Draft National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013
The Committee consisted of the following Members:
Abrahams, Debbie (Oldham East and Saddleworth) (Lab)
† Alexander, Heidi (Lewisham East) (Lab)
Champion, Sarah (Rotherham) (Lab)
† Dobson, Frank (Holborn and St Pancras) (Lab)
† Goodwill, Mr Robert (Scarborough and Whitby) (Con)
† Halfon, Robert (Harlow) (Con)
† Jackson, Mr Stewart (Peterborough) (Con)
† Lamb, Norman (Minister of State, Department of Health)
† Lancaster, Mark (Lord Commissioner of Her Majesty's Treasury)
† Raynsford, Mr Nick (Greenwich and Woolwich) (Lab)
† Reed, Mr Jamie (Copeland) (Lab)
† Shannon, Jim (Strangford) (DUP)
† Stevenson, John (Carlisle) (Con)
† Vara, Mr Shailesh (North West Cambridgeshire) (Con)
† Walker, Mr Robin (Worcester) (Con)
† Wilson, Mr Rob (Reading East) (Con)
John-Paul Flaherty, Committee Clerk
† attended the Committee
The following also attended (Standing Order No. 118(2)):
Abbott, Ms Diane (Hackney North and Stoke Newington) (Lab)
Fifth Delegated Legislation Committee
Tuesday 11 June 2013
[Mr Christopher Chope in the Chair]
Draft National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013
2.30 pm
The Minister of State, Department of Health (Norman Lamb): I beg to move,
That the Committee has considered the draft National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013.
It is a pleasure to serve under your chairmanship, Mr Chope. Entirely in error, I marched straight into the next-door Committee Room and wondered what on earth I was doing and who these people were. I had turned up in the Foreign Affairs Committee, so it is a great relief to see you in the Chair here.
In 2009, the Health Bill Committee considered provisions to allow direct payments for health care, which subsequently formed part of the National Health Service Act 2006 by way of amendment. The purpose of the Health Act 2009 was to allow primary care trusts to take part in a pilot programme to test direct payments for health care. After a lengthy independent evaluation, the pilot programme proved successful, so we are now seeking to amend the provisions inserted into the 2006 Act by the 2009 Act so that direct payments for health care can be extended beyond the pilot programme.
“Equity and excellence: Liberating the NHS”, the White Paper published by the Government in 2010, set out the new agenda for the NHS, based on, first, an NHS that is more responsive to the patients whom it serves; secondly, an NHS in which “no decision about me without me”—that was the phrase used—becomes the norm; and thirdly, an NHS in which people have more choice and, critically, control over the care they receive. We remain committed to that vision, and using direct payments for health care and personal health budgets are a key way of achieving it. The recent care and support White Paper and the Care Bill, which is being considered in the other place, build on the groundwork already laid to achieve our aims, but place further emphasis on personalised, joined-up care. Direct payments for health care will, for example, help to facilitate the integration of health and social care for those people who need the most support and enable them to have a single plan and budget. Direct payments for health care were originally piloted as part of the wider personal health budget pilot programme. It might be helpful if I explain the relationship between personal health budgets and direct payments for health care.
Personal health budgets allow people to spend money on their health care needs as they choose, following agreement with health care professionals and the local NHS. That agreement is found in their care plan and ensures that people can meet their health needs in
different ways—ways that they determine for themselves, in discussion and agreement with their health care professionals, and that work for them. Once the plan has been agreed, the care and support is commissioned, and direct payments are one way of facilitating the provision of that care.Direct payments put choice and control in the hands of individuals by passing the funds to the patient, their family or their representatives, and they empower them to organise their own care and support as agreed in their care plan. It is important to emphasise, however, that direct payments are not an option unless this first stage of care planning has been completed to an agreed care plan, thereby ensuring that money is used for legitimate means to help to improve people’s health care outcomes.
Introducing personal health budgets is operationally complex, and the pilot programme was established to explore the best way to implement them and to assess for whom they would be the most beneficial. Introduced under the previous Government, the programme ran from 2009 through to 2012 and involved a total of 2,700 people. An independent evaluation of the pilot was commissioned and the findings were published last November. Based on the positive findings in that report, this Government committed to making personal health budgets, including direct payments, more widely available. The mandate to the NHS Commissioning Board, known as NHS England, backs that up and sets an ambitious objective that, by 2015, patients who could benefit will have the option to hold their own personal health budget.
