Health and Social Care Bill

My Lords, it is particularly apt that I follow the speech of my noble friend because, in supporting these amendments, I wanted to relate a little of my experience as the Social Exclusion Minister who came in and tried to learn from all the other things that we had done in government—and what we had missed and needed to come back to. One of the issues that we came back to that is particularly apposite to the amendments related to people who do not fit into any category, who are the most vulnerable and who turn up at different places to try to get a service. No service treats them as an individual who has several problems. Most of these people have mental and physical health problems and probably have an addiction. They are probably difficult to deal with and are likely to get aggressive because they know that they are not getting the response they need to help them move forward. We set up some pilot projects which I now work with as chair of the Cyrenians in the north-east—a charity which took up one of those pilots and extended it. The pilot is paid for now by Newcastle City Council and the PCT, which is much bigger than the subsequent clinical commissioning groups will be. I was not sure whether I should raise this matter in the previous group of amendments or in this one, but I do not want to keep having to rise to speak because there are issues here that the Government need to address. I chose these amendments because they relate to the Secretary of State, the national Commissioning Board, and the clinical commissioning groups. Some things will have to cross those boundaries and be paid attention to by more than just a clinical commissioning group on its own, because the people we are talking about do not remain in one place. Sometimes there are insufficient of them in one place for a clinical commissioning group to take account of what they are going to need. We have people who go round and find the most disadvantaged and the most dispossessed—the ones who are not fitting in anywhere. We use ex-clients to go and find them. Most of the money comes from the local authority. We persuaded the PCT to appoint a community matron with whom we work and to whom we send those people. She is then able to assess their physical and mental health needs. This has substantially reduced in-patient care, and because we have a different system we can show that fewer people end up in A&E and are then admitted to hospital. Such an arrangement can save money but is also able to provide interventions at an earlier stage—and that was what attracted me about the amendments, because they relate to prevention, diagnosis and treatment. However, we do not work just with the homeless; we also have three projects for addicts. One of them is a 12-step, 12-week day-centre programme. The programme is fairly tough and the addicts have to be abstinent. We pay for that with money from three PCTs which were so enthusiastic about the work and what it was producing that they are now funding another centre for addiction, where we take in on a residential basis mothers and their children to seek to prevent the children going into care—because that was what was happening. We still have a small problem with the acute providers because sometimes when a family was going to come to us the providers had increased the methadone rather than helped the mothers to come off the methadone. We use the recovery method rather than methadone. I hope that the Committee can see that these are complex cases, with complex interventions that are aimed at preventing more difficult interventions later. I cannot see one clinical commissioning group commissioning any of this work, because it will be too expensive and there will not be a sufficient body of people to justify the work and money that it would need to put in. That is why, in the new architecture, the Government need to think how they will respond to those more complex problems, where the voluntary sector is coming up with more innovative solutions, but they need also to deal properly with what is often called dual diagnosis—I think it is often triple and quadruple diagnosis—where people have more than one problem. We need to bring the different groupings together to make sure that the needs of that individual or that family are addressed in a holistic way. It is important to recognise that more than a physical illness is brought to the table, as it were, in those cases. At least the amendment acknowledges that both physical and mental illness must be addressed. We will get a complex architecture under the Bill, and it will be all too easy for people to fall back through the cracks within that architecture and for there not to be a holistic approach. The next set of amendments, which talk about integration, are also important, and I will come back to them, but the Government need to think again about how to address those complex issues in a way that allows the whole person in that patient to be addressed in a more effective way than we are often able to do at the moment.