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In the Minister’s next-stage review, he embraced the concept of social enterprise and the opportunities for clinical leaders to deliver innovation for the benefit of users. Independent Midwives UK is now a social enterprise in the form of an industrial provident society. It stands ready to deliver services to the NHS within the tariff that a PCT invests in each birth, meeting the national choice guarantees.

We know that many midwives who are frustrated and disheartened with the current structures are keen to work in this way. Until now, there have not been the mechanisms to make this happen, but I am aware that this is changing. Commissioning by PCTs will, in future, embrace a plurality of providers to extend choice and drive up quality. This choice and quality of service should be available to as many women as possible via the NHS, so that maternity choice is not only for those with the means to pay. The Royal College of Midwives is hesitant about direct payments, but if they were linked to the maternity care pathway—that is, normal births—a component could be added based on payment by results if and when complications arose. I have no doubt that direct payments, with women voting with their feet and choosing independent midwives, is the quickest way to improve services.

In response to my amendment, I suspect that the Minister will reply that it is up to the PCTs to decide which services they will offer to individuals. I understand that. However, believing that we are at one on the need to improve maternity services, I seek that the regulations may provide for direct payments to be made for the services of an independent midwife. The circumstances need not be controversial. If the Care Quality Commission found that specific maternity services did not meet the necessary registration requirements, the Minister could then make a direction. It would at least open the door, although, I confess, not as far as I would like. I ask the Minister and his officials seriously to consider the suggestion, and to think through the means to encourage PCTs to include maternity services as part of their plans in piloting direct payments.

Lord Warner: I was first involved in introducing direct payments 20 years ago as a director of social services in Kent, which I think was the first local authority to do so. We did this through involvement in a new care management system. I confess that we did so before there was legislation to permit us to, working on the sound principle—which is still a sound principle—that if there is no legislation to stop you doing it, you should innovate and try things. That scheme, which was initially for elderly people, has gone from success to success under my successors. As the noble Baroness, Lady Cumberlege, said, it has been expanded to, in effect, a kind of credit card, used to enable people to buy services.

The noble Baroness, Lady Barker, raised some doubts about whether direct payments always worked with elderly people. On the basis of the Kent experience, it has worked well with elderly people, for the two reasons that underpin why direct payments work. First, they give people more choice and flexibility about how to get care, what type of care and how it is tailored to their needs. The noble Baroness, Lady Campbell, made that point extremely elegantly and eloquently at

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Second Reading. Secondly, direct payments often enable elderly people to have flexibility of services that allow them to stay in their own homes longer than they would otherwise be able to do. That is well documented in the Kent experience, which is now about 20 years old.

The other reason why the Kent system worked well was that it was integrated into a care management assessment process. There will always be people who do not quite know what they are entitled to or how to fit together a range of services and help in the way that most meets their needs. It is important that we do not see direct payments as an isolated activity. They have to be integrated into the assessment of needs and the help people will be provided with, often by a public service of one kind or another. However, that does not mean that people do not know how to run their own lives or that they do not know what their needs are. They are coping with their conditions and have usually been doing so for quite a long time.

One reason why direct payments have not been extended across local authorities as much as they might have been is professional resistance. We must face up to that. When we introduced direct payments, not everybody in Kent thought, “Yippee! Good for the director of social services. This is a great idea. We are going to go forth and do this”. That was not the reaction. I remember some quite interesting meetings with the trade unions on this issue. There will be a question about whether the professional culture will enable some of this stuff to happen. I am not surprised by the BMA’s reservations and anxieties. I recall the BMA having many of the same anxieties about practice-based commissioning in the early days. There will always be some professional reservations about giving budgets, in effect, to patients and service users to make their own decisions, and we must take them with a pinch of salt. However, that does not get away from the fact that most direct payment systems that have worked have been good value for money and have produced a lot of user satisfaction.

The noble Baroness, Lady Howarth, who has had to leave, asked me to make a point, with which I agree. It is that direct payments sometimes cause problems when people find it difficult to conceptualise the services they need. They know they have needs in a general sense, but sometimes struggle to know precisely how to get services in response to them. That is why the direct payment system needs to be integrated into the process of assessing their needs. Pilot schemes will start to iron out some of those problems.

In taking this initiative forward in the NHS, I hope we will learn from the local government experience. I have often thought that the NHS, which, as a Minister, I sometimes found a somewhat inward-looking organisation, is rather slow to learn from local government, which has often been much more innovative in some of these areas when responding to individual needs.

