Health and Care Bill (Second sitting)

Alex Norris Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

This is the third panel. We will now hear from Simon Madden, the director of data policy at NHSX, who is appearing in person. We have until 2.30 pm for this session. Good afternoon, Mr Madden. Could I ask you to introduce yourself for the record?

Simon Madden: Good afternoon. I am Simon Madden, director of data policy, NHSX.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q46 Thank you, Simon Madden, for your attendance this afternoon. I think it would be safe to say that the roll-out of the general practice data for planning and research scheme did not go as planned earlier this year. It was remarkable that despite the limited engagement, well over 1 million people opted out. What learning do you think we can take from that exercise for the data provisions contained in part 2 of the Bill?

Simon Madden: We have obviously set out the position. The Government have set out the position in respect of GP data for planning and research, in terms of taking a pause and having a conditions-based approach, rather than a clear timeline for the commencement of that. Above all else, I think that the overriding need for trust and transparency—to build public trust in the use of health data—is vitally important, and the ways in which this is governed need to be transparent in such a way that the general public can see quite easily how their data will be used.

Indeed, I think it is a responsibility on Government and those of us in the health and care system more broadly to really promote the benefits of sharing data. It is a public good and, while putting in place sufficient safeguards and then giving the public the opportunity to opt out of that process if they are not convinced by those safeguards, it remains a public good and contributes to the broader health, if I can put it that way, of the health and care system.

[Alex Norris]

Q Do you see the process enabled by the Bill running alongside a future resumption of the GPDPR process—or a conditions-based continuation, as you put it—or would they remain two separate things that overlap?

Simon Madden: Essentially, they are separate in terms of process. The general public will not make a distinction between any things to do with their health data. Whether it is the draft data strategy that we published earlier in the year or the GP data for planning and research programme, to the general public it is about their health data.

It is incumbent on us to make sure that we have a strong narrative that reflects all aspects of health data. We need to reset the relationship between the patient—the citizen—and their health data, so that a perception does not arise that we are taking their trust for granted, because that is certainly not the case. The provisions in the Bill around data are meant, to some degree, to provide clarification where there is some confusion in the current framework about how and when data could be shared.

[Alex Norris]

Building on that point—

[The Chair]

Hang on a second. I had better give somebody from another party a chance.

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[Edward Argar]

Q To what extent would you consider it a fair characterisation that this is, in a sense, evolutionary, and that, actually, to a large extent, the provisions related to data—to go back to what you said—add greater transparency and legal clarity around some things that may have had to happen during the pandemic, and give them a longer-term basis in statute, as debated by this place? Do feel entirely free to disagree with that characterisation, I hasten to add. I am not leading you in any way, but to what extent would you consider that to be a fair reflection of these provisions?

Simon Madden: I think it is a fair reflection, to a certain degree. I think that the thing that we must always be conscious of, particularly in the field of data and technology, is that we see advances but legislation often does not keep up with those advances. It is about ensuring that everyone understands their responsibilities—not just that the public understands the responsibilities of organisations that are safeguarding data, but that those organisations themselves have the right powers to be able to share data safely and securely. I think it is evolutionary in that sense, but it is also about making sure that the provisions in the Bill are keeping pace with the development of technology and how data is used in the real, modern world.

[Alex Norris]

Q I will ask two questions in finishing, if I may, Mr McCabe. The first is a final one on the GPDPR promise. Mr Madden, you said that that is a separate process to the one in part 2 of the Bill—which I completely agree with—but that in the public’s mind, the two are likely to be conflated, and that now would be a good moment to reset the relationship between people and their data. Again, I completely agree with that. Is there any technical reason why we could not run those two processes not as two but as one?

Simon Madden: I should perhaps caveat my previous comments by saying that they very much are, in our mind; it is all about health data. The focal point for us at the moment, which we are working through with Ministers, is the formulation of the final version of the data strategy. Of course, the legislative provisions are within the data strategy. It is very much the case that the publication of that document, I think, is the right moment for that reset where we have more intensified engagement with the public and we really step up the narrative around how health data is used. As one of your colleagues said, the real detail comes in regulations, if there are any regulations around that; and of course there would need to be consultation before the regulations were put in place.

