Mr.
O'Brien: I think that in reading that out, Mr.
O’Hara, it is the first time that you have had to make a speech
in this
Committee. This
is a large bunch of amendments, and it will obviously detain us for a
while. They try to press on a number of points to get complete clarity,
and to explore the nature of the pilots of direct payments. There is a
general question why it is necessary to frame the legislation in pilot
terms. We have heard the Minister pray for a degree of caution, but
that might need to be contrasted with the phrases that have been used
by his former ministerial
colleagues. Section
7 of the regulatory impact assessment
notes: “Some
benefits of increased contestability may arise during piloting;
however, the full benefits are unlikely to arise unless the policy is
introduced
nationally.” It
will be neater to make the legislation underpin the provision of direct
payments, with the Secretary of State retaining powers of guidance over
when those powers might be used for, say, the first three years.
Removing such legislation from the statute book would be no greater
palaver than removing this, if Parliament rejects direct payments after
piloting. If direct payments were accepted, no legislative changes
would be made. As I think that I have already indicated, it may be of
some interest, or even comfort, that the official Opposition are
committed to the direct payments
anyway. The
question of timelines might be something in people’s minds, in
giving the options for the future. A couple of questions arise from the
impact assessment regarding that. The first is a quick aside as to
which Minister signed the RIA. For the first time, none of us can work
out which signature has been used. It is an odd RIA, because words
rather than figures predominate next to the pound signs. Will the
Minister explain how the net benefit of pilots is higher than the net
benefit of straight introduction, and how the cost of straight
introduction can be uncertain when the costs of pilots is established
as a rather precise £23 million? I am interested that the RIA
also mentions a notional health budget, which is currently legal. The
patient would not have the money—we have almost discussed that
already—but
would be able to see the pot, rather like the indicative budgets in
practice-based commissioning. The Committee may be aware that, when he
was a Health Minister, the Secretary of State for Health proposed
giving people an indicative bill at the end of their NHS treatment. I
am therefore interested to find out whether that is something the
Minister would support, because it is patently relevant to the process
of pilots and the particular arrangements on direct
payments. Before
we debate the amendments, it is appropriate to remind the Committee
that, under the Bill as currently drafted, regulations made under this
section will be introduced according to the negative resolution
procedure. That means that the House will not have the chance to debate
the substance of the pilots. It is unlikely that we would want to vote
down the regulations supporting the pilots, but it is likely that we
would want to amend them, depending on whether the Government act on
the debates we are about to
have. The
Committee will be aware of amendment 140, the purpose of which is to
bring the regulations under the affirmative resolution. These debates
will, no doubt, condition our approach and treatment of that. I would
also be interested if the Minister could explain the Executive
provenance of this section of the Bill. Lord Warner told the Committee
that he
thought “the
regulations about direct payments in new Section 12B were drafted by
the Treasury.”—[Official Report, House of Lords,
2 March 2009; Vol. 708, c.
GC212.] Lord
Darzi said that the PowerPoint presentations that he was using came
from the policy strategy unit. I hope that the Minister will confirm
whether the No. 10 strategy unit is calling the shots or whether the
measure originated in his Department, although that might be a moot
question. Amendment
187 goes to the heart of the issue that we, as politicians, face in
this and similar policy areas—the balance of risk. The amendment
would ensure that regulations are published on the balance of risk that
is acceptable to the Government after consultation. I submit that
broadly, as a class, politicians are not the best and most practised at
handling risk. I inevitably speak from personal experience, but that is
partly because it is not usual for politicians to have had hard-line
commercial experience, which is obviously almost completely predicated
on the calculation of risk, and partly because the single event can be
catastrophic for politicians in media terms when, in fact, it may mark
only a small deviation from the norm.
The two major
risks with direct payments are that the patient commissions the wrong
care and suffers as a result, or that the patient commissions, to put
it pejoratively, a holiday in Spain. There is also the more subtle risk
that the patient commissions something that delivers a better health
outcome for them, but that it is seen as a holiday-in-Spain option by
the media. Obviously such risks will be mitigated by the presence of an
agreed care plan. I argue that the patient should be constrained as
little as possible, but—I put this in estimated terms—it
is right that, in this day and age, we should seek to legislate not for
the 2 per cent. who will do the wrong thing, but for the 98 per cent.
who are the experts in their care and will do the right
thing.
