Health and Care Bill (Eighth sitting)
Alex Norris ExcerptsThursday 16th September 2021
(3 years, 2 months ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 16 September 2021 - (16 Sep 2021)
Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to serve with you in the Chair, Ms Elliott. I wish to speak to amendments 28 and 29, and will also briefly address a couple of brief points relating to the clause.
I am grateful for the Minister’s response—it is handy to know in advance the likely arguments against the amendments. I referred to the amendments late on Tuesday afternoon, with regard to private company involvement in integrated care boards. We are heartened to hear what the Minister said about that and look forward to having those conversations. My original notes said that the amendments go a little further and might be a little rich for the Committee’s blood, and that may well be the case, but they are nevertheless important.
As I said the other day, the vast majority—around 70% —of GP services are provided on the general medical services contracting model, between local and national commissioners and a GP or GPs and their practice. A little more than a quarter of services are on the personal medical services terms, which allow greater local flexibility, although I understand that the intention is to phase them out. There is a small but growing number of APMSs, which we are debating. APMSs allow bespoke contracting with private companies, with no obligation for a GP behind them. The Minister mentioned their being time-limited as an asset; I am not sure that that is necessarily true. Of course, there has to be flexibility for commissioners to meet need, but my argument is that this is being misused and is operating as a loophole for private companies to enter the market and cream off profits in a way that I do not think is generally the direction that service users in the NHS want. Colleagues should not think that, because the model currently provides just over 2.5% of contracts, this is in some way small beer. The largest provider of GP services in this country is wholly owned by a US megacorporation and has 500,000 patients on its books. I do not think that is what our constituents want from their national health service in England, and I do not think that is what they expect it to look like either.
Therefore, it is reasonable to use the Bill to try to do something about it, because this will be the model. It will grow at pace unless it is checked, and there are many reasons to tackle the issue. It is not just because I find the model distasteful, which I do. First, such contracts are poor value for money. For a registered patient, the mean payment to an APMS provider is 11% greater than that to a GMS provider. Of course, the Minister made the argument on Tuesday that such practices often serve the hardest cohorts, so perhaps that could account for the difference, but that is not the case either. When patients are weighted according to need, the mean payment is actually 16% greater on APMS contracts—it gets worse. If we read that across the entire patient list across the country, it would be the equivalent of £1.5 billion. That is the risk, if this grows to be the dominant model. Such contracts also provide less satisfactory care, with a 2017 survey of nearly 1 million patients finding that APMS services generated lower levels of satisfaction.
Finally, the contracts are easier to walk away from. Within the NHS, we already know that when it stops working for private providers corporately, they are willing to just walk away from contracts and hand them straight back. I strongly say to the Minister that such arrangements are a distortion of the health service’s founding principles. They are costly, they are of lesser quality and they are less reliable.
Amendment 28 is designed to stop integrated care boards entering or renewing such contacts, and amendment 29 would do the same for NHS England. I fear that the Minister may have slightly catastrophised the impact of that, because if this was accepted today, there would be GP services that could no longer operate tomorrow. For a start, the Bill has an awful long way to go, and I gently say that if there is anxiety about health organisations working in advance and presupposing that this will become law at some point and will be operational in April, I am afraid that the Government started that a very long time ago and have already started to fill places in shadow. I do not think there should be any anxiety about getting prepared in this way, so that there would not be a cliff edge.
I am willing to take the argument that perhaps there is a better and more elegant way of drafting this, and I would happily accept an amendment in lieu, but what I cannot accept is nothing at all. Again, the Minister’s point on Tuesday was very good, because sometimes there will need to be a way to provide flexibility for very bespoke services. I think the example he used was services for street homeless people. Of course, that might be a very different model from that of the GPs on my estate. I would accept that as a principle, but the corporation that has the biggest patient list, at 500,000, is a bricks-and-mortar primary care service in my community. That is not a use of flexibility; it is using that as a loophole.
I do not think that can be right, and I do not think the answer can be that the provision needs to exist and therefore we must open this space for that sort of distortion. We are either saying, “There needs to be flexibility, and here is the best way of having a flexible system. Don’t worry—we’ll make sure it is not misused,” or we are saying that we are happy with such organisations entering the market. The Government need to say which one is their preference.
I will make a point about primary care networks before I move on to clause stand part. Obviously, primary care networks are not in the Bill, but I put quite a lot of stock in them. I think that, locally, they will be a very important unit of organisation of care services in our community. I want them to work, and I am playing an active role in the primary care network in my constituency. I think they have real potential. However, who will lead them if we lose our GP practices to those who do not have an interest in our community? The model will become much more distant and uninterested, based on finances rather than the local population. I believe that would be a very, very bad thing indeed. As I say, the amendments may not offer the best way to close that loophole, but I have not heard a better one, or indeed a desire to close it, so I wish to press the amendments to a Division.
Finally, a couple of quick points on schedule 3, which we do not intend to press to a Division. We have had quite a lot of discussion—the Minister touched on this in the previous stand part debate—about the arrangement of integrated care systems, such as they exist. At the moment, we know that NHS England holds certain responsibilities, the regional teams hold certain responsibilities and CCGs hold certain responsibilities at a local level. It is possible, after these reforms, that CCGs will be replaced by ICBs and the previous arrangements and responsibilities will remain unchanged, with NHS England nationally doing the same things, the regional teams doing the same things and ICBs picking up the responsibilities of their predecessors. I suspect, however, that that is not the intention, so I want to press the Minister a little bit on that.
The explanatory notes, on page 59, paragraph 286, state that the functions relating to medical, dental and ophthalmic primary care sit with NHS England, but that
“The intention is that Integrated Care Boards will hold the majority of these functions…in the future.”
Will the Minister expand on that? Does a “majority” mean two out of the three in a different area? Does he intend—again, we touched on this the other day—that this should all be devolved to the 42 ICBs at the same time, or will there be a sense of when each system is ready to pick up those important services? If so, what criteria will that be based on?
Finally, in case we do not come back to this topic—I do not expect the Minister to have an exhaustive list to hand—what is the thinking on other NHS England national and regional functions? Are they likely to be devolved to ICBs? Can he give an example of what sorts of things might be retained? He mentioned that we would want to retain specialist commissioning at a national level. The final question is this: is it ICB by default unless there is a very good reason why it cannot and therefore it has to be done at a national level, or is it at a national level unless it is proven that ICBs are competent to take it on? The answer may be a bit of a mixed economy, but if that is the case, I am keen to know what criteria he will use, or the Secretary of State will use, to make those decisions.
Karin Smyth
I rise to support my hon. Friend the Member for Nottingham North, who made an excellent case for amendments 28 and 29. While on a primary care trust board, I commissioned APMS contracts under a previous magnificent Government—I am not saying this one’s not magnificent, but—because they offered flexibility. Then, as now, they were a sign of a failure of the system and the model of primary care contracting to deliver, particularly in areas of high deprivation. To provide flexibility in Bristol, for example, we had an 8 am to 8 pm service in the city centre to allow better access for people in the city centre, partly to drive down demand on emergency care services, which is a circle that we just keep on going round. Whether they worked or not is a bit of moot point, but it is a model and it is clear that something is needed—I would certainly concede that—so I understand the Government’s difficulty here with having something that is flexible.
I was slightly concerned when the Minister said that the APMS model would be developed further. I wonder if he wants to come back on that. We have to accept that they are problematic at the moment and we would like to see them go because of that. They are now being used as a back door, a very unfortunate one, for large private companies to start hoovering up general practices, which is, yet again, a sign of failure as to why they cannot survive in their environment. If they are going to be developed further, that is something we would like to hear more about. If not now, perhaps the Minister responsible could come back to us on that. Patients are always surprised when they find out that their GP is a private contractor. I accept that this is a difficult area to be completely black and white on. We are certainly in favour of flexibility in developing services in areas of high demand where, for reasons around capital or the type of contract, a GP might enter into partnerships. We know that the workforce is changing rapidly and the model of partnerships is not as attractive and is not recruiting people into the service. It is—not to overuse the word—a crisis.
I am sure we have all been contacted by various bodies representing GPs in our own constituencies. They are fearful not just about the current pressures, but the future attractiveness of primary care. We are not going to get into the future model of the contract today, but I always pity the poor Minister who has to negotiate the contract.
Chris Skidmore
The amendments would place a legal duty on integrated care boards to support and promote the use and development of research in their local health and care systems. The existing legislation talks about the health system; this is the Health and Care Bill, so it makes sense that the duty to promote research should also promote research in care settings.
Importantly, amendment 7 would promote and support the conduct of research alongside universities, which drive research outputs and innovation in healthcare. We would all agree that that has been highlighted throughout the pandemic: if it was not for our universities, we would not have all received a vaccine, in respect of which the United Kingdom has been at the forefront of research and innovation.
In the specific context of the Bill, it is important to require ICBs to engage with universities and other research settings on the development of the healthcare research workforce. ICBs will have a vital role in ensuring that we have sufficient numbers in not only the health workforce but the healthcare academic workforce, which is key to overall healthcare workforce sustainability. That is particularly important for the development of the clinical academic workforce. Clinical academics work in higher education institutions, conducting cutting-edge research and educating the future workforce while also providing clinical expertise to health and social care services. Because they remain clinically active, their research is grounded in clinical practice and questions that matter to services and patients.
Data from the Medical Schools Council staffing survey shows that although the total number of NHS medical consultants and GPs has risen by 40% over the past 15 years, the numbers of clinical academic have simply not kept up to pace—in fact, they have decreased, from 7.5% to 4.2% of the workforce. The proportion of clinical academic GPs has remained stable, but at just 0.4% of the GP workforce. Furthermore, less than 0.1% of the workforce in nursing, midwifery and the allied health professions are clinical academics. Increasing clinical academic capacity is essential to advancing evidence-informed practice and innovation in healthcare in the future. The point here is that expansion of the healthcare programme of student numbers on the UK Government’s intended scale also requires an expansion of the number of healthcare academic staff.
The 2019 academic staffing centres of the Council of Deans of Health identify challenges for universities in recruiting staff and an ageing academic workforce in healthcare subjects. In England, 36% of academic staff are over the age of 50, and 9% are over the age of 60. That suggests that the academic workforce is significantly older than the healthcare workforce as a whole. It suggests that, within the next 15 years, almost half of the academic staff will be at or near retiring age, with many already likely to have retired. Without significant renewal of the academic healthcare workforce, not enough staff will be left to keep up with the number of students.
It is key that senior leaders in both the higher education and the healthcare sectors cultivate a culture of support for clinical academics. ICBs, health and social care providers and universities need to work in partnership to support clinical academics and clinical staff interested in secondments or joint appointments to universities. There should be opportunities for clinical staff to obtain experience and skills in teaching and also in research.
Amendment 7 ensures that ICBs remember their responsibilities to research, to local research priorities and to developing a local clinical academic research workforce, and universities are vitally involved in that important work. I think I am the only Member of this House who has been both a Health Minister and a Universities Minister twice. When I went into the Department of Health and Social Care, we were talking about integration between healthcare settings and social care settings. We have a similar problem with integration when it comes to looking at the medical workforce and ensuring that the education settings and the healthcare settings also integrate better together.
