Health Bill [HL]

Direct payments for healthcare form part of a wider programme, which I announced last year in High Quality Care for All, to explore the potential of personal health budgets in the NHS. The aim is to deliver better quality care by enabling patients, if they want—that is the principle—to take more control over the way money is spent on their healthcare. The noble Baroness, Lady Barker, referred to a change in policy. I believe that empowered patients who exercise that power in deciding on the treatments they wish to receive is an improvement in policy. We also recently published details of our programme in Personal Health Budgets: First Steps, a fairly comprehensive document, which invites expressions of interest from the NHS in taking part in the pilots. In many cases, a personal health budget would be notional or would be held by a third party on a patient’s behalf. That is permissible under current legislation and we hope the first pilot schemes of this kind will run from later this year. Here we are talking about direct payments as variations of personalised or individual budgets, including notional payments, which are permissible under law, as I said. We want to test direct cash payments to patients where it makes most sense for individuals. The powers in the Bill allow for that. Subject to parliamentary approval for the Bill and subsequent regulations, the pilot programme could be extended next year to include pilot schemes for direct payments for health care. The amendments in this group are concerned with the coverage of direct payments for healthcare, including to whom and in what circumstances it is appropriate to make such payments. Amendment 50, tabled by the noble Baronesses, Lady Barker and Lady Tonge, would allow direct payments for healthcare to be made to a suitable person on behalf of a patient who does not have the capacity to consent and who has not nominated a surrogate beforehand. The Bill is drafted to enshrine the important principle, outlined in new Section 12A, that direct payments may only be made with a patient’s consent. However, as noted by the noble Baroness, it is important that patients who are unable to give consent should not be denied the opportunity of benefiting from a direct payment. As we set out in the department’s briefing note, we intend to allow a representative to hold direct payments on behalf of a patient who is unable to give consent. The role of this person would be to act in the best interests of the patient by holding the direct payment, securing services for them and supplying information to the PCT as necessary. It is important to emphasise that the regulations to achieve this would only apply to people unable to give consent. In those circumstances, we expect that, where a person lacks capacity, their representative is likely to be either a court-appointed deputy or a donee of a lasting power of attorney made at a time when the patient had capacity. Next-of-kin or long-term carers may also be suitable. Regulations under new Section 12B(2) would allow us to define the details—for example, to put in place safeguards to ensure that a surrogate is suitable and is acting in the patient’s best interests. This is a similar approach to that used in social care, where it has worked well to ensure that people unable to give consent or who wish to nominate another are able to benefit from direct payments. I hope that I have reassured the noble Baroness, and that she will find this explanation helpful. Amendment 51, tabled by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, would remove the specific provision for defining the scope of direct payments for healthcare. Amendment 58A, tabled by the noble Baroness, Lady Cumberlege, concerns the use of direct payments for maternity services. It would enable regulations to set out the circumstances where direct payments could be used to secure the services of independent midwives. I have every sympathy with the desire to make the Bill as clear as possible about our intentions for direct payments. However, it is precisely for that reason that I would be reluctant to agree these amendments. As we said in our policy document Personal Health Budgets: First Steps, personal health budgets would not be right for everyone, nor in all areas of the NHS. That is especially true of direct payments, the form of personal budget that gives most direct control to the individual patient. It would not be appropriate—or even possible at this stage—to specify what services or groups of people would benefit most from personal budgets or direct payments. Instead, we want to encourage local innovation and build the evidence base through piloting. Numerous examples have been mentioned earlier: eye care, mental health—as pointed out by the noble Earl—children, chiropody and, certainly, speech therapy. All are good examples of the innovation that we very much hope that PCTs at a local level, in partnership with other stakeholders, would be encouraged to pilot. As I said earlier, PCTs should consider where personal health budgets might have the greatest benefits for patients. Personal budgets might work especially well in areas where choice is available but where current NHS services are not meeting patients’ needs. That might be one very good driver for personal health budgets. Several service areas have been suggested by stakeholders and our policy document has listed some of them. The department is currently running a series of regional events—I have attended at least one—to encourage applications for the pilot programme, and I would be delighted if we received applications covering all the service areas listed and many services that noble Lords have suggested today. I would certainly be very interested in proposals for maternity services, where I know that the noble Baroness, Lady Cumberlege, has a particular interest. There is plenty of evidence, not only in this country but elsewhere, where we have seen independent midwives working very well, such as in New Zealand and certain parts of England where such a service exists. I was delighted to hear the support expressed by the noble Lord, Lord Patel. The noble Earl raised the issue of safety in a transfer to hospital in the case of emergency of a woman who decides to have a home birth. As was said by the noble Baroness, Lady Emerton—she is well equipped to answer that question—most midwives with their professional values have very sophisticated tools for assessing risk and making sure that, if a risk arises, the appropriate transfer arrangements are made in the best interests of the safety of the mother and of the child. I do not believe that direct payments, or any form of budget, should have any impact on the transfer protocol that must exist between the midwife, whether independent or not, and the hospital that might be receiving that patient at a local level. We are keen for the pilots to explore a range of different service areas and models. However, it would be premature at this stage to specify these types of services on the face of the Bill. I have concerns that including a list could turn out to be misleading if, for example, the pilots reveal that one of the listed services is not suitable for personal budgets, but that other, unlisted, services are. We have a lot to learn here. That is the experience and the evidence base that we need to gather on the effectiveness of such a policy. Equally, the services that are suitable may evolve over time. As the concept of personalisation becomes more embedded within the NHS and its culture, and as improvements take place in the way in which services are commissioned, it may become possible to extend personal health budgets more widely in the future.