Integration of Primary and Community Care (Committee Report)
(7 months, 1 week ago)
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Baroness Pitkeathley
That this House takes note of the Report from the Integration of Primary and Community Care Committee Patients at the centre: integrating primary and community care (HL Paper 18).
Baroness Pitkeathley (Lab)
My Lords, many of your Lordships will know that for a long time I have been concerned with health and social care principally though the experience of carers. I have lost count of the number of times I have heard carers say something like, “What I don’t understand is why it doesn’t all fit together. How come the GP didn’t know that Mum was being discharged from hospital? Why did the community nurse and the social worker not know each other? Why have I got to give Mum’s details over and over again to different people?”
So when I was asked to chair a House of Lords special inquiry into integrating primary and community care, I was delighted. I express my most sincere thanks to the 12 cross-party members of the inquiry, most of whom are speaking today, for their knowledge, skills, commitment and wisdom. Most unusually, we had—for reasons beyond anyone’s control—three changes of clerk during our deliberations, so I acknowledge the ongoing support of Chris Clarke and, most of all, Matthew Burton, who was and is a shining example as our policy analyst. I am most grateful to our special advisor, Professor Gerald Wistow, whose long experience in both the health and social care fields was invaluable. I welcome, too, the other speakers in our debate and am grateful that the noble Lord, Lord Jamieson, has chosen this one in which to make his maiden speech.
The inquiry took evidence from 70 witnesses, we had 76 written submissions, and we undertook two visits to projects in areas where integration is definitely benefiting patients. Defining integration is not easy, but we took as our definition something from a government policy paper that had been in use for years before that:
“the planning, commissioning and delivery of co-ordinated, joined up … services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole. Everyone should receive the right care, in the right place, at the right time”.
I guess no one in this Chamber will be surprised that our inquiry found that there is a very long way to go to achieve this, and that patients are constantly being inconvenienced or endangered, or missing improved long-term health, because they are not receiving joined-up care in the right place and at the right time. Poorly co-ordinated care significantly undermines the quality of patient experience in the NHS and can have profound consequences for long-term health.
The inquiry heard of patients suffering vision loss, or facing critical delays in treatment, due to the mishandling or loss of records between services. Patients in care homes frequently endured inconvenient and unnecessary trips to see their GPs or to hospital appointments. Consultants did not talk to each other or consult about patients, resulting in the absurdity of a patient seeing three separate consultants for the three injuries sustained in one fall.
Community nurses were unavailable and rarely in contact with other professionals. Complex care is fragmented across various services, which do not co-ordinate with each other to plan overall patient care and recovery, let alone to take responsibility for the preventive services which we all know are the long-term key to a viable NHS. Social care was not actually within the committee’s remit but witnesses frequently referred to the lack of integration between those two elements as an even more serious problem than the intra-NHS difficulties.
The inquiry identified four key obstacles to integration which could be addressed. I will refer briefly to each of them, with our suggestions for tackling them. The first was structures and organisation. The Health and Care Act 2022 encourages local autonomy and subsidiarity to encourage interservice relationships, but designing a universal policy has proved difficult. The imbalance of power and representation in ICBs, ICPs, local authorities and the voluntary and community sectors limits integration. Of course, it is relatively early days, and almost all our witnesses said that they must be given more time to mature.
We do not propose further reorganisation but suggest that the membership of the governing bodies should be widened and accountability enhanced through better inspection. Health, social care and voluntary sector leaders should work together as equal partners, as they are likely to possess a real understanding of their respective communities. This would encourage integrated policy-making and service provision, as well as a more preventive approach to public health. Importantly, there should be a single accountable officer at place level, specifically charged with working with local leaders.
Our second obstacle was contracts and funding. The NHS allocates an excessive amount of funding to reactive hospital care at the expense of preventive primary and community care. That is a strong statement, but it was not our conclusion: it was the opinion expressed by all four former Health Ministers and Secretaries of State who gave evidence to us. They were from different parties and were Ministers in different circumstances, but they were adamant on that point. Too much money goes to hospitals. Service contracts lack incentive for multidisciplinary care and reform is needed to ensure that this is incentivised.
Co-location encourages better communication and easier access for patients, but the existing GP contract and partnership model hinders this, as does the fragmented funding across different health disciplines. Of course, there is the huge divide between local authority-funded care and that funded by the NHS. The better care fund has made attempts to bridge this gap, but joint funded mechanisms need to be significantly enhanced. The better care fund should cover a larger proportion of relevant NHS and local authority expenditure, and the fund’s statutory responsibilities should be devolved to place-based commissions. This would enable decisions on joint funding to be taken by those with a better knowledge of local needs.
The third obstacle we encountered was data sharing. Single patient records have not been universally adopted, and full implementation faces issues of interoperability and widespread IT inadequacies. For example, we came across people putting the same data into three separate computers because the machines do not talk to each other and the systems are not connected. More frustration was expressed by our witnesses on the inadequacy of connectivity than almost anything else. As well as the technical issues, data sharing is hindered by cultural and perceived legal obstacles. The DHSC should publish guidance that clarifies how data and privacy laws apply to patient data, so that everybody is clear about their responsibilities.
Our fourth obstacle was workforce and training. Staff shortages make integration more difficult; of that, there is no doubt. When you are up to your eyes on the front line, have you time to develop new ideas for integrating? Specialised staff are not trained sufficiently in the work of other disciplines, and there are of course hierarchies of professions and services. Integration needs to be included in all initial clinical training, and clinicians should be introduced to other services by job rotations. Better training for social care workers would enable them to work more effectively with primary and community care workers, and social care must be included in the NHS long-term workforce plan.
Mindful always of the current problems faced by the NHS, we were aware of the shortages of people and resources that undermine integration, however good the intentions of individuals. We emphasise that better integration will reduce the long-term stress on the NHS, as it leads to more holistic and preventive care over time and encourages a problem-solving approach to work that ignores or bypasses artificial professional divisions. Our visits to Coventry and Pimlico provided us with evidence that real integration happens where you cannot see the joins between the professions.
In summary, trusting and constructive working relationships are essential for integration, together with aligned contracts and funding, as well as seamless data sharing. These were the focus of the 16 recommendations that we made to the Government as our inquiry ended. The Government’s response was delayed and when it came, it was very disappointing. In fact, it did not even give the usual “accept” or “reject” response to the individual recommendations, apart from one very lukewarm acceptance. In short, the Government’s response says that everything is under control and all the issues we raised are being addressed.
I will give an example. We found co-location to be extremely beneficial for integration and recommended that the Government should
“investigate different ownership models for GP practices”
and
“their co-location with other community services”.
The Government’s response concedes that co-location can be good but is not required. Although the Government say that NHSE and the DHSC are investigating
“new models of primary care estates”
there is no further information about that, and no timescale is given.
On another of our recommendations—for a single accountable officer—all the Government say in response is that some progress has been made and that a single accountable officer is “one way” of ensuring integration. That is another lukewarm response, which is in direct contradiction to the Government’s previous statements and commitment in the integration White Paper that a single accountable officer must be appointed.
For social care, we make what seem to us to be very sensible, cost-effective suggestions about multidisciplinary teams and joint training, as well as amending the workforce plan to include
“a strategy for increasing the size of the social care workforce”
so that it is sustainable in the future. Again, the Government’s response is immensely disappointing, merely saying that they will “consider” how they will
“support better integration of health and care to create a more flexible, agile workforce”.
In conclusion, I emphasise that the special inquiry was very clear about the purpose of integration: it is not an end in itself, but a means of achieving patient-centred care, reducing inequalities and getting a better balance between community-based care and hospital-based care. Despite endless commitments over many years to the importance of integration, I am sorry to say that the Government’s response to our report is a missed opportunity to show commitment and to bring about important changes, many of which are simple and virtually cost free—I emphasise: they are simple and virtually cost free.
