Health and Social Care Bill

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Lorna Fitzsimons (Rochdale): Does not the right hon. Gentleman acknowledge that currently under the NHS commissioning is allocated between many different bodies that are accountable in different ways to different boards, such as health trusts, health authorities and now the PCTs? There is no problem, so why should there be a problem with the new model, especially given that the elections and accountability in local government are rather more extensive than they are in community health councils?

Sir George Young: If the hon. Lady follows the example that I am about to give, she may realise the issue. At the moment if something goes wrong with care in the community the responsibility rests clearly with social services. People know to whom they should complain. Someone with a grievance goes to his county councillor—or his local councillor if it is a unitary authority—and says, ``The assessment has not taken place. This elderly constituent was entitled to an assessment under care in the community. You have not done it and I want it done.'' That is a matter for the director of social services and the chairman of the social services committee.

Under the primary care trust system, the local authority transfers into a primary care trust its responsibilities for care in the community. If something goes wrong then and there is a complaint to the local councillor, the local councillor can no longer say, ``I will talk to the chairman of the social services committee and the director of social services and we will have the assessment done. We will make the required adaptation to the downstairs accommodation so that that individual can continue to live there.'' Instead, the person bringing the complaint will be told that responsibility has gone to a primary care trust and the local councillor or the chairman of the social services committee no longer has a direct influence on the outcome: it is a national health service body and the local councillor is just one voice. For that reason it is important that issues of accountability are raised during the consultation exercise. It is not clear cut. The Government have not made at all clear the governance arrangements and chain of accountability under the primary care trust.

Another issue that will need to be dealt with in the consultation process is the culture in social services, which is quite different from that in the NHS. For example, social services departments have a charging regime, which has already been touched on by the hon. Member for Sutton and Cheam, while the NHS is free at the point of use. When two cultures are merged—one that charges for services on the basis of means testing and the other that is free at the point of use—important issues will inevitably arise. Which services provided by the primary care trust will be free and which will incur charges? The service is supposed to be seamless and the patient—or customer—is not meant to know at what point in the chain the services are provided. People want an answer to a key question. How will they know that services provided by the primary care trust will not incur charges?

The Minister attempted to provide an answer, but if it is a seamless service—and that is the object of the primary care trust—there must be a point towards the social services regime, at which someone says, ``If that service had been provided in the old days, we would have charged for it, so why not charge for it now?'' So the Minister has glossed over some important issues.

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There are also key issues about resources. Social services receive money through the revenue support grant and the local rates. The county council or the district council debate education and social services, and money is voted to social services, which goes to the care trust. The primary care trust receives its resources straight from the Department via the various tiers in the health service. If something were to go wrong mid year and the primary care trust were heading for an overspend, it would be difficult for the local authority to top it up. It may be easier for the NHS to do so. Those issues have not been considered.

Local authority social services departments are well-established, robust bodies. The primary care trusts, on which we propose to put all this responsibility, are hardly up and running. Most parts of the country have a primary care group. The Government plan to impose on untried and untested bodies major responsibilities that are currently well-discharged by local authorities. That is a leap in the dark, and many questions remain unanswered. I hope that at some point—either in this debate or on clause stand part—the Minister will deal with some of the unresolved issues brought up by this radical change in policy.

Mr. Hutton: We started with a debate about consultation, but we have covered just about everything that is likely to be raised about the subject of a care trust--perfectly properly, of course. I shall deal first of with the points that right hon. and hon. Members have made about the importance of consultation. Consultation will be fundamental. In the NHS, when new bodies are brought into existence or services are reconfigured, there is a well-established pattern of consultation, and we intend that to be the case for care trusts.

I accept some of the points made by the right hon. Member for North-West Hampshire (Sir G. Young) in his helpful contribution to the debate. Care trusts are a big step forward, which is clear from the Bill and the NHS plan. We are attempting to do something that the previous Government considered, but did not do, for a variety of reasons that I am sure he will shine further light on.

Mr. Philip Hammond (Runnymede and Weybridge): And rejected.

