Health Bill [Lords]

My hon. Friend makes a very good point. In many cases, the dividing line between health and social care is very hard to identify, so some thought needs to be given to circumstances where the balance between health and social care is a very fine one and it is difficult to unpick which is which. It would be helpful to know whether the Government have any plans to extend the constitution in that direction, given that, as my hon. Friend says, the current mantra from most political parties seems to be that greater joining up of health and social care services would be a good thing. I want to move on to discuss issues of discrimination and to raise a concern about whether some matters might fall between two political stools. The constitution states that people have""the right not to be unlawfully discriminated against in the provision of NHS services"" on a number of grounds. Age is a particularly controversial criterion, but it is clear that the Government are also using the Equality Bill to try to provide some clarity. However, I am not clear about how the Equality Bill and the Health Bill will join up in practice or whether there is any capacity for some issues to be dealt with less than fully by either Bill. When the Minister responds, will he describe what conversations are going on between the various Bill teams working on aspects of the NHS constitution and equality issues to ensure that that cannot happen? To provide one small example of the sort of problem I mean, the constitution also provides the same""right not to be unlawfully discriminated against in the provision of NHS services"" on the grounds of disability. Research by the Royal National Institute of Blind People shows that many visually impaired people do not receive information in a form that they can read. Depending on which part of the NHS they want to access, anything from 69 per cent. to 81 per cent. of those people cannot read it. The RNIB tells me that a variety of Ministers have said that the Equality Bill provides the best opportunity to deal with the problem of making the information accessible, but a recent letter from the Solicitor-General stated:""We are not persuaded of the case for making specific reference to the provision of information in alternative formats on the face of the legislation"." It would thus be helpful to have some idea of how that issue will be dealt with and which legislation will enable people with visual impairments to access the relevant information. I was intending to go on to deal with issues surrounding health and social care, but we have already covered that, so I will make one final point on the constitution. There were welcome moves in the other place to improve the reviewing of the constitution, but the patient voice seems to be lacking in the review process. There seems to be some resistance to the idea of involving patients and the public on the grounds that that might make the process too long-winded. That seems somewhat ironic, given that page 52 of the good old handbook on the NHS constitution gives patients the right to be involved in the planning of health care services. On one hand, we are giving people a right in a constitution, but on the other we are not giving anybody a right to be involved in its review, which seems to be a major omission. We very much support the idea of direct payments for health care and we very much support the idea of pilot schemes, too. I have often been against pilot schemes in the past, because they seem to have been used as a mechanism for delaying the implementation of policies that have a good evidence base. In this case, the pitfalls are real, so it seems right to pilot the schemes. I welcome the commitment properly to scrutinise the pilot schemes before going a step further. Direct payments are aimed at long-term medical conditions and I believe the pilots are going to start later this year. There is also great potential for such payment schemes in maternity care and mental health, so I hope we can pilot those areas, too. Women often have quite specific ideas about what maternity care they want for the birth, and it would help them if they were free to shop around a little more. There are number of fundamental questions, however. The Secretary of State said earlier that the plan had to be signed off by the care manager. That struck me as potentially problematic. What if there is a disagreement? Many social care direct payments have given the recipients complete autonomy over the way in which the money is spent and the way in which they lead their lives. It seems to me that there ought to be approval of some kind. It could reasonably be argued that care managers should sign off the payments, because we would then know that approved treatments were being given, but that too would reduce patient choice. I am not sure what benefit would be conferred by direct payments. What is the difference between deciding what people should do and giving them the money to do it, and deciding how patients are to be treated and making all the payments for them? I do not see much difference in either outcome of process or increase in flexibility. A legitimate question to be asked is "What will happen if patients underspend?" Will they be able to keep the money? I suspect that that is very unlikely. We should also ask what will happen if patients run out of money. The measure is intended to apply to long-term conditions, which are usually fairly stable. However, people may deteriorate. Another condition—a co-morbidity—may render the treatment of a patient much more complex. Will someone suffering from two or three long-term illnesses have to undergo three different assessments and add up the payments, or will that person be treated as a single patient? A number of answers will have to be teased out in Committee. How will it be possible to calculate the amount that patients will need in order to receive the care that they want? We have all seen comparisons between the amounts spent by PCTs in different health areas, and we know that there are great differences. Will there eventually be a national tariff? Will there be some smoothing mechanism to ensure that people in PCTs that do not fund some services very well are not disadvantaged? The answers to those important questions may not be provided by the pilot schemes if they are conducted on a strategic health authority basis. The Secretary of State said that if a patient chose a treatment that was not regarded as clinically effective, it would probably not be signed off. However, an equality issue arises as well. Is this a bit middle-class? Research shows that some demographic groups benefit from direct payments much more than others. Can the Minister assure me at this stage that equality will be a consideration in the evaluation, so that we can be sure that we are not hitting only certain sections of society? All providers will be required to produce and publish quality accounts. I fear that the process will be time-consuming, and that the ultimate benefit will be limited. It reminds me of the time when standard assessment tests were introduced. My children were quite young then. I remember the headmaster saying "These are standard assessment tasks. There is no way that they are tests, and there is no way that they will ever be used to compare children or to compare schools." When we consider what has happened to SATs, we have to worry about the way in which the quality account data will be used and analysed and the comparative purposes to which they could ultimately be put. I did not intend to say much about pharmaceutical services, but I want to reassure the hon. Member for South Cambridgeshire. I am not sure whether he was involved in health at the time—he may have been involved in education—but at one stage the Office of Fair Trading proposed that pharmacies should be subject to a complete change in the control of entry regulations. There was a move to allow them to open anywhere, to allow a free-for-all and to see what happened after that. We ended up with a bit of a fudge as a compromise, but a fair number of people argued at the time that pharmacies were not like sweet shops or toy shops, and that their provision should be planned as part of the primary health care service. The proposal was considered by the Select Committee, of which the Secretary of State was a member, and he seemed to be persuaded by the argument that control of entry could be used to ensure the provision of better services. I must declare an interest as a fellow of the Royal Pharmaceutical Society, but I believe that if we are to advance the pharmacy agenda and ensure that the public are offered a greater range of pharmaceutical services, needs assessments are essential. That is not about preventing dispensing doctors from doing anything. It is more about giving the public more access to, for instance, smoking-cessation services. I hope that, in the long term, it will mean that when an application is made to open a new pharmacy, the primary care trust will have some control over what happens and will be able to insist that some extra services are provided. I hope that it will mean that we can move away from the supply side, and that people can expect a greater range of services from their pharmacies. I hope that the hon. Member for South Cambridgeshire will eventually see the proposal in a more positive light, because that is how I think it is intended.