Health and Social Care Bill

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Sir George Young: One or two issues are appropriately raised now, including some questions asked earlier that have not been answered. For example, I asked the Minister whether the independent appointments commission or the Secretary of State will be able to veto nominations to care trusts made by local authorities. I hope that he will confirm that local authorities can nominate whom they want to represent them, and that the Secretary of State will not have a veto, as was implied.

It has been a helpful debate, and I am now a lot clearer about what is proposed—although I am slightly more worried. The Minister argued that the arrangement is voluntary and that no one has to enter into it, and that it is not a takeover, but will be on the basis of equality. Many arrangements are, in theory, voluntary, but the Government nudge local authorities to enter into them, so they become almost compulsory. For example, the takeover of housing stock is in theory voluntary, but local authorities know that they will not receive the capital they need to modernise their housing stock if it stays in their control. The only way for them to go is the voluntary transfer route. Local authorities can say that that is voluntary, but it is the only way they can provide the services that tenants need.

We have not touched on a real resource problem, which is that the increase in resources for the NHS has been far larger than the increase to social services, and as a result many directors of social services are looking with some envy at the NHS budget. They are considering the problems confronting them; they are blamed for bed-blocking because they are not making placements in nursing and residential homes. Many of them see care trusts as the way out: as a way to access the limitless resources of the NHS and free themselves from the constraints of local authority budgets. When the Minister says, ``Yes, the arrangement is voluntary,'' he is right in one sense, but many directors of social services know that unless they enter into these agreement, they will be unable to access the resources necessary to deliver a quality service.

What matters is good working relationships on the ground, which we already have with the practice of pooled budgets and lead commissioning. That is the way forward. Having listened to the debate on clause 45, I urge caution before proceeding down that road at any great speed. The Minister's response made it clear that many key issues have not been resolved.

The Minister says that these arrangements are not a takeover. However, local authority social services functions will be bolted on to a primary care trust. It is like badge engineering--it is the same vehicle, but it will be called something different and have a few additional functions. How can the Minister present this measure to local government as a partnership of equals when he has given no assurances about the balance of representation? The Minister will come under increasing pressure from local government, which will see it as a slightly different animal than the one they read about in the NHS plan. If the Minister goes down that path, I urge him not to steam ahead at great speed, but to take local government with him. He should consider some of the issues raised in this helpful debate, and realise that, in fairness to the Committee, the Government have not been able to address some of the real issues as fully as they would have liked.

Dr. Brand: It has been a useful debate. The right hon. Member for North-West Hampshire expressed his anxieties, and my hon. Friend the Member for Sutton and Cheam made perceptive points, which dealt with the position of local government and governance of the proposed care trusts. To pick up the analogy just used, I am sure that the Government are travelling in the right direction, although I warn the Minister that it will not necessarily be plain sailing.

When the Select Committee on Health looked into the relationship between health and social services, we found some excellent examples of joint working all round the country. In Northern Ireland, joint working was enabled by a structure that brought the two authorities together. Curiously, in only about a fifth of Northern Ireland were services integrated even though it has had a joint statutory body looking after health and social services since 1948. That shows the need for the Government to take the people that deliver the service and the community that benefits from it with them when they create such patterns.

We should not be talking of a takeover, but of a merger of cultures. We should not underestimate the difficulties that go with that. We need to evolve a common language. Social work language can be quite different from medical language. More joint training early in people's careers is needed. Although care trusts look like an attractive short cut to joint working, it will be a challenge to make that happen.

We also saw good examples in Scotland of successful integrated work—at times using methods that I shall describe as extra-statutory. Flexible arrangements were made locally, and when we challenged the commissioners on how it was possible to get away with them under present regulations, they replied, ``We ring the Minister in Edinburgh and sort something out.'' That shows what flexibility is needed to make local schemes work.

We also saw good joint working in Rochdale, but there is good joint working between health and social services at patient-client level all over the country. However, that often comes about as both sides of the joint team abandon some of their own rules and regulations, and set aside some of the local statutory regulations on, for instance, charging. We saw many examples of excellent mental health work with one integrated team. It was not possible to tell from the functions of team members whether they worked for social services or for a health authority. Clearly, different charging policies for members of one integrated team would have been nonsense.

The Government are dismissing too lightly the issue of charges and the culture associated with them. No doubt we shall return to that point on clause 48. The schemes that the Health Committee examined were all promoted, and all worked, because the people who worked in them adopted an extremely flexible approach to the statutory charges that were levied by bodies in the locality that were not involved in an integrated scheme.

I am disappointed that we have not, in considering the clause, touched on the importance of a clear commissioning and provider function. I know that it is sometimes thought a bit messy for both PCGs and PCTs—and now no doubt care trusts—to be providers and sub-commissioners of secondary and other services. However, the Minister has not explained clearly the proposed role of health improvement programmes, any relevant condition for joining a care trust, or an integrated planning function.

There are many issues concerning democratic accountability: the relevant input is important with respect to the governance of the care trust, but it is even more important with respect to the workings of the commissioning bodies, which, for a care trust, will still be one or more local authorities, and the health authority to which the care trust is responsible. It would be helpful if the Minister would describe more clearly how democratic accountability will be guaranteed on the commissioning side. We should have a structure for overcoming some of the practical local problems concerning lead authorities and shared social services provision, which were pointed out by my hon. Friend the Member for Sutton and Cheam.

12 noon

Mr. Swayne: In discussing the previous group of amendments we tried to probe the question of who would be on the boards of care trusts, and how those boards would differ from those of existing trusts, such as primary care trusts. I should like to use this brief debate on clause stand part to probe the Minister further. He has assured us that the partnership will be genuine. If we take that assurance at face value, it begs several questions. For example, how will the partnership affect the local authority scrutiny function? If the partnership is genuine, the local authority will have acquired an interest in the trust. How, therefore, can its own independent scrutiny function continue to work effectively? How are the trusts linked to patients forums?

What about performance indicators? Will we develop new ones, tailor-made for care trusts, or will we apply the performance indicators that we have traditionally applied to local authorities or to NHS bodies? What happens when things go wrong? What will the complaints procedure be? Will complaints against the care trust ultimately be dealt with by the local government ombudsman, or by the NHS ombudsman?

The hon. Member for Sutton and Cheam asked some pertinent questions about financing and local authority boundaries. We require an answer on that. The question of how such things will work is not just constitutional and academic, although the discussion is interesting. The issues will have a real impact on the patients at the end of the line.

If a local authority enters into a care trust arrangement, will its social services committee continue to take policy decisions in the same way that it does currently? The hon. Member for Sutton and Cheam raised the question of charging in that respect. There is a fear that in future, existing NHS services will be repackaged as social care services, so that they can be charged for. We will be seeking some reassurance on the issue of respite care, which is currently provided by the NHS. If in future respite care is provided under social care provisions by a care trust, will the existing dispensation continue? Will there continue to be no charge for that care? It would be quite wrong if, in the new world of care trusts, people ended up being charged for a service that they currently get free of charge.

There is a series of pressing questions on the nature of the organisations, the way in which they are to be set up and the way in which they will work. The Minister says, ``We still have to think some of those problems through.'' However, all the questions have profound practical implications, which are bread and butter issues for the people who will receive the services at the end of the line.

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Prepared 6 February 2001