APPROVAL OF PILOT SCHEMES

HC Deb 12 March 1997 vol 292 cc449-56

Mr. Thurnham

I beg to move amendment No. 1, in page 5, line 7, at end insert— '(2A) Before approving any pilot scheme, the Secretary of State shall give consideration to the effect that any proposals might have on the ability of the authority concerned to implement arrangements for the joint commissioning (with any social services authority) of personal medical services in combination with community care services.'. Amendment No. 1 is similar to an amendment that I moved in Committee, although it has been tabled in a somewhat simplified form—which will, I hope, help the Minister to decide to accept it. [interruption.]

Madam Deputy Speaker (Dame Janet Fookes)

Order. I am sorry to interrupt the hon. Member, but there is a buzz of private conversations, which is not acceptable. If hon. Members want to talk, they must leave the Chamber.

Mr. Thurnham

The amendment aims to ensure that, before any pilot scheme is approved, consideration must be given to the authority's ability to implement joint commissioning of primary health and community care.

I am surprised that provision for the establishment of pilot joint commissioning schemes has not been included in the Bill, given that the Government last month announced their desire to move further to break down the organisational boundaries between health and social care through the establishment of pilot primary care joint commissioning projects. The Government said that through the Scottish White Paper entitled "Ready for the Future".

I am disappointed that the amendment that I tabled in Committee was rejected by the Minister. The Bill would be a perfect vehicle for pilot joint commissioning schemes such as those which were specified as an option in the White Paper. The Minister said, however, when I quoted two examples of joint commissioning initiatives, that they were excellent and that the Government wanted to make them more the norm than the exception. I am not sure whether the Minister realised that the two councils to which I referred were Liberal Democrat-controlled. Perhaps he will note that.

The Minister said that joint commissioning is the way forward and a sensible way to provide "seamless care". That being so, I urge the Government to accept the amendment, so that consideration can be given by the Secretary of State, when giving approval to pilots, to the ability of the proposed schemes to take on board joint commissioning with social services. That is especially important in the light of last week's report following the inquiry into the dreadful Martin Mursell tragedy, when a mentally ill patient was released into the community. He murdered his stepfather and seriously assaulted his mother.

The chairman of the inquiry listed what he called the "appalling lack of co-ordination" between health and social services. I want to be sure that nothing in this highly commendable primary care Bill should jeopardise the future of joint commissioning initiatives, especially as the Government describe joint commissioning as the way forward for primary care.

Joint commissioning is necessary given the introduction of community care reforms in 1993. Boundaries of primary and social care have become increasingly blurred, especially where the care of the elderly, the disabled and the mentally ill is involved. Those who previously would have been looked after in long-term hospitals are now living more and more in the community. The process is to be welcomed, but I would not presume to say that it is at all easy.

The gaps and loopholes that we have created are becoming increasingly evident. For example, the practice of bed blocking is one appalling instance of the lack of a coherent framework for health and social care. It has become a particular problem of late in the North Manchester Healthcare NHS trust area. At the launch of the Green Paper on mental health last month, the Secretary of State acknowledged the glaring gaps in the care of mentally ill people because of the failure to ensure interdepartmental co-operation.

The Green Paper specifically examines the need for funding mechanisms to be modified to support more effective partnerships between health and local authorities. If the amendment were agreed to, it would not preclude any of the options set out in the Green Paper. There is no benefit in waiting, as suggested by the Minister. Why wait? Why not allow one option to be implemented now?

There is an overriding consensus in support of joint commissioning. The British Medical Association and many other bodies have made that clear. Mr. Philip Hunt, the director of the National Association of Health Authorities and Trusts, said: We must remove all the obstacles to joint commissioning. Denise Platt of the Association of Metropolitan Authorities said: We call on the government to work with us to develop joint commissioning as a reality for the future. Jennifer Bernard of the Association of Directors of Social Services said We all want the outcomes for users and carers to be the best possible. Closer working is the best way forward. The director of the Sainsbury Centre for Mental Health said: Joint commissioning is happening in some parts of the country, but this is usually because of the determination of a handful of dedicated people who want to make it work. What's needed is a proper statutory framework for joint commissioning which will create a single funding stream. At a recent seminar organised by the BMA on long-term care, 18 different organisations drew attention to the need for pilot schemes, which would allow shared budgets and joint commissioning.

