Sandra
Gidley: I understand the need for some caution, but I
should like to mention a particular constituency case. A mother has a
son with health and social care needs who is in a wheelchair. The
mother is a nurse and would like to provide the nursing care and use
some of the money to get other help around the house. She is not
allowed to do that. She has to employ a nurse and do other work
herself. I know that not many families are in that position,
nevertheless, the mother has been deprived of a choice that would not
make her financially dependent. The same amount of money is coming into
the family, but there is a lack of flexibility over who delivers a
particular type of care. As a mother, she is quite clear that she would
like to do it herself, and she seems to be deprived of it under the
present rules, which seems a shame.
Mr.
Mike O'Brien: The hon. Lady raises a valid point. There
are always exceptions to a rule, but it is there because we must avoid
unpleasant things happening to individuals who may be vulnerable. The
rule that protects vulnerable people may also fail to give them the
higher level of care that may be provided by a close relative. I accept
that her constituent would seem to be such a case. However, it is
necessary to balance the risks. At the moment, we believe that caution
is needed. A mother’s care may be greater, given the nature and
the extent of her qualifications, but we intend to exercise care about
that in the pilots. It does not mean that rules might not be developed
at some stage in future should the proposal become a long-term project
that would allow a more detailed evaluation of the balance of
risk.
Mr.
Stephen O'Brien: I appreciate that we are pressed for
time, but the Minister will be aware that I asked whether there was any
sign of a carer’s wage. I pointed out that the
Government’s promise had created some
expectation. Mr.
O'Brien: We are pressed for time, and I want to ensure
that we get through some of the issues briskly. Perhaps the hon.
Gentleman will forgive me if I return to him on that
question. Amendment
188 would set a notice period. We do not envisage any direct payment
being stopped because of a PCT’s budgetary problems, and
certainly not as part of the pilot schemes. We do not envisage that any
PCT would be so crass that an individual budget would make a great
difference to its overall circumstances. The straight answer is that we
do not foresee that
happening. On
amendment 123 and whether people may top up their direct payments, our
view is that that should not happen. Patients may not top up their
personal health budgets from their own resources, given the health plan
that has been put in place. If they want to buy something additional,
such as health care outside the budget plan, that is a matter for them
and they will, in effect, be paying privately for additional health
care. However, if they have a health budget that they manage, it should
be done within the terms of the funding provided by the public. The NHS
is not there to subsidise private medicine. NHS money should be used to
provide necessary NHS care, not to provide the wealthy with a way of
obtaining a little additional money from taxpayers for something that
they would otherwise pay for
privately. On
maternity services, we want to give women more choice in maternity
care, and the matter was discussed at length in another place. We are
very interested in the principle and we are pleased that one of our
provisional pilot sites at Eastern and Coastal Kent PCT has included
maternity services as part of its proposal for exploring personal
health budgets. However, we have said that PCTs must decide locally
where personal health budgets might bring the greatest benefits for
patients. On
whether we are prepared to consider private sector maternity providers,
we will consider the details of particular circumstances and see how
the pilots operate. A private maternity programme may be developed in
the future and benefit some women, but it is not in place at present.