As a first step, those in receipt of NHS continuing care will have the right to ask for a personal health budget, including a direct payment, from April 2014. People receiving NHS continuing health care are among those with the highest levels of health need. The evaluation identified that people with high levels of need and often, consequently, the largest budgets, such as those in receipt of continuing health care, were the ones most likely to benefit. Furthermore, those receiving continuing health care are more likely to have had experience of direct payments in social care, perhaps before a deterioration in their condition. Allowing direct payments in health care will ensure that they continue to have the same level of control as when they were receiving social care. It may, for example, allow people to continue to employ the same carers, if they wish, and have control over who comes into their home. That is critical to ensuring the dignity of those with health care needs.
The Government believe that personal health budgets should not stop at NHS continuing health care; others should be able to benefit, such as those with long-term physical or mental health conditions and disabilities who access the NHS most frequently. That is because the evaluation suggested that those with personal health budgets tend to manage their long-term conditions better and access secondary care less, which improves their well-being and potentially lowers costs to the system. The indication is that hospital stays will be minimised, which is particularly good for the individual, but is also good for the NHS, where resources can be freed up for other purposes.
Nevertheless, personal health budgets need to visibly produce good results for both the NHS and the people it treats. The evaluation demonstrated that people need
real choice and control over how their budgets are managed, rather than it being a paper exercise, and they must have the option of a direct payment so that they can command real choice and control over how their individual needs are met. Part of the NHS constitution and one of the principles of the NHS is to provide comprehensive health care free at the point of delivery. The Government strongly uphold those principles, and personal health budgets and direct payments for health care will not alter them at all; they simply give people more choice and control over how their NHS needs are met. They give people the chance to have more control over how the services and care they receive can fit around them and their lives, rather than the other way around. What is more, the evaluation showed that this type of system also increases satisfaction and quality of life.It is probable that direct payments for health care, and personal health budgets more widely, will change the relationship between people and the clinicians who support them. We have long had a culture where health care professionals know best and the views of patients take a back seat, which is a rather paternalistic system. We now acknowledge that although the clinical expertise that professionals provide is vital, the individual’s knowledge of their condition, how it affects them and what works for them is also critical. The conversation between the individual and their health care professional should be a different, more real partnership that supports personal health care and produces positive results for the individual.
The potential benefits associated with direct payments for health care do not flow from new money being ploughed into the system; direct payments simply allow people to use money already being spent on their care in a different, more intuitive way. The evidence available suggests that people who are given direct payments spend it on the things agreed in the plan, but periodic reviews will be built in to ensure that care and support continues to meet individual health needs and that the money is being spent appropriately. In the unlikely event that someone misuses their direct payment, the regulations will ensure that the direct payment for health care can be withdrawn and, if necessary, the money recouped through the court system.
The Government recognise that direct payments will not be suitable for all NHS services. The crucial factor is that they need to add value for the individual. Self-evidently, they would not be appropriate for services such as accident and emergency, or for services provided by GPs. Regulations will set out which services are not suitable for direct payments.
Although the pilot programme told us a great deal about how best to implement direct payments and personal health budgets more widely, there is obviously still much to learn. In the circumstances, while the Government are absolutely committed to their wider use, we believe that it is sensible to introduce them on a phased, gradual basis. It will take time for clinical commissioning groups to develop local plans as part of their normal strategic and financial planning and to identify where to introduce them first, based on local needs and priorities. A steady, informed approach, where we learn as we move forward, will provide better foundations for the long-term success of personal health budgets and direct payments.
The pilots demonstrated that where implementation is done properly, the results are powerful; where it is not done properly—where it is bodged, or where there is insufficient planning or real control—the results are sub-optimal, so it is important that we do it properly. The learning has already begun with the consultation on how the regulations should be revised in the light of learning from the pilot programme. The Government response to the consultation will be published in due course, but we believe that the draft order we are debating today will pave the way for the revision of the National Health Service (Direct Payments) Regulations 2010.
In conclusion, we see the proposed removal of the pilot restriction for direct payments for health care as a clear indication of our commitment to ensure that the NHS provides person-centred, personalised care and fully supports the aims set out in “Equity and excellence: Liberating the NHS.” The order will allow the use of direct payments for health care across the NHS in England, giving people more choice and control, and improving the lives of thousands of people who live with long-term conditions and disabilities each and every day. I commend the draft order to the Committee.
2.42 pm
Mr Jamie Reed (Copeland) (Lab): It is a pleasure to serve under your chairmanship, Mr Chope, for what I think is the first time. I thank the Minister for his detailed explanation of this technical statutory instrument.
