend produced last year and which I have read several times in the past few weeks, there are references to the circumstances in which payments will be made. On page 24, there is a reference to the: ""NHS continuing healthcare … mental health services … learning disability services … maternity services … end-of-life care … and … some long-term conditions, especially where there are complex needs or opportunities to focus on preventive interventions"." Page 31 states that, ""personal health budgets can be used for any goods or services agreed as part of a care plan that are likely to meet the individual’s agreed healthcare outcomes and would be appropriate for the state to fund"." It talks about any goods or services that are agreed. On page 38 is a section that deals with the rights of patients to determine what they wish to purchase: ""People should have flexibility to spend the resources allocated to them to meet their needs flexibly, and in ways which reflect their own priorities"." I presume—I am just a consumer not a professional—that there will be circumstances in which the patient argues with the person designing the care package about what should be made available, and there will be divisions of opinion. In many ways, we are absolutely dependent on the expertise of the people who are designing that care package. The noble Baroness, Lady Campbell, in her very famous speech, which deserved a parliamentary award—it was a marvellous speech—commented that she could not get through to the person in the National Health Service what she wanted. They kept telling her that they wanted to spend £3,000 and she kept telling them that she wanted to spend £200. There did not seem to be the ability to communicate. Obviously, she is very articulate and she told them what she wanted, but they were not giving her what she wanted. Do not get me wrong; I am not against the whole idea, but I wonder whether the expertise is there in healthcare, which I would have thought is more complicated than social care, to evaluate precisely what is needed and to ensure that the patient’s care package requests are met. I can imagine circumstances in which the patient might say, "I want a £200 mattress". The manager might say, "It is in your care package, but we think you should have this mattress". I cite my own example. I have a whole series of complaints, one of which is ankylosing spondylitis, which noble Lords will know is an extremely painful and disabling condition. I have three beds in three different places, all of which could have cost me £3,500 apiece if I had bought them from Adjustamatic and not Dreams, where I paid £450 apiece for exactly the same bed. Who is going to determine where the bed is bought? Will the source of the bed be determined? Mine rises and falls. I might wake up three or four times a night, and I press the buttons to change the position of my spine to relieve pain. If I had one of these packages, I might well want a particular kind of bed and they would disagree. I will not have one of these packages, because I will be one of those people who do not want to go into the system. I will rely on the health service to provide for my needs. I am just a little concerned about how that might operate in practice. However, I am also worried about firms, such as Adjustamatic and other companies, which line up to pressure their patients to buy products and ring me up because they know from the records of firms with which I have been in contact to buy pain-relieving equipment that I have a particular problem. People who are in receipt of these payments may suddenly start receiving phone calls and be targeted by people saying, "We think this is a very good product for you. We think you should buy this. You need this massage machine or that exercise machine. You need all these so-called alternative medicines that are now on the market". When all this pressure is put on patients, will they be able to resist the purchase of the product, particularly in the area of pain relief for arthritis and other such conditions, rather than what the person building the care package has decided might be in their best interests? Last week, I received a catalogue from a firm called Verdict. It shows a massage seat that costs £1,299. I know that that chair can be very helpful to people who have a particular kind of pain because I have sat in one in St Bartholomew’s Hospital, and it works very well. What happens if the patient says that he wants one of those chairs, and the person producing the package thinks he does not need it? That potential area of conflict interests me. Amendment 54 refers to abuse. I do not know what the safeguards might be, but is it possible that in a care setting someone might want the client to buy a piece of equipment for him, not for the person who is the patient being funded by direct payment? I hope that these problems will be dealt with in the regulatory arrangements that Ministers will subsequently introduce. Unless I misunderstood the amendment moved earlier by the noble Lord, Lord Hunt, I think that he was trying to relax the regime by trying not to have too heavy regulatory control over what could be acquired in those circumstances. I would worry if the concerns that I am expressing are correct. In those circumstances, there might be greater potential for abuse.