Health and Care Bill

Baroness Harding of Winscombe Excerpts

Lords Hansard - Part 2 & Committee stage
Tuesday 18th January 2022 Lords Chamber

Amendments 70 and 73 are very important too. They would ensure that patients are made aware of new technologies and treatments and, crucially, that patients are involved in decision-making about these treatments and technologies. I know from the experiences that we heard about and the huge amount of evidence that we received in our review that that did not happen. That contributed to avoidable harm on a really shocking scale. Likewise, I have no doubt that if greater progress on digital records had been made at that time, the questions that we had in our review about how many people had been harmed, when and how, would have been answered. Digital records enhance patient safety, so I strongly support these amendments.

[Baroness Harding of Winscombe (Con)]

My Lords, I too stress the importance of digital transformation in our health and care services. I thank the noble Lords, Lord Clement-Jones and Lord Hunt, and my noble friend Lady Cumberlege for their contributions and for enabling us to have this debate.

The way that the noble Lord, Lord Hunt, has characterised this as three different issues interwoven is an extremely good way to think about this. I completely agree that the integrity and confidentiality of patient data, and having the resources to lead transformation, are essential components. I would just like to add a contribution on the third element, the prioritisation of digital and data. I too am going to cite the Wade-Gery review. It is really important that those of us who have worked in digital transformations in other sectors also encourage our health system to look outside. All health systems are probably 10, perhaps 20, years behind other sectors—financial services, retail and, dare I say, even politics—in their digital journey.

This is not just an NHS issue: it is a health sector issue. One reason why that is the case is that we have tended in health to think that digital is “other”, something separate from healthcare itself; whereas, actually, healthcare is that most human of services and digital is an enabler. It is the means, not the end, and it is hugely important that we think of prioritising digital and data as prioritising the overall transformation of care, rather than the digital transformation. This is not just semantics: it is important that everyone owns that transformation, most importantly our front-line clinicians, and that it is not something that is parked separately.

When I was growing up, my parents’ generation abdicated responsibility for the family VCR to the children. Certain business leaders, 10 or 15 years ago, abdicated responsibility for their technology transformation to their chief technology officer. If we really want to see the benefits of digital transform our health and care system, we must not abdicate that transformation to a digital transformation team. It needs to be the business of everyone—most importantly, our leaders. I hugely support the spirit of these amendments and particularly the amendments looking specifically at funding and a duty to lead transformation, but I caution against creating a post of digital transformation because that needs to begin with the chair, the chief executive and the medical and nursing directors, not just an individual with digital in their name.

[Lord Mawson (CB)]

My Lords, my colleagues and I built the first online facility for the voluntary and social enterprise sector in this country in 1997, called CAN Online. We learned rather a lot from doing that, and I actually came to many of the conclusions that the noble Baroness, Lady Harding, is telling us about. When we started this, we naively thought that this online environment was going to solve all our problems, as if it sat “out there” somewhere. We bought 12 computers: they came in very big boxes at that point, as noble Lords might remember. We put them in a room in a conference centre—we were in the Cotswolds—and I invited 12 entrepreneurial people working in the social sector to come and share a few days with them. We connected them all up. We thought it was about technology, but we actually we discovered that it was all about people and relationships; that this technology was simply a tool—an enabler—to facilitate a marketplace that we needed to build between us.

We began to understand that this was not about large systems up there that you plonk in the middle of things in some separate way. It is actually organic: they are very connected, and you need to co-create it and invent it together around the real needs and opportunities that are presenting themselves. I think this technology is telling us something about what needs to happen to the health service. It is organic; it is entrepreneurial; it is about creating a learning-by-doing culture. My colleagues and I have seen examples in the NHS and other parts of the public sector where millions of pounds have been spent on systems that have landed from Mars and have not worked.