I remember, as a loyal Government Back Bencher five or six years ago, listening to Opposition Front Benchers in Committees such as this extemporising at length about the glories of ancient Greece and thinking that if ever I was in that position, I would never, ever subject colleagues—hon. Members from all parties—to such a pitiful display. You will be pleased to know, Mr Chope, that I have not changed my mind.
Norman Lamb: Thank God for that.
Mr Reed: I could recite the Iliad at any minute, so the Minister should be careful.
This is a purely technical statutory instrument. The Minister is absolutely right to say that we must base our decisions about direct payments on visibly good results. With that in mind, the whole House will be aware that there was a consultation earlier this year; I look forward to the Minister informing us of when its results will be published. I would also like to know when the revised regulations resulting from that consultation will be published. I am aware that there is a 28-day window of objection for Parliament following publication. I will not divide the Committee today, but I do seek a commitment from the Minister that he will write to me with the timetable for the publication of both the revised regulations and the most recent consultation responses.
2.44 pm
John Pugh (Southport) (LD): I will be quick, Mr Chope. I think that we all accept these days that for those with a chronic disease, self-management is very important, and that personal budgets have a fair place in that. They have been very successful in social services, so I am not going to speak against anything that the Minister has
proposed. In fact, only this morning I was travelling on the bus with a Labour Front-Bench spokesman who spoke eloquently and forcibly in favour of personal budgets.I want just a little reassurance on a couple of things that the pilot may have revealed. I am sure that the Minister will indulge me by putting some of my concerns to bed. I do not think that the evaluation has serious flaws—although I am not as informed about it as the Minister—but it strikes me that it could have considered whether the fact that people can choose from a variety of providers changed provider behaviour. Did providers in more profitable lines in a particular area seek to advertise or gain a larger market share than they hitherto had done? In other words, was the marketing of medical services affected?
Was there any evidence that, after a deal was reached and a personal budget sorted out, some of the funding was not needed and recouped or was it simply fully used up because it was there? One can imagine a scenario in which someone agrees a personal budget but then, through luck, good fortune or whatever, recovers in pretty quick time but none the less has the budget to spend. Was there any evidence that that was a feature of the regime? Was there any evidence of people exhausting their agreed personal budget? If they did, what happened? Presumably people are given a budget that they then use to access treatment, but did anyone come back and try to obtain further funding?
Those are the obvious concerns, but did the whole system, as used in the pilots, actually reduce or increase the overall health cost? It may be useful for the bigger health economy for the Minister to answer that. The Minister mentioned mental health issues, and it strikes me that the management of such issues—schizophrenia is a good example—can be horrendously expensive. A person going through a long period of abeyance carries hardly any cost at all, so there will be cases where the budget does not fit the illness as well as had been agreed. What happens in such scenarios? My fundamental concern is the maximisation of scarce NHS resources and if the evaluation established that the personal budget was an excellent way of using NHS resources, as well as being satisfactory to patients, I could have no conceivable objection.
I would like reassurances from the Minister on the general cost modelling, the extent to which budgets fitted the needs of the people and what happened when they did not, and whether providers changed their behaviour to include extensive advertising. That last point resuscitates the debate about cherry-picking, because a commercial company could simply go to all the people with personal budgets and make them an offer they could not refuse, which would have imponderable consequences for the health service in general.
2.47 pm
Jim Shannon (Strangford) (DUP): I just want to make a couple of quick comments and perhaps ask a couple of questions. I am conscious that the proposal relates to the NHS in England, but I want to make a personal comment that might be a positive contribution and helpful to the debate. I have a brother who had a
serious motorbike accident some nine years ago. He was in a life or death situation for a series of months and was in coma for 19 weeks. It was questioned whether he would ever return to his home on his own and how it would work if he did. My mother and father look after and are responsible for him—I am his older brother.At that time, the health service in Northern Ireland, which is devolved, was rather reluctant to let him go home, because it was not clear whether he would be able to cope. In the end, he was allowed to go home after consideration from my mother and father and his other relatives. The health service gave my mum control of the finance to bring in carers. Did that help him? Yes it did. It gave him independence and a certain quality of life at home, and that happened because the national health service in Northern Ireland can offer such a scheme to people with such problems. It was probably more profitable to do it that way, but profit was not the motivator. The motivator was being able to offer the care system to the family. Over a number of years, as an elected representative—as an MP and in my former job as a Member of the Northern Ireland Assembly—I have had the job of helping some of my constituents to use a similar scheme whereby parents, or an uncle, or whoever it might be, can have control of a budget to bring in carers.
My brother has carers four times a day; he cannot look after himself entirely, but, with carers, he can. My mother and father control the budget and although that is cheaper, the system is not about finance but about the level of care. That level of care is controlled by my parents and is of such quality that it has given my brother a better life and it has helped him to overcome serious injuries. Such provision has given some of my other constituents that same quality of life.
