Mr.
Stephen O'Brien: I will not press this to a Division. This
exchange is on record, so those who are concerned about understanding
the way forward have a clear idea that the maximum limit is expected to
be three years, with most taking two. The Minister will be aware that
our concern arises because of the Government’s track record in
relation to pilots. We have often had pilots without the
follow-through, so we now want to ensure that there is a clear
programme that is expected not only to evaluate them well, perhaps with
this reserve power that if one or two stray over the time they can have
their evidence captured for the general application, but above all to
make sure that there is an expectation of roll-out. On that basis, I
beg to ask leave to withdraw the amendment.
Amendment,
by leave, withdrawn.
Sandra
Gidley (Romsey) (LD): I beg to move amendment
171, in
clause 11, page 9, line 14, at
end insert— ‘(4A) The
regulations must make provision that the pilot schemes are fully
completed before a recommendation is laid before
Parliament.’.
The
Chairman: With this it will be convenient to discuss the
following: amendment 172, in clause 11, page 9,
line 17, at end
insert— ‘(aa) for a review
to be carried out that involves patients, staff, voluntary
organisations and representative
bodies.’. Amendment
132, in
clause 11, page 9, line 26, at
end insert— ‘(d) the impact
of direct payments on health
inequalities.’.
Sandra
Gidley: I extend my welcome to you in the Chair,
Mr. Key. Amendments 171 and 172 aim to ensure that any
pilots of direct payments are completed and would be reviewed, not only
by an independent person, but also by patients, staff and voluntary and
representative bodies. The number of amendments that have been tabled
around review reflects a concern that, very often, pilots are not
properly evaluated before they are implemented in the NHS. With
regard to amendment 132, about which I shall talk briefly,
it is right to consider the impact on health inequality, but all the
evidence shows that most public health projects are poorly evaluated
and there is little evidence about what works and what does not,
although there are lots of well meaning projects out there. This is an
attempt to focus attention on the review methodologies
beforehand—we need to have in place, at the outset, some idea of
what impacts we are looking for from direct
payments. 10.45
pm In
the other place Lord Darzi said:
“Our general
intention is that the pilots should be clearly defined from the
start”— the
Minister has just confirmed that—
“I can put on
record our intention to evaluate all the direct payment pilot schemes,
not just some of them...We intend the personal health budgets
pilot programme to run for at least three years with direct payments
being used for at least two years. The one-year requirement is
surpassed by our policy”.—[Official Report, House of
Lords, 2 March 2009; Vol. 708, c.
GC252.] The
Minister did not commit, however, to completing the pilot project, or
formally to reviewing, or consulting upon, the outcome of the pilots.
The consequences of such a major change to the delivery of health
services, especially to the intended group of direct payment
recipients, should really not be rushed. A number of concerns have
previously been raised about that. Direct payments for social care have
been in place for some time, but there are many differences between
health and social care, which were highlighted in a previous
sitting.
It would be
useful to hear from the Government that there will be proper evaluation
before a final recommendation is made to Parliament. The reason for
including voluntary organisations and staff organisations is that there
may be significant unforeseen impacts on NHS staff. It is always useful
to consult with user groups—I hate the term “service
user”, but it seems to be the current jargon—because they
will be aware of the real-life implications that affect people on the
ground, which are not always picked up using formal methodologies.
These amendments are an attempt to seek the Minister’s
reassurance that all these factors will be taken into
account.
Mr.
Stephen O'Brien: I am happy to support
amendment 172, which relates to points that we have made
before on LINks, and the hon. Lady includes staff groups and so forth.
On amendment 171, we clearly have to get the balance right between
making sure that the evidence base is there and that we are not unduly
complicating things. I hope the Minister will give us an assurance that
the pilot schemes will have a significant period to run before they are
reviewed, because of the example we have had. To some degree, it is the
mirror image of what we discussed on the last
point. Our
amendment 132 concerns the Government’s figures on health
inequalities. The reason I am very anxious to include the effect that
direct payments have on health inequalities is partly because I think
it is common sense that they will have a major effect and it would be
something of a dereliction of duty if that were not properly taken into
account and measured. We are conscious, as we consider the Bill, that
the inequality gap in infant mortality rates has not reduced
sufficiently to meet the Government’s target. The inequality
gaps in male and female life expectancy at birth have both increased
since the baseline, by 2 per cent. for men and 5 per cent. for
women. If trends continue, the Government’s targets will also
not be met. The relative gap between the routine and manual groups in
the population has widened over recent years since the target baseline,
and the number of sexually transmitted infections has doubled over
recent years. Because of this inability to address the inequality and
poverty that have affected areas even beyond health
policy—health is a key weather vane in respect of
inequalities—a proper measure of effectiveness of direct
payments will be the impact that they make on this poor
record.