The Government merely fudged their response. They lack any sense of urgency to deal with problems that will only become more urgent as our population ages and lives longer, with more comorbidities. We called our report Patients at the Centre. I am yet to be convinced—although I hope that the Minister may prove me wrong—that the Government are really committed to ensuring that patients are at the centre of primary and community care. I beg to move.
Lord Altrincham (Con)
This was an exceptionally interesting inquiry, which was most skilfully pulled together by our chair, the noble Baroness, Lady Pitkeathley, because the waterfront of the inquiry was very broad. As we were following the Health and Care Act 2022, the Hewitt review and the Fuller report, we started our work quite soon after some initiatives in the health service for integration had just started. In a sense, you do not have to do an inquiry to know that there is a whole lot wrong with the health service.
One might think that everything would be somewhat familiar, but one of the fascinating things about the inquiry was how much was rather new and interesting. The first thing that I comment on was that there was a common understanding in submissions of the problems. We heard from completely different kinds of professionals from across the country who shared again and again the same issues, which the noble Baroness, Lady Pitkeathley, has mentioned. In terms of the understanding of what is wrong, we heard Professor Yeandle talk about the fact that integration had not progressed for 25 years; we heard from others that life expectancy had stalled, that people are living too long with sickness, that health services are incredibly underresourced, and that prevention is being ignored. These issues are everywhere, and they are common. At the same time, we had a strong sense from the submissions of a common understanding of the need for change. That was interesting, because again one might think that surely the health service does not wish to change or somehow that these are institutional situations that cannot be changed. But we heard again and again from professionals who knew that they needed to work differently. That was interesting, because if we combine a willingness to change by people with structures in government and organisations that might make that possible, there might be some cause for optimism in this extremely difficult area of public policy.
Again, the noble Baroness, Lady Pitkeathley, mentioned the common understanding of the importance of integration. Everybody knew that integration needed to be done better. Everybody knew that parts of the health service they were working in were performing poorly. We heard from parts of the health service that are performing extremely well. I did not know before being on this inquiry that, if you get sick, you need to be in Greater Manchester. By far the best outcomes in health are in Greater Manchester; it is a great thing to tip off your neighbours. People talk about health tourism in London, but they are missing the best opportunity. The lessons from integration in Manchester and the co-ordination of the local authorities are not easy to transpose on to other parts of the country. We talk about that in our report, because some of these integrated care systems are not aligned well with local authorities; an extremely consistent part of the feedback we had in the inquiry is that you need to align with the geography and the shape of local authority services. We learned that from Manchester and from elsewhere, and it is what we put into our recommendations. The Government said that they are on to it, but they are not doing anything about it. Those will be the frictional areas where the quite large districts that form these integrated care services or boards will break down. We heard again and again that when it gets to county borders or geographic borders—not just whether you are near a teaching hospital but where you get to organisational frontiers, as it were—service breaks down.
That goes on to the issue of the structures that we were talking about. The integrated care system had only just started when we did our inquiry. In a sense, it is almost too soon for us to comment on it. There has been talk about how it should be reviewed after three years, and that will be very important. But we hope that it does in a sense address some of the issue we were trying to review, which was to try and integrate the service much better. It is only just starting out, however, and the districts concerned are very large. Maybe it is too soon to comment on that. We heard very good progress more with the primary care networks and these health centres and health hubs. That was very encouraging, because if the health service was able to provide multidisciplinary teams in a context where you could divide up medical with semi-medical and with not really medical at all-type services, we heard that it would go very well. Professor Everington speaks very well about the differences between biomedicine and social prescribing and providing a broader service. This is a very encouraging area of health, and it would be interesting if that were to be the model.
We also heard from Professor Fuller, but she makes the comment that in her own experience of trying to do the multidisciplinary thing when she is Dr Fuller, when the practice is full she has to work in a cupboard because they do not have the space. That is why the noble Baroness, Lady Pitkeathley, mentioned the importance of providing space where some of these services could take place. That is what Professor Fuller herself has run into.
In conclusion, there is cause for optimism from the report. There are willing people and there are some structures in the health service that are quite new and which might provide some improvement in this area. It has been a pleasure to work on the report.
Baroness Tyler of Enfield (LD)
My Lords, this debate is very timely as it picks up neatly from our recent debate on the long-term sustainability of the NHS. One of the key takeaways from that debate was the urgent need to move to a more preventive model of care, with investment moved upstream. It will be critical if we are to lower waiting times, improve access and reduce health inequalities.
It is indisputable that funding growth in the health and care system is skewed towards the acute sector. Despite the fact that the majority of daily NHS activity happens in general practice in the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts. Community sector funding has grown at only half the rate of hospital trusts in recent years. The answer to overcrowded hospitals is not simply more hospitals; the health and care system must be radically refocused to put primary and community care at its core.
As we have already heard, a more radical shift to a preventive model of health was one of the key findings of our Select Committee, which was so superbly chaired by the noble Baroness, Lady Pitkeathley—whom I always think of as my noble friend. In short, our committee found that a lack of co-ordination between the everyday primary and community services relied on by people using the NHS was leading to substandard care, missed opportunities for home or community-based treatments, and an undue strain on already overstretched hospitals. Our report argued for a healthcare sector where patients were given the type of care they needed, when, where and how they needed it. That might be access to a GP, a pharmacist, a district nurse or a mental health nurse, along with greater focus on more joined-up preventive care. The evidence is quite clear that investing in primary and community care—which includes mental health—results in lower demand in hospital and emergency care. It really is not rocket science.
A wholesale shift in thinking and culture is required, and it goes a lot wider than funding, as our report said. As the King’s Fund has argued, it involves national measures and targets for the health and care system shifting towards longer-term goals to integrate care and ensure that services can focus on population health rather than being focused on short-term acute measures. This approach is very much backed up by the World Health Organization, which has argued that a primary and community care-focused approach is the most effective and sustainable way of improving the health and well-being of our population.
We have already heard about integrated care systems, which have an important role to play in delivering this change, particularly if they focus on population health, as was the original intention. From the evidence we received, it was clear that local leaders know the challenges for their local communities and the local landscape of primary and community care, and they know it best. Leaders of integrated care systems, place-based partnerships, including health and well-being boards, and primary care networks are best placed to design and deliver joined-up primary and community care.
ICBs should be held to account for their achievements in growing primary and community care services rather than for the performance management of hospital systems, and a stronger primary care voice on ICBs and representation from the voluntary sector would undoubtedly help.
It was clear, as we all know, that the workforce is crucial, not just in primary and community health but in adult social care and the voluntary sector. We need a skilled and well-valued workforce to support people to live independent and healthy lives. Surely the Government should now commit to fully funding and delivering the NHS long-term workforce plan, alongside developing an equivalent plan for social care, where workforce shortages are leading the sector to struggle to support those who need social care, in turn placing additional pressures on primary and community care. Can the Minister say when the Government will heed the calls of so many in this Chamber and in the wider sector to produce a workforce strategy for social care?
Other speakers will no doubt focus on the importance of data sharing for successful joined-up services. We must ensure that patient records can be easily accessed across the health and social care system, including in primary and community care. I found the government response to our recommendations on this issue vague and technocratic. Will the Minister please say exactly what the Government are doing to ensure this happens?
I will pick up on a couple of other specific points from the government response. Recommendation 2 of our report said that elected local government officials should be given the right to chair ICBs where that was the will of the board, underlining the truly joint and equal role of NHS bodies and local authorities in producing a holistic health and social care system. The government response did not make clear whether they were prepared to let this happen. Can the Minister please answer this specific point?