[Alex Norris]

Q Finally, I remember from my time in local government that we would talk about the desire in social care to share data with the health service. We talked about, obviously, regulatory barriers that stopped us and we would welcome provisions that removed that, but a very practical obstacle on our list of things in the way was that the systems did not necessarily speak to each other. Do you think that health service systems and social care systems are ready to speak to each other now, or will there need to be, across all integrated care systems, a whole new provider brought in?

Simon Madden: Obviously, interoperability is absolutely key. The information standards piece that I spoke about is part of that, but also, outside the legislative piece, work is going on to create a unified data architecture. This is not about driving or having everything from the centre, so that everybody uses the same things, but about making sure that the architecture enables that interoperability so that the systems can speak to each other. There is certainly a degree of levelling up to do in terms of digital maturity, which is another area in which NHSX is involved, supporting the Department and NHS England. But yes, interoperability is key. We are not there yet; we have some way to go to make sure that everything will flow as it should and the systems speak to each other.

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

Q Mr Madden, I would like to know specifically how the strategy will help us to deliver integrated care within the confines of the Bill, so that we can give better patient outcomes, because ultimately that is what I have assumed the Bill is striving for. You did allude to how that interoperability gives us greater vision into the system. I wonder whether you could help us by bringing that to life. Thank you.

Simon Madden: The best example is something that I have already cited to a certain degree, which is the shared care record. To some degree, that would happen irrespective of whether ICSs and the Bill were in place, because health and social care need to come together; that is something that needs to happen in any event. But what the Bill does is create the proper framework of integration and collaboration. There are other powers in the Bill, for instance the duty to co-operate and collaborate, that I think are going to be absolutely crucial. From a public perspective, they see the NHS and see one organisation, whereas we all know that it is a confederation of organisations, each sometimes with different aims, pulling together. The ICS structure set out in the Bill, plus the data provisions that support that broader approach, will help provide that free flow of information so that clinicians and care professionals have access to the information they need to be able to treat patients in the most effective way.

--- Later in debate ---

[The Chair]

I am really sorry, but we had better move on to Alex Norris.

[Alex Norris]

Q Thank you, Chair, and good afternoon to the panellists. Councillor Jamieson, I will start with you, if I may. You have mentioned on a number of occasions that you see this as enabling legislation and that, rather than prescribing to your community or the community of your members what model they should pursue, it leaves you the space to do that. I have some enthusiasm for that, but one area where that is not the case is schedule 2 to the Bill, which sets out, in schedule 1B to the National Health Service Act 2006, that the chair of the integrated care board must be

“appointed by NHS England, with the approval of the Secretary of State”.

Under paragraph 5, only NHS England can remove a chair if they are unpopular and not doing the job, and there is nothing that you can write into your local decision making to get around that. Are you comfortable with not having any say over your chair when they are appointed or whether they carry on in the job?

Cllr James Jamieson: Clearly, there are two chairs in this scenario, and one of them, as you say, is NHS appointed in effect and the other one could be anybody—it could be a councillor, a local government representative, or a local director of public health. There is a role. I think this is a difficult area, but that is the reality, because ultimately that chairman will be the person who is financially responsible for the NHS trusts in his or her area. I have some sympathy with it; if I could find a better solution, I would seek to find one.

[Alex Norris]

Q Thank you. Professor Rae, you have talked a lot about the challenges to the nation’s health at the moment and the negative direction of travel in recent years. The King’s Fund estimates that, entering the pandemic, the value of the public health grant was 15% less than in 2013. Is that a characterisation that you recognise? What does that mean we do less of than we did seven or eight years ago?