Mr.
John Horam (Orpington) (Con): Further to the point made by
my hon. Friend the Member for Eddisbury on health inequalities, the
Minister will be aware that
there are considerable differences. Even in an affluent borough such as
Bromley, there are areas where health is much worse than the average
for the country, never mind for Bromley. This may reflect my ignorance,
but what is the size of this pilot project? Does it cover the whole
Primary Care Trust or is it a much smaller area? Is it a group of
patients attached to one general practitioner? What size is it? This is
important. Will the number of pilots reflect the health inequalities
throughout the country. Clearly, we need to take bad areas and good
areas and average areas in order to get some sort of feel about how
direct payments will work.
Mr.
Mike O'Brien: It is our intention that we should properly
evaluate all these trials. These pilots are enormously important for
assessing the impact of direct payments and it is right that we should
have a full and comprehensive evaluation of them. The Liberal
Democrats’ amendment would mean that we could not move forward
with direct payments until all of the pilots had been completed. Some
of the pilots may be delayed for all sorts of reasons. They may go
beyond three years. They may have to carry on because of the health
condition of individuals. Therefore we want some flexibility in the way
in which we deliver the evaluation. We also need to make sure, however,
that this evaluation is comprehensive. This is why we have a spread of
70 projects across a range of types of income, area and condition, so
that we can have a proper assessment of where these projects would
bring benefits from direct payments and where they would not. The hon.
Member for Romsey is right to say that we need fully to evaluate this
and that therefore we cannot try to rush through the evaluation. The
evaluation, however, will be going on alongside the pilot. We do not
necessarily always have to wait until the end before much of the work
on evaluation takes place. One of the things we have to evaluate is how
we get applications in. How well is it done? Who gets them? This can be
done early on therefore and it can be evaluated well within the initial
year. Therefore, we have a process of evaluation that evaluates the
different stages of the pilot and identifies what works and what does
not work. The main evaluation, however, will have to wait until the end
so that we can look at the impact it has had on individuals.
We want to
ensure that we involve all the key stakeholders—the patients,
the staff, the voluntary organisations, the representative
bodies—in looking at how direct payments work. It will be
important in evaluating the impact of direct payments on particular
conditions how not only individuals react to the handling of funding
for direct payments but also how the various patient groups see the
implications of direct payments on that condition. We may end up with
an outcome that says that for particular conditions direct payments are
beneficial, while for other conditions they are not. That is probably
where we will end up, but let us see where it goes. We need to have a
broad spread of the various types of direct payment pilots. We then
need to have a full and proper evaluation of them. We need to involve
the various patient groups, and that is our intention—it is not
necessary to spell it out in the Bill. This would not be an effective
evaluation of an important step for the NHS unless we involved the
patient groups. In our policy statement “Personal Health
Budgets: First Steps” we have specified that one of the
principles of personal health budgets is to tackle inequalities and
protect
equality. Our advertisement for the evaluation, which was published in
April, specifically asked research teams, who are now being recruited
to conduct those evaluations, to consider how the impact of personal
health budgets differs between patient groups, looking not only at
health conditions but also socio-economic groups and patient
characteristics such as ethnicity. The advertisement also asked teams
bidding for the evaluation to consider how easily individuals from
different groups can access personal health budgets and the support
that they would need to do so. We are in the process of selecting the
evaluation teams to do that. They will be responsible for ensuring that
the views of all relevant stakeholders are considered in the evaluation
process and that the impact of direct payments on health inequalities
is comprehensively
reviewed. In
summary, we want a broad spread in the size and nature of the different
pilots. We want to ensure that we are looking at the different
characteristics of both income and condition and that we have a spread,
where we are able to get that, of particular
conditions.
Mr.
Horam: How many people will be involved in one particular
pilot? What is the normal number that you would
expect?
Mr.
O'Brien: The broad concern would be to target direct
payments at individuals who have a particular medical condition to see
if they can manage the budget in a way that best delivers for them. We
are also looking at small groups of people who want to work together to
evaluate their budgets to see how that would operate. We want to look
at a spread of different types of project to see what works. I suspect
that we will find that certain things work and others do not. Unless we
have a wide enough spread, geographically and otherwise, we will not be
able to carry out that evaluation at the end of the three-year
period. Dr.