Recommendation 5 was for the Secretary of State to instruct the CQC to develop a specific integration index to compare how well ICSs co-ordinated different services in their areas. The government response does not commit to implementing this. Will the Minster say what the Government’s intentions are in this area?
Finally, recommendations 14 and 16 contained important proposals on training and job rotation. We saw a clear tension between our hospital-centric system of health and care, with increased specialism, and people having increasingly complex health and care needs, which need an integrated, holistic response, hence the need for a different approach to training and job rotation. I would like to see clinical and managerial health leaders strongly encouraged to work in community settings and develop experience across a range of sectors. I found the government response on this unsatisfactory—indeed, there was no response to the point about job rotations. I strongly urge the Government to think again.
Baroness Finlay of Llandaff (CB)
My Lords, I declare and update my interests as listed in our report, as I now chair the Bevan Commission in Wales. It was a pleasure to be on this committee, so ably chaired by the noble Baroness, Lady Pitkeathley. She kept our focus on the topic at hand and worked extremely hard when there were changes of personnel in the clerical staff supporting our committee.
I came to this very important inquiry with experience of having set up hospice services from scratch, where nurses and care assistants needed upskilling and where bringing everybody together, including clerical and reception staff, for open education sessions resulted in them being able to outreach into community services. We established integrated working. Each person knew what the other one could do, and people worked to the top of their game.
As a committee, we were very keen to explore ways to transform the patient experience and decrease demand on health and social care services. We were acutely aware that we should not incur expenditure nor suggest major reorganisation but should reduce the waste from inefficient practices, and that much can be done by different attitudes and approaches.
We were acutely aware that patients want continuity of care. They often feel pushed from pillar to post, not sure whom to contact or even how to contact someone whom they have seen previously. If they get past an answerphone, they find that they are repeating their story time and again, uncertain about who does what and endlessly waiting for the next appointment along a whole chain that feels like a disjointed slow relay. Our suggestion to put health and social care providers together as much as possible, sharing ongoing training, sharing premises and with access to each other’s records, is really at the heart of patients’ experience of integration.
Yet the government response is deeply disappointing. Rather than welcoming our recommendations to provide additional strengths to their plans towards integration—which are outlined in their response—it reads as if the Government are saying, “We are doing it all already”. Yet, time and again, we heard from services about how disjointed they are. We heard about the changes that need to happen to bring health and social care together under one roof in premises fit for purpose, and we heard how disjointed IT systems are. The data held in the different record systems should be viewed as the patient data—it is about them—yet there seemed to be endless blocks to bringing staff and systems together.
We had hoped the Government would welcome our suggestions for patient data to be shared usefully and safely; for the multidisciplinary team to meet together and plan care; for joint education that would upskill social care to remove the risk-averse barriers to interventions that so often result in patients being put in an ambulance from home or a care home and sent to an already overcrowded emergency department for problems such as a blocked catheter or blocked feeding tube to be sorted out, when it could happen so much more easily if staff were upskilled and the patient would not then need to be moved. Many of the bureaucratic blocks could be overcome by honouring contracts that have all staff working together with common aims and contractual changes that reward work done and outcomes, with meaningless bureaucracy stripped out.
We repeatedly heard how patients cannot get the holistic care they need because staff are working in silos, often overseen by risk-averse attitudes from their managers; they do not feel able to do what needs to be done but revert repeatedly to a view of limited job responsibility. By staff working together under the same roof, as we suggested, for evolving general practices and primary care, integrating with local social care providers and the voluntary sector, the culture of care provision could be improved and better monitored to provide far better health outcomes in the longer term, particularly for frail and vulnerable people, for whom stability of place and of staff is especially important.
The Hewitt Review, published in 2023, found that culture, leadership and behaviours matter far more than structures. We wanted to break down the barriers in contracts and in behaviours, but the Government’s response seems to pull back from supporting our recommendations to focus on broad policies that were written recently, rather than address the need to build on them to create the crucial interpersonal relationships that determine good care. We felt disappointment in the Government’s response because it did not build on what they already are putting in place and encourage further integration, and it seemed almost to dismiss some of our suggestions by saying what they were doing but without welcoming our recommendations.
Baroness Armstrong of Hill Top (Lab)
My Lords, I too felt very privileged to be a member of this committee and want to extend once again my sincere thanks to my noble friend Lady Pitkeathley. She worked tirelessly and used the knowledge and the commitment that she always shows, even on occasion in difficult circumstances with an unusually high turnover of staff working to her. However, I also want to thank the staff because they always worked in a professional way to support the committee effectively. I knew I could rely on the very good other members of the committee to be detailed about the report. It now seems quite a long time ago, but I do want to take therefore a slightly different approach to my speech, as it is meant to be fairly quick.
When I was chairing the Public Services Committee, particularly during Covid, I got to know National Voices, a charity that works essentially with people with long-term conditions, often more than one; and these are the people that an integrated care system should be measured against. I want to go back to what National Voices said when it worked with the patients it was seeking to represent about what they wanted from what we call an integrated system but what it calls a person-centred, co-ordinated care system. We have different definitions, and we like the sort of rhetoric of integration, but we must never forget what the real purpose of it is, because creating care that is co-ordinated around the needs of the individual, rather than the requirements of the health and social care organisations, seems as far away today as it has ever been.
National Voices asked patients what they wanted from the system—and I shall give noble Lords some quotes. They said:
“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”.
I do not think that that is an outlandish demand. However, it recognises that, while we may be trying to patch together different services and feel that we have succeeded when two organisations say that they are talking to each other, the end product of integration for service users is an outcome whereby they feel more in control of what is going on. The outcome of all this co-ordination means that they and their carers understand what they need to do to keep improving and help make things happen. They said that they wanted to be able to say:
“I was supported to set and achieve my own goals. Taken together, my care and support helped me live the life I want to the best of my ability. I was in control of planning my care and support. I could decide the kind of support I needed and how to receive it”.
I am afraid that we are still a long way away from getting professionals to talk to each other about the whole person they are meant to be helping. Even when we get to that, unless that collective voice of professionals puts the service user in control, we will not really get the outcomes that we need. How do service users want communication to take place? Again, they have some simple wishes. They always want to be
“kept informed about what the next steps would be”.
They want to be sure that “the professionals involved” have “talked to each other”, so that they can see that they have “worked as a team”. They want to be able to say:
“I had one first point of contact. They understood both me and my condition(s). I could go to them with questions at any time. That person helped me to get other services and help, and to put everything together”.
People with different needs know that they need different expertise, and they welcome that expertise—but first they want to know first that the professionals will talk to each other and that someone will put everything together.
These statements—and I could go on—are straightforward and moderate wishes. As I understand it, integration has been in the last three NHS plans. There was even an integration White Paper two years ago yet, last year, with all the new structure that the Government say we must wait to see, NHS England and the DHSC issued contradictory instructions to ICBs, ICSs and trusts. That means that, if they take any notice, they will revert to working in silos. We have to move away from the rhetoric and get on with delivering what patients need, when they need it and in the place they need it.
Lord Jamieson (Con) (Maiden Speech)
My Lords, I declare my interests as a councillor in Central Bedfordshire and a member of the Government’s Older People’s Housing Taskforce.
I am deeply honoured and proud to be here, making my maiden speech. I am just a little sad as my mother, who was brought up in occupied Holland by a single parent, is no longer with us, but am pleased that my father, who taught me British constitution and about the House of Lords many years ago, was able to see me introduced. I express my huge thanks to all those who have been so helpful and kind, as I go through this astonishing learning curve—Black Rod, the clerks, the doorkeepers, everyone who works in the House and all your Lordships, who have been hugely welcoming. I express a particular thanks to my supporters, my noble friends Lord Porter of Spalding and Lady Scott of Bybrook, and my mentor, my noble friend Lady Redfern, who were all stalwarts in local government before me.
