§ 11 am
§ Mr. Michael Wills (North Swindon) (Lab)
It is vital that service reform is to be driven from the bottom … What are the key elements if we are really to put the public at the heart of public services? First, it means a continuous drive to increase the scope and scale of choice available to public service users.Along with choice we must also provide the public with a louder and clearer voice.Those are not my words, but those of the Prime Minister at Rickmansworth in January, describing a vision that is reflected in the Department of Health's paper, "Building on the Best". I requested this debate to explore how those noble aspirations have played out in Swindon over the last year, with a proposal to improve services for dementia sufferers and their carers.Nationally, around three quarters of a million people suffer from dementia. There are about 3,500 sufferers in Swindon, most of them elderly. The symptoms can pose severe challenges for carers. It is often difficult to devise appropriate care, because responsibility for those suffering from the illness falls between many local agencies, including the mental health trust, geriatric care and social services. Because of the difficulties of allocating responsibility for care, dementia sufferers can end up at increased risk of admission to hospital, occupying acute beds, which can cause bottlenecks elsewhere.
For those reasons, and because I believe that we need to improve choice and service in the NHS, 18 months ago I convened meetings in Swindon with local agencies, representatives of local carers and my hon. Friend the Member for South Swindon (Ms Drown), to try to develop a new and better mechanism for dementia care. Following conversations in the summer of 2002, we worked together between October of that year and April 2003.
After exhaustive discussions of all the issues involved, the local managers proposed a new system, which would offer carers and users of dementia services a menu of care choices from which they would be entitled to choose items up to a predetermined limit. Current statutory providers would offer the choices, along with any voluntary or private sector providers that might he interested in participating in the scheme. The menu would be drawn up and agreed by a standing committee chaired by a carer and comprising representatives of statutory providers, users, carers and the voluntary and private sectors. To enable users and carers to make effective and informed choices about their care, a new information and guidance service would be established to empower and advise them.
The proposal would deliver diversity of provision and choice, and put users and carers in the driving seat by involving them in the responsibility for service provision. It would also tackle the challenges involved in doing so, not least by finding a new way to encourage collaboration between the various agencies in a way that was equitable for all users. Roger Bullock, the consultant for old-age psychiatry in Swindon, describes the programme as
a major step forward—nothing else like it is happening as far as I know. It is also based on true socialist values.281WH The project could have been operational by Christmas 2003, but that would have required two key things from central Government. First, we needed a relatively small sum, around £100,000—about £3 per year per dementia sufferer in Swindon—to provide an information support line, so that carers could make informed choices or, to use the jargon, to tackle the asymmetry of information. That is one of the challenges in providing choice in health care and something that "Building on the Best" recognises is vital. Secondly, and importantly for the agencies concerned, they needed assurance from central Government that they would not be penalised for their initiative and enterprise.
"Choice" is a word like "motherhood"—nobody could possibly be against it. However, introducing choice into public services effectively requires hard decisions. The muddle that the Conservative party has got itself into with its so-called passports shows how difficult the task can be. Among other things, because users have freedom to make choices, no one can predict in advance the exact outcome of those individual decisions. Therefore, no provider can be certain in advance exactly what resources will be required to provide those choices. That demands either surplus capacity, which is expensive, or highly efficient management able to deploy resources flexibly and swiftly to meet shifting demand.
In this case, because it was unlikely that sufficient extra funds would be available for the new service, even after the Government's unprecedented investment in the NHS, local managers were required to be highly efficient in their management of resources. That was a big challenge, but they all felt that the potential rewards for service users were so great that they were prepared to take it on. They believed, rightly in my view, that their skill and expertise and their knowledge of their patients would enable them to meet demand effectively. The enthusiasm and commitment of everyone who took part in developing the proposals were palpable.
Gillian Barber, manager of Swindon's Princess Royal Trust for Carers, told me this week:
This proposal is exactly what we need as it gives carers real choices and would enable them to take more control over their own lives. We had hoped it would have been up and running by now and I am sorry that it seems to have stalled in the Department of Health.All the local agencies felt that although they were doing a good job, they could do still better and this proposal could help them to do so. Although all the chief executives of the various agencies were prepared to commit themselves, they were concerned that their boards would be worried that the new challenge would affect their ability to meet all their Department of Health targets. They needed assurance that if they embarked on this enterprising and imaginative initiative, they would not be penalised by the Department for missing any targets as a result.I therefore spoke twice to the previous Secretary of State for Health and his special adviser and made those two simple requests of them. They were enthusiastic about the proposals and thought that there would be no problem in finding the small sum needed for the information support line and reaching some agreement on targets.
