Health and Social Care Bill

My Lords, if the noble Lord will be patient, I will proceed and answer his questions at the end, as I normally do. It was in recognition of these practical challenges that the Government asked both the NHS Future Forum and the King’s Fund, jointly with the Nuffield Trust, to provide further advice on the practicalities of achieving more integrated services around the needs of patients. We look forward to receiving their advice later this year. So we share entirely the intentions of noble Lords, and that is why Clauses 20 and 23 contain proposed new Sections 13M and 14Y to create duties for national and local commissioners to promote integration across health and social care—that is the first part of my answer to the noble Lord, Lord Davies. New Section 13M creates an NHS Commissioning Board duty to promote integration. Rather than simply requiring the board to encourage clinical commissioning groups to work closely with local authorities, as under this amended duty, the board is required to promote integration by taking specific action to secure that services are provided in an integrated way where it considers that that would be beneficial to the people receiving those services. The duty requires the board to exercise its functions with a view to securing that health services, health and social care services and health and other health-related services are provided in an integrated way where it considers that this would either improve the quality of health services and the outcomes they achieve, or reduce inequalities in access to and outcomes from health services. By other health-related services, I mean services such as housing, which may have an effect on the health of individuals but are not health services or social care services. This requirement would cover both integration between service types—for example, between health and social care—and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This would apply to all the board’s functions not just when exercising its commissioning functions, including when it exercises public health functions under arrangements with Public Health England. The duty also requires the board to encourage clinical commissioning groups to enter into partnership arrangements with local authorities under Section 75 of the NHS Act 2006 where this would secure the provision of services in an integrated way, or that the provision of health services is integrated with the provision of health-related services or social care services. Proposed new Section 14Y creates a similar duty for local clinical commissioning groups. The changes to the regulatory framework give Monitor a role in Clause 59 in relation to improvement in quality and fairness as well as efficiency. The question then is: what actual risk exists of fragmentation at the national level? There is no such risk. Our outcomes frameworks span public health, the NHS and social care; the Secretary of State will aim to improve outcomes in all three components of the care system; NICE will provide quality standards across the whole patient pathway that will push for integrated care; and the care system, nationally as well as locally, will have to pay attention. The Secretary of State’s duties and his actions are, in other words, an embodiment of integration. Our reforms are firmly focused on improving quality and outcomes for patients. We are not in the business of dictating the processes by which this improvement might be achieved, or trying to measure success in terms of whether a particular process has been put in place regardless of whether it actually delivers a good outcome for patients. I make no apology for that. We are of course committed to enabling and facilitating integration, but integration is neither a necessary nor a sufficient condition of a good outcome. Perhaps more importantly, our reforms aim to encourage measurement and reporting throughout the system that will tell us whether it is achieving what we have said it should achieve. Accountability should finally have arrived at all levels in the system. Improvement should result and will be understood through the outcomes frameworks in terms of the actual outcomes achieved and those that matter most to patients, service users, their families and carers and the wider public. The noble Lord, Lord Patel, asked me how competition and integration will work together. As the NHS Future Forum said in its report, co-operation and competition are not mutually exclusive. Both have vital roles to play in improving NHS services. For example, competition enables a patient requiring a hip replacement to choose to have their operation in the hospital that best suits their needs. Should that patient then require rehabilitation and support from local community services after their operation, co-operation is equally crucial in ensuring that this is provided in a co-ordinated and integrated way. However, there have been concerns about how competition and integration can work together, and in particular that competition would prevent integration. In response, we introduced safeguards to prevent this. First, Monitor’s core duty is now clear: patients’ interests always come first. Where an integrated service raises competition concerns, Monitor will focus on what benefits patients. Its role will be to ensure that the benefits to patients outweigh any negative effects of competition. Secondly, Monitor has new duties to support integration where it is in the best interests of patients, working with others to enable integrated care. I listened with growing bafflement to the noble Lord, Lord Davies of Stamford—I do not mean that in too derogatory a way. He used the words ““extraordinary timing”” about the Bill and said that we had missed a trick by not considering health and social care together. I cannot agree with his analysis. I