Mr. Hutton: The hon. Member for Runnymede and Weybridge (Mr. Hammond) says that the previous Government rejected the idea, which is true. We decided to take the step because we wanted to pursue the agenda of partnership working as outlined in the NHS plan. The issue of charging, although it is important, should not frustrate closer partnership arrangements between the NHS and social services. I do not subscribe to his fatalistic view that closer working between the NHS and social care will be frustrated if the social services element is charged for—it is important to bear in mind the fact that not every local authority charges for domiciliary services. That is not the experience in Northern Ireland.

Lorna Fitzsimons: Does my hon. Friend acknowledge that many localities—and I cite Rochdale—have received awards for the seamless service provided currently by social services and the different wings of the NHS when ensuring appropriate after care for our constituents following a stay in hospital?

Mr. Hutton: I agree with my hon. Friend. It would not be hard to find similar examples in other parts of the country. We must approach the establishment of care trusts in a slightly different way. I accept that there may be difficulties and that problems will need to be overcome. However, if we retreat into the second line and say that it is too difficult to explore closer partnership working because the issue of charging is so complicated that it rules out any prospect of those two important organisations working more closely together, we will let down those whom we are here to serve. I believe that there is a way around those problems.

The right hon. Member for North-West Hampshire said that clause 45 would impose measures on local organisations, but he must be aware that we cannot do that under clause 45. The clause deals with the voluntary establishment of care trusts. By definition, if one of the parties chooses not to establish a care trust, then a trust cannot be established under clause 45. We cannot impose anything on local authorities under clause 45; we want genuine partnership if the parties decide to go down that route.

Mr. Hammond: We shall come to clause 46 shortly, but it provides a reserve power for the Secretary of State to compel such arrangements to be put in place. Local authorities and health authorities will therefore be under strong pressure to use the clause 45 route. It is more than a purely voluntary approach.

Mr. Hutton: Of course we will encourage the establishment of care trusts; the concept has a great deal to commend it. It would be a rum state of affairs for a Government to propose a way forward and then to be hesitant about endorsing it or encouraging people to use it. That would be bizarre. It will, of course, be a mixed approach, but we are confident that the flexibility arrangements under section 31 of the Health Act 1999 will deliver improved co-operation and partnership between health authorities, trusts and local authorities. That nut can be cracked in a variety of ways.

The Opposition are entitled to be cynical; some would say that that is their role. However, the right hon. Member for North-West Hampshire has been in my shoes and worn my jacket—he is welcome to it!—and he should know that it is the responsibility of Ministers to deal with the problem of getting social and health care services to work more closely in partnership.

The right hon. Gentleman spoke also about centralisation and the role of local government. He said that care trusts represent centralisation. I remind him that clause 45 is about voluntary agreements between local authorities and the local NHS, and establishing closer working relationships. His argument is not credible. These are partnership arrangements under which a voluntary agreement is entered into by both parties. The Government reject the Opposition's criticism.

Another factor is the wider role of local government. The Opposition seem to regard health trusts as a diminution of local government, and they question local accountability for social services. I reject that view comprehensively. We should celebrate the fact that the Bill creates significant new opportunities for local government to influence the future direction of the national health service. Liberal Democrat Members are always banging on about the so-called democratic deficit in the NHS; they should consider the proposals as a welcome step forward. We shall come to governance arrangements later, but whatever we decide about governance, the care trust model offers local government an important new role in the commissioning of health care services.

The right hon. Gentleman suggests that clause 45 will denude local authorities of that wider responsibility and of the ability to influence events locally. I have great respect for him, but he is wrong. That view takes no account of the wider role that we envisage for local government through the scrutiny committees. Moreover, it does not recognise that when local authority members join the boards under the governance arrangements for care trusts, they will be able to discuss the wider commissioning of health care services in their locality. That will not just be in the context of social services, because board members of a care trust will be more than local authority representatives concerned only with social services delivery, as the board will have commissioning responsibility across the range. That is a genuine enhancement rather than a stripping out of responsibilities for local councillors.

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Prepared 6 February 2001