John Pugh (Southport) (LD): What would constitute a good
result of a review of a pilot? A valid point could be made that the
socio-economic groups exploit private payments in different ways, some
to greater benefit and others lesser, and, as has been suggested, that
may accentuate health inequities. If there is an improvement in how NHS
resources are used, if there is a wholesale uplift in health care and
the efficiency in which provision by the state affects health outcomes,
the Government could reconcile themselves to that—presumably in
the same way that people sometimes argue for tax arrangements that may
not produce more equity but produce greater productivity and benefits
for the state as a whole. What is a bad outcome for a review? A degree
of inequity could be introduced by the wholesale introduction of direct
payments alongside a wholesale improvement in the efficient use of
resources and perhaps wholesale improvements in health
outcomes.
Mr.
O'Brien: That is a perceptive and important question. If
direct payments accentuate inequalities, then they have failed. It is
likely that some individuals will be better able to manage budgets than
others. That may well be attributable to their level of education and
various attributes of their medical condition. We will have to evaluate
this with care. Our aim is to ensure that we do not accentuate
inequalities, particularly social
inequalities, and also that we have an efficient use of resources, but
the primary reason we are introducing this is to see whether we can
better ensure that the treatment of individuals is carried out so that
they will get the highest benefit. It is not either to save money or to
spend more. The amount of money is not the key issue; the key issue is,
what is the real benefit? If we can, as a result of this, ensure that
health service provision for groups of people or individuals, because
of the nature of a particular long-term condition that they have, is
improved, then we are looking at a
success. The
evaluation will be quite tricky; I do not hide that from the hon.
Gentleman at all. We will need to balance a number of factors, and at
the end of the process we will have to make some judgments as to how
and in what circumstances to proceed. That will be the result of the
evaluation, which will be open and published and engage the various
groups, and then Parliament will have to make a decision about whether
it wishes to extend beyond the pilots, and if so, in what form. I hope
that with those explanations, the amendments can be withdrawn and we
can proceed with direct
payments. 11
am
Mr.
Stephen O'Brien: I was particularly interested in the
intervention by my hon. Friend the Member for Orpington, who was
asking, in effect, what the scale of the pilots will be. I understand
from the Minister that there are about 70 projects currently in mind,
of which some will be individuals, some will be groups and some could
even be quite large groups. The issue, which I think the Minister was
hinting at, is not only that there is an effort to ensure that these
pilots have a proper, realistic and tough research-based
evaluation—which will be difficult, as the Minister made
clear—but that it will be difficult, scientifically, to get a
proper statistical distribution that will look across all the various
types, conditions, circumstances, socio-economic backgrounds, and
levels of educational attainment, and that will make a big difference.
The big issue as I see it, which is why our amendment 132 is
germane—I shall not press it to a vote, but we may want to come
back to it on Report; it may even be something that the Government want
to consider in order to improve the Bill on Report—relates to
the answer the Minister gave. He confirmed my motive, which was that
this is not intended to exacerbate, but to help to address health
inequalities, although the primary purpose is on an individual basis,
where the ultimate test will be whether this helps to improve patient
health outcomes, rather than detract or be high-differential in terms
of cost. That is the important area, and a secondary benefit would be
to help to address health
inequalities.
Mr.
Mike O'Brien: I agree with most of what the hon. Gentleman
said, but he said that the pilots can apply to a group of people, even
a large group; that is not the intention. They are primarily for
personal budgets, but they might extend, say, to a couple of people
with a particular medical condition living together, or a group of
people with a particular medical condition, who would be able to manage
personal budgets and are, perhaps, living in the same accommodation. We
are not talking about large groups here; we are talking primarily
about personal budgets for individuals and those who might want to work
together as part of a personal budget project. I do not envisage that a
large group of people would decide to have the money and run their own
health system; that is not where we are at
all.
Mr.
Stephen O'Brien: I am grateful for that answer to my
question. It was the question I was asked on Friday when I visited an
excellent care and nursing home in my constituency—Prospect
House in Malpas. As there is a large collection of people there
suffering from the same age-related conditions, there was a question
mark as to whether there would be a pooled set of direct budgets, which
would slightly defeat the aim of basing help on a personal needs-based
assessment.
I am grateful
for that intervention because it is clear the Minister has in mind that
help is effectively to be directed at the patients on a personal basis.
I hope that will clarify the matter for my hon. Friend the Member for
Orpington. I will not press the amendment at this point, but I hope the
Government will listen carefully and think about how to address this
better in the final shape of the Bill.
|