Amendment 8 returns to this point. It would require integrated health and care boards to work with universities to promote education and training in their local health and care systems. Universities are committed to co-creating healthcare services through working with practice partners, further education colleges and other stakeholders to plan and deliver the future workforce. I know that, when we come to clause 33, we will be talking about workforce planning at length, but this amendment would help to enable us to plan in advance to mitigate some of the problems that come with workforce planning for the future.
Universities are rooted in their local and regional communities and focus on improving healthcare outcomes and driving up economic and social wellbeing through providing programmes to meet skills gaps in those local areas. This is highlighted through the work of the universities during the pandemic, including the University of the West of England in my own locality hosting a Nightingale hospital, and the deployment of thousands of healthcare and medical students and some academic staff within clinical practice to expand the NHS workforce at the height of the pandemic. We all want to pay tribute to those medical students who, with no extra salary, gave up their time to volunteer to help staff on some of those covid wards at the time.
In England, universities currently sit on local workforce action boards and on sustainability and transformation partnerships to ensure that education is central to local healthcare planning. The amendment ensures that universities and colleges continue to be actively engaged by ICBs to plan and deliver on local workforce needs and priorities to ensure a sustainable workforce. This should take place alongside continued work with Health Education England.
Healthcare programmes are holistic and necessarily constituted of theory and practice components. For example, a registered nursing programme consists of 4,600 hours of education across three years—2,300 hours of academic learning and 2,300 hours of theory learning. Universities and their practice placement partners need to be involved in national and local workforce planning to ensure that there is adequate placement capacity in the system. As I saw when I was a Health Minister, placement capacity has long been recognised as a constraint to sector growth. Even if the hospitals wanted to expand, they did not have the placements to be able to deliver on the demand that was there.
ICBs must be involved in developing placement capacity and innovation and work with partners to increase placement opportunities outside the NHS, including in private healthcare, the third sector, social care, research and teaching, and international exchange. ICBs also need to work with education providers to think about developing education placements to support digital innovation and online and blended delivery, particularly considering the learning we have from the pandemic. That will help to support higher education institutions to manage the continued challenges posed by placement capacity problems, considering health service pressures.
Requiring ICBs to work with universities and colleges is also key to ensuring the success of healthcare apprenticeships and new technical qualifications such as T-levels. Universities work in close collaboration with local employers to develop and deliver healthcare apprenticeships. They are also committed to ensuring smooth articulation between further education and higher education, and universities are working with colleges to ensure that the healthcare T-levels and the new higher technical qualifications are rolled out successfully.
The amendment would ensure that the planning of future workforce numbers and sufficient placement capacity for all learner routes must be developed in partnership with education providers. That is crucial.
Alex Norris
I congratulate the right hon. Gentleman on his amendments and the case he made for them. I hope that he remembers with fondness his visit to the University of Nottingham and Nottingham Trent University when he was Universities Minister. He will have seen then the significant role that they play in our community, and I think they provide a good model for some of the things that we are talking about. I hope the Minister will address the points about clinical academics in particular. They were very well made, and I thought the right hon. Member for Kingswood also provided the basis for what will be a really interesting discussion on clause 33.
What attracts me to amendment 7 is that it is really important to send a signal to the leaders of integrated care boards that we want research to be central to their mission, as NHS Providers said in its evidence, and that we do not see them solely as administrators of health and care spending on a day-to-day basis, who every winter have to engage in collective crisis management to keep the lights on. We have much broader horizons in mind for them. If this is about new and enhanced models of more integrated care, we have to harness the expertise of academia. Hopefully, if this was effective and worked as a two-way process, with academics learning from inside the system and the systems learning from best practice from around the different footprints, that would be really powerful.
That relates neatly to the point about inequalities, from the beginning of our line-by-line consideration. The argument in favour of making that a priority was not about some sort of quixotic search for solutions or saying that something must be done, so let us just do something; rather, it is about taking evidence-based, high-quality interventions that work and putting them to work elsewhere. The sort of insights that amendment 7 proposes would certainly do that.
When I read amendment 8, my first instinct was, “I wish I had tabled it,” because I think it is great. We want to foster a culture where we invest in and develop our people. That is true whatever someone’s role is in the health and care service. Of course, that is really important in the NHS, and we all have a clear picture of what that looks like, but it is even more important in social care. We undervalue the role of social care in so many aspects, obviously and most tangibly in pay and conditions, but we also do not invest in people. Imagine how much more attractive a career in care would become if someone’s training prospects went beyond the limited ones offered by whoever their employer happens to be and instead a wealth of other opportunities and courses backed by top higher education providers in their community was opened up.
My family’s life was transformed by the impact that night school had on my mum’s skills. She progressed from being an unqualified person working in childcare and turned that from a job into a career. That was completely transformative, not just for her life but for mine and my sister’s. How terrific would that sort of picture be for people entering the care profession. It would be a wonderful thing. So there is a lot to go at here, and I am very interested in hearing the Minister’s views on how we can try to foster that culture, if not through amendments 7 and 8.
Dr James Davies (Vale of Clwyd) (Con)
I rise to speak in support of the agenda raised by my right hon. Friend the Member for Kingswood in his amendments 7 and 8 and the need for integrated care systems to ensure that NHS organisations for which they are responsible conduct and resource clinical research.
I think all would agree that the UK life sciences sector is world-leading. That was evidenced during the pandemic by the way in which early PCR testing was brought forward for covid, by the recovery trial and by vaccine development and so on. In this country, however, the location of existing activity is all too often limited. We have world-renowned centres of excellence, often associated with teaching hospitals. I would do nothing to weaken that. The Government’s levelling-up agenda needs to extend involvement in such activity across the country. But at the same time, it can strengthen what Britain has to offer to patients and the world as a whole, bringing economic benefit to the country as well as to the NHS through increased income.
Chris Skidmore
I thank the Minister for his considered comments on these amendments. They are probing amendments, and I do not intend to press them to a vote. I hope, however, that the Department will consider not only the discussion that we have had in Committee today, but a letter that was sent to the Minister’s office on 14 September from Universities UK, the Medical Schools Council and the Council of Deans of Health, which have all signalled their support for a form of words in an amendment that recognises the potential difficulties about placement planning and the opportunities represented by putting measures in the Bill about ICBs demonstrating integrated working.
I have been in Bill Committees before—I am now legislating to take out a lot of what I legislated for 10 years ago, when I was dealing with what became the Health and Social Care Act 2012. These Bills do not come around very often, so we have a fantastic opportunity, as the oral evidence sessions demonstrated, and I fully appreciate it. I have removed and re-tabled one of my amendments, to clause 33, as a result of the feedback from the oral evidence sessions.
There is a tension about how prescriptive we should be when the very culture of the Bill is about locally led practice and delivery and ensuring that we give health service managers and clinicians the opportunity to decide what is best for their local areas, so I do appreciate that prescription here may be unnecessary, but I felt it was important that I raised this as an opportunity to make a change in the Bill.
When it comes to clause stand part, I would like to speak more generally on clause 19 about the value of research, which my hon. Friend the Member for Vale of Clwyd has spoken about. I think we have an opportunity—it is one that I do not want to miss—when it comes to embedding research within the future of the NHS. I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Alex Norris
I beg to move amendment 46, in clause 19, page 25, line 37, at end insert—
“14Z58A Power of the Domestic Abuse Commissioner to obtain information
(1) The Domestic Abuse Commissioner may require an integrated care board to provide the Domestic Abuse Commissioner with information.
(2) The information must be provided in such form, and at such time or within such period, as the Domestic Abuse Commissioner may require.”
This amendment places a requirement on Integrated Care Boards to share information with the Domestic Abuse Commissioner at their request.
This is the first of a couple of amendments relating to domestic abuse. I hope it is not necessary, but it is my best avenue for establishing a point. I am really hoping for a one-word answer from the Minister—in my experience, a one-word answer is better than a two-word answer—and I hope that we can make quick progress with the amendment.
In England and Wales, the Domestic Abuse Act 2021 created the post of Domestic Abuse Commissioner, who is in the vanguard of holding to account authorities and agencies to ensure that their process and plans promote our national attempts to tackle domestic abuse. Currently, the post is filled by the excellent Nicole Jacobs. She has the power to obtain information from public bodies such as the local police, the local council and the Care Quality Commission, so that she can express her views as to whether those organisations are acting in line with well-evidenced best practice in the decisions that they take. That is an important way in which we can be assured that public policy decisions on the ground from day to day reflect the national consensus on what we are trying to achieve.
Currently, NHS bodies are in scope of the commissioner’s powers, and I want to clarify that ICBs and any relevant sub-committee would also be in scope. The composition of the boards will not matter, and there will be no shielding behind commercial confidentiality. The body will sit consistently with other, similar bodies, and the commissioner will be able to get the information she needs to do the job that we have asked of her.
Edward Argar
I am grateful to the hon. Gentleman, and I share his view that it is crucial that integrated care boards co-operate with the Domestic Abuse Commissioner. I think I speak for the whole Committee when I say that we agree that the health and social care system has a crucial role in preventing and tackling domestic abuse, and in supporting victims who experience this horrendous crime. Indeed, before the last reshuffle, when I moved from Justice to Health, I was one of the Ministers working with the Under-Secretary of State for the Home Department, my hon. Friend the Member for Louth and Horncastle (Victoria Atkins), on the genesis of what is now the Domestic Abuse Act. Therefore, we wholeheartedly welcome the introduction of the Domestic Abuse Commissioner’s role in the Act.
The commissioner has a vital role to play in monitoring the response to domestic abuse, sharing best practice and challenging bodies, including in health and social care, to go further and to do more. The commissioner will require information, support and co-operation from integrated care boards as well as a range of other public bodies. That is why the Domestic Abuse Act contains a duty to co-operate with the Domestic Abuse Commissioner, and we have made it clear that that will apply to integrated care boards and their component parts. It will also apply to requests for information from the commissioner. That is a little more than one word, but I hope I have reassured the hon. Member for Nottingham North that there is already such provision, as there should be. I hope that he will feel able to withdraw his amendment.
More broadly, the Department for Health and Social Care will be taking steps to ensure that integrated care boards also have the right guidance and support to ensure that they fulfil their duties in relation to domestic abuse, as well as violence against women and girls, and sexual violence more broadly. We will be following the Government’s recent violence against women and girls strategy by engaging with current ICSs, the wider sector and the commissioner, so that we identify best practice and share that guidance across the system to ensure that all parts of the system play their part.
Alex Norris
I am grateful for that answer and clarification. On that basis, I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Question proposed, That the clause stand part of the Bill.
Edward Argar
This clause inserts 31 new sections into the NHS Act 2006. It is the cornerstone of the integrated care board provisions, as it sets out the functions and duties that ICBs are required by legislation to fulfil. Clause 19 contains a number of provisions and duties in respect of ICBs. Given the importance of these provisions in the Bill, I will take Members through them, if they will forgive me, in a little detail.
Alex Norris
I am grateful to the hon. Member for Eddisbury for tabling the amendments and to the hon. Member for Vale of Clwyd for stepping in to give the Committee a chance to discuss them. I agree completely with what he said about the Bill being a real opportunity on child health in this country and I hope that we can take it.
We should be saddened by what Barnardo’s said in its written evidence:
“Children growing up in England…face some of the worst health outcomes in Europe”—
particularly those growing up in poverty. That is really saddening, not least because even prior to the pandemic, according to Action for Children, over 4 million children were living in poverty, including a staggering, breathtakingly sad 46% of children in black and minority ethnic groups. We must seek to do better. These things should stop us in our tracks, given the wealth that we as a country have, the technologies we have, the schooling we have and the assets we have, yet we cannot give our young people, particularly the poorest children, the best start in life. That is really sad.
