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Earl Howe: I shall speak briefly to Amendment 66, the purpose of which is simply to emphasise the importance of evaluating the pilot schemes as thoroughly and inclusively as possible. We cannot predict all the difficulties that may arise as the pilot schemes run on, but, more to the point, I would feel comfortable if the Secretary of State’s evaluation of the pilots was a closed process. There is a lot of enthusiasm out there for direct payments in healthcare, as we have heard, but a lot of nervousness and apprehension as well. It is important that we get this right. I bring us back in particular to support and advice, the quality of which needs to be evaluated as part of the overall exercise if we are to learn the right lessons for the wider rollout of direct payments.
Baroness Cumberlege: I pay tribute to the noble Baroness, Lady Barker, and her diligence in taking through legislation. However, she implied that I had perhaps got wrong what the IBSEN report said. The report says that individual budgets,
- “appeared cost-effective for social care outcomes—i.e. they produced better outcomes for the costs incurred, compared with standard care—but not for psychological well-being, with some differences between groups. IBs were cost effective for mental health service users and physically disabled people with respect to both social care and psychological well-being outcomes. For people with learning disabilities, IBs were cost-effective with respect only to social care. For older people, there was no difference in social care outcomes, but standard care arrangements remained slightly more cost-effective and people receiving these felt happier”.
Perhaps we are quoting from different parts of the same report. I am quoting from the précis that they did to ensure that people could see all the report but in an encapsulated form. I am quoting directly from the IBSEN individual budgets evaluation network.
7 pm
Lord Rea: I shall say a few words about Amendment 65, to which I have added my name. I am considerably reassured by what my noble friend has already said about the evaluation of these pilot schemes, particularly that there will be a reputable, independent, academic body that will carry out the review. Will he confirm that the department will be bound by the findings of this body and that the Government will withdraw or suitably amend certain parts of the scheme according to the recommendations of this independent report? As we have heard, many highly complex issues are involved in these schemes, and it is important that as many as possible of these are ironed out before the scheme spreads to the whole country. I deliberately did not use the term “rolled out” because it has been overused.
The evaluation team and its protocol should be well in place before the pilot starts so that it knows exactly how to conduct the study. Is that in the plan? What proportion of PCTs will undertake these pilots? Will they be involved in mounting the schemes and hosting the valuation teams?
Lord Campbell-Savours: Would it be possible for the local authority overview and scrutiny committees and county authorities to have a role in evaluating the
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Lord Darzi of Denham: There are many amendments so I may take a little time to go through them. Most of them are concerned with the review of the pilot scheme for healthcare direct payments. I re-emphasise that we intend to carry out a thorough and rigorous evaluation of the personal health budget in general and of direct payments pilots in particular. We acknowledge that there are many unknowns and uncertainties, which we have debated today. That is precisely why we need to pilot them. On that same note, I made it clear in High Quality Care for Allthat a number of policies in that document need to be evaluated. We debated the quality accounts last Thursday. On personal health budgets, the department should and will be heading to evaluate policy as academically rigorously and independently as possible. That research will be commissioned independently by an external research group, which I hope will happen some time after the tender has gone out in March.
Amendment 62, moved by the noble Baroness, Lady Barker, would omit our current clauses which provide explicit powers to use regulations to enable us to revoke or amend a pilot scheme. Our general intention is that the pilots should be clearly defined from the start, like any other study, and should be properly evaluated as they run. We hope that there will be little need to change the scope fundamentally once the pilots are up and running. However, and I say this as an academic, there will need to be a degree of flexibility. For example, the power in regulations would allow us to adapt pilots in response to emerging lessons. We will learn a lot of lessons as the pilots are launched. We would be able to extend the scope of a pilot midway if it became clear that there were benefits for other services or for patients, or perhaps if the full effect of the pilot could be measured only if more patients were recruited.
In the last resort, we will be able to cancel a pilot scheme if the model being tested is obviously not working as intended. Being able to have the power in regulations to adapt or stop a pilot scheme is a sensible precaution, but that should not impact the academic evaluation. Even a failed pilot would tell us a lot that we needed to learn, if those rare circumstances arose.
Amendments 65 and 67, tabled by the noble Baronesses, Lady Barker and Lady Tonge, and the noble Lord, Lord Rea, require an independent review of all pilots. Amendment 68B ensures that the pilots run for a year before any decision about national roll-out. At this stage, I can put on record our intention to evaluate all the direct payment pilot schemes, not just some of them. We will probably learn more from those that fail about how we can address the issues that caused that failure. We intend the personal health budgets pilot programme to run for at least three years, with direct payments being used for at least two years. The one-year requirement is surpassed by our policy.