One of Bolton's top doctors on geriatrics, Dr. Arup Banerjee, the medical director of Bolton Hospitals NHS trust and president of the British Geriatrics Society, said only recently: health services have been failing our older generations through inadequate and sub-standard medical and social care. He drew attention to the gap in provision between hospitalisation and care by untrained staff. GPs are in an excellent position to help, through joint commissioning schemes with social services departments. The BMA itself has said that, all too often, GPs experience a nightmare with community care. I should like to be able to ensure that the Bill will take community care into account as a vital factor in the granting of approval to pilot schemes.

9.15 pm

The current legal framework for joint commissioning and interdepartmental co-operation is contradictory and confusing, not only to the public but to GPs and social workers. Under the National Health Service Act 1977, funds can be transferred from health authorities to local authorities, but it is illegal to transfer funds from local authorities to health authorities. At present, the only way around that is via schedule 113 of the Local Government Act 1972, which permits local authorities to have access to the services of the staff of health authorities or trusts.

The Department of Health's own guidelines—in its practical guidance on joint commissioning, published in 1995—state that expert legal advice should determine how joint commissioning projects are established. That is clearly absurd. The needs of patients, rather than inconsistent legal technicalities to be dealt with by expert legal advisers, should determine the provision of services.

The Minister may recall that I have given two examples, relating to Sutton and Bexley. I feel that the health authorities and social services departments of both councils should be commended for their many initiatives. They have worked together to try to secure more and better services for users and carers with the same, or fewer, resources. Sutton is one of the authorities that have approached joint commissioning with enthusiasm and vigour, achieving enormous success in mental health provision. It has helped those with learning difficulties, and integrated the care of older people and those receiving continuous NHS care in the community. The King's Fund has adopted Sutton as a pilot site for a national joint commissioning research initiative involving joint primary care. It is also working closely with the south-west London total purchasing pilot to develop more co-ordinated services for older people.

Bexley is another authority that has established useful precedents of co-operation with the health authority, and a joint strategy for primary care. Those are just two of the many local authorities and social services departments that would support moves to rationalise their options in joining GPs in the provision of comprehensive primary health and social care.

As I said earlier, I was delighted by the publication of the Scottish White Paper "Ready for the Future", which established pilot joint commissioning projects in Scotland. I entirely agree with the Government's arguments in that paper about the need for such projects as a way to achieve a seamless service that is based on the needs of the individual rather than the services of the agency first contacted. The paper refers to the repeated pleas from those who work within the Service for greater flexibility… across the health/social care interface", and goes on to say: Care in the Community is an important policy which complements the development of Primary Care… It requires co-operation at the strategic, operational and service provision levels between health, social work and housing interests and also requires a shift in resources and provision from long-term hospital care to community care. In paragraph 95, which deals with breaking down barriers between health and social care, the paper states: The Government now judges that it would be desirable to move further to break down the organisational boundaries between health and social care, as these can be confusing to patients and can hinder the co-ordinated provision of care. Either the GP or the Social Work Department can be the key to the services needed, and in consequence there can be confusion and uncertainty about who to turn to in particular cases. This is especially so in more complex cases where the need for assistance is greatest. This confusion is not confined to the public. It occurs amongst those responsible for providing the services. It follows that one of the main ways of making the system more responsive to public needs is to help to remove some of the confusion about existing organisational arrangements. Those are the Government's own words.

The White Paper goes on to describe the initiative of six pilot schemes to promote local integration of primary health and social care through the devolution of funding and accountability, and team working across all the professional groups involved in primary care. Health boards, trusts, GPs and local authorities in Scotland will be invited to submit proposals.

The benefits of joint commissioning are many, and will continue to become more important as the impact of demographic changes and community care policies leads to more people needing care in community settings. Joint commissioning would mean a seamless service and solve the problems of inter-agency arguments, cost shunting and loopholes in the provision of care to some of the most vulnerable people. It would give maximum value for money, reduce duplication and provide complementary services. People would get a higher-quality service, which would combine expertise and ideas. It would also give a better general picture of need, and facilitate planning for future needs.