My final point relates to the text of the Bill. I think the regulations about direct payments in new Section 12B were drafted by the Treasury. They seem to shut off many bolt-holes and ensure that there will be a fair amount of control over the way direct payments are used. I hope we will not get into a situation where this

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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. That is why I quite like the look of Amendment 60A—the noble Baroness, Lady Greengross, is not here to move it—which starts to spell out in an interesting way some of that blurry boundary area. It is important that we do not end up with another area of dispute, of which there are often many and as we had over hospital discharge, between social services and the local PCTs. We need a lot of good will about how we will use direct payments, so that this does not become another cost-shunting area or an area of dispute between health and social services.

4.15 pm

Lord Campbell-Savours: Once again, as the non-professional, I shall speak on behalf of the consumers of these services. I listened very closely to the noble Baroness, Lady Cumberlege. Something worried me about her whole contribution and perhaps the Minister will comment on what she said. In the 1980s, a row took place in Workington when the local health authority decided that it wanted to close a maternity unit. Then there were arguments about further maternity units in Cumbria. One of the objections was that people simply wanted their children to be born in a particular area because it goes on the birth certificate. It might not seem particularly relevant for us when we are considering matters of health, but where people or their children are born features on the agenda.

One argument regarding the closure of maternity units in Workington was about where babies would be born. I wonder whether, in the event that we develop a system that allows people effectively to opt out of using the local maternity unit—that is what we will do by providing a system of direct payments to independent midwives, as I understand it—we will pursue a policy that could lead to a reduction in the number of maternity units in an area, which will have consequences. If a maternity unit is taken away from an area, the distance travelled by anyone wanting maternity services is much greater. Consequently, some women might feel under pressure to have the baby at home, which may not be what they would choose. They may want to have the baby in a maternity unit, but may not want to travel a great distance or such a distance from where they live that their relatives are not in a position to visit them. This is a consumer perception of how this would work in the system.

I do not want to do anything which would lead to a reduction in the number of maternity units. It might be that I have completely misunderstood what the noble Baroness, Lady Cumberlege, was advocating. But the consequences of what she seemed to be advocating would be a reduction in the number of maternity units, along with the availability of obstetric facilities and expertise.

Lord Walton of Detchant: I agree entirely with what has been said about supporting the idea in principle of direct payments in the National Health Service, following on the model, to which reference has been made, of

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the efficient way in which such payments could be used in relation to social care. As is plain from the implications of Amendment 60A in the name of the noble Baroness, Lady Greengross, the main purpose of such direct payments will largely be at the interface between medical and social care, I hope. Nevertheless, I appreciate the reservations expressed by the British Medical Association. I suppose I have to declare an interest as a past president, although that was 27 years ago, and I am not in any way involved any more with the policies of the organisation. My anxieties are largely dispelled by the content of the regulations, which, if properly applied, should protect against potential abuse. However, if direct payments are to be used to cover the costs of specific items of medical care, I am somewhat concerned about the extent to which that will be based on evidence. That is rather important. For instance, can someone who is receiving direct payments from a primary care trust use those to pay top-up costs of drugs not approved by NICE?

I have another anxiety on the situation for complementary and alternative medicine. I again have to declare an interest: I chaired the House of Lords Select Committee inquiry into complementary and alternative medicine that reported a few years ago. We recommended and accepted that those forms of complementary medicine regulated by law, such as osteopathy and chiropractic, might reasonably be paid for by the NHS if the general practitioner recommended that the individual in question needed to have the services of a chiropractor or an osteopath. However, if such direct payments were held by a patient, I would be concerned if they were to be spent on so-called disciplines such as crystal therapy, iridology and radionics for which there is no evidence at all.

What control and monitoring would be undertaken of the use of direct payments in specific areas of medical care by the individual? I would like the Minister to give me some reassurance about that.

Baroness Campbell of Surbiton: I was not going to speak until the amendments tabled by the noble Baroness, Lady Wilkins—on which, of course, I have a lovingly crafted speech—but I felt compelled to speak now because of some of the interesting and important comments that Members of the Committee have made.

I would like to add to the history lesson. Actually, the first direct payments in this country were in 1983. Four young disabled people in Hampshire decided that they wanted to use the money that was there to care for them in a residential home as their own and move out, get a home and design their own support arrangements. That was called the 1981 project. They started in 1981 and got out in 1986—it took them that long to persuade the local authority that they had the wherewithal to live the life that they chose and arrange their own care support. In those days, that was completely unheard of; we have come a long way.