282WH I hope that it will be helpful to the Minister, who has not been directly involved, if I recount what happened next. I wrote formally to the Department on 10 May last year, proposing the scheme as a pilot—and received no reply. I wrote again to the Secretary of State on 6 June—and received no reply. The Secretary of State then resigned and I spoke to his successor about the proposal. He, too, welcomed it and asked me to write to him. I did so on 17 June, referring to the earlier letters.
Finally, I received a reply dated 11 July from a Health Minister. It diligently set out the action that the Department is taking to improve dementia services nationally and gave interesting details of initiatives elsewhere in the country. Somehow it managed to overlook the crucial matter of reassuring local managers in Swindon that if they proceeded with the proposal they would not be penalised for being enterprising.
After consulting front-line professionals in Swindon, I wrote again on 31 October asking the Department to reconsider its original response. After sending a reminding letter, I received a reply on 15 December, which attempted to justify the letter of 11 July but still somehow managed to overlook the point of the original correspondence. I wrote again pointing that out. Just before Christmas, by chance, I saw the Secretary of State in the House and pointed out how disillusioning his Department's responses had been for front-line professionals in Swindon. He asked me to write again to his special adviser, which I did on 22 December, offering to engage in dialogue to see whether we could get the proposal moving. To date, I have received no response.
§ Ms Julia Drown (South Swindon) (Lab)I congratulate my hon. Friend on his hard work, and I join him in trying to support dementia sufferers in Swindon and their carers. That is difficult when progress is blocked and bidding processes leave people disappointed. Does he agree that we should encourage the Government to say that we should focus on key areas and develop schemes with professionals? Then we will not have to deal with the loss of morale that we have both witnessed when people become excited about a project but it does not come to fruition.
§ Mr. WillsYes, my hon. Friend is absolutely right. She has identified a crucial problem. If we are to make rapid and effective public service reforms, we have to engage front-line professionals. The Prime Minister has made that point repeatedly—possibly in every speech that he has made about public service reform. I hope that the Department will recognise from this episode that it must learn the lessons suggested by my hon. Friend.
I reflected on the saga over the new year and concluded that there might be an institutional blockage, as emerges occasionally, in the Department, stifling the choice agenda and the programme of reform that the Prime Minister wants to pursue. Two months ago I again wrote to the Secretary of State proposing the creation of a new fund for innovation, specifically to enable radical reforms proposed by front-line managers to take place rapidly. On 1 April—I assume that was coincidental—I received an answer that again somehow managed to oven look my proposal and, without any apparent irony, reiterated the importance of providing choice and empowering front-line managers.
283WH In responding, I hope that the Minister will resist the temptation to reiterate the importance that her Department attaches to choice, to empowering front-line managers and to the need to provide better care for dementia sufferers and their carers. We all agree on that. Instead, I hope that she will reassure me, my hon. Friend, and front-line professionals in Swindon about the way that her Department has handled the proposal from front-line managers to produce a better service and more choice in Swindon.
No one ever expected the proposal to be accepted and funded just like that. If the Department had said, "Thank you very much, it is an interesting idea, but unfortunately we can't proceed with it for x, y, and z reasons", everyone would have understood. Such a response would at least have indicated engagement with the idea. Unfortunately, those professionals who put so much energy and imagination into developing the proposal have not received even the courtesy of a considered rejection of the idea, let alone an active dialogue about it.
I would be grateful if the Minister could supply direct answers to a few questions. First, is her Department prepared to enter into constructive discussions with front-line professionals about ideas that they develop to promote public service reform? Secondly, if so, is it prepared to discuss proposals that arrive spontaneously from the front line, or will it consider only ideas generated within a format determined centrally by the Department itself? Thirdly, if the latter, can she explain how that is consistent with the Prime Minister's view that:
It is vital that service reform is to be driven from the bottom"?Fourthly, does the Department recognise that delivering choice can create difficult challenges for front-line professionals in the effective management of inevitably limited resources? Fifthly, if so. does the Minister accept that, within a framework of inevitably limited resources, delivering choice might involve conflict with targets already set by her Department? Sixthly, if so, does she accept that front-line managers may need dialogue and understanding with the Department, at least in the early stages of delivering the new programme of reform, about how to reconcile the imperatives of delivering choice and existing targets?
Seventhly—this is the question to which I hope the Minister will devote most attention—in any event, is she prepared to enable local professionals in Swindon to enter into a dialogue with the Department on how best to drive forward the imaginative and enterprising proposal that they developed more than a year ago? Finally, if so, when? I am happy for her to write to me with those answers, but I would be grateful for any reassurance that she could give me new.
