Sandra
Gidley: This is a useful string of amendments that tries
to tease out some of the detail behind direct payments. Liberal
Democrats have always supported direct payments in social care, and we
very much welcome them in health care. However, a number of
complexities need to be addressed. Before I turn to the Conservative
amendments, it might be appropriate to direct my comments slightly more
widely, but I promise not to speak during the stand part
debate. I
shall turn to amendment 170. We are very much in favour of direct
payments in health because they provide patients with autonomy. Social
care departments have been very enthusiastic about direct payments, but
on occasions people have been put under pressure to go down that route,
which clearly is not right either. In some ways, therefore, the
amendment is an attempt to predict the future, which is always
difficult—and we
attempt it at our peril. However, for argument’s sake, let us say
that the pilots for direct payments are successful and a trust decides
that a particular form of health care is best delivered by a direct
payment. The amendment
would establish the right of a patient to say, “Actually, no, I
don’t want to go down that route.” Some slight confusion
has arisen over this already. In response to an amendment tabled in the
Lords Grand Committee to define the right to refuse direct payments,
the noble Lord Darzi stated
that “the
NHS Constitution makes clear that patients have the legal right to
accept or refuse treatment that is offered to them and not to be
subjected to any physical examination or treatment unless they have
given valid consent.”—[Official Report, House of
Lords, 2 March 2009; Vol. 708, c.
GC242.] That
misses the point. Payment is not the same as
treatment.
Mr.
Mike O'Brien: I think that I can short-circuit this: it is
not intended that anyone should be obliged to take a personal health
budget. 3.45
pm
Sandra
Gidley: I am grateful for that remark, because it has cut
short my comments. When the Minister sums up, perhaps he would like to
clarify why he feels that it is not necessary to put that in the Bill.
On occasion, it has been a problem in social
care. I
shall deal more generally with the Conservative amendments, many of
which are worthwhile, because they provoke a very useful debate. Given
the complexities in health care, it is right to pilot these direct
payments and not rush headlong into something that has not been thought
through. Health care is not quite the same as social care. People react
to treatments and medicines in different ways. There is no
one-size-fits-all solution. Also, some people do not respond well to
best-practice guidelines from the National Institute for Health and
Clinical Excellence. They might just not work for them. At the heart of
this, we must think about what works for individual patients.
One of my
concerns about the GP having to sign all that off is that we are not
giving patients as much autonomy as we could, and there is a question
to be asked about that. Most of us have a GP we are fairly happy with.
However, I have come across cases of a patient being unhappy with a GP
because they are either too into alternative medicine or too against
it—there is a whole host of reasons. A number of people make
decisions to access other forms of health advice, and it seems that the
GP as the gatekeeper could still be a barrier to patient
autonomy.
Amendment 187
is important. The hon. Member for Eddisbury said, I think, that we
should not get too obsessed about the 2 per cent. of patients who get
it wrong, and that we should think about the 98 per cent. of patients
who get it right. A few minutes later in another context he went on to
mention the Daily Mail. I wonder if this is the Daily
Mail fear test for any Government who seek to introduce this. There
are 98 per cent. of people doing it right, but we all know that the
Daily Mail will hone in on those examples of someone who has had
a holiday in Spain or bought the wrong sort of mattress.
Understandably, the Government want to avoid that, and I am not
unsympathetic to that. I would like
some reassurance on that point, as I think that amendment 187 gets to
the heart of the matter if we are truly interested in giving autonomy
to patients. I also have
problems with the tariff and how it will be priced. It is not always
easy to price a bog-standard course of health care because personal
variations are involved. Some people will cost more and some less. Some
people will have other co-morbidities that complicate their
situation.
From my time
on the Health Committee it is also clear that in the past,
trusts— PCTs in particular—have not been good at working
out the cost of care. One has only to compare the costs of treatment of
different illnesses across a range of trusts, to realise what widely
differing budgets are available for what should ostensibly be the same
sort of care.
I think that
there is now much better financial management in the NHS, and some of
those differences have been ironed out. However, it worries me slightly
that a patient in one part of the country might not have as much money
available to them as a patient in another part of the country. It is
not a north-south thing; there are sometimes widely differing
variations between trusts that sit side by side.
