Health and Social Care Bill

My Lords, much has been said on this group of amendments and I will not delay the Committee too much. I have a great deal of sympathy with the plea of the noble Baroness, Lady Thornton, that we should know what integrated care is. We have had several descriptions around the House. We have within the Bill a duty to promote integrated care, so it is important that we have read into the account the Government’s thinking on what ““integrated care”” means. I think that I echo the noble Lord, Lord Ribeiro, in saying that. I am surprised that my noble friend Lord Walton, who is not in his place at the moment, did not mention Mrs Smith of 66 Acacia Avenue, or we might have said Mr Chowdry of 66 Mafeking Avenue. What does sitting at home feel like to those patients who are in receipt of community care? How does it work out for them? Integration of primary and secondary care with social care provision is what it really should be about. I look to the Government to reassure me that that is what we are talking about. We have to be aware that some barriers in the NHS will require this financial manipulation. On the one hand, there is a profound mistrust by acute providers of the competence of community-based and primary care workers. Sometimes that has been justifiable in the light of the historical deskilling of clinical care that occurs in primary care settings. On the other hand, there is an attitude bordering on paranoia from community and primary services staff about the predatory nature of what Enoch Powell referred to as the ““voracious”” acute hospital sector, which is entirely justified by their experience of being sucked in to the acute hospital, and especially true since payment by results came in, which has had a really negative effect on this problem. Then there is the wild card of GPs who can suddenly bring to a halt community-based care out of hours, if they feel like it, without any impact on their budget at all. Noble Lords who, like me, have spent a great deal of time putting in packages of care will understand how frustrating it can be when it suddenly comes to a halt and nobody has budgetary responsibility for it. If acute and primary care staff and GPs do not trust each other, how will social care hope to get a look-in? We know from many studies around the world—and we have the highest hospital admission rate in Europe—that you can reduce hospital admissions by 60 per cent or so by providing more in cost effective solutions at home to episodes of illness in long-term care conditions. It is crucial that we find mechanisms to produce this integrated care. Normally, a package has to be laser pulses of medical intervention, minutes of special nursing care, and hours and hours of domestic and personal care which is regarded as the ambit of social care services. That means shifting large amounts of money from the NHS to social care providers. We cannot get round that. The balance of this investment in a care package is crucial for developing appropriate care services. How are we to achieve that without significant changes in the way that the tariff is constructed? It is not only a matter of unbundling the tariff; it is also about how you bundle in some areas but unbundle in others for particular pathways of specialist and non-specialist care. That is very difficult, and as the noble Lord, Lord Warner, said, there is no good history of anyone who has done it very effectively anywhere in the world. However, as he and the noble Lord, Lord Patel, mentioned, there are some good examples—indeed, there are even some small examples in mental health trusts in this country. They provide capitation funding for an individual’s care which is then used to provide care across the whole spectrum of care. That has been used very effectively in mental health trusts which give the budget to community care workers to reduce hospital admissions for a particular client group. That can work very effectively, as it does in Kaiser Permanente. What encourages me about the Bill is that with the right design of capitation funding for clinical commissioning groups, we could quite readily move to that sort of funding as an incentive to provide packages of care that reduce hospital admissions. It seems to me that the budget flat-line that we are predicting over the next few years creates an imperative to do this better. Changing demographics also tell us that we will need more health and social care packages, not fewer, so we had better have more cost-effective ones. In seeking a way forward we need to understand what integrated care means to the Government and how this duty will be given teeth, because we need it desperately. There ought to be financial arrangements that can support and develop it. I believe that we can work on this, but I would like to know how the Government currently envisage that we shall do it.