§ The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)I congratulate my hon. Friends the Members for North Swindon (Mr. Wills) and for South Swindon (Ms Drown) on raising this subject. The care of dementia sufferers is an important subject that I appreciate is close to the hearts of both my hon. Friends.
I have carefully listened to and appreciated the comments made by my hon. Friend the Member for North Swindon. I start by paying tribute to the staff in 284WH the local health economy who are, as both my hon. Friends will agree, committed to the improvement of local services. My hon. Friend the Member for North Swindon posed some specific questions and I have a little time in which to respond. I shall set out a little of what the Government are doing to improve the care of dementia sufferers before addressing the points that he raised.
Dementia impacts on the lives of the sufferers and those around them. It can exacerbate other illnesses and have a profound effect on the independence and dignity of those who suffer from it. If we contrast the resources available today with those that will be available in 2006, we see that another £1 billion a year will be spent on social services for older people. The package that is coming on-stream focuses on six main themes: providing faster assessment, stabilising the care home sector, expanding the range of services, providing easier access to community equipment, increasing choices for older people and providing more support for carers. All those services are relevant to older people with dementia.
Those with dementia and their carers need high quality, effective care. About 600,000 people in the United Kingdom suffer from dementia and they receive good care and support. Much of that comes from their family and friends, who work tirelessly to ensure that the partner, parent or neighbour is cared for in the best possible way. That is why, in 1999, we introduced the carers grant to support councils in providing breaks for carers in England. It has been increased to provide an extra £225 million over the past four years. It is worth £100 million this year and will continue at least until 2005–06 by which time it will be worth £185 million, helping an additional 130,000 carers. Councils will be able to use the money to give carers help to take a break from caring and also to give them ongoing support.
It is important that we get the framework and the services in the right place at the right time. That is why we have the national service framework for older people, which we launched three years ago. It is a 10-year plan and contains a standard dedicated to the improvement of mental health services for older people. Standard 7 is designed to ensure that the right services meet the needs of older people with mental health problems and people of all ages with dementia, whether they live at home or in residential care, or are cared for in hospital. It is also there to ensure that older people have access to integrated NHS and local authority mental health services that provide effective diagnosis, treatment and support for them and their carers.
There is an emphasis on the early diagnosis of dementia, and our priorities and planning framework requires that services to meet the needs of people with dementia and depression be given a high priority. By April 2004—which is now—protocols must be in place in all health and social care systems to provide those integrated services. The information that is being gathered suggests that that milestone is being met. That means that health and social care organisations will work together to provide the services that older people with mental health problems need.
285WH I now turn to my hon. Friend's proposals, which he has outlined and explained. I am obviously aware of his correspondence with my ministerial colleagues about the proposals for services in Swindon. I appreciate that he has been unhappy with the response, but it remains the case that the Department does not give money on an ad hoc basis for projects such as the one that he has described. That is partly a result of the fact that we have shifted the balance of power to a local level by devolving funds to a primary care trust level. The latest round of allocations means that Swindon PCT has £166.7 million for 2004–05, a cash increase of 9.5 per cent.
None of the growth money in the latest round of allocations to PCTs has been identified for specific purposes. That gives NHS organisations the maximum flexibility to use the resources available to meet national and local priorities. Avon, Gloucestershire and Wiltshire strategic health authority, the local SHA, is aware of my hon. Friend's proposals.
§ Mr. WillsI did not want to interrupt the Minister's flow, but I was getting the sense that she had formed the impression, despite what I have said and despite my correspondence, that I was unhappy with the response because no money was coming forward. That is not the case. I am unhappy with the response because, despite the extensive correspondence, none of it addressed the key issue that I raised.
The worry locally was not about money; people recognise the Government's enormous investment in health care and are grateful for it, as it is making a huge difference in my constituency. My hon. Friend the Member for South Swindon, too, acknowledges the transformation in Swindon; the PCT is working incredibly well as a result of the reforms and the Government money. There should be no misunderstanding about that.
Local people were worried about what would be required to introduce choice into the local service in caring for sufferers from dementia. No response from the Department in the last year even acknowledged the issues, let alone addressed them or said how the targets would be managed. I hope that the Minister will refer to that issue.
§ Miss JohnsonI will indeed. I was just coming to the point about the potential conflict in respect of targets. The role of targets in all public services is under examination as part of the current spending round; the Department of Health has said that it wants to consider how targets are set and used throughout health services, and a dialogue is continuing on the matter at all levels.