If we get the
understanding of risk right, we are more likely to get the pilots and
the direct payments right. What is clear is that every possible
permutation should be piloted. Baroness Barker, who speaks for the
Liberal Democrats in the other place,
said: “one
of the great benefits of direct payments is that they enable people to
take risks if they choose to do so.”—[Official Report,
House of Lords, 2 March 2009; Vol. 708, c.
GC228-229.] Individual
budget pilots have shown that it is the empowerment that comes from
being allowed to take the risk almost as much as the care that is
commissioned that contributes to the individual’s health and
improving well-being. That ties in strongly with another common agenda
across the House: that the sense of dignity of independence should be
an overwhelming driver of well-being and, indeed, community and
family-based
care. That
covers amendment 187. I will reserve my position on amendment
170 until the hon. Member for Romsey has made her case. I shall move
straight on to amendment 15. On 13 January 2008, the Government
trialled something called a carer’s wage, which was mentioned in
the newspapers. It was reported in The Sunday Times under the
headline, “Cash reward plan for forgotten army of
carers”, and in the Daily Mail on 14 January under,
“Brown promises a decent wage for family carers”. Reports
said the proposal was at an early stage and that it could form a key
element of the carers strategy. Needless to say, there was nothing to
that effect at all in the carers strategy when it was published. I hope
that the Minister will therefore take the opportunity to clarify
whether a patient will be able to pay their carer with money from a
direct payment, and if not, will he state whether the Government will
deliver on the promise of a carers
wage? The
amendment also touches on the question of budget pooling. In the other
place, Lord Warner expressed the hope
that “we
will not get into a situation where this innovative change that the
Minister and the Government are introducing is stymied by very
restrictive regulations in the inevitably blurred boundary area between
health and social services.”—[Official Report, House
of Lords, 2 March 2009; Vol. 708, c.
213.] I dare
say that that is something with which we are all familiar from
countless constituency cases. Budget pooling, meaning a single direct
payment funded by NHS and social care, which the Opposition support and
have argued for, while fully recognising that it carries with it some
complexities and complications, would enable the patient to negotiate
that blurred boundary and close the gap between the two. It would also
prevent direct payments from being chipped away by PCTs keen to
cost-shunt their responsibilities on to local authorities. I am
therefore keen to hear what plans the Minister has to pilot pooled
budgets. Will the legislation allow pooled budgets to be piloted under
this Government or, indeed, a future Government?
Amendment 188
can be dispatched quickly, as I am just looking for an assurance from
the Minister that patients with direct payments will not find them
stopped suddenly for PCT budgetary reasons, and particularly not
without notice. What circumstances is that section intended to cover,
and what is the notice period likely to
be? Amendment
123 allows us to explore the relationship between direct payments and
top-ups. Will the Government be piloting direct payments in cancer
care, which can be
almost akin to a long-term condition in some cancers? In addition, would
a patient be allowed to top up their direct payment privately in order
to get services not available on the NHS. That, as I am sure the
Minister recognises, was part of the process under discussion in the
report that the previous Secretary of State commissioned and on which
he then made a statement to the House. Will the Minister be looking to
pilot that
process? As
the old joke goes, all of us have been touched by a midwife at some
stage in our lives, and amendment 189 is looking for the assurance from
the Minister that midwifery services can being procured through direct
payments. In the other place, Lord Darzi
said: “I
would certainly be very interested in proposals for maternity
services”.—[Official Report, House of Lords, 2
March 2009; Vol. 708, c.
222.] That
gives the Minister the opening. However, how does he propose to cater
for unpredictability, such as the need to transfer from a home birth to
a consultant-led obstetric unit in the event of unforeseen
difficulties?
That also
bears on the question of independent midwives. Will the patient be able
to commission an independent midwife, particularly where a local
service is not available from the NHS? On that, Lord Darzi
said: “There
is plenty of evidence, not only in this country but elsewhere, where we
have seen independent midwives working very well, such as in New
Zealand and certain parts of England where such a service
exists.”—[Official Report, House of Lords,
2 March 2009; Vol. 708, c.
222.] Will
there be a requirement that patients must buy an indemnity for that, or
indeed for any service that they buy? I hope that the Minister will be
able to give us a view on the question of
indemnity. Amendment
124 is framed to reassure PCTs that they will, with regard to
subsection (1), not face a clawback of any savings that they make
through piloting direct payments. Under proposed new paragraph (m),
they will be able to supplement their budgets if they lose money at
that stage. I do not for one second underestimate the complexity of
that area. The amendments might seen rather counterintuitive in a
sense, as surely either the Department should keep the savings and sub
the deficit, or the PCTs should do so. However, such a system would
create perverse incentives in the pilot phase, and I dare say that the
Minster and his officials have been thinking about that.