Professor Maggie Rae: I am still a fan of the fact that you need public health and local government. I started my career there and moved to the NHS; I moved back to local government; and now I am moving back to the NHS. What we need is flexibility, so professional groups can work there. I would highly recommend all my public health colleagues and public health registrars to get experience nationally, regionally and locally. That makes you a much better, capable public health practitioner. However, you cannot deny that you can do the same for half the money.

I know that when the announcement was made about public health moving into local government, I did do the rounds saying that it would be a really good thing. I have to say that some very experienced people from councils were saying to me, “Well, I know what will happen. We will get the responsibility, and then they will take the money from us.” I said, “No, no, that won’t happen because public health has always been ring-fenced.” When we were in the NHS, the public health funding was ring-fenced. I have to confess that I was naive, wasn’t I, because actually the grant was cut. I do believe that every pound you spend at the local level in that local government setting you will get back tenfold because of all the social capital you can get from it. That is the reality. If your plans are ambitious, you do not need a lot of money. Lots of the interventions on obesity, smoking and all the other things do not take a huge cost in comparison with some of the high-tech NHS ones. If you have the ambition, you need to follow it through with the necessary resources to do it.

I have been public in saying—I am probably with Councillor Jamieson—that in the ideal world, and I have been a director of adult social care, as well as a director of public health, we are not in camps with our bags of cash. We actually put all of our money together for the resources of the population. I would like to see the ICSs mandated to spend so much on prevention and health inequalities wherever the money comes from, because if we continue with what we are doing at the moment—waiting too long to intervene—none of us will be able to afford the mountain of the problem that you will build up. There is no money available in the world to do that.

There have been some early positive signs that we mean business this time with prevention and health inequalities, but we have to deliver. Having just looked at the social care paper today, I struggle to find prevention. I know from being a director of adult social care that if we do not intervene early and get people to be ageing well and healthy, we will not have the carers in the world who can look after them. Again, I make the plea for the resources. It does not take a lot—I am not asking for billions—but a small amount of resource could make a huge difference. If we continue to cut the public health grant, well, we will continue to have poor health, I think.

[Alex Norris]

Q I have a question on fluoridation. At the moment, there is broad agreement that the system does not work: local communities, through their local authorities, can try to lead the process and take it through. I know from my time on my local authority, where I was very keen to do that, that it was very, very hard to do, although not impossible. We are taking away that grassroots, ground-level approach and replacing it with a top-down, Secretary of State-led approach. That has many attractions, in the sense that it takes away from some of the parochial concerns and planning concerns about where you have pour the stuff in to make it work. At the moment, we are going from one to the other. Would you have any anxieties if, rather than moving from one to the other, we kept what we currently had and added the new model to it, so that rather than either/or, it is both?

Professor Maggie Rae: My experience is that there are some things you can legislate for—seatbelts would be the classic example, or smoke-free places—that work really well, but for most things, if you really want to get action, you need to take the public with you. Certainly, if you fluoridate the water, you will have some very direct oral health benefits. Dental decay, for example, is a classic. However, you probably will not fix every little problem you have got, because it takes more than just fluoridation. Most people’s teeth fall out because of gum disease, so you have to have a wider educational programme with the public.

I also know from my work as the director of public health at the local level and my early days work in Scotland that I could take you to lots of families where they do not drink water, so it is not that obvious to me that that is just going to fix the problem as easily as we think it will. I think you need an all-encompassing programme. While we wait for any implementation of the fluoridation, today children will be having their teeth taken out—children of four or five. That is unacceptable because, alongside that, we should be ensuring that there are the educational programmes and the supply if people cannot afford toothbrushes and toothpaste. That would be a nice easy fix for something to do.

We obviously have a huge population who have already lost their teeth, and one of the biggest problems of the elderly is pure nutrition because they simply cannot eat. It is a problem that sometimes you think legislation will fix it top-down, but I think in everything you do it is much better to see public health people as being responsible to the population. In my experience, you really have to take the population with you to have any chance of implementation, whether you have legislation from the Secretary of State or not.

