Health and Social Care Bill

Memorandum submitted by the Alzheimer’s Society (HS 108)

1. Introduction

1.1 Alzheimer’s Society welcomes the opportunity to submit written evidence to the Public Bill Committee of the Health and Social Care Bill.

1.2 Alzheimer’s Society is the leading care and research charity for people with Alzheimer’s disease and other forms of dementia, their families and carers. The Society has expertise in providing information and education for people with dementia, carers and professionals. It provides a helpline and support for people with dementia and carers, runs quality day and home care, funds dementia research and gives financial help to families in need. It campaigns for improved health and social services and greater public understanding of all aspects of dementia.

1.3 Dementia is one of the biggest health and social care challenges of our time. There are over 635,000 people with dementia in England and the financial cost is estimated to be £15 billion per year [1] . One in three people over 65 will end their lives with a form of dementia [2] .

1.4 People with dementia are core users of health and social care services:

o Two thirds of people with dementia live in the community [3] .

o One third of people with dementia live in care homes. Two thirds of care home residents will have a form of dementia [4]

o Up to one quarter of hospital beds are occupied by people with dementia aged over 65 years at any one time [5] .

2. Summary of issues covered in this memorandum

2.1 Alzheimer's Society supports the government’s vision of the NHS, as described in the Health and Social Care Bill, which aims to put patients and the public at the heart of the NHS, deliver improved outcomes for patients and increase integration between health and social care. We are working with a number of national charities [6] to strengthen requirements in the Bill to ensure this vision becomes a reality. In this briefing we highlight the following concerns we have about the Bill and the changes we would like to see:

· Strengthened patient and public involvement in commissioning

· Clarity around whether there will be additional funding for local HealthWatch to reflect additional functions they will have around supporting patient choice

· Increased integration between health and social care

· Stronger requirements for multi-disciplinary working

· The importance of the NHS Commission Board and the governing board of GP consortia having expertise of older people’s health and care issues

· Issues around competition and licensing of NHS providers

· Giving local HealthWatch, local authority overview and scrutiny committees or local Health and WellBeing Boards the power to petition a commissioner in their local area for a service to be ‘designated’ setting out clear reasons for their request.

· In the interim and depending on the outcome of Value Based Pricing, GP consortia should have the same duty to fund NICE recommended drug treatment that exists under the current system for PCTs.

· An obligation for GP consortia to regard NICE Quality Standards in a similar way to the NHS Commissioning Board.

3 Strengthening patient and public involvement in commissioning

3.1 We have raised jointly with a number of other leading national charities the need to strengthen the patient and public involvement provisions in the Bill. Changes we would like to see include:

· A definition of public involvement in the Bill

· A requirement for the NHS Commissioning Board and GP commissioning consortia to report on all their duties, including their duty on public involvement

· Regulations to require scrutiny functions arrangements made by the local authority to be independent and led by elected representatives

· The need for the governing board of GP consortia to include lay members

· A requirement to involve Local HealthWatch in the development of GP consortia commissioning plans.

3.2 We recognise that the Bill seeks to move away from prescriptive legislation. However, we maintain that strengthening requirements in the Bill on public involvement is needed to deliver the government’s vision of the NHS of ‘no decision about me without me’ but with local flexibility about how public involvement is undertaken.

4. Funding of local HealthWatch

4.1 We believe it is not currently clear whether there will be extra funding for local HealthWatch to discharge their additional functions around providing advice and information to enable people to make choices about health and care services and its role within the Health and Wellbeing board. While there is additional funding available for the local authority to commission complaints advocacy, and it is possible for HealthWatch to take on this role, this funding is not designed for and will not cover the other functions taken on by HealthWatch. The additional functions of signposting and assistance around choice of services are particularly key for people with dementia, who may lack the capacity to make choices about their own care.

5. Integration of health and social care

5.1 Multidisciplinary Commissioning

5.12 Good dementia services require effective joint working between health and social care. People with dementia and their carers come in contact with a wide range of professionals, such as nurses, allied health professionals, psychiatrists, and social care workers, and it is vital that they have a clear and explicit involvement in commissioning dementia care services.

5.13 With other leading charities we have highlighted concerns about the strength of provision for social care and health professionals who are not GPs to be involved in the commissioning process. In particular, we do not feel that section 140 in clause 22, which states:  

"Each commissioning consortium must make arrangements with a view to securing that it obtains advice appropriate for enabling it effectively to discharge its functions from persons with professional expertise relating to the physical or mental health of individuals."  

provides a strong enough impetus for GP commissioning consortia to meaningfully involve other health and social care professionals in commissioning. While we acknowledge that one of the proposals the GP pathfinder consortia are testing is multi-disciplinary commissioning we would like to see this aspect of the Bill strengthened from the current requirement to ‘obtain advice’ to a ‘duty to involve a range of health and care professionals’ in commissioning. This change will help ensure that collaboration between professionals is at the heart of the Bill.

5.2 Stronger involvement of local authority representatives on GP consortia

5.21 Alzheimer’s Society recognises the important role Health and WellBeing Boards (HWBB) could play in encouraging greater integration between health and social care. Given the priority that has been attached to dementia, it is vital that the Health and WellBeing Strategies, to be developed by local authorities and GP commissioning consortia, will have a strong focus on dementia and have regard to existing dementia strategies that are being developed by PCTs and local authorities.

5.22 We remain concerned that with the abolition of PCTs the co-terminosity of boundaries between health and social care will be lost, and this will create barriers for joined working. Furthermore, there is a concern that where a GP commissioning consortia straddles two or more local authorities it will have two or more Joint Strategic Needs Assessments and Joint Health and WellBeing Strategies, which may establish different priorities.

