Health and Social Care Bill

My Lords, I will speak to Amendment 203A in my name and those of my noble friend Lady Finlay and the noble Lords, Lord Patel of Bradford and Lord Patel. I will speak also in support of Amendments 135C and 135D, tabled by my noble friend Lady Finlay. The Bill seems to favour the commissioning of services through the any-qualified-provider model rather than being concerned primarily with commissioning an integrated model of care. Amendment 203A would introduce a duty on clinical commissioning groups to commission multiple providers of health services competing to deliver a section of the care pathway only where they can demonstrate to the NHS Commissioning Board that the approach is beneficial to patients. Integrated care pathways are particularly important in complex, long-term conditions such as serious mental illness or challenging behaviour, for example in someone with learning disabilities who is also on the autistic spectrum. There have been attempts in the NHS to deliver integrated care pathways, with varying degrees of success. The introduction of a plurality of providers in mental health services in recent years is already showing signs of fragmenting complex care pathways in some instances. The disaster of Winterbourne View is just one example of how commissioning one provider to deliver part of a pathway without planning, commissioning and co-ordinating the whole of an integrated pathway can be an expensive and tragic mistake. The further introduction of competition between providers has the aim of reducing the cost of provision while maintaining and improving the standard. This is a noble aim on which we may all be able to agree. However, commissioners must evaluate whether the aim is being achieved, recognising that care pathways vary hugely in different conditions and even for different patients. The variety of provision needed means that we cannot easily—if at all—prescribe a rule to cover all situations. Of course, the health service exists to serve patients, not providers. It is in this light that we must consider proposals to introduce competition between providers, and it is because of this that the burden of proof must be on those who favour increasing competition to show that doing so would benefit patients. The risk is that many providers will compete to provide more profitable parts of a pathway, cherry-picking the parts they would like to offer, perhaps only to the least complex patients, thus leaving unmet the less easy to cost and define but still essential parts of the pathway. The importance of an integrated care pathway cannot be overestimated. The comfort patients take in knowing that their entire provision is being dealt with in a coherent, joined-up way may be put at risk under an any-qualified-provider system. As always, it is the most vulnerable patients whose needs may remain unmet. Rather than supporting one lead provider, we must create integrated pathways across primary, secondary and tertiary care, in partnership with social services and community support agencies as appropriate. The continuity of provider is important for people with complex needs who cannot cope with having their trusted provider changed for financial or other reasons on a regular basis. The only reason should be that the clinical outcomes are no longer satisfactory. I suggest that we need a measure of whether any given change benefits patients. We need criteria against which we can judge success. The amendment has three suggested criteria. The first is to improve the quality of services, including the outcomes that are achieved from the provision. The second is to reduce inequalities between persons with respect to their ability to access services. The third is to reduce inequalities between persons with respect to the outcomes achieved for them by the provision of the services. Each of these criteria would admirably test any proposal, but any change meeting all three would have a powerful endorsement to be carried through. To accept changes that meet some but not all the criteria could result in the desired objectives not being met. I suggest that, with the criteria, commissioners will be able to judge whether the providers of choice will be able to collaborate to deliver co-ordinated, integrated care pathways.