Integration of Primary and Community Care (Committee Report)

Baroness Pitkeathley Excerpts

Thursday 9th May 2024 Lords Chamber

Moved by

[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.

--- Later in debate ---

[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.

Motion agreed.