I started life as an engineer in Sheffield, working for British Steel. It is a tragedy in this country that we do not support our engineers enough, and I moved to marketing and banking as I sought to further my career and pay the bills, before getting involved in politics locally, then nationally as chairman of the LGA. Why? Because I, like councillors across the country, just wanted to do something for our communities and get stuff done.
One of the great successes of our society has been increased life expectancy, something I am sure that all noble Lords will be pleased with. In 1970, the average male life expectancy was 69, compared to the average age of a Peer today, which is 71. Today, someone retiring can expect to live to 85—a quadrupling of retirement. This is great news, but it comes with costs, most visibly in health and social care. This is exacerbated by other trends: a declining birth rate, along with people starting their careers later, and smaller and more disparate families. Long gone are the days when we had three generations of one family living in the same street or town, supporting one another. There is a breakdown of our traditional communities as we live more insular and transient lives.
There is one statistic that really brings this home: the proportion of the working population employed in health and social care. Currently, it is around one in seven. A recent Dutch report estimated that it would be one in four by 2040 and, without change, would inexorably rise to one in three. This is simply not sustainable; we need to think radically differently if we are to have a sustainable system and ensure that we all enjoy a fulfilling old age. It will require cultural change and a willingness to embrace the politically difficult. I am an optimist, and I believe this can be done, and we will achieve it.
I welcome this report, and the great work of the committee and the noble Baroness, Lady Pitkeathley, and its recommendations, many of which are in line with the work of the Local Government Association. We need to focus on prevention and early intervention—keeping people healthy for longer and out of hospital—and the crucial roles of primary, community and social care, integration, colocation, data sharing and a genuine, joined-up approach.
There are other key issues, such as housing and community. Living in isolated, inappropriate housing does not work. I saw the difference first hand, when my Dutch grandmother moved to an older person’ apartment in her sixties, next to shops, older people’s clubs and transport, and lived there for more than 30 years, needing virtually no additional help until very late on, and had a great life. My English grandmother continued to live in the family home, and had a very different set of outcomes.
We need homes that are suitable for later living, which are part of a community and in the community. There are many life-changing stories from the extra care housing we built in central Bedfordshire, but we need much more of this. Technology offers the opportunity to deliver so much more—AI, diagnostics, personalised medicines, robotics and health monitoring automation. We need to embrace this, but it will mean a radical change to the way in which our public services are delivered.
Finally, on keeping active, Department of Health figures show that only 17% of men and 13% of women over the age of 65 are sufficiently active. This is not just about exercise. Older people have so much they can contribute to society. We need to include them, and they need to include themselves. The retired can and should be the bedrock of our communities. While there is much that government should do, this is a much broader issue. We personally need to think about what it means to get older, and how we plan for it. We should not abrogate this and rely on others. People think about pensions, but not about housing, personal resilience, building their community networks and ensuring their own fitness and quality of diet. This is what I mean by cultural change. If we are to have a sustainable and positive old age, we as a society need to embrace it, recognise our own responsibilities, build communities and accept a changed public service delivery model.
Baroness Redfern (Con)
My Lords, it is a pleasure to follow my noble friend Lord Jamieson’s excellent maiden speech. I have enjoyed our mentoring discussions since he entered the House. Having served a successful term as chairman of the LGA, he noted in his leaving remarks:
“When we can speak with one voice, and with coherent arguments, we have real strength”.
That is crucial to the LGA’s ongoing success, now and into the future.
My noble friend also held the position of leader of Central Bedfordshire Council. His further interests are, in particular, sustainability, improving the health service, and the levelling-up agenda. I know he is committed to all councils playing their part in improving the health of their residents, meeting their housing needs and providing green spaces, which we all agree are vital to improving well-being and tackling social isolation. Yes, my noble friend certainly has much to contribute to the House and we look forward to his future interventions in the coming months. Finally, I am told that his immediate plan on leaving the LGA was to see Bruce Springsteen, but I do not know whether he managed to do it. He says that he did, so there we go.
It is indeed a privilege to speak in this important debate. I thank the Government for their response on this area of primary and community care. I thank our chair, the noble Baroness, Lady Pitkeathley, for her excellent chairing throughout our meetings, when we had the opportunity to hear from the many witnesses who gave up their valuable time to attend. I also thank our much-valued secretariat.
The value of collocation and multidisciplinary working in primary and community care is unquestionable, but having said that, care will continue to vary, whether in urban, rural or, indeed, coastal communities. It is valuable to pool additional funding into the BCF where that need is greater. I agree with the importance of all local authorities keeping boundaries under review, with support from all affected partner local authorities.
The overwhelming issue is the major barriers arising from the variability of our IT systems. Much work is needed in all areas to bring those systems together so that they are compatible, and to make real and lasting improvements by promoting interoperability between IT systems. That would not only make it easier for people to track information but allow for quicker decision-making, acknowledge patient privacy and, above all, cut bureaucracy. In essence, data sharing must improve so that we can say that data is just one click away, sweeping away the many fragmented systems that ask patients over and over again to supply the same medical information and engulf them in bureaucracy.
I am pleased to note that the Government have emphasised how important it is to provide additional clarity where necessary to support further integrated working practices. They have also acknowledged that the digital transformation of health and social care is a top priority for the DHSC by enforcing these standards through compliance notices, together with financial penalties, in parallel with an accreditation scheme. The framework accreditation programme will simplify procurement and speed up the adoption of innovation through frameworks, so I welcome NHS England changing the NHS standard contract by requiring trusts and foundation trusts to use only accredited frameworks from April 2024.
I turn to the estate. In essence, in many instances the answer to overcrowded hospitals is not building more hospitals but linking with intertwined primary care and social care services, as infrastructure is simply too important and costly to get wrong. If this does not happen, more expensive hospitals will need to be built to manage acute needs that could have been prevented or better managed.
For most people, being treated at or as close as possible to home is best for their health and is how they want to be cared for, rather than leaving their health needs until they require hospital treatment. That is best, and cost-effective for the NHS, but there is a cycle of invisibility of primary and community health and care services, which are hard to quantify and easy to overlook because less data is available.
Equipping our valued staff with improved training, creating opportunities through built-in shift flexibility for health workers, and giving greater responsibility for good career progression will no doubt improve morale and retention. For those reasons, that will attract and interest new employees, making the NHS a serious, attractive proposition now and for their future progression. As ICSs become more involved in education, training and planning, a plus point must be extending the provision of placements across primary, community and social care, in particular the independent and voluntary sectors, so that students can gain valuable experience of care outside hospitals, thereby introducing them to wider career opportunities.
Delivering primary care with the premises and tools needed to keep patients healthier for longer has to be a win-win: reversing the predicted rise in demand for high-cost, reactive, hospital-based care; supporting people in taking care of their health and well-being; and intervening early, keeping people healthy at home for as long as possible, and enabling them to retain their confidence, particularly when they live on their own.
This is against the background of an expected increase of 25% in the number people in the UK aged over 65 by 2050. That is certainly a massive challenge for any Government. I welcome the expansion of community pharmacies, which are showing good signs of integration and co-operation and take significant time away from GPs. The Government are consulting on extending prescribing rights to dental therapists and hygienists; this is hopefully to be concluded soon, ensuring a faster service. Therefore, patients must be given more powers, via the NHS app, to control their own health and NHS services, and to facilitate self-care in collaboration with professionals. Unfortunately, we have low levels of digital literacy among some staff, patients and service users; that is a barrier that must be worked upon and overcome.
Yes, much has to be done. Much more needs to be done if we are to see patients at the very heart of their health journey.
