My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.
Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire—and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter—that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis—some old person who can no longer cope in some way—his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.
Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week—it is not an exceptional situation—to patients, their families and carers, who are the victims of it.
The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.
Sadly—I deeply regret this—the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice—the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.
I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?
My second question to the Government is: given that they did not decide to go down that route, what contribution to a solution to the problem that I have just outlined is represented by this Bill? Of course, I have tried to answer that question for myself by reading the relevant clauses of the Bill but I have not come up with a clear or definitive answer—one that satisfies me. I think that the answer is that it makes no change at all. So far as I can see, Clause 10 simply incorporates into the Bill and carries forward the duties currently imposed on health authorities and PCTs by Section 3 of the 2006 Act. I do not have that Act in front of me but, if I recall correctly, Section 3 includes a reference to aftercare. PCTs can, if they wish, commission aftercare, which is obviously a social care issue, although I have never heard of them doing that.
Similarly, what about the influence of hospitals on the plans of local authorities, and the influence of local authorities on the plans of commissioning groups and the future clinical commissioning groups? Again, it seems that Clause 187 of the Bill simply replicates the provisions in the 2006 Act for local authorities to have the right to consultation and influence over the plans of NHS bodies. Therefore, it does not make any substantive change. It does not do anything that addresses the problems of articulation between the NHS and particularly the secondary sector—the hospital sector—and social care. I may be wrong in that. I hope that I am and, if I am, I ask the Minister to tell me why I am wrong and in what respect the Bill genuinely attempts to address this major structural problem, which has been around for a long time. It would be a wonderful opportunity for this coalition Government to do something about this problem, if they have the will to do so. I hope that the Minister is going to tell me that I have missed something and that this issue is addressed in Clause 195 or whatever. Perhaps he is going to tell me that there is nothing in the Bill but that he intends to put forward regulations to address the problem, in which case I shall welcome that statement and listen with great interest to what he has to tell me. This is a major national problem. There is a serious failing in the way that our healthcare service operates that needs to be addressed.
I make one final comment on integration, but integration of a slightly different kind. The Government are consulting at the moment with a consultation document about the future of social care. I have read that document and responses have been asked for in writing by 2 December. That is extraordinary, is it not? The Government bring forward a new Bill and we are starting the Committee stage, which will probably go on until after 2 December, although I have no idea for how long—none of us does. At the same time, they are consulting on a document about social care. One might think that they would design a new social care system, look at how it needs to be integrated with the rest of healthcare and then come forward with a coherent Bill. Frankly, it is the most extraordinary way of doing anything. It would be the most extraordinary way of running a railway. In my view, it is the most extraordinary way of legislating and the most extraordinary way of running the health service. I hope that the Minister is not too upset by my strictures, which are not personally addressed to him, but an answer does seem to be required as to why these two initiatives seem to be proceeding in parallel with no apparent integration at all.
Health and Social Care Bill
Proceeding contribution from
Lord Davies of Stamford
(Labour)
in the House of Lords on Wednesday, 2 November 2011.
It occurred during Committee of the Whole House (HL)
and
Debate on bills on Health and Social Care Bill.
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2010-12Chamber / Committee
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