5.24 In order to ensure that health and social care can become truly integrated, we would like to see plans being developed to help consortia tackle some of these issues before they arise, in particular caused by the loss of co-terminosity, and the swift dissemination of good practice.

6 Membership of the NHS Commissioning Board and GP consortia

6.1 The Bill defines membership of the NHS Commissioning Board (Section 1). In light of the fact that older people, including people with dementia, are heavy users of heath and care services, Alzheimer’s Society would like to see that a member of the Board includes someone with expertise in older people’s health and care issues.

6.2 The Bill is not prescriptive of membership of the GP commissioning consortia Board. We also believe that included on this Board should be a member with expertise in older people’s health issues so they are at the heart of commissioning decision-making.

7 The Tariff

7.1 A tariff sets the price that commissioners pay to providers for NHS services, eg a hip operation. We shared the concerns of many other organizations, including the King’s Fund and the British Medical Association (BMA) that if competition on price is encouraged through a maximum tariff, this may result in poorer quality services.

7.2 Therefore, we were pleased that the Secretary of State for Health ruled out competition on the basis of cost (reported in the FT newspaper on 3 March). Alzheimer’s Society agrees that quality should drive the commissioning of NHS services.

8 Licensing of NHS care providers

8.1 The Bill would establish powers for Monitor to license providers of NHS care (including NHS foundation trusts, social enterprises, and private and voluntary sector providers). It is important that the fee that the license holder pays to Monitor does not discourage voluntary providers from bidding for NHS services.

8.2 We support the provisions in the Bill for exemption regulations to ensure that the regulatory burden is not excessive, and believe that this provision may be particularly beneficial to voluntary sector providers. We are concerned that before making exemption regulations the Secretary of State must only ‘give notice’ to Monitor, the NHS Commissioning Board, the Care Quality Commission and its HealthWatch England committee and that only the Secretary of State can approve exemptions. We believe the DH should consult widely on proposals for licensing arrangements, including exemption regulations, and that the above organisations should be fully consulted on which organisations should receive an exemption.

9 Designated services

9.1 A ‘designated service’ is one which is deemed too important to fail or cease to be provided. In the Bill GP commissioning consortia, the NHS Commissioning Board or the Secretary of State can apply to Monitor for a service to be designated. Alzheimer’s Society believes that local HealthWatch, a local authority overview and scrutiny committee or local Health and WellBeing Board should have the power to petition a commissioner in their local area for a service to be designated setting out clear reasons for their request. The commissioner should be required to respond to the petition for designated status with an explanation as to whether they intend to proceed with an application to Monitor. This measure would seek to enhance the involvement of influential local bodies in the process of getting a service designated.

10. NICE

10.1 The bill provides little detail on the new role of the National Institute for Health and Clinical Excellence (NICE), including what weight the guidance and standards will have and how this will impact on the social care services which now fall within their wider remit. While we anticipate that the regulations will address many of these concerns, we feel that this may have a real impact on the care of people with dementia, for whom access to a range of high quality social care services are often essential to improving quality of life.

10.2 In particular, we were pleased with the NICE Dementia Quality Standard which was released last year, and we would like to see it strongly reflected in commissioning plans going forward. While the Bill places a duty to regard NICE Quality Standards on the Secretary of State and on the NHS Commissioning Board, this duty does not appear to be reflected for the GP commissioning consortia who will be carrying out the majority of the commissioning which affects people with dementia. We would like to see an obligation for GP Consortia to regard NICE Quality Standards in a similar way to the NHS Commissioning Board.

10.3 We also recommend that, in the interim and depending on the outcome of Value Based Pricing, GP consortia have the same duty to fund NICE recommended drug treatment that exists under the current system for PCTs. This is of particular significance to people with dementia following NICE’s new draft guidance (January 2011) extending access to drug treatments. We are also concerned around the transition between the funding of drugs recommended in the NICE Guidance and Value Based Pricing. It is possible that, unless carefully managed, the drugs recommended in one system or the other may take priority, and not actually deliver the best treatment for the patient at the best value. We will raise these concerns directly to NICE in the consultation on Value Based Pricing.

10.4 We are also concerned that NICE’s strongly medical orientation may cause difficulties when they are called to assess social care interventions. By their very nature, social care interventions serve needs which do not fit neatly into the medical model of the health system, and it will be hard to establish common criteria on which to make comparable judgements on the effectiveness of interventions. As social care interventions are essential to many people with dementia and if delivered in a timely and effective manner can reduce some of the burden on the health service, it is essential that that these will are included in guidelines and Quality Standards. It is vital that NICE staff have expertise in social care interventions.

March 2011


[1] Alzheimer’s Society (2007) Dementia UK , a report to the Alzheimer’s Society by King’s College London and the London School of Economics. Alzheimer’s Society: London.

[1]

[2] Brayne C, Gao L, Dewey M & Matthews FE, Medical Research Council Cognitive Function and Ageing Study Investigators (2006) Dementia before Death in Ageing Societies – The Promise of Prevention and the Reality. PIoS Med 3(10):e397.doi.1371/journal.pmed.0030397.

[2]

[3] Alzheimer’s Society (2007) Dementia UK , a report to the Alzheimer’s Society by King’s College London and the London School of Economics. Alzheimer’s Society: London.

[3]

[4] Alzheimer’s Society (2007) Dementia UK , as above .

[4]

[5] Alz heimer’s Societ y (2009) Counting the Cost: caring for people with dementia on hospital wards’.

[5]

[6] Age UK, Asthma UK, Breakthrough Breast Cancer, British Heart Foundation , Diabetes UK, National Voices, Rethink, and the Stroke Association