Baroness Barker (LD)
My Lords, I too pay tribute to the noble Baroness, Lady Pitkeathley. She and I have sat on a number of Select Committees in recent days, and I have to say that she was excellent as the chair of this committee. She steered us through the depression of weeks on end of people coming to tell us how the IT problems in the NHS were really difficult—and somebody else’s fault. She also took us through the days when people came from NHS England to tell us how perfect the situation was, and how our fears were groundless.
The noble Baroness, Lady Redfern, and I, week after week, bowled questions to people about IT, data-sharing and data governance, and I do not think we ever got a straight answer. Nor does the Government’s response deal with a critical question: who is responsible for the co-ordination of patient data? We can talk about anything we like, but until that question is answered and can be answered by everybody, we are going round in circles—and so are patients.
In preparation for this debate, I went on to the new NHS information portal. There is a lot of good stuff and good guidance on there, but nothing sufficiently definitive, as yet, to lead us out of the central problem: the responsibility of GPs to be the guardians of data. Such is the amount of patient data they have to deal with and co-ordinate that they are drowning in the system. As we have heard, they are having to deal with different IT systems. I know the noble Lord, Lord Altrincham, talked up Manchester, but I urge him to recall that, while Greater Manchester was recording increased health outcomes, two of the boroughs were not. Those boroughs were Oldham and Rochdale, areas I happen to know extremely well, and where for decades there has been a lack of GPs and community health staff.
In London we still have major hospitals that cannot talk to each other because they run on different IT systems. It is as simple as that. Therefore, unless and until we can go back and deal with some of those issues, which we flagged up in our report, we are on a hiding to nothing.
We know that the Pharmacy First programme is being rolled out. Only last week, in a report in the Guardian, pharmacists were cited as saying that they are not being given data. I think this is because GPs are being highly cautious and reluctant to pass on information in case they are held responsible for a data breach.
There are other parts of the health service in which that same problem comes up again—ophthalmology and audiology. Most people who have a problem with their eyes go to an optician, not a GP. The opticians do tests, then they refer somebody to a GP and, if there is a problem, they are sent to the ophthalmology department where, several months later, they go through exactly the same tests and get the same results. The same thing happens in audiology. The story of audiology is not one of the private sector and the NHS working together in a triage system; it is a story of delay, duplication and waste. If we cannot get it right for two conditions for which we have systems that could be put together quite easily—provided a data protocol was established—how will we do it for something such as complex neurological conditions, or some of the conditions that the noble Baroness, Lady Redfern, referred to in connection with old age?
I take the opportunity to say that noble Lords should listen to Hanif Kureishi talking this morning on the “Today” programme about what happened to him when he had a blocked catheter, and how he nearly ended up being unnecessarily blued and two’d into A&E, all because somebody could not find a community nurse. They did at the last minute, and he was sorted out.
One of the things we did not manage to get down to in the report, because we were so busy talking to all the GPs who could not sort out these data problems, is the lack of community health staff and the lack of local authorities that know where the health deficits are in their area, working in partnership with primary healthcare staff. I was sitting in an NHS hospital yesterday and I noticed a screensaver that read, “Confidentiality of patient data is everybody’s responsibility”. What it did not say is, “Co-ordination of patient data is nobody’s responsibility”. That is the issue we looked at and on which we came up with several recommendations. It is a great shame that the Government did not listen.
Baroness McIntosh of Pickering (Con)
My Lords, I congratulate the noble Baroness, Lady Pitkeathley, and the committee on their report and on securing this debate. I also welcome my noble friend Lord Jamieson and congratulate him on his excellent contribution today.
I declare my interest as an adviser to the Dispensing Doctors’ Association, and the fact that my late father and brother were both dispensing doctors. Dispensing doctors are general practitioners who provide primary healthcare to around 9.9 million rural patients. Almost 3.5 million of those patients live remotely from a community pharmacy and, at a patient’s request, dispensing doctors are allowed to dispense the medicines they prescribe for them. Only certain patients are eligible to receive dispensing services from a dispensing doctor. In total, around 7% of all prescription items are dispensed by such doctors.
The unique benefit of a dispensing doctor service is that it provides access to medicines and general healthcare under one roof. They provide a total network of 1,107 dispensing practices, spread across England, Scotland and Wales, and are a wonderful example of integration between prescribing and dispensing services that are collocated.
Turning to the conclusions of the report and the Government’s response, I think it is important to note that in Scotland health and social care partnerships have existed for a few years, yet funding arguments continue and, despite integration, there is still inadequate funding for social care, with a lack of care placements, delays in discharge from the acute sector and difficulties admitting patients in A&E, so integration has not yet met the needs of patients in Scotland. I ask my noble friend directly: does he agree that neither GPs nor their contracts currently prevent shared facilities? There used to be physios, district nurses, health visitors and others all collocated at a surgery, but it was these very organisations that removed themselves from the premises, not GPs.
I have some points to put directly to my noble friend the Minister. Remote consultations are simply not the answer. Complex patients and multiple conditions need more face-to-face time with GPs. Social care is means-tested; healthcare is needs-led. The difference between them must be addressed before integration can proceed further. Does he not agree that coterminous health and social care areas do not necessarily work for health, where patients may be given a choice, and it could actually destabilise current general practice if that were to happen? I also ask him to consider that it is not about who owns GP practices, which is perhaps a red herring. The Government must address the rules about occupation, then ownership itself becomes irrelevant. Will my noble friend and his department be mindful of the poor history of contracting, particularly GPs contracting out for out-of-hours service?
I ask my noble friend this directly, because this is something where NHS England, particularly in parts of Suffolk, has got the wrong end of the stick: why has EPS for dispensing doctors, and indeed hospitals, not been commissioned and the infrastructure put in place? The question of who is to pay for that infrastructure remains a vexed issue. I put to my noble friend the words of Dr West, who chairs the Dispensing Doctors’ Association; they strike a chord with those of many others, such as the noble Baroness, Lady Barker, and my noble friends who talked about data sharing, as well as the noble Baroness, Lady Pitkeathley. He asks why there is not one prescribing record per patient. Currently, there are different records for GPs and each hospital where that patient may be treated.
Will my noble friend urgently address the issue of GP training? The government response says:
“We will ensure that all foundation doctors can have at least one 4-month placement in general practice by 2030 to 2031”.
I am staggered, as I am sure others are, that this is not already the case. How can it be that, among doctors who are reaching the end of their training and are looking to have a placement, there are still about 100, as of this week, who do not yet have a placement to go to? That is unacceptable when they have reached the end of what is already a very long period of study and training.
To conclude, if integration is to proceed, which I would welcome, it has to be costed and well thought through. There is no one size fits all. What may well work in an urban area such as Pimlico, which was the example that was chosen, may not work in North Yorkshire or other very rural, sparsely populated areas. It has to be acceptable for the doctors and healthcare workers as well as the patients. Again, I note that integration in Scotland has not yet brought benefits to patients. I urge my noble friend the Minister to put GPs at the centre of patient care and ensure they have access to all patient needs, to ensure better care and fewer emergency admissions to hospital and a joined-up healthcare and social care service.
Lord Allan of Hallam (LD)
My Lords, I congratulate the noble Baroness, Lady Pitkeathley, and all the members of the committee for a very useful report on the challenges of integrating primary and community care, and for some potential solutions. I am grateful particularly for an opportunity to talk about data and technology in the health and care system, which is one of my favourite topics. I also congratulate the noble Lord, Lord Jamieson, on a thoughtful maiden speech. I was delighted to hear that he studied and began his career in my home city of Sheffield. Once people have followed the advice of the noble Lord, Lord Altrincham, to get their health sorted out in Greater Manchester, he might agree that they might then want to cross the Pennines to get a decent higher education in Sheffield.
