Clause 11
Health Bill [Lords]
3:45 pm
Sandra Gidley (Romsey, Liberal Democrat)
I am grateful for that remark, because it has cut short my comments. When the Minister sums up, perhaps he would like to clarify why he feels that it is not necessary to put that in the Bill. On occasion, it has been a problem in social care.
I shall deal more generally with the Conservative amendments, many of which are worthwhile, because they provoke a very useful debate. Given the complexities in health care, it is right to pilot these direct payments and not rush headlong into something that has not been thought through. Health care is not quite the same as social care. People react to treatments and medicines in different ways. There is no one-size-fits-all solution. Also, some people do not respond well to best-practice guidelines from the National Institute for Health and Clinical Excellence. They might just not work for them. At the heart of this, we must think about what works for individual patients.
One of my concerns about the GP having to sign all that off is that we are not giving patients as much autonomy as we could, and there is a question to be asked about that. Most of us have a GP we are fairly happy with. However, I have come across cases of a patient being unhappy with a GP because they are either too into alternative medicine or too against it—there is a whole host of reasons. A number of people make decisions to access other forms of health advice, and it seems that the GP as the gatekeeper could still be a barrier to patient autonomy.
Amendment 187 is important. The hon. Member for Eddisbury said, I think, that we should not get too obsessed about the 2 per cent. of patients who get it wrong, and that we should think about the 98 per cent. of patients who get it right. A few minutes later in another context he went on to mention the Daily Mail. I wonder if this is the Daily Mail fear test for any Government who seek to introduce this. There are 98 per cent. of people doing it right, but we all know that the Daily Mail will hone in on those examples of someone who has had a holiday in Spain or bought the wrong sort of mattress. Understandably, the Government want to avoid that, and I am not unsympathetic to that. I would like some reassurance on that point, as I think that amendment 187 gets to the heart of the matter if we are truly interested in giving autonomy to patients.
I also have problems with the tariff and how it will be priced. It is not always easy to price a bog-standard course of health care because personal variations are involved. Some people will cost more and some less. Some people will have other co-morbidities that complicate their situation.
From my time on the Health Committee it is also clear that in the past, trusts— PCTs in particular—have not been good at working out the cost of care. One has only to compare the costs of treatment of different illnesses across a range of trusts, to realise what widely differing budgets are available for what should ostensibly be the same sort of care.
I think that there is now much better financial management in the NHS, and some of those differences have been ironed out. However, it worries me slightly that a patient in one part of the country might not have as much money available to them as a patient in another part of the country. It is not a north-south thing; there are sometimes widely differing variations between trusts that sit side by side.
It occurred to me—particularly in light of coming financial pressures, which we all acknowledge—that direct payments could be used by some trusts as rationing by the back door. The cost of a certain type of care might escalate, but the cost over a period of time might be increased only by inflation. Those two things can be widely differing. Therefore, I seek assurances that there will be not just an annual uplift but reviews of the budget.
The hon. Member for Eddisbury raised queries about money or savings running out, and it is useful to clarify what will happen if, for very good reasons, the budget comes to an end. I am not clear how that will be tracked or how the patient will know how much they have left. Who will monitor that? I gather that in some parts of the country, there have been experiments in social care with a card that allows people a monthly budget that they can use. I do not think that we have the technology for that, but it is an interesting idea. Will it be a yearly budget? What happens if it runs out after six months? Will it be divided into monthly sections?
I was pleased to see amendment 189 on maternity. I raised the issue of maternity services on Second Reading. I think that the ministerial response at that stage was, “I don’t really understand that. We have choice, anyway.” I can assure the Minister that women do not have choice in all parts of the country. In some areas women are still denied a home birth. Obstacles are put in their way. A lot of community maternity units have closed down or consolidated in recent years, and increasingly people might be looking to the independent midwifery sector. It creates an interesting precedent, but one that is worthy of discussion. I would not want this to be seen as a wholehearted rush towards embracing the private sector, but in maternity specifically there are quite broad issues around the use of independent midwives.
Amendment 127 is useful. The hon. Member for Eddisbury mentioned Baroness Barker’s comment that she was not told about insurance or whatever. My experience with social care shows that it is the big barrier to the adoption of direct payments. Direct payments work brilliantly where you have people who are confident about what they are doing and it is fairly simple. They work brilliantly for people who have clear ideas about what they want to do and want to take absolute control. They work less well, unfortunately, in people who might be a little older or frailer, or might for many reasons have difficulties in understanding a complex situation.
Quite serious issues can arise if someone suddenly becomes an employer. It is sometimes quite difficult for Members of Parliament to understand the vagaries around employment law, if one has staffing problems. So direct payments will only really work if advice and support is clearly available to people.
Finally, it was pertinent to raise the problem of prisoners, and particularly drug and alcohol treatment. There is an opportunity here for people with alcohol problems who might not be in prison and who have trouble accessing services, because many services rely on drug money and it is more difficult to access services if the problem is purely to do with alcohol. If people were given a budget to manage their condition, it would save the NHS a lot of money in the long term, because a lot of evidence shows that some interventions do work in a good proportion of people, and if people have budgets available, services that are currently lacking in many areas of the country might be developed.
Direct payments are a fascinating proposal. We need to retain enough flexibility so that if pilots go in the wrong direction, we do not stop completely. Also, the analysis of the pilots—what went wrong and what went right—has to be open to wide public scrutiny. An underlying concern is that it looks good on paper but does not give patients as much autonomy as some of us might wish.