Health and Social Care Bill

My Lords, I would like to make a contribution. I was very interested that the noble Lord, Lord Warner, said in his introduction that he felt that integration was sometimes used as a defence against competition. He cited Kaiser Permanente, as did the noble Lord, Lord Patel. Closer to home, I was really interested to see that Assura Cambridge—Assura is an independent company—was involved in an integrated care organisation. It was a pilot that was designed to improve the quality of end-of-life care locally and to ensure that 50 per cent of patients who knew they were dying would do so in a place of their choice. After five years, the aim is to increase this figure to 75 per cent. Assura Cambridge, which is a partnership between Assura Medical and 16 GP practices in Cambridge, worked with a range of care providers to plan, co-ordinate and improve the delivery of care to patients in the last year of their lives. The project team was led by Assura Cambridge and included representatives—this is important because it shows real integration—from Cambridge University Hospitals NHS Foundation Trust, Cambridge Community Services, NHS Cambridge, which is the primary care trust, the Cambridge Association to Commission Health and the DoH integrated care organisation pilot team. This collaboration and partnership had a very simple system, which was to use ““just in case”” bags. The system was adopted to ensure that GPs had the appropriate medicines to hand for terminally ill patients in advance of their need. By taking this very simple step, the integrated care organisation was able to ensure that 87.5 per cent of deaths occurred in the patient’s usual residence or place of choice, compared to only 50 per cent of deaths without using the system. In this case it was Assura Medical that acted as the glue to ensure that collaboration brought about an integrated solution, which has since exceeded the project’s aspiration. That is very interesting: it needed someone from outside the NHS to bring all these people together. When I talked to some of them, they said, ““We haven’t got the time to do that. We just couldn’t fit all that together””. It was an outside organisation that was able to do that. Recently I went to the Royal College of GPs’ annual conference in Manchester—no, I am sorry, Liverpool; I know there is a great difference between the two, but I have been travelling a lot recently. There was great debate about the ethical issue of GPs commissioning. The person promoting this was Professor Martin Marshall. He asked the audience of GPs—the place was packed—what the most frequent diagnosis that came through their surgery door was. As you might expect, the GPs mentioned coronary heart disease, diabetes and so on. Professor Marshall said, ““No, it’s LIS””, and everyone looked very puzzled. He said, ““Lost in the system””. I thought that was interesting. ““Lost in the system”” is the problem when we do not have integration. It seems to me that integration happens on three levels, so maybe we have to define it more closely. The first is within community services. A GP said to me the other day, ““District nursing—they’re the enemy””. When you start at that base, we have an awful lot of work to do just to get integration within the community. As the noble Lord, Lord Patel, said, you have to get the whole team to work, and to work beyond the team as well. I have done a bit of work with maternity services. This is the next tier up—integration between community and hospitals. One of the things that we have tried very hard to do is to get midwives to have caseloads, so that they are there when the woman is pregnant, looking after her. They will perform the delivery, which will not necessarily be at home—it can be in hospital—and then do the postnatal care. It is brilliant. It is what women want and it provides continuity and integration. Try getting that to work—it is very difficult, because of the territories; hospitals often do not want the community midwives to come in, on to their territory, and perform the delivery. Integration happens in some places but it is very hard to roll out. That is the second tier—the hospital and community tier. The third tier comprises social services and health and is a very difficult area, as the noble Baroness, Lady Murphy, said. It is about silos and hierarchies. It is not just about territories; it is about who employs the staff. Having spent a few days in Torbay, I was very interested to see that the social workers there are now employed by the PCT. The social workers have been TUPE-ed across. A single organisation employs both health and social services staff. I went to some of their meetings and was very impressed by the integration that they had achieved. That was very encouraging. I note that new Section 14Y on page 37 contains a duty to promote integration as regards CCGs. Subsection (1) states: "““Each clinical commissioning group must exercise its functions with a view to securing that health services are provided in an integrated way where it considers that this would— (a) improve the quality of those services””," and reduce health inequalities. The new section goes on to say a bit more about integration with social services. Health and well-being boards have a duty to encourage integration under Clause 192 on page 193. Subsections (1) to (4) of that clause contain a lot of detail on that duty. Clearly, there is a great will within the Government to achieve integration. I am sure that the noble Lord, Lord Warner, who is extremely persistent and determined, will keep up the pressure in this regard and we will see how this all pans out. However, I go back to the level of the individual and to what one of the amendments of the noble Lord, Lord Warner, says about joint assessments. That is absolutely critical for an individual. Given the personalised budgets whereby individuals can spend the relevant money as they wish, there will be superb integration—as long as we can get some joint budgets—because those people do not see the boundaries that I have mentioned. They do not care who employs who. They want a service that works for them. When they are in charge, have the money and can choose the services they want within that budget, we will see a very different health service and provision of social services. We will then see real integration.