The recommendations in the report on structure were really interesting and substantive. I shall talk about them first, then go on to the data. The report talks about integrated care boards, integrated care services and integrated care partnerships. If I may coin a Latin-based neologism, we could refer to them all as ICXs—integrated care entities. Some valid questions are already being asked about their effectiveness. Having to talk about them in this convoluted way in a sense already indicates that there are some real questions of accountability: who is doing what? To an extent, the thing that is supposed to pull everything together is itself causing some confusion. I read the Government’s response and, on the recommendation on maturity, they said that they were going to start a three-year research programme. This is great and serious, but three years from now will be a long time from when the ICXs were set up.
The Government also talked about the CQC process and about NHS England surveying people to ask about the effects on them in 2025-26. Does the Minister feel there is a sufficient sense of urgency? Trust and morale once lost are very hard to rebuild, and there enough indicators out there. The Government have placed a lot of store on the ICXs delivering all this. If they cannot deliver more quickly, and if we have to wait another three or four years before we really start to understand it, there are some genuine questions to be asked. None of us wants another reorganisation, but we need this thing to work, as the committee’s report has highlighted.
I turn to my favourite subject. Building to some extent on the comments from my noble friend Lady Barker, we need to understand that an interaction with the health and care system is, in technical terms, an event. The real priority is to get a proper record of that event. Three things need to be noted. Who was the person who had the treatment? Which organisation treated them? Ideally, that would go down to the individual, but certainly we want to know the organisation. Furthermore, where did it happen? With these three accurate identifiers, it is possible to start to pull the data together, whichever system it is stored in.
Each person has an NHS number. I shall be interested to hear from the Minister as to how he feels about the rollout of the NHS number. This report talks particularly about NHS organisations. To what extent is this being used within the NHS and other organisations? It is still certainly my experience—and that of others—that hospitals want a hospital number. Why do they want this? Why are they not dealing with the NHS number? It is critical that there is a real push to make sure that the NHS number in which we have invested and which is given to people is being used.
The Government have invested in something called the unique premises reference number—the UPRN. Every single premises in the United Kingdom has its own number. Government policy is to use that everywhere but, again, we are not seeing this happen. I am ready to hear from the Minister about the extent to which this is being pushed out across health and care so that, when talking about where someone is treated, it always means the same place.
Lastly, is there a unique set of basic organisational codes? There are tens of thousands of records so, in that way, it would be possible to identify the organisation that treated someone. Absent all of this, there is something called fuzzy matching. For example, John Smith, who lives in the High Street, was treated at some vaguely named health centre. Humans like that, but computers hate it—computers need precision. Those are the basics. We can then move on to the content of what happened in the interaction. Again, that is complicated. I think we would go a long way and solve a lot of the problems highlighted in the report by just knowing who the person was, uniquely, where they were treated and which organisation dealt with them. That could be done much more quickly.
The report’s recommendation on the data protection guidance was really important. My noble friend Lady Tyler talked about the Government’s response as being vague and technocratic. We end up talking about data protection in these very technical terms, and end up saying that data protection law says no as a default response. If we think about it in much more human and intelligible terms, would anyone be surprised that the data was used in a particular way? This is a basic human test that we can all understand.
If I go to an A&E department, and my medical data goes to the ward then to my GP, I am not going to be surprised—in fact, I will be surprised if it does not make that journey. If you pass it on to a dentist or an optician, I may be okay with that, but I would probably want to have a conversation about it, and say it is fine for some of my medical data to go to dentists and opticians some of the time. If you pass it to a pharma company for something totally unrelated to my own personal care, I might be very surprised and very angry. It is about applying those kinds of human tests.
There is a legal basis behind this that is missing. Will the Minister look at making sure that the people who work in the system are given training to understand the principles behind data protection? I suspect a lot of it is very detailed, telling them what the law says and how to tick the boxes; that is what gets us into this frozen position where data does not flow when it should, and people are surprised it is not flowing. Sometimes data may end up flowing where it should not, because people have not understood that it is happening. In their response, the Government talked about the secure data environment and things like OpenSAFELY. Those are very good solutions for dealing with areas where people would not want data to be flowing freely. We have created a place to deal with that, but let us get the data moving to where we want it to go.
Finally, I wanted to touch on workforce. The NHS workforce plan, which we have all welcomed, rightly focuses on doctors, nurses and other associated medical professions. However, when we are talking about this kind of work, in a lot of cases we need people to be skilled up. We need a very skilled workforce in other disciplines—for example, in change management, which is itself a discipline. Encouraging people to work differently is not something that happens overnight, and it is not necessarily a medical skill. The ICXs would benefit from having a skilled workforce who understand how to do change management.
Contracting is rightly a major feature of the report. It is about writing better contracts and being more insistent with those you are contracting with. It is not just about pounds and pennies and value for money. It is about saying, “We are not going to buy your system if it hasn’t got the right data standard, and I am going to insist on that because I know I can. I am not just going to sign whatever you stick in front me”. That kind of contracting ability is really important. Data analysts, who can look at all the data generated by these systems and figure out what is going on, are highly skilled professionals. I do not think we have got to the point in the workforce plan where we understand that need and how we are going to meet it.
We have an excellent report, and I thank the committee for what they produced. It has zeroed in on some of the real priority areas. The Government’s response is well intentioned but thin, and I hope that the Minister can put a bit more flesh on the bones of what they are going to do in practice.
Baroness Merron (Lab)
My Lords, I congratulate my noble friend Baroness Pitkeathley on her incisive introduction of what I consider to be a pragmatic and thoughtful report, although I am sure it did not make for pretty reading by the Minister. I thank all members of the committee for their thorough application to the task that was before them: to shine a light on integrating primary and community care to put patients at the centre, which is exactly how it should be. They have done it by offering solutions that are, to quote my noble friend Baroness Pitkeathley, “simple and virtually cost-free”. I am sure that your Lordships’ House would say to any incoming Government, “Watch and learn”.
I am delighted to commend the noble Lord, Lord Jamieson, on his excellent maiden speech, through which he surely honoured the memory of his late mother. As the noble Lord so clearly understands the links between health, housing, environment and other factors, I am sure that we can all look forward to his constructive future contributions.
Day in and day out, primary and community care services provide vital support to millions but, like much of the NHS, they are under considerable strain. Yet, as the noble Baroness, Lady Tyler, said, acute services receive more attention and priority from the Government.
The backdrop to this debate is that backlogs have now reached more than 1 million in community health services. The latest NHS data shows primary care delivering almost 30 million more appointments in March, which is an increase of 25% compared to the same period before the pandemic. Yet, as your Lordships’ House has noted on many occasions, the greatest economic returns from the NHS budget come from investing in primary and community care. This makes good sense.
Some £14 is added to the economy for every £1 invested, and, crucially, it lowers demand in the need for hospital and emergency care. This begs the question being probed in this debate, and which is the headline question to put to the Minister: if these points are accepted—and maybe they are not, in which case I am sure the Minister will say that—then why is there a concentration on acute services, at the expense of prevention and proper integration between primary and community care? There is also a lack of proper integration between the NHS and social care. Why has this situation been allowed not just to develop but to deepen in its severity?
The noble Lord, Lord Altrincham, highlighted that it was repeatedly put to the committee that poorly co-ordinated care undermines the quality of patients’ experiences and can have profound consequences for their long-term health. It should not be that somebody’s health and well-being gets worse because professionals do not contact each other; because patients are made to make inconvenient and unnecessary trips to multiple locations and practitioners; because staffing is inadequate; or because records are not being shared. It is telling that a broad range of witnesses repeatedly spoke of the problematic lack of integration between social care and the National Health Service, even though social care was not within the remit of the report.
For all this, I have heard noble Lords describe the Government’s response to this report as delayed, disappointing and failing to match words with the necessary focus and action. I welcome the principles behind the report’s key recommendations. I trust that the Minister will do likewise and tell your Lordships’ House what more the Government will be doing than is currently the case.
