Health and Care Bill (Fourth sitting)

Alex Norris Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Dr Whitford]

Q In the morning sitting we heard from Professor Marshall, who was talking about your own ICS. I asked about the problem of the power imbalance between the partnership and the board, and he mentioned that you have a primary care sub-group. We have had a lot of discussion about how we gather the voices and ensure everyone is there. What led Gloucestershire to develop that? How do you feel it is working? Do you think that is a good model? How do you ensure the board listen to what the partnership come up with?

Dame Gill Morgan: It is about multi-layering of advice. We will have a primary care sub-committee partly because managing primary care, and all the things that come through GMS and the opportunities, is expert; we do not want it to be subsumed by a generalist groups. We want it to have proper focus, because if our vision of the future is right, we need better and more engaged primary care at local level that can link its services more effectively with support in the hospital and the community. That is the objective, so we will have that.

We will also have an ICB. GPs will have different views. That is one view, which is about me as a jobbing GP. I go in in the morning, and I do my work and all of those things. I need to be supported to do that, but I also need GPs in the system who are engaged in management. We are very proud of our primary care networks, which are beginning to pull together around our localities, because we are smaller and it is not a big place.

There are models where they are working with second tier local government, where they are beginning to think about housing, and they are working with the voluntary sector, so when they are talking about frailty, it is not a GP or a hospital conversation; it is a system conversation in this place. All of a sudden there are things that can be unlocked. If we leave it in any one box, as we have always done in the past—there is a box for acute, for this and for that—we do not get this. Our task is to make those boundaries semi-permeable, with the expectation that we look at the patient flowing through all those boundaries, rather than pretending that patients sit in an individual box, because they do not.

Louise Patten: Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.

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

Q Thank you both for coming this afternoon. Dame Gill or Ms Patten—it is fairer to ask the question more generally—suppose the integrated care partnership itself put forward plans for the footprint. The integrated care board, under this draft legislation, has to pay due regard to that. If you disagreed with that as a board, how would you manage that? How would that be resolved? How would that manifest locally?

Dame Gill Morgan: The first thing is that you would try to make sure that you have developed a mechanism for engagement and trust, so that you do not get into those sorts of disagreements. If you get into those disagreements while you are sat around the board, you have failed to do the task of integration and partnership. That is what happens in the conversations about how we solve it. If we ever got into that sort of difficulty, it would have to be resolved at the integrated care board, and we will have local government, public health and social care on our board as full and equal partners.

[Alex Norris]

Q That is a very helpful answer, thank you. Obviously there would be old informal mechanism. From my time as chair of health and wellbeing in Nottingham, I remember that the best thing you could ever do was just phone someone up and talk about it. Beyond that, for systems that may not be advanced or relationships that may not yet be embedded, is there a good formal mechanism that we could be writing in to ensure that that existed?

Dame Gill Morgan: The more you try to write in legislation, the more it becomes the lowest common denominator and the less you unleash the innovation that you want. I would do something quite different. I would probably write something that requires the different models of ICSs to be formally evaluated over a period of time, so for the first time we could look to structural change and say, “This is what it has demonstrated, not just against the outcome measures measured by the Department of Health and suchlike, but this has been a structural change that has added benefit, or not.” If you are going to do that, it must be done from day one. I think that is more important than trying to put something about solving problems in the Bill. You will never hit the particular strange circumstances of a locality that has problems, because they are always serendipitous.

[Alex Norris]

Q Louise, with your broader advisorate hat on, what do you feel about the selection of chairs and how we could get local voices into both the selection and—hopefully never needed—removal of chairs?

Louise Patten: The selection process for chairs and the executive team has got to be about what this integrated care system requires, what sort of leadership, and what are the partners that we have got. No two ICSs are the same. In order to achieve that, it needs to be a local discussion about what it is that this system needs to make sure it has the best leadership to take it forward. That will involve discussion with local people, local stakeholders and potentially the public to sort that, because the leadership will be different in different ICSs.

[Alex Norris]

Q You said, “What does the area require?”, so you would say that local people would have as good or a better understanding of that than, say, NHS England at the centre in Whitehall.

Louise Patten: The two will have a very good idea collectively about what leadership is required: one from experience of leaders and the other very much from the grassroots level of, “If this is our system, this is what we need.” It is a combination of the two.

[Alex Norris]

Q So in your modelling it would be a partnership of the two.

Louise Patten: It is both/and.

[Edward Argar]

Q I only have a couple of questions, Mr McCabe. I welcome the witnesses and thank them for their evidence so far. One question will be one that I have asked witnesses in previous sessions. We are seeking with this legislation to recognise the existing evolution of the system and the limitations of legislation in driving implementation and behaviours on the ground, as opposed to people finding their own ways of working within a framework. We have therefore focused on a permissive as opposed to a prescriptive approach. Do you believe that we have got the balance right in seeking a permissive framework rather than a prescriptive one? Are there any examples that you would add to what you have already said to illustrate your perspective on that?

Dame Gill Morgan: Yes, I think you have got the balance, and that is the joy of working with a Bill team. I think the balance is right. You have tried not to be prescriptive and tie our hands, but you have been clear in the sense of setting a direction and focus that we will all take into account, so you do not have to tell us things to make the NHS do it. We do it because we pick up the runes.