I did not want the Committee to feel that I was too much of a Pollyanna about direct payments. If the noble Baroness, Lady Barker, had not told her story, I too would have told a horror story, because there are horror stories, largely when people’s support arrangements fall apart because their impairment suddenly increases

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or a loved one leaves them and they do not have enough hours in the day to get support in. All those things can happen; life happens. When things fall apart, you need a good local support service to help you through it. You need somebody to assist you to find a new personal assistant or look for the support that you need. Often when direct payments fall down, it is because the local authority does not have support services and does not have people there to assist you—to know how to recruit, employ and maintain your personal assistance. Also, often the advocacy and extra support for people who have extra support needs—for example, people with learning difficulties and older people—simply is not there because it is not invested in. We will need to look at that investment. However, I am getting a little confused as to whether we are talking about direct payments or individual budgets. They are different. I use direct payments; I do not use an individual budget. We need clarification of what we are talking about.

It is important that we understand that direct payments are simply a mechanism. They are not a service in themselves; that comes after the direct payment. You receive your direct payment, then you develop your service. Until you are assessed, your hours have been decided and the direct payment has gone into your bank account, you cannot begin to build your service. Again, it needs to be understood that direct payments are much more than simply handing over the cheque. That is when the real work begins, and again that is why we need decent support services, which I will talk about a little later when I support the amendment in the name of the noble Baroness, Lady Wilkins.

Clarification from the Minister of what we are discussing here would help. I thought that we were discussing direct payments as a mechanism. I also remind the Committee that the noble Lord, Lord Darzi, assured us that this will simply be a pilot, through which we begin to look at what works and what does not. So far as I am concerned, everything is up for discussion.

Baroness Cumberlege:Before the Minister replies, I thank the noble Lord, Lord Campbell-Savours for entering the debate. I have never heard the argument about the birth certificate before. It is a very interesting one. I was born on the north-west Indian frontier and have a birth certificate that is very strange indeed. It is quite a treasure, really. It is written on a piece of tracing paper and is signed by the Minister of People. I have never found it to be a problem.

I have a very simple line on the closure of maternity units; if women do not want to choose them, they should close. There must be something about them that really is not very satisfactory. The tremendous strength of independent midwives is their partnership with the woman with whom they are dealing. They would never force a woman to have a baby at home if she did not want to, but they give real choice, which in some areas in this country is simply not available to women. If a pregnant woman goes to a GP, that GP will say, “No way should you have a home birth”, but when the woman builds a relationship with the midwife, and the midwife and the woman are confident that home is the right place, the woman should have a

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home birth. The one problem at the moment is that independent midwives do not have access to acute maternity units, but that is changing; it will alter quite soon. That makes employing an independent midwife even more appealing, as the midwife follows the woman into the hospital and delivers the baby in the hospital, as well as doing the antenatal and postnatal care.

I have a quick word to say to the noble Lord, Lord Walton. 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.

Lastly, I should say to the noble Baroness, Lady Campbell, that I am talking about direct payments.

Baroness Emerton: I shall speak on two issues: learning disabilities, which my noble friend Lady Campbell raised; and what happened in Kent, which the noble Lord, Lord Warner, mentioned. I declare an interest as a regional nursing officer responsible for managing the closure of a large institution. We could not have effected that change without the direct payment system for learning disability clients who went to individual homes, so I fully support it.

4.30 pm

The noble Baroness, Lady Cumberlege, spoke about independent midwives. I declare an interest as a regional supervisor of midwives for 17 years, with the implementation of independent midwives happening during that time. There were considerable problems with the implementation, but the noble Baroness, Lady Cumberlege, is right that from the mother’s point of view, it was absolutely right. The noble Lord, Lord Warner, raised a question about professional antagonism to changes. Here, we have a problem, because with the independent midwives, just as with any other midwives, the bottom line is the safety of the mother and the baby. As long as that is the bottom line, it can be a very healthy and happy outcome.

At the same time, I have sat on and chaired the professional conduct committee for what was the UKCC, where we had one or two cases where the independent midwives had acted as independent and not within the regulations. As long as independent midwives are prepared to accept self-regulation through the Nursing and Midwifery Council and the Care Quality Commission, it will be fine.

Travelling from home to hospital has to come into the equation in the assessment of antenatal care. If it is not near enough for the mother to be transferred in an emergency in the case of an abnormality happening during labour, it is the responsibility of the independent midwife to seek assistance. That is part of her role. I raise those points and ask that the Minister might take them into account when he looks at the role of independent midwives.