In the light of their arguments, the Government should include the amendment, to ensure that the growing problem of gaps in provision between health and social care are taken into account when approving pilot schemes. The Bill gives an opportunity to make progress on the development of a seamless service of primary care.

When the Minister replied to these same points in Committee, he said, it seems sensible to consider the responses to the consultation on the Green Paper before progressing with any legislation."—[Official Report. Standing Committee D, 27 February 1997; c. 207.1 I can see nothing whatever to be gained by waiting. I can see no reason why we cannot proceed. That does not preclude any other options that were in the Green Paper. There is nothing to be lost by proceeding. I urge the Minister to accept the amendment.

Mr. Malone

The hon. Member for Bolton, North-East (Mr. Thornham) raises an important issue. He gave examples of a number of sensible objectives on which we are at one, but I hope that I can persuade him that his amendment is not necessary. I draw his attention to clause 4, which requires health authorities to comply with any directions given to them by the Secretary of State about the extent to which, and the manner in which, they are to consult on proposals. It also requires health authorities to make a recommendation to the Secretary of State when they submit proposals for a pilot scheme to him. The Secretary of State will be able to direct them on the matters that they must take account of when they submit their proposal.

The hon. Gentleman's objectives can already be achieved through the exercise of the direction-making powers as matters proceed. I can reassure him-I hope that he will find this helpful-that we want health authorities to consult on proposals locally, including, where appropriate, social services departments. In the recommendations that health authorities make, we will want them to set out the impact that the proposals would have on local services. The hon. Gentleman wishes to achieve that through his amendment.

We will want assurances that the new arrangements will lead to improved local services and not just skew services in one particular direction at the expense of other patient services. That is an important criterion, to which the hon. Gentleman referred, and it is a matter on which we have made some progress. In 1995, we published practical guidance on joint commissioning. There will be a development programme, including a series of locality workshops, to encourage and enable authorities to develop their joint commissioning further in taking this work forward.

A second strand of the development project is the establishment of a number of locality sites to explore the involvement of GPs and primary health care teams in joint commissioning. I hope that I have been able to reassure the hon. Gentleman that not only is this something we expect to happen, there is a programme of work to ensure that it will happen. The provisions in the Bill are sufficient to ensure that. I ask the hon. Gentleman, having considered that, to withdraw his amendment.

Mr. Thurnham

I am sorry that the Government do not feel able to accept the amendment, and hope that if we cannot make further progress in this Parliament there might be an opportunity to make rapid progress in the next. I shall not press the matter further now. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr. Thurnham

I beg to move amendment No. 2, in page 5, line 12, after 'practitioners', insert 'or dental practitioners'.

Mr. Deputy Speaker (Mr. Michael Morris)

With this it will be convenient to discuss the following amendments: No. 3, in page 5, line 16, after 'practitioners', insert 'and dental practitioners'.

No. 4, in page 5, line 18, after 'practitioners', insert 'and dental practitioners'.

No. 5, in page 5, line 20, after 'practitioners', insert 'and dental practitioners'.

No. 6, in page 5, line 23, after 'consult', insert '(as appropriate)'.

No. 7, in page 5, line 23, leave out '(as appropriate)'.

No. 8, in page 5, line 29, after 'services', insert; and dental practitioner" means a dental practitioner whose name is included in a dental list (within the meaning of section 3(3) above).'.

Mr. Thurnham

The Secretary of State must have regard to the distribution of services when he gives approval to pilot schemes. These amendments correct what I can only think was an oversight on the part of the Government. It must have been an error that dentists were not included in the Bill.

Clause 1(1)(b) specifically calls for dental services to be provided by pilot schemes in the same way as medical services.

Clause 3 details the nature of dental services that can be provided under a pilot scheme in the same way as clause 2 details medical services.

Clause 5, which establishes the factors on which approval of pilot schemes should depend and the obligation of the Secretary of State to have regard to their effect on the distribution of services and so on suddenly seems to forget about dental services and talks only of general practitioners. The distribution of dental practitioners has been entirely forgotten.

There are enormous variations in dental health between different parts of the country. The paper, "An Oral Health Strategy for England" contains a map from which it is clear that the north-west region is the worst for dental health. The bottom 12 areas are all in the north-west. The tables published by the British Association for the Study of Community Dentistry show, sadly, that Bolton, of which my constituency is a part, is at the bottom of the national league table, along with north and central Manchester.

