Health and Social Care Bill

My Lords, we have had a very interesting debate on this imaginative amendment from my noble friend Lord Warner. Today’s debate might well be the only debate on social care in the whole life of this Bill, including in the Commons. I would like to talk about some real people, with real conditions and real problems, because it is only by testing this Bill against those that we will know whether it is going to work, and whether the issues that are being raised by noble Lords across the House are going to be taken into account. I would like to pick up where the noble Baroness, Lady Greengross, left off, and talk a bit about dementia, partly because I have a very close friend whose wife has dementia and I have been following the path of this for the last seven or eight years, but also because this is an issue that affects hundreds of thousands of people. The Alzheimer’s Society reckons that: there will be 1 million people with dementia by 2025; dementia costs the country £20 billion now; one in three people over 65 will die with dementia; only 40 per cent of those have a formal diagnosis—that figure varies enormously across the UK; and, of course, which is the reason why they are important to this debate, people with dementia are very significant users of health and social care services. We know that people over 65 with dementia are currently using up one-quarter of hospital beds at any one time. The current system of charging for care, such as help with eating, hits people with dementia hardest, as the noble Baroness, Lady Greengross, has said, and amounts to what the Alzheimer’s Society calls a ““dementia tax””. We know all of this. The All-Party Parliamentary Group on Dementia, the National Audit Office and the Alzheimer’s Society have identified that significant resources are wasted on poor-quality care—for example, through crisis admissions into hospital or long-term care. There are opportunities to save money in dementia care across a wide range of settings; for example, by investing in early intervention and prevention services. In a way, those matters are the test of this Bill. Can we save the money and deal with the people who have got dementia? How can we promote a shift of NHS resources away from acute hospitals into community-based services, as recommended by the NHS Future Forum and the recent inquiry by the All-Party Parliamentary Group on Dementia? I know that the Government recognise that a sustainable NHS in the future requires a new long-term settlement on social care to ensure quality for people facing disability and long-term illness. We think that this amendment will help with that. When I was looking at this amendment, I remembered that I myself was given a speaking note that said, ““Of course, health covers social care, too””. That is not good enough any more; it is not good enough to say that by writing health into the Bill and giving the Secretary of State responsibility for it, we are somehow covering social care. Apart from anything else, it has not worked. We know it has not, and we are where we are. There are some very serious issues. What does my friend whose wife has Alzheimer’s face? For seven years they have been coping as her Alzheimer’s has progressed, and coping very well indeed, but he is now getting on, too. I thought it might be worth looking at what is in store for him, and perhaps when the Minister responds to this debate he can also address what is in store for this person. We know that the local authority is making cuts in day care; he has told me that his respite is being reduced at the moment because of the strains under which the local authority finds itself. We know that the assessments for his wife—and himself, possibly, as he gets older—will get more and more difficult as the criteria move up the ladder of seriousness. I am concerned about the immediate problems that my friend and his wife face, but I have become concerned about the medium term as well, which is about the transition and the risks that are posed to people like him in the transition to the new architecture of the NHS. He is absolutely the ideal carer that my noble friend Lady Pitkeathley has been talking to us about for many years. He and his family have taken responsibility for his wife’s condition. He has managed the system on her behalf. However, he is getting old and tired and he will get frail himself. These are the people who fall down the gaps in our system. When I was preparing for this debate, I also looked at the report by the King’s Fund on integrated care. Obviously, we all know the King’s Fund well; it tends to talk about structures and theories and so on, but this report did point to examples, one of which was mentioned by the noble Baroness, Lady Barker, about care for older people in Torbay. I would like to raise two issues that the report referred to and then I would like to mention the ingredients that the King’s Fund says are important for integrated care, and to see how those apply to what is proposed in this Bill. One of the schemes that is commended by the King’s Fund report is the Bolton diabetes centre, which was, "““set up in 1995 and is the base for a team of community-based specialists. The team reaches into the local hospital for inpatient care, and out to general practices to provide support and undertake shared consultations. The vision is of care that is patient centred and delivered in the appropriate place””," for the person concerned. The centre has aspired to develop, "““a fully integrated diabetes service without gaps or duplication and with smooth and quick referral from primary care to specialist advice. Patients and staff have reported high levels of satisfaction with the service, and in 2005/6 Bolton reported the lowest number of hospital bed days per person with diabetes in the Greater Manchester area””." That is a very good example of a scheme that is working. Another example in the King’s Fund report relates to something that has