Will the
Minister clarify whether PCTs will be able to keep any savings and
whether they will be subsidised for any loss? That is linked to a point
made in the other place by Lord Darzi, who said
that “where
PCTs do not wish or are unable to apply to be pilot sites, I do not
want to force them to do so. We are looking to harness existing
enthusiasm in the NHS for personalisation, rather than to impose pilots
on PCTs by selection by the Department of
Health.”—[Official Report, House of Lords, 2 March
2009; Vol. 708, c.
GC247.] 3.30
pm I
admire the commitment to local choice, but I would be very concerned if
direct payments were limited to PCTs with effective visionary
leadership. Is there a case for pilots to assess how unenthusiastic
bureaucrats—let us not pretend that there are not
some—can also be encouraged to roll this out? Western Cheshire
PCT in my constituency is set to pilot a range of continuing and
end-of-life care services, but I note—perhaps it has
moved on rapidly since I last checked—that the Minister’s
PCT in Warwickshire is yet to do so. We need to compare and contrast
areas to find out why there are such differences. On amendment
125, will the Minister explain why he is not piloting the commissioning
of urgent care with a direct payment? On amendment 126, what sort of
end-of-life and palliative care commissioning pilots will he be
running? As I am sure he is aware, that question has been asked by many
outside this place who take a grave and well-informed interest in such
things.
On amendment
127, Lord Darzi said:
“Will
patients be employers? The answer is yes; they could become employers,
as I said earlier, with all the employment regulation that comes with
that.”—[Official Report, House of Lords, 2 March
2009; Vol. 708, c.
GC239.] The
Government should set out clearly the nature of this employment status.
Administering direct payments can be very difficult for patients or
their delegates. Baroness Barker recounted the comments of someone who
said that the direct
payment “is
brilliant, because it enables me to go on
working...However,” the
local
authority “doesn’t
tell you anything about insurance or national insurance. It
doesn’t tell you anything about what to do if it does not work
out with the person whom you’re working with. It doesn’t
tell you whether it’s up to you as the employer to deal with it
and, if you are, how you do that. There was an organisation that helped
us a lot, but unfortunately it’s packed in and there’s
nothing now.”—[Official Report, House of Lords, 2
March 2009; Vol. 708, c.
GC204.] I
can also report—this is the reason for the amendment—that
we had an hour at the end of the health debate at the last Conservative
party conference on caring for our elderly population, which I accept
the Minister did not attend. I am told that that is the first such
debate at any party conference. We were privileged that Sir Terry
Pratchett came to make one of his first big speeches about the early
onset of Alzheimer’s.
During the
course of a conversation, which a former newscaster mediated, a
wonderful woman called Marianne Talbot gave testimony from her
experience. She is known for her punchy contributions to Saga blog and
is also a lecturer at Oxford university. She has looked after her
father and, most recently, her mother, who have gone through dementia
and Alzheimer’s respectively. She looked after her mother, who
only recently went into a home, as her carer for two years. With all
her intelligence and capabilities, she said that she hit the brick wall
when one of the package of six carers wanted to go on maternity leave.
She felt that she did not have the capacity, knowledge, expertise or
confidence to deal with
that. If
we are going to make the direct payments really work, we have to
recognise that support and advice services have to continue to be
provided and ensure that such services are still available and
operating properly. That is what the amendment deals with. Local
authorities are immediately in the frame to support such a service. By
doing that, one can expect to see direct payments come through
better.
On amendment
128, the 2008 Budget announced the extension of the tariff to community
services in mental health. When will that work be done and how much is
it predicted to save? The Minister may choose to write to us about
that. Will direct payments be extended to
community services as they are currently? If not, will they be extended
to direct payments when the tariff is introduced? Amendment 129
raises the question of direct payments and prisoners. The Government
have completely failed to get to grips with prison health—we
have had quite a lot of contentious discussion on that—and they
have let down our prison population as a result. We might have liked to
have a debate on that today, but I suspect that that is not quite
appropriate. If public and mental health issues were addressed in
relation to prisoners, that would go a long way towards reducing
reoffending rates. There is a lot of common ground across the House,
particularly among those who are concerned that many prisoners might,
had they had mental health and drug treatment as a priority, not have
found themselves so much on the wrong side of the criminal justice
system.