[The Chair]

I am going to go to the Minister now because of time.

--- Later in debate ---

[Dr Whitford]

Q And that would apply also to things like sharing patient information of a certain type, and whether it was anonymised or pseudo-anonymised and so on? That would be a concern for you?

Eluned Morgan: Absolutely, and we are developing our own systems in relation to those things, of course. It is our patient information, and we should be deciding who has access to it and when.

[Alex Norris]

Q I thank you, Minister, and your officials for your time this afternoon. You mentioned correspondence with Ministers in the UK Government. Is that correspondence publicly available, or is it something you are willing to make publicly available?

Eluned Morgan: I am more than happy to send the correspondence that I have sent to Minister Argar to the Committee, so you can see it. It sets out all the issues that we are concerned with in relation to the Bill.

[Alex Norris]

Q In your conversations, have Ministers shared with you an impact assessment for the Health and Care Bill?

Eluned Morgan: I am not aware that we have seen an impact assessment. Lyn and Mari may have more to add.

Lyn Summers: No, we have not.

[Alex Norris]

Q That is helpful, thanks. To change tack slightly, in 2016 the Welsh Government brought in legislation around safe staffing levels. Are you able to talk us through that and say, five years on, what impact that has had?

Eluned Morgan: This is in relation to nursing. We have a law on safe staffing levels in nursing. Not only has it been implemented, but it has been extended since we brought in that Bill. It is something that the Royal College of Nursing is hugely appreciative of, and something that we are keeping an eye on. It has made a difference to patient safety, and we in the Welsh Government take it very seriously.

[Edward Argar]

Q Good afternoon, Minister and colleagues. Thank you for your evidence and answers so far. By my reckoning, of the nine issues on which we had a discussion, we reached an agreement on seven. I think there are two outstanding, which are the ones you have highlighted in your evidence. I owe you an answer to your letter, but I think we are meeting shortly to further discuss that.

I want to pick up on something that colleagues have touched on and which you have highlighted around the model of integration in Wales—the unitary model, for want of a better way of putting it. I acknowledge that you said it was early days, but I would like to get a sense of how you feel that model is delivering a national system but allowing local flexibility, and of the extent to which it is delivering, even in its early days, improved health outcomes for patients in Wales. As we look at ICSs and closer working between local authorities and the NHS in England, it may be instructive for us to learn from your experience, even if it is not a direct parallel, and from what you are seeing, even in these early days.

Eluned Morgan: We had a parliamentary review that looked at our NHS and care system, and went into a lot of detail about what we could change. A lot of it was about the need to integrate—[Inaudible.] What we have done as a result is take an interim step towards better integration. We not only set up the legislative framework for that, but put significant funding into driving these health and care systems to work together. We had an integrated care fund and a transformation fund. We found that both the health service and the care service really liked the new approach. They really have engaged. We have kind of allowed a thousand flowers to bloom here, and there have been some really innovative ideas and work. How do we get people out of hospital quicker? How do we drive that change? There have been some great examples.

What we are still struggling with, if I am honest, is that we are still finding difficulty getting both the health service and the care service to understand that what they have changed and what works well now needs to be mainstreamed. There cannot be additional funding forever. The purpose of that additional funding was to give the confidence to do it in the mainstream. We are finding that they have pocketed that money, saying, “This is great. Can we have more, please?” We have tried to make it clear to them that that was never the idea. The idea was for them to have that transformation funding to drive change.

That is our next challenge, and that is what we are working on now, but there are ways of doing that. Clearly, this is a difficult time to be doing it, but some health boards are frankly being driven into closer working relationships, because there are so many examples of delayed transfer of care given the infrastructure at the local government level. Do not forget that in Wales we have not seen anything like the cuts that have happened in England, but even we are feeling the pressure in quite a significant way, and we are having some real issues in relation to recruitment to the care workforce in particular. That is the biggest challenge for us at the moment.