not featured very much in these debates, and that is stroke care. The report says: "““Stroke care in London and Manchester has been improved by planning the provision of these services across networks linking hospitals. Manchester uses an integrated hub-and-spoke model that provides one comprehensive, two primary and six district stroke centres. Results include increasing the number of eligible patients receiving thrombolysis within the metropolitan area from 10 to 69 between 2006 and 2009. In London implementation of a pan-London stroke care pathway and the development of eight hyper-acute stroke units has improved access and reduced length of stay in hospitals: 85 per cent of high-risk patients who have had a transient””—" I can never pronounce this word— "““ischaemic attack are treated within 24 hours, compared with a national average of 56 per cent, and 84 per cent of patients spend at least 90 per cent of their time in a dedicated stroke unit, compared to a national average of 68 per cent. Five of the top six performing hospitals in the National Sentinel Audit for Stroke are now London hyper-acute stroke units””." We know that hundreds of lives have been saved in London and hundreds of people have gone on to make a full recovery from a stroke there. According to the King’s Fund report, the first core ingredient of integrated care is: "““Defined populations that enable health care teams to develop a relationship over time with a ‘registered’ population or local community, and so to target individuals who would most benefit from a more co-ordinated approach to the management of their care””." How will that be achieved without, for example in London, NHS London to drive the integrated stroke system? How will that be achieved when we have clinical commissioning groups that are not coterminous with their local populations? How will that be achieved with health and well-being boards if they do not have the right powers and tools at their disposal and the right kind of accountability to deliver? Another core ingredient is: "““Aligned financial incentives that support providers to work collaboratively by avoiding any perverse effects of activity-based payments; promote joint responsibility for the prudent management of financial resources; and encourage the management of ill-health in primary care settings in order to prevent admissions to hospitals and nursing homes””." One of the issues I would raise regarding that is how ““any qualified provider”” fits into the kind of integrated pattern of care that is being suggested here? Another core ingredient is: "““Shared accountability for performance through the use of data to improve quality and account to stakeholders through public reporting””." Again, we are addressing issues of public accountability throughout this Bill, and again we can see that, if you are going to deliver integrated care, that is a very important matter. The report goes on to talk about: "““Information technology that supports the delivery of integrated care, especially via the electronic medical record and the use of clinical decision support systems, and through the ability to identify and target ‘at risk’ patients""A physician–management partnership that links the clinical skills of healthcare professionals with the organisational skills of executives, sometimes bringing together the skills of purchasers and providers ‘under one roof’””—" which is, I suggest, a challenge at the moment— "““Effective leadership at all levels with a focus on continuous quality improvement""““A collaborative culture that emphasises team working and the delivery of highly co-ordinated and patient-centred care””—" we have to test that collaborative culture, and we shall be doing that next week against the competitive stream that is in Part 3 of this Bill. Finally, the report mentions: "““Multi-specialty groups of health and social care professionals in which, for example, generalists work alongside specialists to deliver integrated care””." The last, but in a way the most important ingredient—which should have been at the top of the list, so the King’s Fund should take a slap on the wrist for that—is: "““Patient engagement in taking decisions about their own care and support in enabling them to self-care””." I think there is precious little in this Bill that delivers that kind of patient input, so we hope to improve it. My final remarks are that I support, of course, the remarks that have been made about moving towards Dilnot and making sure that its proposals are carried out. If this amendment helps to take that forward, then I think that is right and we should support it. The noble Baroness, Lady Barker, was quite right, though, when she said that the Law Commission report was crucial to this exercise and to the national assessments. I do not think it is a case of one being set against the other, but there is absolutely no doubt that it is vital for the delivery of national assessments. I understand that the noble Baroness and her colleagues have not appreciated the attentions of some of the campaign groups that have been concerned about this Bill. Well, you know what? You cannot choose your campaign groups. As a politician, you just have to listen to what they say and then decide whether you like it or not. The noble Baroness has obviously not enjoyed their attentions, but I wish them all the best. I think they are doing exactly the right thing, but I would say that. This is an important issue. We easily lapse into structures, and words about structures, and we lose sight of the fact that this is about our fellow citizens. When I look around this Chamber, I know that a lot of your Lordships are carers who are taking responsibility for people in a very direct fashion. I will not say who you are, but I know who you are and I know that you are as passionately concerned about this matter as we are on these Benches. It is very important that we take the opportunity this Bill offers to make progress on this issue.