Health and Social Care Bill

I would be grateful if the noble Lord would bear with me for a couple of minutes while I go through a few paragraphs and try to explain how this clause poses some problems, because I agree that it is pretty complicated. The new commissioning consortias’ duty in the Bill is to arrange for health services provision that applies to those enrolled patients registered with them. This contrasts with primary care trusts, and the other structures that will be disbanded when the new structures come in, because the population of the consortia will be drawn from the patient lists of member general practices rather than from residents living within a defined geographical area. That means that as clinical commissioning groups they will have the freedom to choose who they take on to their registers, regardless of where they live. As a consequence, the population for which a clinical commissioning group is responsible may include not all individuals and families living in the local area, so may not represent an area-based population. However, it may have some people whose primary residence is a long way away but who decide to register with a GP because that is where they work and where they are during the week. It has been suggested that individuals and families who are not enrolled within a local commissioning group’s general practitioners may not be covered and would therefore need to be covered by a small number of more centralised clinical commissioning groups, which will effectively mop up those individuals and families who lack membership within a local clinical commissioning group. I would therefore be grateful if the Minister could confirm the arrangements for those patients, such as people who are homeless, and who may for whatever reason not be on a particular general practitioner’s list. Can he also explain to the Committee how these patients will be allocated to receive primary medical care services since that allocation duty currently falls to primary care trusts, which will not be there in the future? The services will be designated from the commissioning board, which is at quite some distance from patients who do not have a GP and from individual GPs. The combination of removing geographical responsibility for the provision of healthcare, together with the removal of practice boundaries, creates a number of risks: an inability to plan for local services; a risk of worsening health inequalities and social segregation; and fragmentation between social care and healthcare—the former being based on local authority boundaries and the latter then being based on a potentially England-wide catchment area, depending on who registered with a GP. Allocating resources based on the GP-registered list rather than any geographical population will mean that there would not be coterminosity with public health—or, importantly, with local authority services, which are responsible for much social care and for the safeguarding of children and vulnerable adults. A lot of those responsibilities for safeguarding held by a local authority relate to the geographical area of a local authority. With GPs potentially competing for patients across the whole country there could be fragmentation, especially if someone registers near their place of work as when they are ill they are likely either to be at home or to return home, which may be many miles away. They may need services at home, particularly medical and nursing care, if the condition is sufficiently serious to require them. Yet the GP with whom they are registered for primary medical services would then be at a distance that would make home visiting impossible. In April of this year the Health Select Committee emphasised the importance of aligning care to geographical boundaries, making this point: "““Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning ""bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities””." To paraphrase that, I hope that my amendment is in line with the recommendation of the Health Select Committee. The local authority will take over many functions of current PCTs, especially over safeguarding, as I said. This is important, particularly for children who are unable to transfer their own care. Different children from the same family who are at particular risk and on an at-risk register will potentially be registered in different places by abusive parents who deliberately want to ensure that they limit, or almost exclude themselves from, surveillance. I am sure I do not need to remind the House that the tragedy of Baby P was an example of a parent who avoided surveillance and, tragically, avoided it far too effectively. The other difficulty is that there are families who have very complex lifestyles, with different members registered at different distances, particularly if they are mobile families. This will make it very hard to obtain an overall picture of the health, education and safeguarding services if these are not coterminous. Where local authority, education authority and health provision are coterminous, there is a much better chance of a good transfer of important data on the welfare of these children who are at risk. Public health is a major and very welcome focus of the Government. This amendment is also necessary to ensure that the NHS will adequately address those issues of health improvement such as smoking cessation, screening for disease, immunisation and so on, where treating people as a population rather than a collection of separate individuals is more effective. Public health can achieve optimal population health outcomes only if there are area-based organisational structures and frameworks in the health system. That becomes particularly important in more rural areas, as it ensures optimising efficiency, accountability and effectively integrated care. The amendment also supports the Secretary of State’s responsibility for issues of health protection, such as the control of an epidemic of infectious disease. Such an epidemic cannot be dealt with just by treating individuals. It requires an area-based approach, using vaccinations, population monitoring and so on to ensure disease containment. Additionally, without coterminous working of health and local authority, planning of capacity becomes harder. General practice can certainly do much to improve its quality of service in some areas, particularly access to primary care through extended hours, out-of-hours coverage of the population and decreasing the dangers that are encountered with the lone-worker GP who does not have contact with other colleagues. General practice could go towards federated models of practice; that is not incompatible with the spirit of this amendment. However, all these improvements need geographical areas to function properly and drive up quality of care. Epidemiological research has been a strength of the UK, building on registers of a precisely defined denominator of patients, categorised by age, sex and so on, and known to be living in a particular environment. Weakening it by multiple registration will break the link of geography with health and may impede the aim of driving up quality. It will certainly impede our ability to carry out effective quality-based research on improving health in the future. Another area that I want to address briefly is that of the medical examiners in relation to coronial jurisdictions. Their work depends on them being geographically area-based and seeing the death certificates of all the general practitioners within that area as they come through. There is a concern that if there is wide fragmentation it may be more difficult to pick up trends that should not be there. Amendments 10B and 11A seek to delete ““or”” and insert ““and”” to make subsection (1) of proposed new Section 1A of the 2006 Act refer to the prevention, diagnosis and treatment of illness, and then go on to public health. I suggest that these amendments are logical as they would ensure that the Secretary of State has a duty to improve all three of those aspects in relation to illness. The measure also emphasises the importance of public health in conjunction with the prevention, diagnosis and treatment of illness. I stress that ““illness”” includes both mental and physical illness.