On the issues that we would be more concerned about, I personally am concerned about the ability of the Secretary of State to call in changes. In part that is because the one thing I think the NHS has learnt in the time that I was out and came back is how to do relatively good consultations. We have just finished a massive consultation. Patients have gone with us. The local communities have gone with us, mostly. We have had citizens juries and all sorts of things to reach a consensus about the direction of travel. The worst thing in the world would be that people say, “There is no point in engaging in those mechanisms locally because, at the end of the day, we will just complain to the Secretary of State and it will not happen.” If that becomes the way people manage that part of the Bill, it will take us backwards, not forwards, in terms of proper citizen engagement.

Louise Patten: On balance, it is about the Secretary of State’s powers of reconfiguration, and NHS leaders in general are concerned about that. It is not so much about the Secretary of State having an early understanding of the reconfigurations or the intent, but about the fact that that decision could be taken at a point where all the evidence is not ready to be properly considered.

Building on Gill’s point, patients and the public would be very frustrated if they felt that they had not had an opportunity to be answered, so we are asking, if not for the clause to be removed, for at least the clinical case for change to be considered from the ICB. Coming back to clinical decisions about clinical services, we want that accountability to local communities, not just up to Whitehall, and some transparency about why the decision was made, and on what basis and information it was taken.

--- Later in debate ---

[The Chair]

I know it is fascinating, but we had better go to Mr Norris.

[Alex Norris]

Q Thank you, Chair, and good afternoon, Sir Robert.

We have spoken quite a bit in these proceedings about the relationship between the integrated care board and the integrated care partnership, the fact that the board has to pay “due regard” to the integrated partnership’s plan, and what that due regard means. You talked about that in your written evidence, and you suggested mechanisms for resolving the situation—or at least making account for a situation where the board sets aside the ICP’s plan. Could you talk a little more about that?

Sir Robert Francis: The first requirement is that there needs to be clarity about what happens in those circumstances, which I am not sure we see in the current legislation or in the guidance that NHS England has produced, which I briefly read. Our suggestion is that there should be a provision inserted into the Bill that, if there is a disagreement, and the board decides to do something that is contrary to the views put forward by the partnership, it should then be obliged to set out their reasons for that. In other words, there should be transparency, which enables accountability, if it is necessary, to be more easily handled.

That would be the major thing we would require, but there also needs to be a better understanding, as far as the public is concerned, about the relationship between the two. I have heard what has been said today, and I must say that I am not clear that the partnership is a sub-committee of the board. That is because the Bill explicitly says that the creation of the partnership is a joint matter between the board—I think, or the NHS—and the local authority. It strikes me that that is not clear.

That is important because, if there is a disagreement, local people are entitled to know why. It would be good if they could also be persuaded that whatever is happening is actually the right thing for them, but they are certainly entitled to be part of the discussion. For that to happen, there need to be reasons given. Another thing that might send a shiver through some spines is that if there is an obligation to give reasons, it might be easier for those who object to the course being taken to challenge it.

[Alex Norris]

Q Do you envisage, when setting out those reasons for disagreement, that they would be publicly available?

Sir Robert Francis: Yes.

[Alex Norris]

Q Thank you.

We will move on to something else that you said in your written evidence. On Tuesday, we had a very good conversation about data, but the whole thing was about quantitative data. In your written evidence, you talk about qualitative data, and it is very easy for us, as Members of Parliament, to conceive of the importance of that, as it is something that we routinely draw on. With your insight from leading Healthwatch, how can we develop systems that properly trap that, use that and prioritise that just as much as the quantitative data?

Sir Robert Francis: Technically, these days, that is no problem at all. You will not expect me to explain that to you, but the qualitative data—comments from the friends and family test, or similar things—is easily mined these days. You can develop a view of the sentiment that comes through it, and you can then dig down more closely into specifics if you need to. That information is extremely valuable to Healthwatch in determining what people think about a particular subject or services, and we feel that there should be a recognition that that data, in that form, should be capable of being shared with a statutory body like Healthwatch, and possibly others.

We also think that—I am sure others might agree—while quantitative data is extremely important, it is informed by qualitative data. The personal impact—good or bad—of things that happen in the service are best described by the people who have received that service. If you just look at figures—I am afraid that this was a problem at Mid Staffs—you lose a great deal, and the trigger for change and improvement is lost.

[Edward Argar]

Q I will try to be brief in the five minutes that we have left. Sir Robert, I have two questions: one with your Healthwatch hat on; and one in your personal capacity—and also as an eminent lawyer.

We sought with this Bill to be permissive rather than prescriptive; behaviours, and how things work on the ground, are often as, if not more, important than the framework. Notwithstanding your on-the-record comments about Healthwatch participation in ICB levels as a formal member, what else would you draw out as opportunities within the framework to build on patient participation and accountability to those who pay for, and use, the service? Are there other opportunities, that, with a small tweak either in guidance or in the Bill, we could seize more effectively?

Sir Robert Francis: I suspect that there is something around reporting, particularly with the oversight of quality, inequalities and matters of that nature, which would be of assistance. I agree that flexibility of engagement is really important, and Healthwatch claims no monopoly over this. I see it taking place in guidance. If the emphasis is to change culture to one where the service is being responsive to people’s needs, as opposed to providing them with what the service thinks they need, there could be greater emphasis in the Bill on ensuring there is a strategic plan for engagement. There could be more emphasis on how the ICS is going to engage with local people and communities, and an actual requirement that it provides comprehensible information to the community about how people should be able to communicate with it. I know they sound like matters of detail, but if there is an obligation to make such things clear, it does not prevent flexibility, but it does oblige organisations to actually do it—and mean it. There will be lots of other ideas, I am sure.