Dentists in my constituency, and the dental consultants to the Wigan and Bolton health authority, are extremely concerned about those figures. I share their concern that the Bill should play its full part in raising standards of dental health. It is vital that the distribution of dentists should be included in the Bill, as is the distribution of GPs. Dentists in my constituency and the dental consultants to the Wigan and Bolton health authority have pressed me on what the Bill will do to improve dental health in the north-west, which is bad and, in areas such as Bolton, deteriorating.

The single biggest issue for dentists who are concerned about primary services is fluoridation. Legislation is weak in that area. I was disappointed recently to receive a letter from the Minister in which he said that it should be a matter for the courts if a water authority does not go ahead with fluoridation when it has been requested to do so by the health authority. That fills the health authority with dismay.

I received a copy of a letter, dated 13 February, from North West Water to Wigan and Bolton health authority, in which the company made it clear that it will not go in for fluoridation unless Parliament decides that it should. It is wrong for the Minister to say that these matters should be taken up in the courts. We need much stronger legislation to ensure that fluoridation is introduced. The figures show that lack of good dental health correlates to deprivation. The best way to solve that problem, and hence provide better primary care services in the north-west, is to introduce strong legislation on fluoridation.

I quoted figures in Committee to show that the situation in Bolton is deteriorating. The number of five-year-olds who are free from dental decay has decreased from 41 per cent. in 1988 to only 26 per cent. in 1994. There is no chance of our achieving the Government's target of more than 70 per cent. of five-year-old children free from dental decay by 2003 unless much stronger measures to deal with the problem are taken.

The Minister may be aware that I am carrying out my own pilot scheme in my area—my own initiative—to help improve primary care services. I carry in my pocket a child's toothbrush, courtesy of sponsorship by Colgate and North West Water. I have already visited half the primary schools in my constituency to discuss with the children how they could better clean their teeth. I hope that the Minister will tell us whether pilot schemes could be introduced in the north-west to deal with the problem of deteriorating decay, so that dental practitioners and the dental consultants to the Wigan and Bolton health authority can have confidence that the Bill will help to address one of the most serious health deficiencies in the north- west.

Mr. Malone

I remind the hon. Gentleman that the distribution of the dental work force has an entirely different history from that of general practitioners. The statutory system established in 1947–48 did not include dentistry. Dentists have differing commitments to the NHS, and the distribution of dentists is often not the whole story, because they are free either to participate in NHS services or provide private services. If we were to impose a national distribution service of dental health care, I am not sure that it would work.

We want to use the dental work force as it is spread around the country in a more innovative way to deal with problems of oral health care. I hope that that deals with the hon. Gentleman's point and gives him the reassurance that he was seeking. What is important is how dentists spend their time, not how many of them there are in a particular area. The purpose of the Bill is to ensure that dentists can be targeted by contracts to meet local priorities in the most effective way.

The hon. Member described an oral health scheme in which he is actively participating. A scheme where it can be demonstrated that there will be an improvement in local oral health care over a segment of the population. rather than one in which people carry toothbrushes around in their pockets, is precisely what the changes in the Bill presage. That is what we said in our Green Paper, what we have said since, and what the Bill will bring about.

The amendments would give unnecessary and inappropriate weight to the number of dentists in a given area in the assessment process for pilot proposals. The information would not even enable us to influence the overall number of dentists providing NHS services. That must be done through contract. The Bill will provide the ability to target improved oral health care on areas of population that are deprived of it just now. I hope that the hon. Member will understand that that is the proper purpose of the legislation, and that his amendment is effectively unnecessary.

9.30 pm

Mr. Thurnham

I am disappointed that the Minister is not able to accept the amendments. I feel that they would improve the Bill. If we had more time, we could debate the matter further, but I shall not press the matter now.

The issue is of serious concern. There is a high concentration of poor dental health in the north-west. According to Mr. Colin Dean of the Bolton Dental Company, Bolton has the highest concentration of dental manufacturing businesses in the world, which indicates the extent of the problem. I hope that the Minister will be able to address the issues that I have raised in the remaining days of this Parliament, and that they will be fully addressed in the next Parliament. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.