The only enhancement that I would make to the amendments is that, rather than making them about ages nought to 25, I would extend the range to include the six months prior to birth, because we know how important those services are. I hope, in that spirit, that we may hear some enthusiasm from the Minister and his Government about implementing all the recommendations of the Leadsom review. I know that it will be hard, because it will involve acknowledging some dreadful decisions over the past decade, such as the reduction in Sure Start but, nevertheless, that report has real potential to be the bedrock for a return to something much closer to proper early intervention in this country. We might not have the saddening and completely avoidable outcomes that we have, so I hope that we hear some good news from the Minister on that.
Edward Argar
I am grateful to my hon. Friend the Member—I cannot pronounce that—and to my hon. Friend the Member for Eddisbury, on whose behalf my hon. Friend for Vale of Clwyd spoke. I also wish to put on the record my gratitude to Lord Farmer and his team for the work that they have been doing in this space. I have had the pleasure of meeting them, and—to reassure the shadow Minister—I have already met once, or possibly twice, with my right hon. Friend the Member for South Northamptonshire (Dame Andrea Leadsom) to discuss her review. I know that my hon. Friend the Member for Bury St Edmunds has also worked with her on it, and we continue to work together to try to find ways to move that forward.
I hope that all Members agree that the creation of integrated care boards and ICPs represents a significant opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people. We acknowledge that these amendments understandably intend to ensure that the needs of children and young people aged 0 to 25 are represented on the ICP and are considered by the ICP when developing its strategy. While we entirely agree with the intentions behind the amendments, we come back to the point that we wish to provide local areas with the flexibility to determine what will work best for their systems, their priorities and how they develop their plans and membership. Overly prescriptive approaches in the Bill would risk making it harder for systems to design the approaches that will work best in their area.
Turning to amendment 54, we would not want ICPs to create plans for children disconnected from the wider healthcare system. We know that the very best systems consider how their health systems are meeting everyone’s need, including where there are transitions between different stages of life. However, I do hope that I can provide some further comfort for my hon. Friend the Member for Vale of Clwyd. We are working on bespoke guidance for babies, children and young people, which will set out clearly how ICBs and ICPs are obliged to deliver for them. This will cover the importance of the ICB forward plan and the ICP strategy and how they can set clear objectives for babies, children and young people. The Department is working closely on the drafting of this guidance with NHS England, the Department for Education and, indeed the relevant Minister, my hon. Friend the Member for Chelmsford (Vicky Ford)—I presume that she is still the relevant Minister as we speak. We will also be working with all stakeholders, including the National Children’s Bureau, in the coming months. I suspect that this is a theme and an issue that we will return to at various points both in Committee and indeed in the further passage of this legislation.
I hope that I can reassure my hon. Friend the Member for Vale of Clwyd on this matter. I entirely understand where he is coming from, but ask that, on this occasion, he does not press his amendment—or the amendment of my hon. Friend the Member for Eddisbury—to a vote.
Alex Norris
Amendment 83 builds on my hon. Friend’s argument about creating some balance between the integrated care partnership and the integrated care board, so I will not repeat it. I simply underscore the fact that the ICPs have the money, power and accountability at the moment, but there is a risk that they become a closed shop and not bodies about integration at all.
We are told that integrated care partnerships will be the way in which the broader health and care family and the community will come together as they lead and play a pivotal role. We need a safeguard in the Bill to ensure what we would do if the relationship breaks down. The amendment is a version of what Sir Robert Francis from Healthwatch said about one possible way in an evidence session. I am not prescriptive about this, but I am keen to hear what the Minister might suggest to give us comfort on this. If the ICPs are to function as promised, their plans ought to have some sort of status, so that if the integrated care board chooses to diverge, it must make a public statement that it is going to within 30 days and then publish its reasons with evidence within 60 days.
There is an equivalent provision in NHS England for responsibilities held at a national level. If nothing else, this is basic accountability. It does not restrict any activity, so there is no risk in it. Even if a partnership does not like the decision made or value the reasons given, it cannot remove the chair of the board. Although the constitution has already prevented that, at least we will know what has happened, so the safeguard is quite modest. There is a blizzard of different ways to do it, but I hope that we can have some comfort on ensuring a balance between the partnership and the board, if not at this stage, then by the time we come back on Report.
Karin Smyth
Will the Minister share with us what he thinks the difference is between ICPs and health and wellbeing boards?
Health and Care Bill (Fifth sitting)
Alex Norris ExcerptsTuesday 14th September 2021
(3 years, 2 months ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 14 September 2021 - (14 Sep 2021)
Alex Norris (Nottingham North) (Lab/Co-op)
I beg to move amendment 21, in clause 4, page 3, line 5, at end insert—
“(d) health inequalities.”
This amendment would modify the triple aim to explicitly require NHS England to take account of health inequalities when making decisions.
The Chair
With this it will be convenient to discuss the following:
Amendment 22, in clause 4, page 3, line 5, at end insert—
“(1A) In making a decision about the exercise of its functions, the health and well-being of the people of England must be NHS England’s primary consideration.”
This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.
Amendment 23, in clause 19, page 18, line 13, at end insert—
“(d) health inequalities.”
This amendment would modify the triple aim explicitly to require integrated care boards to take account of health inequalities when making decisions.
Amendment 24, in clause 19, page 18, line 13, at end insert—
“(1A) In making a decision about the exercise of its functions, the health and well-being of the people it serves must be the primary consideration of an integrated care board.”
This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.
Amendment 25, in clause 43, page 47, line 32, at end insert—
“(d) health inequalities.”
This amendment would modify the triple aim to explicitly require NHS trusts to take account of health inequalities when making decisions.
Amendment 26, in clause 43, page 47, line 32, at end insert—
“(1A) In making a decision about the exercise of its functions, the health and well-being of the people it serves must be the primary consideration of an NHS trust.”
This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.
New clause 13—Secretary of State’s duty to set targets on population health and reduction of inequalities—
“(1) The Secretary of State must, at least every five years, publish a report setting targets on—
(a) the improvement of the physical and mental health of the population, and
(b) the reduction of health inequalities.
(2) The Secretary of State must publish an annual report recording progress against the targets in subsection (1).”
Alex Norris
It is a pleasure to serve with you in the Chair, Mrs Murray, and to make my first contribution to the proceedings. It will perhaps give my hon. Friend the Member for Ellesmere Port and Neston a chance to bask in his new-found responsibilities, while I pick up the cudgel with the Minister. I am afraid I do not have such luxury as he does.
This group of amendments relates to health inequalities and to the priority that we give to the health of the nation, rather than the structures that serve the health of the nation. I will go through each amendment in turn, but I want to talk about a couple of themes that cover them all.
I strongly believe that addressing health inequalities ought to be a foundational priority of any Government of the day. What could be crueller than having such a significant element of a person’s future—how long they will live, how long they will live in good health and what diseases they are likely to acquire—preordained at birth? That has always seemed cruel to me.
Government are not a passive part of that process. The decisions that are taken in this place play an active part in those inequalities. For example, the decisions taken later today and on universal credit will widen them. We should seek to use this Bill as a turning point in our battle against health inequalities in this country. This should be the Bill in which we say that the national health service, and those who need it locally, must be central to addressing health inequalities in this country and that the Government will resource them properly to do so.
It is not a moment too soon to do this. The legacy of this decade of austerity, which my hon. Friend the Member for Ellesmere Port and Neston talked about, is that for the first time in a century the increase in life expectancy has stalled. What does it say about us, the most technologically advanced generation in history, that the increase in life expectancy stalls on our watch?
Within that there is a yawning gap in healthy life expectancy between those who live in the best-off and the worst-off communities. On the basic life expectancy measure the gap is 10 years, but on healthy life expectancy, measured by the age at which people have their first disability, the gap is 18 years between communities like mine and the communities that are best off in this country. How sad that is; how sad is what it says about us.
As the 2020 Marmot review concluded,
“health is getting worse for people living in more deprived districts and regions, health inequalities are increasing and, for the population as a whole, health is declining…the country has been moving in the wrong direction.”
Again, we heard evidence about that in the evidence sessions of this Committee. We ought to use this Bill as a moment to do something about it.
These inequalities are not just about socioeconomic status; they are about race as well. Research by the King’s Fund shows that
“people from the Gypsy or Irish Traveller, Bangladeshi and Pakistani communities have the poorest health outcomes across a range of indicators.”
Covid has shone a light on both race and socioeconomic background as drivers of inequalities. We entered the pandemic thinking it would be a great leveller and that the virus would not know people’s postcode, job or ethnicity. Actually, we quickly learned that that was not the case and that someone was twice as likely to die from covid if they lived in the most deprived communities. A man from a black African background is nearly four times as likely to die of covid as I am. Those inequalities, and how they played out, whether in housing, in occupation or pre-existing health, offered a breeding ground for the virus. That is devastating for individuals, but it is worse for all of us, because it has spread and strengthened the virus. Those health inequalities are bad for everybody.
Just before I turn to my amendments, I should also say that it is strange, given that half of all health inequalities are driven by smoking, to see a Health and Care Bill that does not talk about smoking at all. I hope that when we get to part 5, where some of the public health elements are found, we might collectively do better there.
Amendment 21 seeks to address the point about inequalities by adding to the triple aim for NHS England as set out in clause 4. The triple aim for the national health service is a good thing. It shows the system and those who work in it and lead it, whatever their role, what we want them to prioritise. The three strands of that triple aim are noble: the health and wellbeing of the people of England, the quality of service provided and the efficiency and sustainability of resources. However, that is not robust enough to ensure not just due regard for health inequalities but strong action.
I will not prejudge what the Minister will say, but I suspect he may say that promoting the health and wellbeing of people in England is the aim that covers inequalities. That is an important pursuit, but it is not explicit enough. It is just about general improvement. For example, we hope the Government would expect to see a resumption in the increase in life expectancy. That would be a general improvement in the health and wellbeing of the people of England. The problem with that is that it would not address the point about healthy life expectancy. There would be general and maybe even aggregate improvements for possibly a great deal of the population, but not enough to deal with the extraordinary and growing gaps for others. I think we ought to want to do something about that.
Accepting the amendment would mean the Government would send a signal to NHS England that tackling health inequalities ought to be at the centre of its mission. A quadruple aim may not be as elegant as a triple aim, but it is important that tackling health inequalities is recognised in the Bill. I know that the Minister wants the legislation to stand the test of time. He suggested I said something from a sedentary position about multiple pieces of legislation, which I genuinely believe I did not, but we ought to say that we are here because the 2012 Act was so bad. That there have been nine years since that Act is not a strength on the Government’s part; it is a weakness that they have defended something that has not worked for a long period of time. If we want the Bill to stand the test of time, then we ought to say what we want the health service to do. By putting that in the Bill, we would do that.
