Health Bill [HL]

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 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 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.