It occurred
to me—particularly in light of coming financial pressures, which
we all acknowledge—that direct payments could be used by some
trusts as rationing by the back door. The cost of a certain type of
care might escalate, but the cost over a period of time might be
increased only by inflation. Those two things can be widely differing.
Therefore, I seek assurances that there will be not just an annual
uplift but reviews of the budget.
The hon.
Member for Eddisbury raised queries about money or savings running out,
and it is useful to clarify what will happen if, for very good reasons,
the budget comes to an end. I am not clear how that will be tracked or
how the patient will know how much they have left. Who will monitor
that? I gather that in some parts of the country, there have been
experiments in social care with a card that allows people a monthly
budget that they can use. I do not think that we have the technology
for that, but it is an interesting idea. Will it be a yearly budget?
What happens if it runs out after six months? Will it be divided into
monthly sections?
I was pleased
to see amendment 189 on maternity. I raised the issue of maternity
services on Second Reading. I think that the ministerial response at
that stage was, “I don’t really understand that. We have
choice, anyway.” I can assure the Minister that women do not
have choice in all parts of the country. In some areas women are still
denied a home birth. Obstacles are put in their way. A lot of community
maternity units have closed down or consolidated in recent years, and
increasingly people might be looking to the independent midwifery
sector. It creates an interesting precedent, but one that is worthy of
discussion. I would not want this to be seen as a wholehearted rush
towards embracing the private sector, but in maternity specifically
there are quite broad issues around the use of independent
midwives.
Amendment 127
is useful. The hon. Member for Eddisbury mentioned Baroness
Barker’s comment that she was not told about insurance or
whatever. My experience with social care shows that it is the big
barrier to the adoption of direct payments. Direct payments work
brilliantly where you have people who are confident
about what they are doing and it is fairly simple. They work brilliantly
for people who have clear ideas about what they want to do and want to
take absolute control. They work less well, unfortunately, in people
who might be a little older or frailer, or might for many reasons have
difficulties in understanding a complex
situation. Quite
serious issues can arise if someone suddenly becomes an employer. It is
sometimes quite difficult for Members of Parliament to understand the
vagaries around employment law, if one has staffing problems. So direct
payments will only really work if advice and support is clearly
available to people.
Finally, it
was pertinent to raise the problem of prisoners, and particularly drug
and alcohol treatment. There is an opportunity here for people with
alcohol problems who might not be in prison and who have trouble
accessing services, because many services rely on drug money and it is
more difficult to access services if the problem is purely to do with
alcohol. If people were given a budget to manage their condition, it
would save the NHS a lot of money in the long term, because a lot of
evidence shows that some interventions do work in a good proportion of
people, and if people have budgets available, services that are
currently lacking in many areas of the country might be
developed. Direct
payments are a fascinating proposal. We need to retain enough
flexibility so that if pilots go in the wrong direction, we do not stop
completely. Also, the analysis of the pilots—what went wrong and
what went right—has to be open to wide public scrutiny. An
underlying concern is that it looks good on paper but does not give
patients as much autonomy as some of us might
wish.
Mr.
Mike O'Brien: I remember once I was asked to arrange a
meeting between a senior social worker and a fundholder who had his own
care budget. He had in effect a surplus on that budget and wanted to
deploy it to further care. The social worker took the view that the
money had to be returned. The person, who had considerable
disabilities, took apart the social worker’s arguments and
clearly established that it was his budget, which he would continue to
run. He was doing so perfectly competently, which everyone conceded,
and the budget provided him with the liberty and the capacity to make
decisions about himself and his disabilities, which was very important
to him. Both the social worker and I learned that, in the appropriate
circumstances, individual budgets can provide freedom and enhancement
for individuals. So I very much favour the piloting of such budgets to
see how we can extend them into health and whether they can provide
that same freedom.
However, as
the hon. Lady said, it depends on the circumstances of each individual.
We certainly must not get into a position where we give a budget to
people who do not want one. We will not oblige people to have a budget.
Also, if people have particular infirmities or disabilities that make
it inappropriate for them to have a budget but they still make a
request for one, an evaluation will have to be made to establish if it
is appropriate for them. Furthermore, it may well be that a carer of an
individual requests a health budget for that individual’s care.
Again, an evaluation would have to be made to establish whether that
carer was the appropriate person either to hold a budget or to deliver
it.