I wanted to make that contribution in a positive sense. I am conscious that the shadow Minister might have some concerns, but, from a personal point of view, on behalf of my family and my constituents, I have seen the benefits of this scheme and I would highly recommend it, if it is carried out under the best conditions, because it gives quality of life to those who need it and control of care and the purse strings to families. We should look at this not because saving money is our primary goal, but because that quality of care is something that we should try to achieve for all.
2.51 pm
Norman Lamb: First, I am grateful to the shadow Minister for his confirmation that there will be no Division on this order. I think that there is a common view on the power of this concept, which is to be welcomed. I confirm that we anticipate responding to the consultation before the summer recess and I am happy to write to him to set out the time scale for when the different steps will happen.
My objective is to proselytise for the measure and to achieve as much momentum as possible. There is a danger that introducing the right to ask for a personal budget or a direct payment will mean that clinical commissioning groups put it into the “too difficult” box and maintain the traditional way of working. We must go ahead and make the case for this transformation of care.
I am grateful to the hon. Member for Strangford for giving us a personal illustration. Irrespective of the financial consequences—as long as the scheme remains sustainable—the most important thing is the impact on the individual and, critically, their families. The evidence from the pilots showed overwhelmingly that, just like in social care, as my hon. Friend the Member for Southport made clear, if this is done properly—of course, if it is bodged, it does not work—it can have a powerful impact in improving people’s lives.
I talked to a chap from Kent who had been a service user as part of the pilot and I heard him talk about the impact that the service has had on his life, just as the hon. Member for Strangford talked about his brother. Now, for the first time, he has control of his life and, rather than having things done to him, he can now determine what his priorities are. He had seen a significant reduction in his number of admissions to hospital and that has a massive impact on well-being.
My hon. Friend the Member for Southport asked about the impact on providers. The pilot areas were quite small scale, so it is hard to draw any clear conclusions on the overall impact on provider behaviour. This is a supposition, but it is quite possible that if providers, whether they are state providers or others, must provide a good service to be allowed to provide that service at all, they might sharpen up their game. Where there is a monopoly in the public or private sector, and providers know that they will always provide the care irrespective of what the individual wants, there is a risk that complacency, arrogance and a lack of focus on the individual’s interests can set in. I think that there is a potential beneficial impact on provider behaviour, but I cannot say that the pilots provided any conclusive evidence of that.
My hon. Friend also asked what would happen if the money ran out. The NHS retains a duty of care to the public, and no one will be denied health care, whether or not they have a personal health budget. The pilots, however, show that personal health budgets militate against the risk of money running out. We have seen that good care planning ensures that individuals’ needs are met and that there is enough money in the budget for that. It forces both the commissioners and the individual to think about how best to spend the money, rather than doing so in a more haphazard way as is the case if provision is simply imposed on the individual and the routine services are there irrespective of the individual’s needs.
John Pugh: On a point of clarification, am I right in saying that if someone gets and uses a personal budget in social services, they will have to fund any further service that they want, other than the most basic statutory service? Is the Minister saying—although it should not happen like this—that if, for example, someone blows their whole personal budget for dealing with their rheumatism on crystallography but needs further help the NHS will retain a residual duty to provide the services that person would have received had they not had a personal budget? Am I correct in understanding the matter in that way?
Norman Lamb: The individual will not be abandoned. Obviously, management of the budget is important, and so is ensuring that the money is being spent as has been agreed in the planning. If the money is spent inappropriately or not in accordance with what has been agreed, for example down at the betting shop, there is the potential to recover the money, as I indicated in my opening speech. However, people will not be abandoned if they have a health need that goes beyond what their personal budget provides for.
The personal budget is not designed to include all an individual’s NHS needs. People will not be expected to pay for unplanned or emergency care from their personal health budget or for normal general practitioner services. The size of the budget will vary depending on the individual’s needs and there is no defined way of setting budgets. Pilot sites tried a number of different methods, including calculating the cost of an individual’s care in the previous year, or calculating the cost of services that they would have traditionally accessed. Clinical commissioning groups will need to develop their own local budget setting processes, which will be informed by the experience gained during the pilot programme. The toolkit contains two budget setting guides, which will help commissioners. Budget setting is an area that will, inevitably, continue to develop. It is now early in the development of the concept, during the roll-out phase of personal health budgets.
I hope that I have responded to all the questions. If I have left anything out, I will be happy to write to hon. Members.
2.58 pm
Committee rose.