First, we must understand the detail of this technology, and the opportunity that it brings. Later on, as we go through the amendments, I will share with noble Lords some technology platforms that we are working with across the country that have absolutely understood this. When they are engaged with the NHS, instead of the system getting behind them and building on their success and knowledge, it never follows up on the conversation with them. They never heard from the NHS again. There is a disconnect going on, and a fatal misunderstanding of how this new world now needs to work.

I welcome these amendments and this conversation, but we must understand—from those of us who built some of this stuff, even in the clunky old days of 1997 —that it is all about the relationship between people and technology and a learning-by-doing entrepreneurial environment.

--- Later in debate ---

[Lord Crisp (CB)]

My Lords, I declare my interest as an adviser to Well North Enterprises, which was mentioned by the noble Lord, Lord Mawson. I congratulate him, and other noble Lords from different parts of the House who have spoken on this amendment, on making the whole issue extremely clear.

I will make a few very specific points. First, we have heard about great big projects making a massive different. Everyone in your Lordships’ House, I am sure, knows of smaller examples that are making a real difference, as well as the larger examples, and how the small examples are important and add up.

Secondly, this is about change happening locally, but it is also about what is happening globally. I have previously quoted, in this House, a saying by a friend of mine, who used to run the Ugandan health service, that “Health is made at home, hospitals are for repairs”. It is a powerful expression, and one might say that health is made at home and in the community, and in the workplace and in the school. It also contains the notion that health can be created; it is not just about preventing disease.

Noble Lords may like to know that, more recently, globally, the WHO published the Geneva Charter for Well-being at the end of December, which explicitly talks about the creation of a “well-being society”. So this is a global movement we are talking about, not just a local one—although, as the noble Lord, Lord Mawson, has continually emphasised, this is about the importance of practical changes at the local level.

I will make two final points. The big one is that when we think about the membership of the ICBs, it is important we have the insiders there—the clinicians and the people who know how the systems work—but we also need some outsiders there. Referring to the debate on the last group, this is not just about different skill sets; it is about different behaviours and doing different things in different ways. Those of us who have worked within the system are bound by the system and think in terms of the system and its regularities.

The sort of people the noble Lord, Lord Mawson, is talking about do not start by thinking about the system; they start by basing things on relationships and learning by doing—a point that he emphasised. So there are different ways of doing things, and it is important that, as these boards are constructed, they bring in people with that different approach, alongside the great knowledge and skill that NHS and other clinicians bring to this. I know that we will really achieve success by bringing together insiders and outsiders, and getting people working together and understanding how to do things.

My final point is that this amendment proposes having a person representing or drawn from these groups on the ICB. I recognise the debate that has been going on about tying the hands of local people about what is happening on these ICBs. I understand that as these things get larger not only are you including more voices but also, implicitly, you are including more vetoes. The health service has, over the years, suffered from having too many people with too many vetoes in terms of making change happen.

I understand the complexity and difficulty here, but the final part of my point is to ask the Minister a question. I asked him a question earlier, because—I do not know whether I am alone here—I am not sure that I understand how, in reality, all these bits will fit together and work together in this new structure. I know he committed, in an earlier part of the debate on the Bill, to providing us with a diagram and perhaps more of an explanation of how it will all work. I can see how the complexities of everything we are talking about here can be difficult.

The single point I want to reinforce is the importance of not just having insiders in the decision-making process, but also having more disruptive influences. It is not just about skill sets; it is about different ways of thinking and behaving, and a focus on relationships, not just on systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I also rise to support the noble Lord, Lord Mawson, in his amendment, and congratulate him and his colleagues on the extraordinary work they have done.

I support the Bill precisely because integration will be key to delivering the health outcomes that we all seek. But I worry that, if the Bill is just rearranging the organisational deckchairs, with exactly the same people in different organisations with different three-letter acronyms, we will not change anything at all.

I think that, over the course of the nearly three days we have spent in Committee and on Second Reading, there is cross-party agreement on the nature of the problem we are trying to solve. In each debate we have had over the last two and a half days, whether on health inequalities, mental health, the social determinants of health, or person-centred digitally enabled care, there has been extraordinary cross-party agreement on the nature of the problem. As the noble Lord, Lord Clement-Jones, said, we are debating and disagreeing more on the means to the ends than anything else.