The budget
will be supervised and people will have access to advice. Furthermore,
there will be someone who has to supervise the way in which that
individual budget is used. There will be a care plan—in effect,
a health plan—that will set out the parameters for the use of
public money. If the money is deployed appropriately and there is a
surplus, it is envisaged that the individual will be able to identify,
within the terms of the care plan, ways in which that surplus could be
deployed. However, if that individual found that there was a deficit in
their care plan, an evaluation would again have to be made. Was that
deficit the result of an inappropriate pricing of the plan, or was it
the result of the inability of the individual, their carer or whoever
was managing that budget to manage it properly? At that point, a review
would have to take place about the way in which the health budget was
going to
progress. A
number of questions have been raised by the hon. Member for Eddisbury.
First, he asked who signed the regulatory impact assessment. It was my
noble friend, Lord Darzi, the Under-Secretary of State. I will pass on
to him the concern that was expressed—that his signature needs
to become a bit more legible—but he is, after all, a doctor so
we have to make allowances.
I was asked a
number of other questions. I was asked whether any difficulties in the
budgets for PCTs might lead to individuals in one area finding that
they did not receive the appropriate budget while individuals in
another area did. The individual circumstances of a PCT should not
determine an individual patient’s budget; it is the health care
needs of that individual patient that should determine that budget.
Therefore, the area where an individual lives should not determine
whether they are able to get a certain amount of
money. It
will be up to PCTs to determine the number of pilots that they conduct.
They will have to make that judgment and they will have to conduct the
pilots within their budgets. It has been indicated to us that a number
of PCTs are very interested in taking this process forward. So we are
very encouraged by the interest that has been shown.
I was also
asked who had made some of the rules and in particular whether it was
the Treasury. In fact, the rules were made by the Government, who have
collective responsibility. In practice, however, most of the work was
done by the Department of Health policy and strategy unit. So that is
the answer to that
question. 4
pm Some
pilots are specifically investigating the idea of pooling social care
budgets and health budgets. If we can get the handling of the issue
right, there is an opportunity for pooling budgets. However, the
handling is the key and the devil is in the detail. We must work out
how pooling can be done. Ideally, individuals with quite complex care
and health needs must be able to ensure that they have a single budget
for them, and we want to pilot how that might be
delivered. I
am conscious of the time, so I shall go through the amendments briskly.
First, amendment 187 is about
“the balance of
risk between the patient’s autonomy to use the direct
payments” and
attaining proper spending accountability. We aim to put the power into
the hands of patients and to give them the support they need to
exercise it. Essentially, we
want an agreement about how the patient will spend the money,
supervision and negotiation of that agreement and then allocation of a
budget. I am not talking about a bunch of fivers in the hand but about
access to a budget so that health care can be purchased appropriately.
I hope that deals with amendment
187. Amendment
170 relates to what the hon. Member for Romsey said about ensuring that
a patient has to give consent, and I hope I have dealt with that
matter. We do not want such a provision in the Bill because we want to
see how things develop in the pilot. The amendment relates both to the
individual and to those who have the ability and the right to make
decisions on their behalf. Some individuals may have disabilities, but
it may none the less be appropriate for them to have individual budgets
because of the complexity of their care needs. It is essential that the
decision should be arrived at by them. I cannot envisage a situation in
which people who do not want a budget are somehow obliged to manage it,
because they clearly would not do it. There has to be consent and, more
than that, there has to be a seriously informed level of consent behind
the administration of the
budget. Moving
to amendment 15 and whether a direct payment can be used to pay a
carer. The answer is yes, but we are concerned about situations in
which resident family members are living with someone and in control of
the budget. We need to exercise a certain degree of care. Except in
exceptional circumstances, regulations on social care direct payments
do not allow carers to be paid through direct payment if they are
spouses or other relatives who live in the same house. Social care
direct payments may be used for some family carers if they are
non-resident. We intend to follow that example with health care direct
payment. We
are concerned about evidence from social care that suggests that
resident family members can become dependent on direct payment as a
significant source of their household income. The effect of that is to
limit people’s independence and choice, as they feel obliged to
continue to employ a resident family carer even if that is not the best
way to meet their personal needs. We need to exercise a high degree of
caution in that
area.
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