My Lords, I shall speak to Amendments 238AZA and 238CA, which concern integration of services. Integration is a word that is used very often in the Bill.
My amendments would require all health and well-being boards to take a local lead on integrating health-related services with health and social care. General duties to promote such integration are held by the NHS Commissioning Board and clinical commissioning groups. The amendments would ensure that health and well-being boards also played their part.
Integration of the planning and delivery of health and social care with health-related services is crucial for improving the health and well-being of local populations. Evidence and experience show that health and care services can be made more effective, efficient and accessible when integrated with wider support services. The Bill references this network of support as "health-related" services. This covers a wide range of provision that contributes to children's and adults' health and well-being. The National Children's Bureau, the National Housing Federation, St Mungo's and Homeless Link have come together to call for a clear role for health and well-being boards and they support close integrated working between health-related services and health and social care. This is clearly an issue that has implications across all sectors-health, education, children, housing and employment.
As the Bill stands, clinical commissioning groups and the NHS Commissioning Board will have a general duty to promote integration of health services with health-related services, as well as with social care. Health and well-being boards' duties to support close working and partnership arrangements are limited to health and social care, with only a power to encourage close working with health-related services.
I am concerned that, without the support of their local partners through health and well-being boards, the NHS will struggle to deliver on this wider integration agenda. As health and well-being boards will be the key forums for local partnership working, they should have duties in this regard; for example, with children and young people. Schools and colleges, children's centres and youth services are vital settings for delivering health outcomes. The national evaluation of Sure Start found that a child with access to a children's centre-formerly Sure Start-had more immunisations and fewer accidents than young children living in other areas. School health initiatives have had a positive impact on health and behaviour among pupils.
Evidence suggests that health, social care, education, early childhood, youth and other services are not always working in partnership to secure good health outcomes for children and young people. The Marmot review identified a lack of consistent partnership working between such bodies as a barrier to delivery. Similarly, the Kennedy review highlighted the fact that the requisite links between the NHS, social care, education and the criminal justice services to support children and young people are not always made. This report recommended that local partnerships, covering all services for children, should have a duty to ensure that local organisations work together. Close working between local partners is particularly vital for children with complex needs, such as disabled or looked-after children, who need co-ordinated interventions from a range of services.
Improving people's health is rarely achieved by clinical interventions alone, but is dependent on the wider determinants of health; for example, housing support acts as a health intervention and can help people to improve their well-being, manage their health better and prevent the need for more acute services. A lack of good housing can also be a major determinant of poor health: eight out of 10 homeless people have one or more physical health needs and seven out of 10 have at least one mental health problem. The average age of death of a rough sleeper is estimated to be 40 to 44 years.
I chair the National Treatment Agency for Substance Misuse and I am well aware that, in tackling drug and alcohol use, we also need to tackle the social issues such as housing, employment and education. The Marmot review, Fair Society, Healthy Lives, noted that,
"this link between social conditions and health is not a footnote to the 'real' concerns with health ... it should become the main focus".
The role of health and well-being boards in promoting integration across local services was debated in Committee on
However, in response to separate amendments aimed at strengthening the role of health and well-being boards in engaging and working with specific health-related services, the noble Earl, Lord Howe, responded:
"we want to avoid being overprescriptive. On the other hand, we are clear about what best practice looks like, and ... we have provided for statutory guidance".-[Hansard, 19/12/11; col. 1542.]
The relevant statutory guidance has been published in draft form by the Department of Health. Although it makes broad references to vulnerable groups and wider services like housing, there are no clear expectations for how, when and where this integration could take place or which client groups or needs would particularly benefit from this. The Bill offers opportunities to integrate services beyond traditional primary and secondary care to reach across initiatives to improve lives. These amendments would ensure such opportunities will be taken by local partners. I look forward to the Minister's response and hope that he can give me some reassurance.