I am sure that many noble Lords will, like me, remember the ambitions articulated during the passage of what is now the Health and Care Act to formalise the integration of primary and community services. However, NHS leaders are telling us that this is not supported by the current commissioning and contracting arrangements. The policy continues, they say, to be developed in silos from the centre, both at NHS England and at the department. I will be interested to hear the Minister’s response to this observation.
For many of us, being treated at home, or as close to home as possible, is best for our health. It is how we want to be cared for. It is also the most efficient and cost-effective for the National Health Service. Nobody wants to be left waiting until hospital treatment is needed; that makes no sense at all. As envisaged in the Health and Care Act, integrated care systems still have the potential to create more joined-up health and care, with primary care being integrated into broader NHS services in the community, through schemes such as Pharmacy First and through the extension of access to services, such as by evening appointments to fit around the needs of local populations.
There is no appetite for further structural reform, but we need to know what is working and what is not. What assessment have the Government made of the effectiveness of ICSs? What are the obstacles to success and how will they be overcome? Is everything in place to ensure that ICSs can make the best possible use of their allocated funds to plan and innovate?
The report highlights the need for a seamlessly integrated patient-centric healthcare sector where patients are given the type of care that they need, when, where and how they need it, whether that be through access to a GP, a pharmacist or a district or mental health nurse. I can tell the House from these Benches that if the next Government are a Labour one, we are committed to making change so that more people get care at home in their community—shifting services out of hospitals and into the community, so that the NHS becomes as much a neighbourhood health service as it is a National Health Service.
The report also says that the Government should focus more on preventive rather than reactive care to tackle the needs of an ageing population, many of whom are coping with complex health issues which require intricate and continuous care. We share that view and are committed to change: we will focus on prevention, shifting the focus to embedding long-term planning, tackling the social inequalities that influence health, ensuring children have the best start possible, empowering people to take responsibility for their health, improving screening programmes and boosting capacity in local public health teams.
I was struck by the observation articulated by the noble Baroness, Lady Finlay, that the committee heard more frustration expressed by witnesses on the inadequacy of digital connectivity than almost anything else. They identified technical issues, cultural attitudes and misunderstandings about GDPR. The noble Baroness, Lady Barker, put it well: that currently, the co-ordination of patients’ data is no one’s responsibility. How do the Government intend to address that point?
What is the Minister’s view as to whether legislation and guidance need to be reviewed to ensure that the tension, whether real or unjustified, between data privacy and effective healthcare planning and provision is overcome? As the noble Lord, Lord Allan, raised, does the Minister consider that appropriate training has been and is being given?
Turning to the workforce, dealing with the problems of its recruitment, retention, numbers, training, morale and well-being will support the integration of services, as spoken to by the noble Baroness, Lady Redfern. What plans are there to include integration in training, and how will NHS and local government staff be made aware of other services and how to work closely with them? Does the Minister consider that the social care workforce should be a component of the NHS long-term workforce plan?
Putting patients at the centre is, as my noble friend Lady Armstrong wisely observed, far from outlandish. Wrapping the NHS around the patient, instead of the patient having to wrap themselves around the NHS, is how it should be. I hope that this report will contribute to that outcome.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I too thank the noble Baroness, Lady Pitkeathley, and all the committee, for their work on this report. I hope that noble Lords will see from my speech that this report is appreciated. Directly on the question of the noble Baroness, Lady Finlay: the recommendations are welcome, and I hope that my speech will set out how we are acting on them.
Before I get into the detail, like other noble Lords, I want to acknowledge my noble friend Lord Jamieson’s maiden speech. He brings a wealth of experience to this, both professionally and from local government. I was particularly struck by his passion for housing. I must admit it is one that I share: it is core to so many people’s lives, in terms of well-being, their sense of happiness, security and stability, and, of course, their health. I look forward to discussing further how we can make that the core of so many things. As the noble Baroness, Lady Merron, rightly said, the noble Lord’s mother would be proud of him today.
I will start by recognising the points made by all noble Lords about the importance of primary care and community care integration. The noble Baroness, Lady Pitkeathley, said that nearly all of the four former Ministers strongly made the point that we see more and more resources going to hospitals, and we also know that there are more and more patients who do not need to go there. Around 50% of the people who go to A&E do not really need to be there. We see a lot of children under 12 going in with tooth decay, when better primary care and dental services would avoid that. Unless we change things, we will see the situation set out by the noble Lord, Lord Jamieson: staff levels in healthcare will go from one in seven of the population to one in four, and then one in three.
I think we all agree that we have to get upstream of the problem. The noble Baroness, Lady Tyler, rightly set out the need for prevention. I have seen some excellent examples of that, and Redhill is just one. The noble Lord, Lord Altrincham, and others described the excellent examples we have seen in the work of Professor Sam Everington in east London: making primary care central to care in the community, and assessing how many services can be taken out of acute settings.
As the noble Baroness, Lady Armstrong, said, centring the service around the needs of the individual, in contrast to the existing set-up, needs a shift in resources towards primary care. Our belief is that that can occur only if the ICBs, ICPs and ICSs are equipped with the information and have that helicopter view and the ability to shift resources from one to the other.
The noble Baroness, Lady Merron, asked a very direct and correct question about why we are increasing hospital care resources. I have some lived-in experience of that. It is a gutsy move to say that we will shift resources away from the hospitals. To make the whole equation work, you are often talking about reducing hospital services and the number of hospital beds, and putting them in the community instead, which we all agree is absolutely the right way to go. But we all know the reaction you get from local groups as soon as you try to do something like that. I completely agree that “neighbourhood health service” should be the name. It takes cross-party work to do that, regardless of who is in government after the next election. Speaking candidly, we need to provide each other with air cover during some of those difficult conversations, including with the ICBs and ICSs. For my part, I pledge to play that role, whether I am sitting on this Bench, the Bench opposite or any other bench after the election.
I am sorry that the government response was seen as disappointing. I hope we can address a lot of the issues raised by the noble Baroness, Lady Pitkeathley. We agree with the whole emphasis of the report and its recommendations, the analysis of the problems and the need to focus resources on primary care and prevention. We also agree with the substance of most of the recommendations.
Our main difference is whether we should be mandating the recommendations on the ICBs, ICPs and ICSs, versus enabling them to adopt them. For want of a better word, this is a bet that we are putting on the ICBs, that they are the right bodies to do this, giving them the time and the space to try to do that. I admit that I am naturally resistant—and that is likely to show in the emphasis in many of my replies—on whether we should be mandating them, when we want to give them the flexibilities to do those things at a local level. We should be enabling them to do it, and we should be encouraging them to do it, but where we stop earlier is on whether we should be insisting and mandating them.
I hope that that gives a general sense, but I shall turn to each part, starting with structure and organisation. I agree with the committee’s recommendations to allow the ICSs the appropriate time to mature before introducing any wholesale system reforms. I hear the point of the noble Lord, Lord Allan, that three years is a long time. We need to make sure that we get some of those early indicators as we go along, but at the same time we need to give them time to bed down and accept that some will do a better job than others, which of course is the inevitable consequence of giving people the ability to manage their own local systems.
On the integration, we are giving these bodies the ability to bring together the NHS, the councils, the voluntary sector and the others, with the focus on prevention and better outcomes. The noble Lord, Lord Altrincham, and the noble Baroness, Lady Tyler, emphasised the importance of prevention, and the noble Lord, Lord Jamieson, addressed the raising of life expectancy and quality of life. I am pleased to inform the House that we see the NHS health check as a flagship cardiovascular disease prevention programme. As mentioned, using the app is a key way in which people can engage with that, book their services and have a lot of those type of tests at home.
