Health Bill [HL]

I do not think that the noble Baroness, Lady Barker, needs to apologise at all for the number of amendments she has tabled for this section of the Grand Committee. They all appear to be based on very real concerns. I identify myself with everything that she has just said. I shall speak to my Amendment 51, which I signal to the Minister at the outset deploys the standard Committee device to leave out a passage of the Bill in order simply to debate it rather than to indicate dissatisfaction with it. On talking to people outside Parliament in the medical community and the voluntary sector, we have a division of views about direct payments. As the Committee knows, I am very much in favour of the concept, although we need to tread carefully in introducing them, which is why I very much support the idea of pilots. I think that much of the voluntary sector would express a similar view. However, the BMA is very wary of the idea. In fact, I think that one could say that it has considerable reservations about the whole notion. It sees direct payments as making continuity of care more difficult and not easier, and fears that they will increase bureaucracy and transaction costs. While I think that those concerns are overplayed, we should not ignore them, coming as they do from the BMA. It would be helpful if the Minister would address those particular issues in his reply. Setting those concerns aside, there is no getting away from the fact that with direct payments there is a trade-off between patient empowerment—leading to, one hopes, better outcomes—and financial risk for PCTs, which lose control of commissioning while having to pick up the tab for the services commissioned. Most enthusiasts for the concept of direct payments would say that this risk can be managed and minimised if we are careful about how the scheme is rolled out, and to whom. Like the noble Baroness, I should like to hear more from the Minister about the kinds of people for whom the Government regard direct payments as being suitable. An example is eye care. Like pharmacists, opticians tend to be conveniently located in shopping areas and supermarkets. As we all know, optical practices already provide high-quality eye care, yet too many patients travel to overstretched hospital eye departments for relatively routine check-ups which could be managed equally well or better in the community. In Wales and Scotland, community optometrists play this sort of enhanced role in eye health services, so there would seem no reason why the same should not happen in England. Many people with mental health problems would say that the chance to be in the driving seat when it comes to choosing and buying services is exactly the kind of empowerment which will contribute to a more rapid recovery. Of course, certain kinds of mentally ill people may not prove suitable to handle direct payments, but many will be. I therefore would be glad to hear the Minister say that mental health care will not be ruled out as an area for trialling when the pilot schemes are commenced. From all that the Government have said, they see direct payments as being suitable for those with stable, long-term conditions whose healthcare needs are reasonably predictable. I agree with that. As we discussed at Second Reading, very often the people in receipt of direct payments for healthcare will be those who receive means-tested social care—I am thinking here of the physically disabled. Will the Minister say whether children, for example, or people who lack mental capacity and are looked after by other people, as asked about by the noble Baroness, will be excluded? There has been a lot of discussion about maternity services. On the face of it, if we believe in choice for expectant mothers, why not empower them to buy the kind of service that they want when they give birth? However, this is one area in which things are not quite so simple, because giving birth is not always a predictable process, given the risks and complications that may arise. Will the system be able to cater for a situation in which, say, a woman who has opted for a home birth with a midwife suddenly needs to be moved to a consultant-led obstetric unit? In other words, how much flexibility will be built in to enable people to switch the service that they purchase, especially bearing in mind that the cost of two alternative services may be very different? Finally, will the Minister clarify the extent to which those in receipt of direct payments will be allowed to use them for purchasing services that are not available on the NHS? One of the principles set out in Personal Health Budgets: First Steps, a copy of which I have here, is that having a personal health budget does not entitle someone to more, or more expensive, services. Nor does it entitle them to preferential access to NHS services. If a service is not available from the NHS locally, will it be possible for someone to buy that service from the independent sector?