Amendment 22 also addresses the triple aim and creates a hierarchy within. High-quality and sustainable services are important, but when commissioning decisions are being made at a national level, as happens with NHS England, and those decisions affect our constituents, we do not want equal weight being given to organisational considerations. The whole point of the Bill as explained on Second Reading is to move to an integrated system that is built around the health and care needs of the population, rather than around organisational boundaries. We all recognise where that butts up in our casework and the frustration that that causes for us and, more importantly, for our constituents—those who have to make multiple calls to arrange care for loved ones and so on. If that is our purpose here, we want health and wellbeing to come first. The amendment seeks to do that and says that the primary aim of the three is the health and wellbeing of the population. If that means that there is a knock-on effect on political decisions on funding, as discussed in the previous set of amendments, so be it. It will be for the Government of the day to ensure that NHS England has the resources to do that well.
I draw the Minister’s attention to the very recent precedent in the Medicines and Medical Devices Act 2021, the Bill Committee for which took place in this room or an identical one. I was a member of that Committee, as were the hon. Member for Bury St Edmunds, who is not in her place at the moment, and the hon. Member for Erewash. When we discussed the triple aim of that Bill, I moved an amendment to prioritise patient safety over all other considerations, because I thought that was an uppermost consideration. It was originally rejected in Committee, but the Government brought it back in later stages, which was the right thing to do. Rather than waiting to bring this back later, we could address it today. I would be very interested to hear the Minister’s comments on that.
Amendment 23 is a counterpart to amendment 21, but it operates at local level. Whereas amendment 21 applied to NHS England, amendment 23 applies to local integrated care boards—to say that, as part of their responsibilities, they must take inequalities into account. Of course, all the arguments that I have made for NHS England also apply here, so I will not repeat them, but this is quite a profound case at local level. From the written evidence, the hearings and the contributions from hon. Members throughout the Bill’s stages and elsewhere in this place, we can see that there is considerable anxiety that we will end up devolving fixed financial settlements down to the integrated care system level. That suits Ministers, because it means that they can devolve financial responsibility so that the Treasury can know what it is spending on a certain function, but all the tough decisions that get us to that point have to be taken at local level. I do not think that is a dystopian scenario, because that is literally what we do with social care already in local government.
The Government know that they do not resource local authorities sufficiently. As a result, social care is squeezed. What happens in those circumstances is that the systems start to worry about running out of money. The hon. Member for Central Ayrshire made a point about end-of-year capital that I recognise from my time in local government, but it works in reverse—when Christmas comes about, there is a spending freeze on everything, and the chief executive of every council in the country ends up reviewing every purchase of more than about a fiver. That is the reality for the systems, and local commissioners will be pressured to think in the interest of resourcing their system, rather than tackling health inequalities. That runs straight into the argument for amendment 24, which is a counterpart to amendment 22 and which says that the hierarchy within the triple aim ought to apply at an integrated care system footprint.
In paragraph 44 on page 18 of the explanatory notes, the Government have told us that the purpose of the triple aim duty is to
“require organisations to think about the interests of the wider system”.
I get that, but I do not think it is quite right, because the primary responsibility is to think about the interests of the wider population. It flows from there that the best way to address the health needs of the population is a system-based approach, which is the Minister’s central argument for this entire piece of legislation—so organisations have to think about each other. However, the primacy is the need of the population.
Perhaps the Minister will say it is axiomatic that health systems will prioritise the wellbeing of their community above everything else, but I do not think it is inconceivable at all that at some point in any given year—never mind at some point in the future—system leaders in one of those footprints will feel distressed about their finances and may take the wrong message, or perhaps the wrong bit of cover on a commissioning decision, about putting population wellbeing in the same tier as system sustainability, as if those two things could be co-equals and, if in tension, could be resolved either way. I do not think that is right, and I would be interested to hear the Minister’s view on that.
Amendment 25 requires health trusts to pay regard to “health inequalities”. Again, it is a counterpart to amendments 23 and 21, and it is for the same reasons as for NHS England and integrated care boards, so I will not repeat those arguments.
Amendment 26 is a counterpart to amendments 24 and 22, requiring the prioritisation of population health and wellbeing at trust level, for the same reasons that I have just mentioned. Again, I will not repeat those arguments.
Alex Norris
Turning briefly to the points made by colleagues, the hon. Member for Central Ayrshire made the same arguments I did about patient safety and the Medicines and Medical Devices Act 2021. She made very good points about the health and wellbeing amendments, and I thought she was right to say that there is a real public appetite, now in particular, to tackle inequality. I do not think the public would be surprised to see the Government enter this space.
The hon. Member for Arfon made a similar point about whether levelling up is a political slogan or a public policy programme. It is very hard at the moment to find evidence for the latter, but this would be a really good piece of evidence for it. It is not just a north and midlands versus south issue. As my hon. Friend the Member for Bristol South said, there are some constituencies, like my own, where every single super output area would be in the hardest pressed decile in the country. However, there are many more where there is a greater range—they have some of the poorest parts of the country, but they also have some of the best off. This is something that ought to be at the top of the priority list for every integrated care system in every constituency.
On new clause 13, the Minister said that five years is too rigid. He almost suggested that the Government might outperform. I will believe it when I see it, but there is no evidence from the last 11 years to suggest that that is in any way a risk. Nevertheless, if he brings this back with a two, three or four-year time period rather than five, I will be the first to join him in the Division Lobby to support it.
On amendments 21, 23 and 25, the idea of a “fourth limb” made it work conceptually—I quite like that. What I did not give much succour to was the idea that inequalities lie somewhere else on the statute book, in a way that health and wellbeing and organisational sustainability do not, and therefore it would not need that co-equivalence because it already exists. I did not agree with that point at all.
On the point about inequalities being part of the guidance, I suspect that that will not be the last time that is said in this Committee. Guidance is guidance; legislation is legislation. One of those is an awful lot more powerful and eminent than the other. My view is that if we want to send a clear signal about something, we do not take it out and stick it in the guidance.
I do not give much succour to the point about elevating one of the triple aims either. The Minister said that that would undermine the triple aims. He talked again about the interest of the wider system, but I think all of us are more interested in the wider population. One of those clearly comes before the other. The needs of the one flow into how to organise the system. To organise a system that is supposed to come together in the interests of population health, I would really like to think that population health is more important than the system. I am not sure about the idea that, as a result, worse decisions would be made, and I would be interested in hearing an example. I have to say that that point did not resonate with me.
I am conscious of the reply from the Minister and, indeed, of the time, so I will not press new clause 13 and amendments 22 to 26. However, I do wish to push amendment 21, because if we are talking about NHS England—that totem of healthcare in our country—I really think we ought to send the signal that health inequality should be one of its priorities.
Question put, That the amendment be made.
Health and Care Bill (Sixth sitting)
Alex Norris ExcerptsTuesday 14th September 2021
(3 years, 2 months ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 14 September 2021 - (14 Sep 2021)
Karin Smyth (Bristol South) (Lab)
Further to those points about clarity around the exercising of powers, the move to give NHS England that power is entirely sensible. The medical, dental, ophthalmic and pharmaceutical services have had a lower profile in our constituencies over the last few years, as I think we would all agree. It is important to give them the profile they need to be integrated into the system, because they have certainly not been so far.
The evolution of delegating that power to CCGs came late in the day, and remains muddled around the commissioning of primary care services. Therefore, while allowing the delegation of function is entirely sensible, it is not clear, as my hon. Friend the Member for Ellesmere Port and Neston has said, when or how that delegation will be sought. I think the Minister was referring to the involvement of the Secretary of State, but I am not sure in what circumstances the Secretary of State would be doing that, and why this would not be when NHS England, or NHS England regions, decides that the ICB is of a maturity to accept commissioning responsibilities.
One assumes that NHS England believes that at the moment some of those putative organisations are mature enough already; will some of them start doing that on day one, six months in or a year in? How will we know and how will they be resourced to do it? Is it a transfer of power? How NHS England and the local ICB, without representatives of medical, dental, ophthalmic and pharmaceutical bodies, will be taking that on board is all very opaque.
Alex Norris (Nottingham North) (Lab/Co-op)
My hon. Friend has a local Mayor, but my community does not. If someone lives in Greater Manchester there is a Mayor, but in other places there may not be. We have a very asymmetric model of local devolution. Does she agree that an asymmetric model of devolution, where some ICBs had certain powers and others did not, would be undesirable and may create more confusion than it solves?
Alex Norris
I beg to move amendment 32, page 120, line 26, in schedule 2, at end insert—
“(d) at least one member nominated by the mental health trust or trusts that provide mental health services within the integrated care board’s area;
(e) at least one member nominated by the Directors of Public Health that serve each local authority within the integrated care board’s area;
(f) at least one member nominated jointly by any NHS trust, NHS foundation trust and local authority that provides social care services within the integrated care board’s area;
(g) at least one member nominated by the trade unions representing the health and social care workforce that serves the integrated care board’s area;
(h) at least one member appointed to represent the voice of patients in the integrated care board’s area.”
This amendment would require integrated care boards to have members nominated by Directors of Public Health, mental health trusts, social care providers and trade union representatives and a member representing patients.
The amendment seeks to enhance the prescribed members of the integrated care board. We have not been able to move the Minister on the chairing, but I hope we might be able to do a bit better on the board members.
These are exceptionally important roles. The decisions that these bodies make will shape communities and lives. As we have heard, the boards will be accountable for spending hundreds of billions of pounds of public money. We are banking on their leaders taking good care of that very profound responsibility, and taking integration from an academic concept, or something that is seen in some places, to a real-world idea across the country. That is a big ask, and we need the very best people on the boards and the best range of voices.
Prior to coming to this place, I was a system leader in my local health system. I chaired my health and wellbeing board for a number of years and led my council’s health and care functions. That dual responsibility is hard, because our every instinct is to think “system first”—certainly in local government, because we know that the best prize and the best step changes in the wellbeing of the community come when organisations work together. We know that, but we also butt up against the grinding realities of one-year budget cycles and diminishing financial resources, so we find ourselves in one meeting—a board meeting perhaps—where we are desperately trying to move forward the cause of integration, or the common cause of the shared vision in a community, but we know that when we get back we have to meet finance colleagues in local government, and there is a reality to that.
That duality is really hard. I always likened it—people rolled their eyes in my health and wellbeing boards, and they may roll their eyes in this Committee too—to playing for an international football team, because people come from their clubs, but they come together for a common purpose. They wear a different shirt. The reason that matters is that they do not forget who they were previously—none of that goes away—but in that moment, they are trying to work in a common cause and put aside any of the parochial or local differences they have. That worked best with a balanced and diverse set of voices and experiences around the table, and I do not think that the Bill supports the appointment and assembly of a balanced and diverse set of voices.
The more I have listened to the Minister, the more concerned I have become about that issue, because on two occasions he has characterised integrated care boards as essentially NHS fund-holding bodies that therefore sit within the NHS accountability structures. I absolutely agree that that is true, certainly in this schedule, but in that case, is this not just a bigger CCG with an integrated care partnership moored to it? What really is different here?
We have said throughout—and have been told that we are wrong, and perhaps overly cynical in saying so—that this is an NHS reorganisation Bill, not an integration Bill. I am afraid that the Prime Minister rather weakened Ministers’ arguments by saying that there needs to be an integration White Paper, which I thought was an extraordinary indictment of this legislation. If this is a Bill regarding integration, who is integrating with who? There do not seem to be multiple parties; there seems to be a single party, perhaps with different elements and slightly different email addresses, but still with broadly the same accountability structures. At this point, this does not feel like integration.
