Health and Social Care Bill

My Lords, I thank the noble Baroness, Lady Thornton, for her comments about integration, because I agree with her that we do not have a clear definition. On page 18 of the Bill, new Section 13M is headed: "““Duty as to promoting integration””." Although the words ““integration”” and ““integrated”” are used in the section, there is no clear definition. Yet, in new subsection 4, there is an attempt to define ““health-related services”” and ““social care services””, but not until new Section 13Z3 is there an interpretation which tries to define the ““health service”” and ““health services””. We do need some clear definition of what we mean by integration. Let me tell you what I thought integration meant, when I first took on an interest in the Bill, and I will illustrate it with some examples. Integration, for me, was not being able to talk to my GP colleague about a patient without having to go through the PCT. I could not just pick up the telephone and say, ““I’ll see your patient next Friday””. It had to go through a bureaucratic system before the patient got to me. From a clinical point of view, when I was referred a patient with gallstones on a Monday morning clinic, after discussing and examining the patient, confirming that she did indeed have gallstones—and I used to have an ultrasound machine in my out-patient clinic, so it was easy to make the diagnosis—I said to her, ““I think we can deal with this quite easily with a keyhole operation to remove your gallbladder, but I suspect you may also have an ulcer in your stomach, so before I put you on the list for surgery, it might be a good idea to exclude that””. I went down the corridor to see my gastroenterology colleague, told him about the problem, and he said, ““Not an issue, bring her along, and I’ll see her””. Before I knew it, I had had a phone call saying, ““I will deal with her next Thursday and gastroscope her””. The net result of that was that within a week we had an answer for the lady, and I was able to put her on the waiting list for surgery. However, when choice and tariffs came in, it was essential, for the hospital to be paid, that when the patient came to see me in the outpatients’ clinic and was diagnosed with gallstones, I would have to refer her back to her GP, who would then make another consultation with the clinician gastroenterologist in order for her to have the endoscopy to diagnose her ulcer. Those were two inconvenient visits for that patient, purely to fulfil the need to manage the tariff and the issues around choice. For me, an integrated service gets rid of all those barriers. We should also remember that this is the Health and Social Care Bill; it is about integrating services from the beginning to the end. I have tremendous sympathy and support for Amendments 103 and 290, from the noble Lord, Lord Warner, because they are about getting rid of episodic care. It was precisely the episodic tariffs that required my patient to make two visits to the hospital when one would have done. I hope the Minister will take this into consideration when reviewing this. It is important that we find a formula, or a way to look at the care pathway, and find a way to cost that, rather than the episodic costing of care.