remind the noble Lord of some of the history of social care reform. It is difficult and complex, and requires careful consideration, which may explain why the previous Government never got close to a workable plan. That is why we feel that the process that we put in place last year, with the commission headed by Andrew Dilnot, was the right one. That has not stopped us considering how the Bill can improve health and social care working together in the ways that I have set out. The noble Lord asked why the system in Northern Ireland is not applicable in England. The simple answer is that health services in different areas develop in different ways. Successive Governments have endorsed a commissioner/provider split as a key way to drive quality and efficiency. The Government fully subscribe to that principle and are promoting integration within that context. The noble Lord challenged me to cite one example of how the Bill improves the legal framework to support integration. I have mentioned one or two. We have drafted the Bill with consideration of how the structures it establishes can support integration more effectively than the current system—for example, how CCGs will be different from PCTs. At present, PCTs do not have any duties relating to integration other than the need to co-operate with other NHS bodies and local authorities. We felt that that was insufficient and those who have spoken tonight appear to agree. As such, CCGs have duties not only to co-operate but also to promote integration. That is again in new Section 14Y, which I mentioned earlier. They also have to be part of health and well-being boards, agreeing a joint strategy which their commissioning plans should be consistent with. I say this not to imply that integration as an issue is solved but that we have thought very carefully about the role that legislation can play in supporting integration. The Bill is drafted on that basis. My noble friend Lady Cumberlege highlighted the importance of personal health budgets in helping to improve integration of services for individual patients. I absolutely agree with what she said. In our response to the NHS Future Forum report, we committed—subject to evidence from the current pilots—to using the mandate to the board to make it a priority to extend personal health budgets, including integrated personal budgets, across health and social care. My noble friend Lady Barker raised the crucial issue about information sharing. I agree that appropriate sharing of patient information is absolutely vital to ensuring the high-quality provision of care. Our intention is to move to a system whereby the information centre holds confidential information securely and can join up data from a number of sources, for example—and crucially—linking interventions with outcomes. The information would be made available more generally in anonymised and de-identified forms, so it could be used for many purposes, including to enable more integrated provision of care and for public accountability. This is an area that is under development, but it is an area in which the information centre will play a key role. The noble Lord, Lord Beecham, asked about the community-based budgets. We want to ensure that GPs and councils have the flexibility to pool and align funds locally, where this will improve outcomes for local people. We think that health and well-being boards provide the ideal forum for local application of community budgets, and we intend to explore any barriers to pooling and aligning through early implementers for health and well-being boards. My noble friend Lady Jolly asked how we would measure the effectiveness of integration and how we would report on it. Both points were extremely important. The NHS outcomes framework sets out the areas in which the NHS must improve in order to fulfil the system-wide quality duty with the supporting suite of indicators. Integration per se, as I have indicated, is neither measurable nor an explicit outcome, but the results of integration will show through in measured improvements in outcomes. As for reporting, CCGs’ annual reports will have to cover all the CCGs’ functions and duties including their duty to promote integration. The noble Lord, Lord Patel, spoke about diabetic care and pointed out that it was all too often fragmented. As he will know, NICE published a quality standard in diabetes earlier this year, which addressed care along the patient pathway and included guidance on avoiding foot ulceration and other avoidable co-morbidities. Indeed, NICE quality standards are intended to describe integrated care. The noble Baroness, Lady Masham, asked what would happen to wheelchair services in the new system. CCGs will commission wheelchair services, taking on the function from PCTs. In doing so, they would want to work and co-operate with their local authority colleagues. The noble Lord, Lord Warner, asked me specifically whether I was up for further integration amendments. He spoke eloquently about the need for integration to be more than just a rhetorical flourish. I could not agree more; what we need to do is to focus on the changes that will make a real difference. For example, how do we ensure that professionals from health, social care, social services and others work effectively together when their functions overlap? It is precisely that sort of level of technical and essentially non-legislative detail that the Future Forum is looking at now—and I look forward to its report. So while I would not say that my mind was closed to amending the Bill further with regard to integration, I am very keen that our focus as a Government is trained on making a real difference, whether in the Bill or outside it. With that, I hope that I have covered the points and questions that have been raised and respectfully suggest that the amendment is withdrawn.