In the previous sitting, the Minister described the current composition of the boards as a de minimis one, and said that there could be more members. I hope there is an expectation—he might address this when he replies—that generally, there would be more than the five people currently set out. Paragraphs 3 to 7 of schedule 2 set out the minimum of five members who will form the integrated care boards: the chair and the chief executive—there must be two of them—and then one member to represent all the NHS trusts, one person to represent primary care, and one person to represent all the local authorities in the area. The first time I read about those three ordinary members, I thought, “Those poor people.” One person to represent all the trusts in an area? One to represent all the local authorities in an area? Goodness me, that is a challenge.
I understand that the Minister is not keen to be overly prescriptive beyond what is in the Bill, and that there is a desire to strike a balance between being permissive and being prescriptive—trust me, nobody gets more frustrated with people in London telling people in Nottingham what to do than I do. However, given what is in the rest of schedule 2, I think the Minister is in danger of undermining that argument.
As we have heard, paragraph 4 says that only NHS England can choose the chair; paragraph 5 says that only NHS England can remove the chair; paragraph 14(2)(a) says that NHS England can vary the constitution of a local integrated care board; and paragraph 14(2)(b) says that NHS England can stop any other amendments to that constitution. We should not give too much succour to the idea that this part of the Bill is going to be particularly permissive, and that there is not going to be prescription in there. Of course there is, because we want local communities to shape their planning and their approaches, but we also think that there are minimums—I think we could find a level of commonality relatively easily—and we want to establish them as a backstop. Obviously, we have five here, but I think we ought to go a bit further.
As such, my amendment suggests five other members, the first of whom would be a representative of a mental health trust or similar. Again, if the Minister thinks I am wrong or that I have misunderstood this, I would be keen to hear from him, but I think it is exceptionally unlikely that the ordinary member chosen to fill the role described in paragraph 7(2)(a) on behalf of NHS trusts in a particular integrated care board footprint would not be from the biggest acute trust in that patch, or at least from one of its acute trusts. Our big hospitals are the gravitational centres of a local health system. They are totemic to a local population, they are massive financially, and they are exceptionally powerful in terms of soft power in a community. That means that there is one place and that place is gone, so once again, there is nothing for mental health.
We talk so often in this place about the need for parity of esteem between mental and physical health, but this is an opportunity to demonstrate that in practice, and we are not taking it. Beyond the fact that we ought to be putting mental and physical health on an equal footing, so many of the knotty issues that we will want local health systems to tackle will be rooted in issues relating to mental ill health, so I think there needs to be a voice at that table that can give balance to the decision making.
Edward Timpson
I am grateful to the hon. Gentleman for giving way, and I understand his desire to try to push the agenda of some very important parts of our healthcare system, including mental health. Is he cognisant of the evidence that we heard from Dame Gill Morgan, who has already set up an ICS and who has perhaps done some of the testing for us on what works best? She said:
“In our case, we will have mental health and social care around the table, not because we are told to but because we could not imagine how we could do our work at a local level without having those people feeling that they are full partners and sitting around the table.”––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 133, Q186.]
Does the hon. Gentleman think it is important that we listen and learn from the experience to date in order to ensure that—to use the hon. Gentleman’s football analogy—we do not have too many people on the pitch? The analogy falls down, because it is possible to have only 11 on a football pitch. The danger is that we end up with too many people, which is unworkable and unmanageable.
Alex Norris
I am grateful for that intervention—I am going to stop at 10. That evidence actually supports the point the I am making. When we heard that evidence, the witness said that it was automatic to them, but of course we would want someone from a mental health background and someone from a social care background. I completely agree. What I am saying is that if that is so clear and obvious, which I believe it is, why on earth would we not put it in the Bill? It was clear and obvious enough that we wanted to have someone on behalf of local authorities, and that we wanted someone on behalf of primary care. If it is clear and obvious in those cases, it is clear and obvious in these, too. That was my reasoning, and it was obviously echoed in the evidence submitted by the Royal College of Psychiatrists and the Mental Health Foundation. That is the first thing I want to say about the amendment.
The second relates to a director of public health drawn from that patch. Goodness me—as my hon. Friend the Member for Ellesmere Port and Neston said this morning, if anyone has proven themselves under fire over the last 18 months, it is our incredible DPHs. With a unique combination of knowledge, training, local insight and cross-system relationships, they have done an extraordinary job for us in pulling together our approach to the pandemic. We should be using that to pull together our approach to all sorts of big issues that we face in our local communities.
The DPHs are the human embodiment of our communities’ joint strategic needs assessment. They bring that to life, and they could bring that to the table. If we want our system leaders to go beyond their organisational concerns when they go into their integrated care board meeting, who better than the person who develops the insight into system need? The DPH is exactly the right person. They also provide an invaluable director-level connection to all the departments of the local authority that have such a profound impact on the wider determinants of health—housing, leisure and planning. What a wealth of knowledge, and what connections, they would bring to the table.
Thirdly, the amendment provides for a designated social care representative. The stated aim of the Bill is to drive integration and to foster collaboration between health and care partners. I really want that to be the case, rather than this being just a reorganisation Bill. It is a 135-clause Bill, and two of the clauses are about social care, so it is not unreasonable to say that perhaps there is an imbalance. Rather like the much-hyped social care reform and funding plan that the Government are discussing downstairs at the moment, the clauses in the Bill neither reform nor, in the main part, fund social care. Again, social care is left trailing behind. It has been battered for 11 years and, as a result, we see rationed care, dreadful terms and conditions for staff, and services that are just not fit for what they were supposed do. If the Bill really is about fostering collaboration, social care ought to be explicitly represented.
I am conscious that there is a nominated local authority representative under paragraph 7(2)(c) of schedule 2, but that person will already have quite a lot on their plate. They will have to represent the broader views of the entire local government family. Nottingham and Nottinghamshire is probably one of the simpler planning footprints in the country, but it is still 11 counties, and representing all those views at once is very difficult. It is too much—and not credible—to represent not only 11 council chief executives, but 11 directors of adult social care and children’s social care, as well as all the other functions of the local authority. A social care lead, who convenes the social care leads in the given geography, would give the ICBs the specialist knowledge and insight to create and foster the environment for a true partnership between health and care.
Fourthly and penultimately, amendment 32 would replace the staff voice through recognised trade unions. As has already been mentioned, our health and social care services are well served with amazing staff. They are our experts. They are the people who feel things on the frontline and who know, when they go, “Here we go—here’s a new initiative”, whether it is practical and rooted in real-world experience. They have that very direct experience of population health and how it is changing over time.
The staff are the ones telling us about the fractures in the health and care system that make their jobs harder—the fractures we are supposed to be dealing with. They were the ones—boy, should we have listened to them then!—who told the Government very clearly what the impact of the 2012 reforms would be on the system and about the greater fracturing of the system. They were not listened to then, but they should have been and they should be now.
Prior to coming here, I was a union organiser. I know one thing for sure: senior management always think they can speak for the staff, but I am afraid they generally cannot. That is not a criticism; their lives at work are very different. The health and care family is better served when all aspects are covered, rather than some speaking for others. If we are going to develop really significant plans at these boards, the discussion would be incredibly enriched if the voice of the frontline was there, to sense-check things, to highlight things that are working already and the workarounds that staff develop as time goes on, and to assist on planning as well. There is an awful lot they could contribute.
Finally, and crucially, let us have a representative of the patient voice. The whole reason why any of us come to this place is that we want to give communities a voice. We think that is important. The key way we do that is to listen to people. If we do not, we do not do very well for very long.
We want our communities to have brilliant health and care services, but sometimes we make it harder for them to tell us what they want. We have tremendous mechanisms for finding out. The evidence of Sir Robert Francis from Healthwatch was particularly pertinent on not just using numbers, but the wealth of qualitative information. Let us have someone who is an expert by experience and who can draw on and bring that with them, and speak for thousands of other experts by experience. We must believe that they have as much to contribute as senior leaders. Not only would they bring insight, but it would give legitimacy to decision making, which is something that we have real concerns about, as we have said on discussion on multiple groups of amendments.
Those are the extra five members we are suggesting. If anyone listening at home is keeping score, that means five members—the chair, the chief executive, the acute lead, the primary care lead and the mental health lead—who owe their employment fundamentally to the NHS, and five—the local authority lead, the DPH, the social care representative, the staff representative and the patient representative—who do not.
If the Bill is about integrating and not about a restructure and reorganisation that involves the big acutes taking on the rest of the system, that might be quite an elegant balance. Of course, local systems could seek to augment that, which would be a matter for them, but this would be a very solid foundation, which I think enriches the board. I look forward to the Minister’s response.
Dr Whitford
I, too, rise to support the amendment. This is probably one of the most important amendments so far. In the witness discussion, we came back time and again to which voices would be on the ICB and would be able to influence. I agree that, with all the talk of parity of esteem, it seems incredible that there would not be a voice representing the importance of mental health on the board. Similarly, with the talk of moving to population health and wellbeing, there is a need for directors of public health to agree policy and to feed in information about the underlying health inequalities, life expectancy and so on in the local population. Not to have a social care voice when what the Government say is that they are trying to integrate the NHS with social care seems quite bizarre.
The NHS and social care are both services delivered by people for people and having both the workforce and staff voice, and the patient voice, is therefore important. On the staff voice, the “Learning from Scotland’s NHS” report from the Nuffield Trust highlights that the success of both the Scottish patient safety programme and the Scottish quality improvement standards was driven by the fact that frontline staff were involved as drivers, champions and developers from the word go. These programmes have been able to run over years, building on experience that is then shared with other sectors and specialities. It is important to get this part of the Bill right, or else priority will not be given to integration, population health or wellbeing. Of all the things that have been discussed so far in Committee, and through the witness statements, this amendment is one of the most important.
Edward Argar
I think that all add value, but equally, in some circumstances, we see different local arrangements; in some localities, some people fulfil more than one role or sit in different places.
The hon. Gentleman asked me to cover his specific point about the guidance before I conclude: the guidance will not prescribe additional roles in the same way that legislation prescribes or mandates, but it does seek to set out best practice, highlighting what would be deemed to be best practice—drawing on experiences such as Dame Gill’s, I suspect. We would expect that ICBs would pay due heed to that guidance, alongside their de minimis legal and statutory obligations.
If in time, when those ICBs are up and running, it becomes clear that that approach needs strengthening and that we need to add further requirements, regulation-making powers in schedule 2 will allow the Secretary of State to do so at a later point. We believe that it is right to start at this de minimis point in the Bill. It reflects our view, which I have articulated throughout, that we must not attempt to over-legislate at this stage on the composition of ICBs, letting them evolve as effective local entities, to reflect local needs. It may not fully reassure the hon. Gentleman, but there is a mechanism whereby further changes could be made in future, although we do not believe that will be necessary.
The amendment takes a different approach, which is essentially more prescriptive and less permissive. I do not dispute the sincerity of that approach, but it comes down to a matter of where we feel the appropriate balance should be struck. I fear that, although the shadow Minister and I are quite close to one another in our region of the east midlands, we are slightly more distant in respect of the amendment, but I am grateful to him for affording the Committee the ability to debate a key point of principle in the approach to the Bill.
Alex Norris
I am grateful to the hon. Member for Central Ayrshire for her contribution and for sponsoring our amendment. She spoke about the way staff have not only improved patient safety and the quality improvement programmes, but made them stand the test of time. We are sometimes in danger—the Bill is a good example—of building things that do not stand the test of time and keep being changed, and she went through all the various situations. If we pass any test, it should be that one. The amendment is certainly one way of improving our chances on that.