With respect to the committee’s recommendation relating to a single accountable officer and coterminosity, ICSs have the flexibility to develop accountability arrangements that best meets the need of their local population. We have various successful models of accountability implemented, including as partnerships and committees. Again, where an ICS identifies that its boundary is not meeting local needs, it can request a review. Local authorities are a critical partner here. The NHS has recently published a process for boundary change requests that requires support from all local authority partners in this. At the same time, the noble Baroness, Lady McIntosh, mentioned in her speech some of the challenges around being coterminous with borders, and how that can cut across some of the things that we want to see happening in terms of choice. It is not always a straightforward question. Again, that shows that this should not be something we are mandating, but we are enabling the ICBs to address that, if it is the right thing for their area.
On the question of the noble Baroness, Lady Tyler, on elected officials chairing ICBs, NHS England has set criteria prohibiting all ICB chairs and non-exec members from holding a public office role, or a role in the healthcare organisation within the ICB area. However, the elected local authority, the local government officials, are able to chair the ICP—the partnership—which of course is a very important committee that sets the health and care strategy.
The committee recommends that the CQC pilot ICS assessments are widely disseminated—a point the noble Baroness, Lady Tyler, also raised. I can confirm that the CQC will publish the pilot findings as narrative reports that will be available to the public. The CQC assessments will consider how well health and social care are working together to deliver high-quality care, and the assessment will also score each ICS against the three themes of leadership, integration, quality and safety—I think that is four themes, actually; that is what happens when you try to adjust the brief.
On primary care contracts and funding, as the noble Baroness, Lady Redfern, also mentioned, the primary care contracts are kept under review and we will consult the profession on any proposed changes. As I think noble Lords know, we launched a public consultation in December 2023 on inclusive schemes and expect to publish a government response later this year.
On the co-location point which the noble Baroness, Lady Pitkeathley, raised, the Government agree with the benefits of co-location and multiple disciplinary teams for promoting integration, and we expect the different models of integration to be implemented across the country based on local needs and the availability of estates.
The noble Baroness, Lady Merron, mentioned investing in primary care. We want GPs to deliver the best care to patients, which is why we are backing the NHS with this significant capital investment in this space. That includes the £4.2 billion this year in operational capital for integrated care boards to allocate locally, including to primary care.
The committee outlined a suggestion to better utilise the better care fund and pooling of budgets. The Government encourage local areas to maximise the full potential of the better care fund and to pool budgets. We have seen local areas committing additional money to their better care fund to support joint commissioning and integration. Place-level committees are crucial to delivering integration, and the Government published a toolkit in October 2023 to support the development of shared outcomes as a powerful means of promoting joint working.
As the noble Baroness, Lady Armstrong, raised, proactive care involves providing personalised and co-ordinated care and support for people living with complex health and care needs. A good example of where this works well is the Jean Bishop Integrated Care Centre in Hull, a geriatric-led multidisciplinary service. Measured outcomes show that, between April 2019 and September 2022, the service contributed to a 13.6% reduction in emergency hospital attendance for patients aged over 80. Over the same time, there was a 17.6% reduction in emergency department attendances for patients in care homes. However—this also relates to the point on training later on—where we have fantastic examples such as that one, we need to make sure that that is disseminated and understood as part of the integration sharing.
On systems and data sharing, I have to admit that, like the noble Lord, Lord Allan—this will not be a surprise to many people—I am a fellow data anorak. I understand the importance of the NHS number and common place references in that. I learned about fuzzy data matching the hard way in one of my earlier jobs. You need only to look at what happened to the local Laura Ashley store in Kyiv, funnily enough, to see the consequences of fuzzy data matching and having a misallocation of dress sizes, shapes and colours because I did not fully understand the skew references in terms of fully data matching. Therefore I understood the hard way and the consequences of that.
I think we all understand the point the noble Baroness, Lady Finlay, made about the frustration that many people increasingly express.
The DHSC was called by the report to
“publish high level guidance to standardise the collection of data and portability requirements in commercial data-sharing software, especially for social determinants of health”,
and mandate how clinicians “code” information. The noble Baroness, Lady Barker, raised a key point on responsible handling of data. We already set standards of coding for data and set national standards for data systems to ensure interoperability. The Government have published a plan for digital health and social care that includes milestones for setting standards on interoperability and systems architecture, enabling all relevant health and care data to be accessed by those with a legitimate right to access it at the point of need, no matter where it is held. We are also moving to a system of data access by default for secondary users of NHS data, which will be supported by the implementation of the secure data environments—SDEs—which mean that data from NHS and related services can be used for research without identifying information needing to be shared.
The report also calls for one or more interoperable data systems to be centrally procured, as was rightly flagged as a key issue by the noble Baroness, Lady Barker. We do not believe that the solution lies in the purchase of a single system for the NHS—we have all seen the past problems that has led to—but we believe it involves the need for a common set of standards and cloud-based architecture to ensure that digital records can be shared electronically, that services are interoperable, and that you can connect information based on the NHS number of the individual rather than one organisation. That will improve the provision of safe and personalised care as patients move between different parts of the health service and the social care system. The approach taken seeks to strike an effective balance between central and local initiatives.
On the question from the noble Baroness, Lady McIntosh, about sharing one prescription record, I say that this is where we see that Pharmacy First has been a vital enabler. Making sure that we have the systems right so that the pharmacy can write into the GP records to show what it is prescribing the patient gives a blueprint that we can repeat across all the systems—it gives the writing capability to do that, so to speak. All 42 ICBs have had a connecting care record solution since March 2022, which is fundamental to how services can share their information.
I am coming up to time. I will quickly say that I agree with the point made by the noble Baroness, Lady Merron, on workforce and training, and that integration of training should be part of all that. I conclude by saying that I will follow up in writing, as ever, to make sure I pick up any questions that have not been answered. I thank all noble Lords for their contributions, particularly the noble Baroness, Lady Pitkeathley, and congratulate the noble Lord, Lord Jamieson, once more on his maiden speech.
Baroness Pitkeathley (Lab)
My Lords, it is the end of a long day, and I will be brief. I thank everybody who has spoken. It was a particular pleasure to hear the maiden speech of the noble Lord, Lord Jamieson, and I look forward to hearing from him a great deal more in the future. I said that I remain to be convinced by the Minister, and I must say that he has made a good fist of it: I feel a bit more convinced now than I did by the Government’s response about the commitment to integration.
What I do not think that he or the Government, or perhaps many other people, have yet done is make this crucial leap of thinking: integration is not an end in itself but only a means to give patients a better experience. If that sounds a bit vague, let us also remember the practical outcomes which come from giving patients a better experience: you prevent unnecessary hospital admissions, as noble Lords have heard; you head off at the pass preventable illnesses, so you save money, and it is a very good investment; and you make use of the most precious of all resources, the patient’s own experience. Nobody knows better about their health than the patient, but they so often feel disempowered because no one listens to them. I hope my colleagues on the committee will remember the nameless professional who said to us that it really did not matter if patients had to tell their story lots of times to lots of different people, because it helped them get their story straight—come on. Those are the kinds of attitudes that we have to overcome. Integrated working in productive teams helps staff retention because staff are happier and more satisfied; integrated training spreads skills and knowledge in a very cost-effective way. I hope the Minister and his colleagues will keep our recommendations under review. Many of them are, as we have emphasised, easily done and at low cost.
We have talked about integration for so many years—for too long. As one of my colleagues said, it is not rocket science but it does require changes. These are not only changes in the way we distribute resources but changes in the mindsets of professionals at all levels in ICBs, in NHSE, in the DHSC and in political parties. The matter is urgent: with every day that goes past, the health of our nation becomes worse. The rewards are great for everyone, but most of all for patients, if we really do manage to put them at the centre.