I understand that my hon. Friend is not saying that resourcing is the issue. I shall explain how a proposal would normally be dealt with, because if the matter is not about funding it is about getting agreement to go ahead with the proposal, as my hon. Friend is suggesting. He will correct me if I am wrong. but as I understand it, the strategic health authority has not yet seen a formal, agreed, detailed proposal on the matter. I appreciate that my hon. Friend seeks reassurance before the work progresses, but the route normally taken is that a formal, agreed proposal, which clarifies the necessary 286WH governance and accountability arrangements when funds are being allocated, is put to the local SHA for its consideration. Proposals then go into the bidding round for consideration as part of the local delivery plans, which will also include funding allocations from all the participating parties. The SHA might usefully work on addressing outstanding issues—
§ Miss JohnsonIf my hon. Friend wants me to answer those points perhaps he will give me a minute to reply; he can then respond if he wants to do so.
On the discussions that have taken place, the question whether there are conflicts between targets and choices is partly a matter of what happens about the targets, but generally there are choices to be made by the authorities who put money into local services. That is principally, in this case, the PCT, but other local authorities may have allocations of money which are relevant to the proposals. It is up to them to take decisions on how they spend the money available to them. We encourage them to be innovative and creative in doing so, within the existing arrangements. There is nothing in those arrangements that would preclude acceptance of the proposal, although it has yet to be considered by the SHA.
§ Mr. WillsI am grateful to the Minister for giving way again. As I have come up against a brick wall in my correspondence, I am seizing this rare opportunity to raise these matters. It has taken a year to get this stage.
With respect to my hon. Friend, she has still not quite got the point. What she says may well be so, but that is not what people in Swindon felt. For many good reasons, the hard-pressed but extremely competent and professional front-line managers work within a tight framework of targets, and they were anxious that if they took what would have been a very innovative step—I know of no evidence that it has happened anywhere else—they might be penalised. All they needed was some reassurance that they would not be penalised. They simply needed someone in the Department to say, "We will have an understanding with you about this. Do your best. We will not let you have carte blanche to ignore all the targets because they are set for good reasons, but if we can see that you are genuinely trying to improve service for users and to promote choice, we will not hold you to account if you miss some marginally important target as a result." Managers may or may not be right to be worried, but they simply need some reassurance from the Department. They do not mind hearing the word "No". No one in public service does. They simply want a dialogue with the Department.
§ Miss JohnsonI am grateful for that further clarification. I understand what the problem is, but I am a little mystified about how it has arisen. That reassurance should have been available through talking 287WH to the strategic health authority. If the SHA has issues with this, it is initially a matter for local dialogue. I am not aware that that dialogue has taken place.
§ Miss JohnsonI am happy to keep giving way, but there is a danger that I will not be able to make my final points.
§ Mr. WillsI want to make one last point. I realise that because I have intervened so often my hon. Friend may not deal with all the points that I have raised, and, as I said, I would be happy if she gave me her detailed response in writing. My final question could be added to her list: why did nobody, in any of my correspondence or conversations, tell me to go to the strategic health authority?
§ Miss JohnsonAs my hon. Friend will appreciate, I have come in only at this juncture. I am at a loss to explain what has gone wrong. There may have been a breakdown in communication somewhere that has been unhelpful to his constituents and the front-line managers who have been doing the work. I appreciate the point that he is making. I am sure that the Under-Secretary of State for Health, my hon. Friend the Member for South Thanet (Dr. Ladyman), will be happy to meet him and my hon. Friend the Member for South Swindon to discuss the matter further.
This has been an unhappy process, as my hon. Friend the Member for North Swindon is pointing out. I do not believe that there are any obstacles in the system to prevent the scheme from going ahead. As I said, there needs to be a dialogue with the strategic health authority for the proposal to be approved and included in the local delivery plan. I am sure that we can arrange for a meeting to take place. I cannot promise my hon. Friend how soon it will be—it depends on his diary—but it will be as soon as is reasonably practicable on all sides.
I trust that if my hon. Friends identify similar issues where local managers are uncertain about how much freedom they have, they will reassure those managers that their first port of call is to their immediate line management and then on to the strategic health authority. If uncertainty persists, I hope that we will be more speedy in giving reassurance by saying "Aye" or "No" to proposals such as this one which, I recognise, has been drawn up with a lot of local support and involvement and has the potential to drive forward the choice agenda in Swindon.
§ Sitting suspended until Two o'clock.