I am grateful to the Minister for his comments, too. I understand the de minimis point, but I still cannot envisage a scenario in which we would not want a mental health rep on the board. I live in undoubtedly the best place in England—in Nottingham—but we still have mental health problems and need mental health leaders. If we need mental health reps, and we certainly do, I think that everybody probably does.
The Minister’s response did not quite address the point about balance. The balance of the five members is four NHS and one non-NHS. The whole business maxim is no mergers, only takeovers. If the provision is really about integration and partners coming together on an equal footing to improve the population’s health, everything that we have heard so far does not fit with that. What we have heard so far is about organising this round with the terms of reference that NHS England wants, and if local communities and local authorities wish to be part of that and know their role within it, that is absolutely fine. I think we should aspire to do better, so I will press the amendment to a Division.
Question put, That the amendment be made.
Alex Norris
I beg to move amendment 30, in schedule 2, page 120, line 26 at end insert—
“(2A) The constitution must prohibit representatives of GP practices with active Alternative Provider Medical Services contracts from becoming members.”
This amendment would mean that the only GPs able to participate in integrated care boards would be those whose practices are on the standard General Medical Services (GMS) contract.
The Chair
With this it will be convenient to discuss the following:
Amendment 33, in schedule 2, page 120, line 26, at end insert—
“(2B) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care boards.”
This amendment prevents private providers of healthcare services from becoming members of integrated care boards.
Amendment 27, in clause 20, page 29, line 9, at end insert—
“(4) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care partnerships.”
This amendment prevents private providers of healthcare services from becoming members of Integrated Care Partnerships.
Alex Norris
We have not had success with chairs, and we have not had success with who should be on the board, so we move on to who should not be on the board. Let us see whether this alternative tack might prize the Minister away from not giving us his support.
The amendment would mean that representatives of GP practices with alternative provider medical services, or APMS, contracts were prohibited from participating in integrated care boards. That would mean that, under schedule 2, they could not provide that primary care representative.
Let me briefly explain the context. The vast majority of practices—nearly 70%—operate under the general medical services, or GMS, model. That is the standard contract and the most usual model of partnership whereby a CCG or NHS England contracts with a local general practice. Another quarter or so operate on personal medical services, or PMS, models. There is a little more flexibility for commissioners to tailor to local need—this is not agreed as a standard contract like the GMS at national level—and again the arrangement is with a local practice. However, these are not particularly en vogue; they are being phased out, I understand.
That leaves the remaining portion, which is on APMS. That is a much more flexible contracting model and very much a child of the previous decade. Here, commissioners can contract with organisations other than GPs or GP partnerships, and can contract, for example, with private companies.
APMS contracts—without that GP requirement and with shorter durations—offer the easiest way for large private companies to take over practices. Those are companies motivated by profits, rather than their patients, and their having a voice on the board would run contrary to what I am sure Members on both sides of the Committee seek to achieve. I would say it was contrary to the triple aim of the Bill.
However, this is a model on the march and one that could change general practice beyond recognition. My colleagues and I do not think it should exist, but we will make our case on that when we deal with clause 16 and amendments 28 and 29, so I shall have to keep the Committee in suspense. The amendment would mean that a representative from such an APMS partnership could not be part of the ICB and could not fill that place.
As my colleagues and I have made clear previously, we think it paramount that the Bill put patients front and centre. For many patients, using the health service begins and ends with their GP for big parts of their life. The GP is someone they have known for years, someone they can trust and someone who plays an active role in and knows their community.
The pandemic has created some access issues, but the care that people have received is still exceptional. The latest GP survey found that 89% of patients said that the healthcare professional they last saw was good at listening to them and giving them enough time, 88% said that that healthcare professional was good at treating them with concern, and 93% said they were involved as much as they wanted to be in decisions about their care and treatment. Our local GPs are really good and do the job really well. It is not much of a stretch to think that those are the sort of people that the public want speaking for them in these ICB structures. That would be very welcome.
We also know that, whether my supposition that the ICBs are going to be really big CCGs is right or not, CCGs had significant involvement from primary care clinicians and the ICBs will have less. That is definitely a point beyond contention, but there is still a reserved place on the board. However, this is a perfect opportunity for local GP leaders to fill that space, and with regard to APMS contracts, I do not think that those representatives will provide that same involvement.
I appreciate that the numbers will be relatively small—indeed, this might be quite unlikely to happen—but we should bear it in mind that APMS contracts do not require a GP to be a contract holder. They do not offer the same benefits to an ICB as a general or personal medical services contract holder, who is contractually required to be a GP. That is a significant difference. This position on the board should bring important perspective; it should not be wasted.
This is about two things: first, showing the best possible voice and secondly, putting a stop on creeping privatisation. Ministers have been at great pains earlier in the process, and certainly on Second Reading, to say that this is not about privatisation. Well, this is a very good chance to prove that.
Edward Argar
With your indulgence, Ms Elliott, I will turn to amendment 33 first. Integrated care boards will be NHS bodies, whose membership consists, at a minimum, of individuals appointed by NHS providers, providers of GP services and local authorities that coincide with the ICB. Any perceived risk of privatisation through the ICB membership provisions is, I believe, entirely unfounded—and, I feel bound to add, potentially unfair to the many public servants in the NHS who work for ICBs. Although service provision—I emphasise the word “provision”—by the independent and voluntary sectors has been, and continues to be, an important and valuable feature of this country’s healthcare system under successive Governments of all political complexions, it was never the intention for independent providers, as corporate entities, to sit on integrated care boards, nor for an individual to be appointed there to be a representative of such an interest in any capacity.
People must therefore be assured that the work of integrated care boards is driven by health outcomes, not by profits, and I am sure that there will be a consensus on that principle across this Committee. That is why there are already safeguards in place to ensure that the interests of the public and the NHS are always put first. The ICB chair has the power to veto members of the board if they are unsuitable, and NHSE has the power to issue guidance to ICBs in relation to appointments as part of its general guidance-making power. That sits alongside the robust requirements on ICBs to manage conflicts of interests, and NHSE’s wider duty to issue guidance to ICBs.
I turn to amendment 30, which seeks to exclude individuals whose GP practice holds an alternative provider medical services contract from being made a member of an ICB. APMS contractors include some private and third-sector organisations, but also some GP partnerships. These contractors include, for example, social enterprises and partnerships that provide services to homeless people and asylum seekers. This amendment would potentially prevent some individuals from being on ICBs, on the basis of the type of NHS GP contract that their practice holds.
I do appreciate the intent behind the amendments, namely the desire to avoid the appearance, and potentially even the risk, of privatisation and conflicts of interest. However, the effect would be to limit the ability of primary medical service providers to appoint an ICB member who might best meet the requirements of the local population, by reducing the diversity of GPs who could be appointed. While I can understand the intent behind them, I fear that these amendments do not do what they seek to do, and they would have unintended consequences. I will turn to those shortly.
We recognise that the involvement of the private sector, in all its forms, in ICBs is a matter of significant concern to Members in the House, and we are keen to put the point beyond doubt. However, having taken appropriate advice, I am afraid that that these amendments would not cover a number of scenarios—for example, lobbyists for private providers, or those with a strong ideological commitment to the private sector—and they would therefore not be watertight
As it stands, these amendments may well not offer the robust assurance that perhaps hon. Members intended. Therefore—this is where I may surprise the hon. Member for Ellesmere Port and Neston—to put this matter beyond doubt, we propose to bring forward a Government amendment on Report to protect the independence of ICBs by preventing individuals with significant interests in private healthcare from sitting on them.
As hon. Members will know from their attempts to draft these amendments, avoiding unintended consequences is not a simple matter. If appropriate, I would be happy to engage with either the hon. Member for Nottingham North or the hon. Member for Ellesmere Port and Neston in advance of Report. We may not reach a consensus, but, as they both know, I am always happy to have a conversation with them.
The Government are firmly committed to the founding principles of the NHS. We recognise the importance of its values, and the public service ethos that animates it. It is by no means our intention to allow private sector providers to influence, or to make, decisions on spending on the commissioning board—the ICB—and the spending of public money. The Bill does not allow that, but we will look to see whether we can find a way to put that unfounded fear to bed once and for all with an appropriately worded amendment that does not have unintended consequences.
Although I appreciate that much the same motive underpins amendment 27, it is worth considering why the integrated care board and the integrated care partnership are different bodies. The decision to create integrated care partnerships came from discussions with a number of stakeholders who revealed a strong case for the creation of a committee to consider strategically not only the health needs but the broader social care and public health needs of a population. It is not a body like the ICP, as we have heard, which will be directly accountable for the spending of NHS monies.
We therefore do not intend to specify membership for the ICP in the Bill, as we want local areas to be able to appoint members as they think appropriate. To support that, we have recently been working with NHS England and the Local Government Association to publish an ICP engagement document setting out the role of integrated care partnerships and supporting local authorities, integrated care boards and other key stakeholders to consider what arrangements might work best in their areas.
We would expect members of the ICP to be drawn from a very wide variety of sources and backgrounds, including the health and wellbeing boards within the system; partner organisations with an interest in health and care, such as Healthwatch; and potentially voluntary and independent sector partners and social care providers at that level, as well as organisations with wider interests in local priorities, such as housing providers.
To exclude independent providers from both the ICB and the ICP would, I fear, risk severely reducing the extent to which all parts of the broader health and care ecosystem could be drawn upon in the ICP context. It would exclude valuable expertise and would, for example, prevent social care providers who provide a small amount of domiciliary care to the NHS from sitting on the ICP. Furthermore, the ICP will not make commissioning decisions or enter into contractual arrangements that are binding, or make decisions about who gets funding allocations. Those are functions conferred on the ICB, hence the distinction that I make.
I therefore believe that membership of individuals from independent providers on the ICP does not present a conflict of interest in the way that hon. Members have asserted, certainly in the context of the ICB. I suspect that we may debate that further in the coming weeks, but taken with the ICB and the comments that I have made, we believe that this provides the right balance between recognising the distinctive accountabilities and responsibilities of the NHS, local authorities and other partners, and strongly encouraging areas to go further in developing joint working.
I hope that what I have said provides some reassurance to Opposition Members, and that they will be willing—I see them nodding—to engage with me to see whether we might find a greater degree of consensus. I should also say that I will obviously speak to the Scottish National party spokesperson on this as well, as I have done throughout. I addressed my remarks to the shadow Minister, but of course I extend that offer to her. I hope that on that basis, the Opposition Front-Bench spokesman will consider withdrawing the amendment.
Alex Norris
If the Bill is about collaboration, we ought to model that here. Given that very gracious offer, I am very happy to beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
The Chair
We now come to amendment 33 to schedule 2, which has just been debated. Justin Madders, do you wish to move the amendment formally?
Health and Care Bill (Fourth sitting)
Alex Norris ExcerptsThursday 9th September 2021
(3 years, 2 months ago)
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Dr Whitford
Q
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
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
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 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
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
Louise Patten: It is both/and.
Edward Argar
Q
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.
Alex Norris
Q
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
Sir Robert Francis: Yes.
Alex Norris
Q
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
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.