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However, it would be unnecessarily prescriptive to put these details in the Bill. For example, the current drafting requires a review of “one or more” rather than “all” pilot schemes. This wording does not signal any intention to cut corners on evaluation, but it provides a degree of flexibility. There may be circumstances where it is not appropriate to review all pilots together before a decision on national roll-out is made. If one pilot took significantly longer than others to produce results relating to certain demographic groups or a certain condition, but the evidence from other pilot sites for or against direct payments was overwhelming, I would not wish to create unnecessary delay before making a decision. These pilots will deal with different conditions and different demographics. Noble Lords will also appreciate that there may be a range of pilot programmes running covering a range of services. The legislation allows us sufficient flexibility to allow direct payments for one service, while continuing to pilot others.
Amendment 66, tabled by the noble Earl, Lord Howe, requires the department to carry out a formal consultation before any review takes place. As an integral part of the review, I envisage that the evaluation team will gather the views of individuals and organisations. My noble friend Lord Campbell-Savours raised a point in relation to the overview and scrutiny committee. It will be one of the stakeholders, and I have no doubt that that academic evaluation will include it as part of its stakeholder team. I am confident that the review of the pilots will draw on a far wider and richer range of evidence than would be produced by a conventional consultation exercise.
Amendment 66A ensures that regulations require that the review evaluates the impact of direct payments on specific patient groups. At this stage, as I explained earlier, we do not intend to define the types of patients or services that would be eligible for a personal health budget, and we are awaiting the different and, we hope, innovative bids that will come in following the call.
Amendment 68 requires the Secretary of State to present Parliament with the findings of the review of the pilots before making any decision to roll out direct payments for health care nationally. I emphasise that before the Government can extend direct payments more widely, both Houses of Parliament must give their express approval through the affirmative resolution procedure. That is an important safeguard; it is a stronger safeguard than these amendments provide. At that stage, we will need to lay out our evidence, so that your Lordships may make an informed decision. It is not necessary to add an explicit requirement to present Parliament with the findings from the evaluation.
I turn finally to Amendment 68A. New Section 12C provides a power to extend direct payments nationally by allowing the Secretary of State to make an order repealing the limitation that direct payments may be made within pilot schemes only. New Section 12C also provides a power, at subsection (6)(b), for an order to amend, repeal or modify any provision of the 2006 NHS Act. This amendment would remove that provision.
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I can understand that, on first glance, this may seem a sweeping power for the Bill to contain. However, it simply provides the power to make any consequential amendments to the NHS Act that may be necessary to facilitate the wider rollout of direct payments. It is tightly constrained by subsection (7), which makes it clear that the power may be used only for the specific purpose of making changes relating to direct payments and not for any wider reason. We believe that this is a balanced and proportionate approach, which was endorsed by the Delegated Powers and Regulatory Reform Committee in its report on the Bill.
The need to retain flexibility for the pilots inevitably means that we cannot prescribe every detail in the Bill. However, I hope that Members of the Committee will be reassured by my answers, particularly by the use of the affirmative procedure as a safeguard before any future extension of direct payments. Therefore, I hope the noble Baroness is able to withdraw her amendment.
Baroness Barker: I thank the noble Lord, Lord Darzi, for that very full response to the large number of issues raised in this group of amendments. When I moved the amendment, I should have said that I took considerable care to look at the material provided by the department, for which I am very grateful to the noble Lord. The other week, his department gave Members of the Committee a briefing on direct payments, specifically about the evaluation.
This may be known in the business as the curse of PowerPoint, because there are some very brief headings, about which I meant to inquire. What the evaluation that the department is about to commission will cover is set out and includes financial impacts. What do the financial impacts concern? Does the evaluation refer to the financial impact on patients, providers or commissioning? That is not clear. Analysing innovation and responsiveness in the provider market is also referred to. What about market failure? We know that when market mechanisms are introduced, that can bring about market failure. Part of this is designed to do that. We have not had extensive market failure in the social care world, because the pilots have been running alongside the existing system of commissioning block contract services. That might be the case for the pilot phase, but I imagine that, ultimately, it will not be further down the line.
I should say to the noble Baroness, Lady Cumberlege, that I did not seek to imply that she had not done her homework or that she was misquoting. She was reading from the summary and it is right to say that that is part of the report. It is a bit like going to the theatre and seeing the Reduced Shakespeare Company do the “To be or not to be, that is the question” soliloquy, and then not hear the rest of it.
In the full report, the points made by the noble Baroness are put into more detail and more context. The researchers are more tentative about what their findings may mean for the future: for example, when there is a more fully developed supplier market in social care, individual budgets have been running for a considerable time and no longer is block contract tendering going on by local authorities. It talks about how, if the price of an individual care service goes up,
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7.15 pm
Lord Darzi of Denham: Thank you. I spend a fair bit of time teaching the Department of Health how to do PowerPoints, but this one comes from the policy strategy unit, which knows how to make PowerPoints. That is why the words used are “financial impacts”. That refers to page 58, point 20B, which states that financial impacts across the health and social care system include demand growth, doubled running costs, the costs of support and brokerage and also value for money. That is what the bullet point refers to.
