Health Bill [HL]

My Lords, I wish to speak to Amendments 25 and 31 in this group. As this is the first group of amendments on the subject of direct payments, perhaps I might reflect on the discussion in Committee. It would be accurate to say that we had an extensive debate—almost a full afternoon of one of our sittings in Grand Committee—during which the Minister was bowled question after question about direct payments, individual budgets, the principles underlying them, what the Government’s intentions are, the extent to which individual health budgets might be brought into play in respect of different patients and different conditions and the limitations of the proposed pilots. I thank the noble Lord, Lord Darzi, for his letter of 18 March in which he restated, to a large extent, the answers that he gave in Committee. However, detail is lacking and that continues to be a source of considerable concern to many of us on this side of the House who are supportive of the principle of direct payments but have considerable concerns about how they might be introduced and about the potential detrimental effects which they might have on the National Health Service and particularly on the provision of services. Since the Committee, the noble Baroness, Lady Campbell, has been kind enough to arrange a meeting for all Peers, attended by the noble Baroness, Lady Thornton, at which she and several people from the disability organisations with which she has long been associated and academics such as John Glasby from Birmingham University set out the experience of disabled people. They talked at considerable length about what they consider to be the potential benefits to service users of individual budgets. It seems to be my misfortune throughout this Bill to refer to the noble Baroness, Lady Campbell, when she is not in her place and I regret that I have to do so again. It would not be inaccurate to say that although there was considerable support for the potential for direct payments at that meeting, again, when Members of your Lordships’ House raised issues and asked questions, there were no answers. I find that deeply troubling. That meeting gave rise to the tabling of Amendment 31, which, as noble Lords will see, bears a resemblance to an amendment tabled by the noble Baroness, Lady Greengross, in Committee in which she set out a list of conditions and services to which individual health budgets might apply. The purpose of both these amendments is to probe the Government’s intentions on the extent to which direct payments will be introduced in the NHS. It is of considerable interest and should give rise to a degree of concern that many of the organisations that have supported the principle of direct payments or individual health budgets have expressed their support on the understanding that they will be available to a small minority of patients who suffer from long-term conditions, and that there will be adequate advice and support for any person who has an individual budget. Neither of those two statements can be made with any certainty, given what is in the Bill and our discussions so far. Amendment 31 refers to two particular conditions, both of which, in different ways, highlight some of the potential issues associated with individual health budgets. In Committee some noble Lords expressed the view that palliative care services, given their place in the National Health Service and the fact that they are largely supplied by independent organisations, principally charities, should be funded through direct payment. But the major providers of hospice care in the country have a very different view. By definition, palliative care—end-of-life care—is provided to individuals but it cannot be predicted when any particular individual will need it. At the moment part of the function of the NHS is to study populations and the incidence of conditions, and to make an assessment of the level of service needed to deal with them. That process runs right through to budgeting. There is an attempt at the heart of the NHS to address issues such as pooling of risk and equity of service. If palliative care came to be primarily funded by direct payments, the ability of providers to predict and provide a certain level of service would be extremely difficult. It might signal the end of the provision of palliative care within the NHS and I want to establish whether the Minister can envisage that as a consequence of the introduction of this policy. At the meeting arranged by the noble Baroness, Lady Campbell, noble Lords who were interested in the subject discussed at considerable length the benefits of this service, and there are benefits. In Committee we discussed the fact that services can be more personalised and more effective for individual patients, and can contribute to greater health outcomes. At the meeting noble Lords—particularly the noble Baroness, Lady Cumberlege, who, I am sorry to see, is not here to take part in this debate, although she talked in Committee—saw that maternity services would be a good candidate for individual health budgets. Maternity services are required, usually, with about nine months’ anticipation of the need for them arising. They are planned on the basis of population studies. Thinking about the matter in greater detail, within the NHS there is at the moment a considerable move towards midwife-led units, on the basis that the majority of deliveries are uncomplicated and routine. However, there are always births that do not go according to plan and in which there is a sudden and urgent need for a woman to be referred to a consultant obstetrician. The reason for suggesting that maternity services should be included in the pilots for individual health budgets is to test the point that I raised in Committee. To what extent has the Department of Health analysed the risk of turning some services, which may be elective, over to individual health budgets, and to what extent might they then jeopardise acute services because of the coexistence of the two? Amendment 25 suggests that it is the responsibility of the department to set out much more clearly than it has done to date those conditions and circumstances under which direct payment may, must or must not be made available. It is essential not only to the future of the policy but to the expectation that will be placed on it by NHS staff and, most particularly, by users. Both amendments signify a degree of frustration on my part that, having had detailed discussions about these matters over the last three months, we are no further forward in understanding just how radical this policy is intended to be and just what its potential implications are for NHS providers and patients.