Health and Care Bill (Third sitting)
Alex Norris ExcerptsThursday 9th September 2021
(3 years, 2 months ago)
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Alex Norris (Nottingham North) (Lab/Co-op)
Q
Pat Cullen: Where do I start? They feel exhausted, demoralised; they are tired to say the least, and they are very concerned about the future. Why is that? Because they do not have the workforce to deliver.
The Chair
Could I just remind the shadow Minister to stick within the scope of the Bill, please?
Alex Norris
On a point of order, Mrs Murray. How our staff are at the moment is within the scope of a Bill about the NHS, I would have thought.
The Chair
Okay, but can we just make sure that we stay within the scope of the Bill?
Pat Cullen: I will try and answer in relation to the Bill. All the issues that I have just spoken about in relation to that exhaustion, the tiredness and the fact that they are not able to provide the care for their patients—there are opportunities in the Bill to correct some of those things. Again, going back—I hate to harp back to it in my Northern Ireland words—but the fact is that if we ensure that accountability sits with the legislator and with the Secretary of State, to ensure that we do not find ourselves back in this place again, with 40,000 vacancies going into a pandemic or at any other emergency situation we find our nurses in, that will absolutely assist and support. However, there are opportunities for the workforce in the Bill that we do not believe are being grasped at the minute, and that is further adding to the demoralisation that they are feeling.
Professor Helen Stokes-Lampard: I will keep it succinct. I completely agree that the clinical workforce—doctors—are demoralised, and I think anxiety would be the greatest feedback that we get: anxiety and fear of the amount of risk that is being held in the system at the moment. We are in the grip of a third wave of this pandemic, which many in the media seem to have completely forgotten about. People are dying by their hundreds on a daily basis still. This is a huge challenge. It goes back to exactly the point in the Bill about workforce planning for the future, so that we never find ourselves in a similar situation again. While we cannot predict when the next pandemic will hit, we can certainly be assured that another pandemic will come. The challenges around the climate and the global problems are going to impact on our health and wellbeing hugely, and we can plan for them now if we choose to. So, fearful and anxious, but we can do something about it. We have a unique moment in time to grasp this, and this legislation is one part of that unique moment in time.
Professor Martin Marshall: You will not be surprised to hear that morale in general practice is at rock bottom. We read about it in the newspapers every day. Surveys that we have conducted of our members suggest that 60% of GPs say that their mental health has deteriorated significantly over the last year. Anxiety, depression, suicide, ideation—33% of GPs say that at least once a week they find it almost impossible—
The Chair
I am just saying from the Chair that we are here to talk about what is in the Bill and to take evidence on the Bill, so we should stay within the confines of what is in the Bill.
Alex Norris
Q
Professor Martin Marshall: There could not be a worse time for general practice to introduce the Bill, but I do not think that means it should not happen. It has to happen now. The NHS is ready for it, so it has to happen. The fact that general practice does not have the capacity or capability to engage fully with the implications of the Bill will mean that the Bill will not realise its full potential.
Professor Helen Stokes-Lampard: From my point of view, there is never an ideal time to introduce legislation and, certainly, in the midst of a global pandemic is on nobody’s agenda as a good time to do anything legislatively. However, the consequences of not doing it are that the integrated care systems, which are in a really vital part of their evolution and formation, will stall and therefore are far more likely to fail. So my view and the view of the Academy of Medical Royal Colleges is that we absolutely must go ahead with this legislation in the timeframe. There is never a good time to have a baby or move house, but you still need to crack on and do these things at bad times.
Pat Cullen: Same here: never a right time. If you were to ask nurses on the ground today, carrying out patient care in frontline services, they would say that anything that might improve where things are at the minute will be a bonus. But the issue is how it plays out and whether we are listened to. The professional royal colleges do represent nurses. I am here representing 480,000 nurses today. It is really important that we get this right. There is never a right time, but it is actually a great time if we do get it right.
Alex Norris
Q
Professor Martin Marshall: I cited earlier the example in Gloucestershire. It has very purposefully built a primary care subgroup of the board in order to provide that clinical expertise and that clinical sounding board to everything that goes on at board level. That seems to me to be a really good way of moving on from a single GP on the board—which will be helpful but will have limited impact—to actually making a real difference on the ground. The real change, of course, will not happen at ICS level anyway. It will happen at local level; it will happen at the place level. That is where real change in integrated care, from the patient perspective, will be enacted and will be felt.
Professor Helen Stokes-Lampard: To build on what Martin has said, there are great examples of clinical panels, which is essentially what we will be talking about. That is a model that works extremely well and which can be broadly based and covering a huge range: primary and secondary care—the whole range of specialities. But in the same way, citizen panels have become something that can be hugely helpful as well. I am very anxious that we also hear the patient voice in the decision making at community level.
There has been a covid culture of creativity. When there was less top-down insistence on following direct process at the start of the pandemic, a lot of creativity was allowed to flourish. I feel we need to capitalise on that culture of creativity. These kinds of panels are exactly the sort of output that has come and they have been hugely beneficial. And, of course, the move to greater digital working has meant that we have been able to reach people that we have not otherwise been able to get. Clinicians leaving the clinical environment to participate has become easier when they can do so remotely. There is a dividend that we should build on.
Pat Cullen: To add to that, I fundamentally believe that the patient voice must be heard in those structures beneath the board. That is how we will really influence and move forward in terms of what is required, and those voices will feed into the population needs assessment at local level. But there needs to be a nurse involved in each one of those structures that feeds right in through to the director of nursing that sits on the board, and that is how you will hold the accountability line up and down.
Health and Care Bill (Second sitting)
Alex Norris ExcerptsTuesday 7th September 2021
(3 years, 2 months ago)
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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)
Q
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
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.
Edward Argar
Q
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
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
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
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.
Alex Norris
Q
“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
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
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.
Dr Whitford
Q
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
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
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
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
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.
Health and Care Bill (First sitting)
Alex Norris ExcerptsTuesday 7th September 2021
(3 years, 2 months ago)
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Justin Madders
Thank you. For the last minute, I am going to hand over to my colleague.
Alex Norris (Nottingham North) (Lab/Co-op)
Q
Danny Mortimer: We have a really constructive set of relationships in the NHS with our trade unions, on both terms and conditions and the social partnership forum, which the Minister’s colleague Helen Whately chairs and which brings trade unions and employers together.
There is an interest in how the health service organises itself, and there is an interest in how the health service and our friends in social care can better work together to relieve the pressure that our colleagues were experiencing even before the pandemic. Of course, there are other things that people are interested in as well. There are outstanding questions about long-term pay strategy, and there are other issues around working environments and support that Navina touched on. Those are really important as well.
There is a recognition, when I speak to trade union leaders and representatives, of the opportunities available through system working to improve service delivery, and therefore to help their committed members do their jobs better and relieve the pressure that they have been under for far too long.
Cervical Screening
Alex Norris Excerpts(3 years, 4 months ago)
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Alex Norris (Nottingham North) (Lab/Co-op) [V]
It is a pleasure to serve under your chairship, Mr Pritchard. I would not normally make the Front-Bench contribution for the Opposition virtually, but I am afraid that I, too, have been pinged by the NHS app, so I am beaming in live from Nottingham. I thank my fellow pingee, my hon. Friend the Member for Gower (Tonia Antoniazzi), for securing the debate through her role on the Petitions Committee. The points that she made about testing have been a common thread throughout the debate, but she also mentioned the impact of covid, which I will reflect on shortly.
The petition has received close to 150,000 signatures, which is frankly an incredible effort. As well as showing the strength of feeling on this important topic, it is a physical demonstration of the legacy and impact of young mother Fiona Mathewson, who tragically lost her life to cervical cancer last April, at the age of 30. I send my best wishes to the Mathewson family—Andrew, Harry and Ivy. I lost my father to cancer when I was Harry’s age, and I know the impact that it has on a family. I hope the Mathewson family can take comfort from the incredible campaign that they have run, and from the way that they have been able to turn such awful grief into positive action. It is because of them and because of Fiona that we are here today. I hope they have seen that across the debate all four countries of the UK have been represented with very thoughtful and impressive contributions, starting with their own Member of Parliament, the hon. Member for Berwickshire, Roxburgh and Selkirk (John Lamont). He mentioned the twin giants of prevention—screening and HPV jabs. I, too, will reflect on those.
My hon. Friend the Member for Pontypridd (Alex Davies-Jones) was very generous with her personal experience, and we are glad that it has had the ending that it has had. It might make people watching the debate think about a screening they have missed, whether it relates to their cervical health or otherwise. That is a really important lesson that people have taken from her, and I know that she inspires people in that way.
Important points were also made by the hon. Member for Rutherglen and Hamilton West (Margaret Ferrier) around health equity, particularly in the lesbian and bisexual community but also around those who suffer from sexual violence. We really must ensure that we tailor our messages and the way we contact people, in order to understand their different circumstances. They may present in different ways or need different support, and we would always want that support to be available to them.
As always, my hon. Friend the Member for Coventry North West (Taiwo Owatemi) brings her experience as a senior oncology pharmacist. She knows much about the impact of cancer on people’s lives and how to design cancer services. When we talk about covid in the cancer space, we generally talk about missed screenings, the backlog or late presentation, but she made an important point about the mental impact. It is hard for me to imagine what it is like to be called for a smear test, but she talked about hurdles getting in the way and said that this is very big hurdle that can make people set it to one side. That point was very well made and linked to what the hon. Member for Strangford (Jim Shannon) said about the importance of effective communication.
Finally, my hon. Friend the Member for Wythenshawe and Sale East (Mike Kane) talked about the importance of brilliant British science, which is something we have seen clearly over the last 16 or 17 months. We need to back our brilliant British science companies, in order to get the best possible outcomes for ourselves here in Britain, and around the world.
As we have heard, every year in the UK around 3,200 people get cervical cancer and Cancer Research UK estimates that 857 people died of cervical cancer in 2018. While the incidence rates have not fallen significantly in the last two decades, the good news is that mortality rates have continued to fall, especially among older patients. Since the beginning of the 1970s, the mortality rate has dropped from 10 women per 100,000 to approximately 2.5 per 100,000. That is significant progress that has saved the lives of many women.
The NHS cervical screening programme is a huge part of this, with the NHS estimating that it saves 5,000 lives a year, which is truly wonderful. In 2019, HPV primary screening was added to the programme, replacing cytology, as the hon. Member for Central Ayrshire (Dr Whitford) said—a major step that the NHS believe has the potential to eliminate cervical cancer by spotting earlier those 14 types in the HPV infection that combine to be the main cause of cervical cancer.
Earlier diagnosis makes such a difference; quite simply, it saves lives. Where the cancer is diagnosed at stage 1 or 2, one-year survival is over 90%, which drops to 75% at stage 3 and 50% at stage 4. Data from the National Cancer Intelligence Network also shows that the cervical cancer three-year relative survival rate is higher among people diagnosed by screening than by any other route. If there is a message to come out of today’s debate it is the importance of screening.
We know there is scope to improve in this area. Exciting new advances using mRNA, gene therapy, artificial intelligence, combination therapies, robotics and many more, such as those mentioned by my hon. Friend the Member for Wythenshawe and Sale East, will transform our care in cancer. As we restore services affected by the pandemic, we should not be looking to restore what we had 18 months ago, but to embrace new developments and build new pathways of care.
