Health and Care Bill

Debate between Baroness Harding of Winscombe and Lord Crisp

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

[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?