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Lord Patel: I support the amendment tabled by noble Baroness, Lady Cumberlege. I must be the only obstetrician in the land who thinks that mothers have a choice at birth, and that choice includes having an independent midwife. I have said so for many years, and I have been looked at disapprovingly by my colleagues. The noble Baroness said that continuity of care during labour is of paramount importance to the mother. It is a shame that we do not have enough midwives to provide that care, either in the home or the hospital. Women will choose independent midwives for the very reason that they will provide continuity of care.

One other point that the noble Baroness made is also correct. Independent midwives have to abide by the regulations set by the midwifery council. Therefore, they are professionals, and they know that if the mother requires transfer to a hospital for care, there is no reason why they should not continue to provide that care, even if that care then requires a doctor or a consultant. The independent midwife is as much a professional as a midwife working in a hospital and is perfectly capable of assisting a consultant obstetrician to provide care if required. I support the amendment, and I hope that we will have the opportunity for direct payments to be included for mothers if they wish to have home delivery and the services of an independent midwife.

Baroness Murphy: I rise to add my tuppenceworth to this debate. I very much support the amendments but, at the same time, I support direct payments. We have tended to forget that, at the moment, the NHS Act prevents any direct payments, which has meant no choice at all of people such as community physiotherapists, community occupational therapists and community chiropodists. My own service—I declare an interest as a supporter of that which I proposed—took over the scheme from Kent into a scheme in Lewisham and integrated it into our dementia services. We also successfully used the scheme of direct payments from Lewisham Borough Council, which was at first a great anxiety for social services. Again and again, I heard arguments from professionals in social care services about why direct payments would not work and why mentally ill people and their families would not be able to use this scheme directly.

This proposal will create the same sort of anxieties. The arguments that will be used will be similar to the ones proposed by the noble Lord, Lord Campbell-Savours. For example, should we allow people to buy their own toenail-clipping service? That is one of the huge arguments in services for the care of the elderly. You have to have a dedicated chiropodist doing an assessment who then comes along, looks at your toenails and allocates you so many minutes of toenail cutting. Most elderly people say, “I just want someone to come along and cut my toenails every month”. I am glad that the Minister agrees about that point.

There are opportunities to reduce costs from some of the areas that are currently organised for us. Audiology, optical services of various sorts, chiropody, community physiotherapy and other services would benefit from this sort of approach, where cost allocations by senior managers or middle-grade managers in the NHS make it very difficult for people to get the services that they

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need. Community speech therapy is another example. There will be arguments about this, especially if direct payments are coming from patients going outside the NHS or to another team. I have seen huge arguments between the great edifice of Barts and the London NHS Trust and community health services in Hackney about who should be allowed to look at feet and do minor podiatry operations because of the movement of one tiny budget from a hospital to a community service. I see this proposal as a positive thing and a bit of a Trojan horse to drive into areas of competition which, in community health services, have been pretty well non-existent.

I also take the point about individuals and I remind the noble Lord, Lord Warner, that there was tremendous support from the case managers in Kent for the handling of individual care budgets in the same way that there had to be in the Lewisham scheme, but that was the joy of watching case managers actually develop the skills. Enormous skill in case management will still be required to handle these cases properly and for case managers to learn a lot more about employment law, contracts and so forth with which they are not very familiar at the moment in the NHS. I strongly support this at the same time as wanting to see some of these amendments reflected in our overall scheme for the direct payment pilots that are so important.

Baroness Finlay of Llandaff: I have hesitated over whether to speak now or later, but this debate has gone on for some time so I thought that I might chuck my questions for the Minister in now.

How will evidence-based care be monitored? The term “complementary therapy” has been bandied about but we should be clear about whether we are talking about complementary or alternative therapy. Indeed, if we are talking about complementary therapy, how will that be assessed? To comment on what was said by the noble Baroness, Lady Cumberlege, I should say that one of the difficulties is that many patients like certain things, but the trial of benefit—comparing some of these therapies against things such as going to the hairdresser—has never been done. All those things make patients feel better, but should NHS money pay for them? There may be no evidence of harm, but we need evidence of benefit if we are going to spend NHS money on something. I am not sure that anyone has died for lack of complementary therapy, but I think that patients have suffered for lack of complementary therapy given in conjunction with their mainstream therapy to support them through it. That is different from alternative therapies, and it must be sorted out.

Will the Minister say how commissioning from the voluntary sector will be worked out? How will the tariffs be worked out? How will patients who want to go to direct payments be affected if they wish to buy a service from across one of the borders—either into Scotland or into Wales? It is very unlikely that they would want to buy a service in Northern Ireland, but certainly patients who live just on the English side of Offa’s Dyke may well wish to purchase from Wales.

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