In the other
place, Baroness Masham of Ilton
asked: “Will
drug and alcohol services be included in direct payments? So many
people are sitting in prison now and not getting the right treatment,
because it comes from another budget and health or social services
simply do not want to pay for it.” —[Official Report,
House of Lords, 2 March 2009; Vol. 708, c.
GC219.] The
noble Lord Darzi, somewhat unusually, failed to give an answer on that
point, so I hope that the Minister will take the opportunity to do
so. With
amendment 130, I wish to probe the Minister as to whether direct
payments will be used to fund complementary therapies. There was some
discussion about this in the other place, and not necessarily because
many of their lordships are of a different generation. Lord Darzi
confirmed: “Any
intervention that will improve the health and well-being of the patient
that is signed off by the care manager within the care plan would be
implemented.” —[Official Report, House of Lords, 2
March 2009; Vol. 708, c.
GC223.] The
big “if” in that statement is that it will be allowed if
it is signed off by the care manager—so it is not whether the
therapy will improve the health and well-being of the patient, but
whether it will do so in the opinion of the care manager. Lord
Campbell-Savours
said: “I
can imagine circumstances in which the patient might say, ‘I
want a £200 mattress’. The manager might say, ‘It
is in your care package, but we think you should have this
mattress’,” —[Official Report, House of Lords,
2 March 2009; Vol. 708, c.
GC231.] not
that one. Whom does the Minister’s team envisage will be the
care manager? Will it be the GP or a PCT worker? What are the perverse
incentives of having budget holders signing off care plans? Will the
care manager be someone open-minded who supports the patient’s
choice, and will they be
constructive? Baroness
Cumberlege made the helpful
point: “I
remember when we had GP fund-holding. It was very interesting to see
the enormous difference that that made to complementary therapies and
the number of people who went to their GP. We should remember that it
was the last time that patients really had some power over their care.
The GPs wanted to respond to patient choice because it affected their
income. A number of people—the figures are quite
startling—chose to have complementary therapies, and, so far as
I know, no damage was done. As soon as GP fund-holding was done away
with, those figures fell.”—[Official Report, House of
Lords, 2 March 2009; Vol. 708, c.
GC216.] As the
Minister is aware, we certainly pledge to return to real budgets for
GPs.
Some
complementary therapies, such as acupuncture and hydrotherapy, have
brought benefits to many people, whereas most of us would regard some
other therapies as being a touch more wacky. Even if some of them are
regarded as being a bit off-norm, if they deliver improvements in
health and well-being, and in doing so make a saving to the NHS, the
question will arise whether they are likely to be included in a care
package. Any clarification that the Minister can give on that would be
helpful.
To some
degree, this issue ties in with the long-running campaign, with which
many Members have been strongly engaged, about supplements as a matter
of patient choice, particularly because it seems that what appears to
be the norm across the rest of Europe could damage access to
supplements and in certain concentrations in this country.
Amendment 131
addresses the purchase of care across national borders. I shall not
take long over this, but I want to make sure that it is not overlooked
as the last amendment in this group. This issue is particularly
relevant to those of us who have constituencies that abut a national
border, as I do with Wales, which is a completely different nation for
health purposes. Many issues are daily of great stress to the Countess
of Chester hospital, which receives lots of blue-light admissions from
Wales, partly because it is in the interests of those people to benefit
from the shorter waiting times. Many of my constituents who live in
Farndon wish to cross the River Dee by the old Roman bridge to get to a
pharmacy in Wales to get free prescriptions, but it is not quite as
simple as that because the GP with whom one is registered has an
effect. Those issues are causing considerable worry, and we are
worried, particularly in relation to this clause, that the Government
are dragging their feet over putting in place guidance on health care
at the European level. Presumably, individuals could request that their
PCT commissions care from within the EU through the direct payment. I
am talking about care that, if commissioned abroad, could be topped up.
Will anything prevent them from commissioning care outside the UK? That
will probably be a tough question for the Minister to answer off the
top of his head, but perhaps he has the answer to hand.
I conclude my
remarks on a very long group of amendments covering a very broad range
of necessary questions, although I have not touched on the Liberal
Democrat
amendments.
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