Let us see how things develop and what the circumstances are. We do not
have a closed mind. We are willing to look at how that
develops. I
was asked whether people would need to buy an indemnity. That is a
problem. If people are producing an entirely privately funded
provision, they would have to consider the implications. An additional
budget will not be provided from outside to ensure that something the
NHS would not otherwise have to provide will be
provided because someone has decided to get a service from the private
sector. People will have to bear that in mind. On amendment 124, the
benefits of any cost savings would be deployed in the personal
budgets. I
was asked whether we would pilot in areas that are unenthusiastic. We
are not planning the pilots in those terms. We want to see whether the
scheme can be a success. It is not just about testing in enthusiastic
areas. If it can be successful in some areas, it may then need to be
tested in less enthusiastic ones. We will see how that works. It will
be a matter of working out how we engender enthusiasm in those
areas. On
amendment 125, we do not envisage that the scheme could be used to
commission emergency and intensive care, because it would be difficult
to set a meaningful budget. In many cases, there could be a lack of
clinically appropriate treatment choices for people to make. Our
personal health budgets are unlikely to add any significant benefit in
that area at present and could even introduce some complexities, so we
are not envisaging that being part of the
pilots. With
regard to palliative care, we could see some significant progress in
terms of individual budgets. Personal budgets could give patients
greater choice and control in designing support to give them the best
possible quality of life. Several of our provisional sites propose to
explore aspects of palliative care, especially end-of-life care, and
supporting people with long-term conditions. We are keen to explore
that further. However, we are also aware that people may not wish to
manage a budget during what can be a stressful, difficult period. No
one should be forced to take more control of their care than they feel
comfortable with. It is vital that we get the balance
right. Rather
than just saying, “Here’s a budget plan, now get on and
do it,” which we might do with some people, we would not
exercise such a hands-off approach in that area. There needs to be a
level of support for people, particularly in end-of-life care, that may
go beyond that available in some other areas. It is about ensuring that
we get the level of support right in such circumstances, but the
personal budgets really could provide a significant advantage and could
improve the circumstances of
individuals. Amendment
127 relates to individuals who become employers. People who receive
direct payments will need to understand and fulfil their obligations as
employers. Primary care trusts involved in the pilots will need to
ensure that patients and carers have the information and support they
need to act as responsible employers. We know from recent research that
care workers employed using social care direct payments may not receive
sufficient training opportunities. However, other people receiving
direct payments to employ care workers are keen to ensure that their
staff have not only good, appropriate terms and conditions, but access
to training. There are issues that we will need to explore through the
pilots, but, yes, there are obligations on employers and, if people
decide to employ others, as part of their budget they are taking on the
things that go with
that. Amendment
128 relates to the use of community services tariffs when using a
direct payment to purchase care. Where local tariffs exist for
community purposes—we
are encouraging their development—they may provide the pilot
sites with a useful basis for calculating a direct payment or other
type of personal
budget. Amendment
129 relates to prisoners. I do not envisage that direct payments would
become available to prisoners. I appreciate what the hon. Member for
Eddisbury said about prisoners having mental health problems, but the
NHS and the services within the Prison Service are a better way of
dealing with that, rather than giving the prisoner a budget with which
he then buys his own care. That is not an area in which I envisage
direct payments being appropriate, although I hear what he
says.
4.15
pm Amendment
130 relates to complementary therapies. We do not intend to rule out
the use of direct payments to purchase such therapies. Many people find
complementary therapies useful as part of a wider package of
care—for example, using acupuncture as part of a package of pain
relief that includes drugs and traditional physiotherapy. The whole aim
of personal health care budgets is to allow a flexible and personalised
approach, not to draw up a national list of eligible treatments in some
kind of regulation. However, any therapies would have to be agreed as
part of the health plan as likely to meet the person’s health
care needs. No money would be spent on services that are not in the
agreed health plan.
Amendment 131
relates to the purchase of health care from devolved Administrations or
from other countries in the EU. The hon. Member for Eddisbury referred
to his personal circumstances and his constituency having a proximity
to another country. We do not intend to introduce any specific
restrictions at this stage. In principle, a direct payment or other
personal health budget could be used to purchase care from providers
elsewhere—in other countries in the UK or in the European
economic area—in the same way as a traditionally commissioned
service. Any use of overseas providers would have to be agreed with a
PCT as part of the health care plan. Direct payments should not be a
way to get access to treatments that other patients in the UK would not
be entitled to receive. We would need to look carefully at all these
issues.
I hope that I
have covered most of the many questions raised and I hope that, on that
basis, the amendment will be withdrawn.
Mr.
Stephen O'Brien: The Minister has done his best to tackle
all the issues that were raised. I am sure that he recognises that it
took us some time to put them together to make sure that they were
properly explored. The devil will be in the detail—he used that
phrase in relation to pooling, which is interesting—and that is
why it has been important to look through the provisions. It is also
why there is justification for pilots and there will be concern to make
sure that they can convert into a roll-out once lessons are well
learnt. On that basis, we have had a useful exercise, which is the
purpose of the Committee, so I beg to ask leave to withdraw the
amendment.
Amendment,
by leave, withdrawn.
Ordered,
That further consideration be now adjourned. —(Mary
Creagh.) 4.18
pm Adjourned
till Tuesday 23 June at half-past Ten
o’clock.
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