On screening frequency, which this petition relates to, cervical screening in England is offered to the cohort aged 25 to 64. While routine screening is now offered every three years up to the age of 49, and every five years between the ages of 50 and 64, the UK National Screening Committee has recommended that for those who test negative for high-risk HPV, the interval can be extended to five years. I understand that this will be implemented once necessary IT developments allow it. Can the Minister confirm when that is likely to be?
I fully sympathise with and appreciate the arguments for more screenings that have been made in the petition. Any lives saved strengthen the case far more than anything I can say, but I strongly believe that it is right that this decision is made by the experts on the UK National Screening Committee and not by us politicians. Where clinical evidence supports their decisions to screen at the intervals they say and not to extend testing to 18-year-olds, which I know there have been calls for, then we support that.
Beyond that, the Government must do more to increase take-up and ensure that all those eligible for a cervical smear test attend their appointments when they are invited or as soon afterwards as possible. We must also ensure that preventative measures, such as the vaccination, get out into secondary schools and are fully taken up. I would be interested to hear the Minister’s reflections about further plans to develop this, because we know we are not getting it quite where we want to.
The aim is for 80% of women to access their test, with 75% being considered acceptable. In the year prior to the pandemic, it was 72%, a little bit up from 71.9% the year before. That is not where we want it to be and we must do something different. As my hon. Friend the Member for Gower said, the pandemic has worsened the situation.
Jo’s Cervical Cancer Trust estimates that around 600,000 cervical screenings failed to go ahead in the UK in April and May 2020. NHS England’s own data shows that no clinical commissioning group screened over 80% of eligible women in the third quarter of 2021. These numbers are people who could be living either with high-risk HPV or with cancer itself and do not know it yet. I hope that the Minister will expand on the data to paint a fuller picture of the situation as she sees it and to share with us the steps for how these services will be caught up, so that we can reach those who have missed out.
To conclude, those who raised this petition deserve real commendation for their excellent efforts. I am sorry that perhaps the evidence is not pushing us in the direction that they have encouraged us to take. However, I hope that when Harry and Ivy are teenagers, they might look back on this debate—perhaps wondering why we are all beaming in from different parts of the country, in our own bedrooms or in other rooms in our homes—and see that this was a galvanising moment for politicians to come together across Great Britain and Northern Ireland to improve screening rates and the uptake of the HPV vaccine. I also hope they see that, as we went forward, we embraced improvements in technology and cancer care, and that, as a result, we got more and more brilliant outcomes for women in this country. I hope that when they look back in many years’ time, they will be very proud of their role, and the role of their family and their family friends, in achieving that.
Draft Medical Devices (Northern Ireland Protocol) Regulations 2021
Alex Norris Excerpts(3 years, 4 months ago)
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Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to serve under your chairship, Dr Huq.
The Minister and I have had a touring show in Committee, implementing various parts of the Northern Ireland protocol, and this instrument is very much in the same vein. However, unlike the Minister himself, the Northern Ireland protocol is not ageing well. [Laughter.]
Lord Frost said last week that it is wrong to view the Northern Ireland protocol as a “definitive” text. I would say that when we consider instruments of this nature—I have done an awful lot of them now—the things that we are doing feel rather “definitive”, and it is an extraordinary failure of statecraft to characterise an agreement that the UK entered into willingly in this fashion. I recommend that hon. Members read the transcript of the consideration of this instrument in the other place. It is quite something to read the level of criticism of the status of Northern Ireland now with regard to instruments such as this one, with much of it coming from some of those who were the most enthusiastic about our embarking on this course in the first place.
So why are we here today? As the explanatory memorandum says, it is not to implement the EU medical devices regulation, which came into effect from 26 May; Northern Ireland has taken those rules in a way that the Government said it would not have to. Within that regulation, there is latitude for individual countries to diverge from the MDR where national law differs and in the areas that the Minister talked about: on single-use devices and custom-made devices, we differ. This instrument is therefore necessary to ensure that we can do that across the whole of the United Kingdom. Of course, we support that idea, so I will not seek to divide the Committee today. However, I will briefly pick up a few points with the Minister regarding alignment, enforcement, and the conformité Européenne or CE mark more broadly.
First, the instrument addresses the fact that, although the EU MDR is fully applied, our MHRA remains the regulator. Therefore, we need to give it—again, this is why we support the SI in front of us—provisions for enforcement of fees and so forth where national divergences exist, so that we can have alignment. However, I wonder what this will mean in practice for the people of Northern Ireland. What impact will there be if the European Medicines Agency and the MHRA depart markedly from each other’s regulatory regimes, and what would that mean for businesses and their products? What conversations has the Minister had with colleagues in the Northern Ireland Executive?
While the Northern Ireland protocol is in effect, and very definitively so, a CE mark is required to go to market. That is potentially advantageous for patients in Northern Ireland versus those in Great Britain, as the vast majority of products—for example, 600,000 medical devices—that have been approved in the EU are already CE-marked across the whole of the UK. That would continue to be the case under the protocol, but the situation could change in Great Britain after 2023. Indeed, I believe that the plan is to introduce the new UK(NI) mark. At the moment, we have access to 600,000 devices with the CE mark, but we do not know what the plan will mean in years to come.
Will the Minister give some detail about parliamentary opportunities to scrutinise and improve plans for the relationship between the CE mark and the UK(NI) mark? That will become a fundamental question of patient safety across the UK in years to come, and we really ought to have a very strong plan for it, all lightness aside, even if there are elements of the Northern Ireland protocol that the Government think will be dropped at some point. This element definitely will not be, because it is a core part of our medical devices regime going forward. We would benefit from having more opportunity to discuss that point.
On enforcement, the SI will give the MHRA powers to serve notices for breaches of the EU MDR, so manufacturers will need to take a number of steps to ensure that their goods can still be sold after the deadline, as noble lords mentioned in great detail when they considered the SI. What discussion and consultation have the Government had with the sector? I agree wholly with the judgment that the SI does not pass the threshold for an impact assessment, but ongoing consequences may do so in the future, so I am keen to know what sorts of questions the Government have received.
My final point is on an issue that I raise every time we have a matter relating to the MHRA, but I am never quite sure that we get a strong answer. There was a similar issue in Committee yesterday. What enforcement capacity does the MHRA really have for the range of duties that it has acquired through our exit from the European Union, through the Medicines and Medical Devices Act 2021, through the SI on coronavirus tests that we discussed yesterday, and through the responsibilities picked up in the SI we are debating? Are there more people doing enforcement than there were three years ago, when none of those responsibilities existed? Is the funding for that on a sustainable footing? Is it something that can be built around? Can people be trained and developed and become real experts on this issue? We will need that to have a secure regime, because we will lose all our protections from working in a flock with our colleagues on the continent. The Minister mentioned that the SI does not apply to in vitro devices and that we still rely on the 2002 regulations. Are there plans to update that in due course?
This is the tip of a bit of a whopper of a mess. Approving the SI is the right thing to do today to ensure that, to the best of our ability, Northern Ireland can be part of our medical devices regime. In the conversations that we are having outside this place on issues relating to this matter, the central question should always be patient safety, but the central question is now about borders and bureaucracy, which is what we were told it would not be about. I hope the Minister can address my questions.
Draft Medical Devices (Coronavirus Test Device Approvals) (Amendment) Regulations 2021
Alex Norris Excerpts(3 years, 4 months ago)
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Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to serve under your chairship, Mr Davies, and to be part of the proceedings that make first use of a new power under the Medicines and Medical Devices Act 2021; it feels like a long time since we were sitting in a similar Committee Room debating that Act. I am grateful to the Government for the briefing session for Members of both Houses last week, in which we were able to ask a number of important questions.
High-quality testing is a crucial part of fighting coronavirus. Knowing who has it and who they have been in contact with, and supporting them and their contacts as they isolate themselves, is a core way of preventing transmission. Even as we start to reopen significant aspects of British life, that basic principle will remain with us for some time, so it is right that testing be put on a high-quality, properly regulated footing. While members of the public are not at direct risk from bad tests, the knock-on impact of a false positive or negative is serious, so we need to set up a regime that reduces the risk of that as much as possible. Of the 280 tests available, only 50 would pass the relevant standards. That is sobering, and good reason for us in this place to act. We therefore do not intend to divide the Committee, but I would like details from the Minister.
The explanatory memorandum describes the regulations as “urgent” action. We are some 16 months into this crisis, and the powers have been available under the 2021 Act for some months; is this the fastest the response could have been? When the regulations were considered in the other place earlier this week, there was a suggestion that the reason for the new-found urgency was that the Government wish to transition to a charging model of testing, rather than the current public health model in which tests are made widely available for free. Lord Bethell said that was not the case; I am hoping that the Minister will give the same commitment, and will say that free testing will be available after the regulations are approved next Monday, and while we deal with the current peak of infections.
The Minister talked about a partnership going forward. I understand that the Government cannot be expected to carry the entire burden indefinitely, certainly not for private entities, but what will that partnership look like for the rest of this year? Assuming that we do not lose free tests in the short or medium term, there is an expectation that we will start to see an increase in testing through the private route. I did not hear, in the Minister’s opening speech, assurances on how those tests will be linked to NHS Test and Trace. There is value in testing in and of itself—it lets individuals know whether they need to self-isolate—but the point of having a central system is that we can have surveillance around the virus, and critically we can seek contacts and get them to isolate, too. Will the obligation still be on the individual, and will there still be support from the state?
I asked this at the briefing but did not get a particularly detailed answer, so I will try again. On the fees regime, we support, of course, the discount for small and medium-sized enterprises, which make up the bulk of the market, as the Minister said. In general, though, that £14,000 figure seemed quite high, not to mention suspiciously rounded, for a full cost recovery model. Will she share the breakdown of the costs? If she does not have that information with her, perhaps she might put it in the Library, because there is interest in it.
The instrument allows the Secretary of State to exempt tests on a case-by-case basis to avoid supply issues for the NHS. However, tests procured by the Department of Health and Social Care or the NHS are exempt already, so why is that necessary? The main weakness of the 2021 Act was that it allowed too much regulation to be implemented or set aside at the stroke of a pen by a Minister acting as a Caesar, rather than as someone who is accountable to Parliament. There does not seem a lot of point in doing what we do, either downstairs or up here, if a Minister can later decide that they are not interested in a certain provision of a regulation or Act. That should be avoided as much as possible, and I cannot see its value in this case. I may be missing the point, but I hope the Minister will address that, or at least say what safeguards will be put in place, and what reporting there will be of the provision’s use.
In a growing market such as this, there will still be some who choose to break the rules, thinking it a route to quick profit. Presumably the enforcement will be for the Medicines and Healthcare products Regulatory Agency. Is it suitably resourced to tackle this in the short term, as it beds in? Will it have a specific team on it? Similarly, what will the fines regime look like, and will it compound for repeat offenders?
To finish where the Minister finished, the shadow Health Secretary, my right hon. Friend the Member for Leicester South (Jonathan Ashworth), is fond—I wish he was not so fond—of saying that we are in an era of pandemics. I am not attracted to that characterisation, but as the Minister put it, disease management is something that, globally, we clearly have to get much better at. This may not be the last time that we deal with something like this. The points that she made on the management of the Ebola virus were very interesting. On future-proofing, how portable is this model for testing in future pandemics? Or will it hold merely for covid-19? Rather than waiting 16 months, we would be able to implement it much more quickly.
As I said, I do not intend to divide the Committee. I know that I have fired off a number of questions. I hope that, if the Minister does not have all the information today, she might be able to follow up in writing.