One of the means to the ends is local—genuine local ownership and leadership. Like many in your Lordships’ House, I have made the pilgrimage to Bromley by Bow and I have also been to St Paul’s Way. When I first joined the NHS, about five years ago, I was told to go to Bromley by Bow, and I was told by a number of NHS insiders how brilliant it was, but how impossible it was to replicate anywhere else. “Go and have a look at it, Dido,” they said, “because you’ll be amazed and impressed, but no one’s worked out how to spread it”.

What I have actually discovered, as we have heard today from people with far more experience of place-based leadership than I have, is that brilliant though Bromley by Bow is, it is not alone. There are fantastic place-based leaders in communities across the country. It is those local groups and leaders who we owe the exit from Covid to more than anyone else, I suspect.

I have had the privilege of working alongside them. I have been to north-west Surrey with the noble Lord, Lord Mawson, but also to Wolverhampton, to the Guru Nanak Sikh gurdwara, one of the first local testing sites for NHS Test and Trace. I have been to Gloucester and spent time with Gloucester FM, a local community radio station that for the first time in its existence got funding to run an advertising campaign to encourage people to come and get vaccinated in the local community. That was the first time it had succeeded in working collaboratively with the local NHS.

I have been across the country in the last two years talking to people from groups who feel excluded. Whether it is the Roma Gypsy community, Travellers, refugees, taxi drivers or faith leaders from a whole host of communities, all have told me—in both my previous role as chair of NHS Improvement and as executive chair of NHS Test and Trace—how in different ways they felt excluded not just from the NHS but from society in general. They also said, generally to a man and a woman, how hard the NHS is to work with when you are from a small, outside local group, as those of us who have worked in the NHS know.

It is with that knowledge base that I wholeheartedly endorse the spirit of the amendment of the noble Lord, Lord Mawson—but with a “but”. I have been consistent in the last two and a half days of Committee in being nervous about adding specific roles and experiences to what is now a growing list of characteristics and past experience we would all like to see in this new three-letter acronym NHS entity, the integrated care board.

I would like to post a question to the Minister. It is clear that we need these local voices—the grit in the oyster, as my noble friend Lady Cumberlege described it; the difference that the noble Lord, Lord Crisp, is referencing; people from outside the system—if this new reorganisation is going to be anything more than a rearranging of the deck chairs. How will we ensure that those local voices are genuinely heard in an integrated care board?

[Lord Kakkar (CB)]

My Lords, I rise to support the amendment in the name of my noble friend Mawson and others, and in so doing congratulate him on his thoughtful introduction. It is clear that one of the most important aspects, and the purpose, of this Bill is to ensure integration at a local level. But the purpose of that integration must surely be—as has been confirmed by the Minister—to improve health outcomes for the entire population. It is well recognised that that can happen only if the social determinants of health in local communities are addressed appropriately and effectively, in a way that our health system has not been able to do to date.

If we accept that to be the purpose, then local integration—that focus on and understanding of the social determinants of health—and responding to local needs must be secured in the organisation of the integrated care systems and their boards. As we have heard from the noble Lord, Lord Mawson, and others, to achieve that, one must not only understand, appreciate and hear the local voice, but be clear that the culture that is established in these systems is responsive to those voices and is determined to act on them and the understanding of the local situation—particularly those social determinants that extend far beyond what has been and can be delivered through healthcare alone—and focus on other issues such as housing, education and employment. It would be most helpful if the Minister, in answering this debate, could explain how that is going to be achieved in the proposed construction of the integrated care boards.

Of course, one recognises that Her Majesty’s Government are deeply committed to this agenda. But it is clear that if these boards are not constructed in such a way that they can change the culture and drive, in an effective and determined fashion, a recognition of those social determinants and create opportunities at a local level to address them, much of the purpose of this well meant and well accepted proposal for greater integrated care at a local level will fail.