Baroness Barker: Perhaps the Minister might write to me about the issue of provider failure; I do not want to prolong things now. The noble Lord will understand why there has been the concern that there has been about the pilots. The potential impact of individual budgets on the healthcare service is enormous. The pilots in social care were not able to talk about longer-term effects, such as the effects on the number of providers, choice and so on. There are still many questions to be answered. That is why I moved the amendment, and I welcome the Minister’s response. I beg leave to withdraw the amendment.
Amendments 63 to 69B not moved.
70: Before Clause 10, insert the following new Clause—
“Choice to top-up accommodation provided under NHS continuing health care
Where it is the responsibility of the National Health Service to provide care and accommodation, or a direct payment to meet these responsibilities, under National Health Service continuing health care, the Secretary of State may direct that in cases where a person chooses to move into or remain in accommodation that is more expensive than the National Health Service has established is necessary to meet all their needs, that the person or a third party may make payments to top-up any extra hotel costs.”
Baroness Barker: I thank the Committee for being prepared to put up with a bit more of me at this time of night. I promise that I will be Trappist the next time we meet; that is an absolute promise. I am sad that we are so late in the day, because Amendment 70 is quite important. This is about continuing care payments. Noble Lords will have heard the noble Lord, Lord Darzi, reiterate the points made by the department about top-ups for drugs and its response to the Richards review. An ongoing source of contention has been the level at which the NHS provides continuing care and
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The problem is that sometimes the NHS is willing to only pay a certain level of hotel costs. That means that older people in particular may not be able to go into a home that either is of a quality or a standard that they want, or is not near their relatives. The amendment seeks to establish that people who are in receipt of continuing healthcare can make a top-up to that to enable them to receive that healthcare in a home that they wish to be in, but which the NHS may perhaps not fund or not fund to that level. We are talking about a group of people whose needs are such that they cannot manage some of the more creative arrangements used by other people in order to get round their health problems because they are restricted in mobility. The amendment could make an immense difference to a small but significant group of people. Therefore, I beg to move.
Lord Darzi of Denham: I start by putting firmly on the record that the Government are committed tothe NHS as a service based on clinical need and not the ability to pay—and the new NHS Constitution, as we debated last Monday, enshrines that principle.
Our position is clear on the general question of patients wishing to pay for additional private care. As noble Lords are aware, we debated the Richards review and the Government's response to it. Similarly, we have made it clear that personal budgets and the direct payments that we will be piloting may not be used as part payment for privately funded healthcare. I know that noble Lords will wholeheartedly agree that there must be no question of creating a two-tier system where those who can afford it can buy a better standard of NHS care.
However, we know that there have been concerns about a specific question relating to NHS continuing healthcare patients who want to make a contribution towards the “hotel” costs of their accommodation. From the perspective of the patient, those costs may not appear to be part of the core clinical package of NHS care, so I agree with the noble Baroness that there can be confusion among patients about whether they are allowed to pay for them. The issue was raised during the consultation on our draft guidance on secondary care and we are currently considering consultation responses.
I understand that it can be a particular concern for people who transfer into NHS continuing healthcare
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Lord Walton of Detchant: Might I raise an issue about which the Minister may not be aware? At the beginning of the National Health Service—and I remember it well because I was practising medicine before it came in—it was possible for individuals to purchase what was known as an amenity bed while continuing to have hospital care. They could pay an additional sum simply to have the convenience of a more comfortable room, for instance. It was purely for the hotel component of their care and not for anything to do with their medical care. That went out a long time ago, but this rather reminds me of that method.
Lord Darzi of Denham: I am grateful for the noble Lord’s intervention. I believe that that still happens although we may be talking about slightly different things. The issue needs more clarity. It was raised in the consultation and most of us would agree that NHS continuing healthcare is a complicated area and there are many implications to think through.
I reassure the noble Baroness that we will continue to look at this. I hope that we will be able to address the issue, although perhaps not in the context of this Bill. It is an issue that the department is looking out with great care. With that reassurance, I hope that the noble Baroness is able to withdraw her amendment.
Baroness Barker: I thank the Minister for his kind and full response. I hoped that we might have got to it quicker, but I realise that he has a lot on his plate. The issue will not go away. It will come back, and we will return to it at another time.
Baroness Thornton: This may be a convenient moment for the Committee to adjourn until Thursday at 2 pm.
The Deputy Chairman of Committees (Baroness Pitkeathley): The Committee stands adjourned until Thursday at 2 pm.
Committee adjourned at 7.25 pm.
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