Health and Care Bill (Seventh sitting)

Alex Norris Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

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

I beg to move amendment 34, in schedule 2, page 120, line 26, at end insert—

“(2C) The constitution must require integrated care boards, and any committee or sub-committee of the board, to meet in public and publish all papers and agendas at least 5 working days before each meeting is held.”

This amendment mandates integrated care boards, and their sub-committees including “place based committees” to meet in public and publish all papers and agendas at least five working days before each meeting is held.

It is a pleasure to resume proceedings with you in the Chair, Mrs Murray. This is a resumption of our discussion on schedule 2, which lays out the rules under which integrated care boards must meet. For all the talk of local flexibility, the reality is that the regulations are quite tight in schedule 2; the amendment seeks to tighten them a little more, but not disproportionately so.

The amendment asks for two things: first, that the boards meet in public, and, secondly, that they publish their papers five days in advance. To start with meeting in public, it has been mentioned on a number of occasions that the 42 different integrated care boards are in different states of development. There will be systems that are well advanced and model good behaviours of transparency and accountability, but we have to set regulations to ensure a minimum floor standard, and this is what the amendment does.

For a struggling system, the worst-case scenario, as we have said before, is that it can become a closed shop of leadership appointed centrally by NHS England and the leaders of the big acute trusts, because it is they who have the power and the resources. We cannot legislate to improve the culture of those systems—that is not what legislation does—but we can ensure proper oversight to try to minimise the risk, and meeting in public is a good way to do that. Sunlight is the best disinfectant, as they say, and this will mean that the public have a good sense of what decisions are being taken in their interests.

A key part of that citizen oversight is to know what decisions are being taken and when. Including a provision in the constitution to publish papers with five working days’ notice seems a good way to do that. I would argue that that represents rather basic good governance, so it is a very low bar to clear. We have spoken before about wanting to allow integrated care boards to be able to vary to fit their local circumstances, but I cannot see under what circumstances it would be desirable or relevant to vary the publication of that information. I do not think there are any local circumstances that would call for that. The requirement would mean that members of the public, elected representatives and those who represent staff or anyone with a general interest would understand what is going to be decided and when, and would give them the opportunity to make representations so that the board members are making decisions in the full knowledge of the facts and the views of the broader system.

In the amendment, that requirement also applies to all committees or sub-committees. This matters, because we heard in the evidence sessions that it is almost inevitable that every system will want to establish sub-committees, both thematic—we heard from the system in Gloucestershire about its primary-care themed one, which I thought was a very desirable way to use a sub-committee—or, inevitably, given what we have said about the size of the footprints of some of the integrated care boards, place-based. It is important that the provision applies to those bodies too.

The question matters even more to the integrated care partnership and its status, and I hope the Minister will be able to address it. My reading of clause 20 and proposed new section 116ZA of the Local Government and Public Involvement in Health Act 2007 states that this is a committee of the integrated care board and the local authority. I would argue that that remains an oddity, because the process was pitched to us on the idea that we have an integrated care board that will be the official NHS fund-holding body, but then we have the integrated care partnership that will provide the broader involvement on an equivalent basis, not as a sub-committee. I hope that point can be addressed, but nevertheless it will be important for that body that the public know what is being discussed and when. We will come back to clause 20, but the commitment from the Government that the meetings and papers should be public is a good thing.

Conceptually, the amendment lands the ICB and any sub-committees at about the level of an executive board of a council. That to me feels about right. The Minister may have reflections about circumstances where, by exception, the boards may need to meet in private for certain decisions, as local authorities would do. There are ways to do that for councils, so I do not think it is beyond our wit to do the same for these bodies, too. As a default, the basic principle of public meetings, with papers published five working days in advance, seems sound.

[Karin Smyth (Bristol South) (Lab)]

I offer my support to my hon. Friend and agree with everything he said. There may be a response from the Minister, although I do not know what he will say, but there is some discussion that perhaps the amendment is not necessary, as this already happens and the Bill refers to publishing—but that is not true. There are exemplar trusts and bodies across the country that have a culture of openness, but NHS boards are secretive and protected.

We have numerous examples of whistleblowing and good journalism uncovering the depths of NHS bureaucracy. Boards with which I have dealings, not just locally in Bristol, do a lot out of the public eye, and a culture of not liking scrutiny has evolved over a couple of decades, even though they should be really proud that people are taking an interest. We need to change that culture, and having a reference in the Bill would help.

Trade union colleagues have often come to me to complain about how they are blocked from getting key information about plans for changes. Changes are announced, and management often want to start TUPE discussions without really understanding what is behind the change. The use of freedom of information requests results in variations across the country in who responds and how they respond. That needs to stop.

The default should be to make things public unless there are reasons not to. I was a non-executive director back in the noughties, and was led by a chair who had come from local authorities—a Labour chair, but I do not think that matters. People who were used to chairing in local authorities found it quite peculiar that the NHS wanted to discuss matters in secret. As a board, we made it the case and culture that managers had to say if there was a really clear reason, and on several occasions we challenged why things were not done properly.

The new NHS is not commercial. The Government tell us that we are not quite getting rid of the purchaser-provider split, but we are moving away from competition as the driver of the health service. The confidentiality argument should be disappearing. I hope that the Minister accepts that the very highest standards now need to be set around openness and transparency and need actually to be enforced. All levels of the NHS and all these committees and sub-committees, however we end up organising them, have to be cognisant of the Nolan principles, which should drive all their work.

If a trust is finally forced by a tribunal to disclose information, it should have been provided earlier. There should be consequences. Where there is a bad culture, we need to change it. To reference my hobby-horse, there should be a business case to support every major decision. Later we will discuss my new clause 7, which comes from the pain I have experienced trying to unearth business cases, particularly in wholly owned companies and subsidiaries, to deliver facilities management. I have asked for business cases only to be told, “No, it is confidential.” There should be no need for it to be confidential at all. I do not understand how a business case can be confidential—at best, a few lines might be sensitive, but not a full business case.

That shows that NHS bodies who fear a change think they have something to hide. It is wholly wrong. If a change is proposed, the case for change should be published. We need to know why it is necessary. I would go further; I would publish all details of the tender process and the contract management. If anyone wants to do business with the NHS, which we welcome, they need to be open and transparent. It really is a test of the intention to change course and move to an integrated, collaborative model, because as we exit the market, we need to be make sure that the wellbeing of the public and the patient really comes first in commissioning. As I say, that culture needs to be changed.

To come back to my theme, ICBs need to be the bodies that the public recognise and understand as being where some sort of accountability resides. That means that nothing should be secret. Let us go further: the public has the right to question. That is what we come back to. There has to be a figurehead—ideally an elected figurehead —or non-executive directors who can be truly independent and challenge that secretive culture. I hope the Minister will look favourably on the amendment.

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To summarise, I endorse what the shadow Minister and the hon. Member for Bristol South were saying, which is that the principle of transparency is one to which I think we would all expect these bodies to fully adhere. On that basis, I gently encourage the hon. Member for Nottingham North to consider not pressing his amendment to a Division.

[Alex Norris]

I am grateful for the contribution from my hon. Friend the Member for Bristol South. I completely agree that where we will see the worst practices across footprints, each and every one will be secretive and not invite scrutiny, so it is very important that we set arrangements to ensure that that cannot happen.

I am grateful for the clarification that the 1960 Act will apply, which assuages my first concern. On the second, relating to the notice of board papers, the Minister has essentially said that local footprints will have to set that element of the constitution themselves, but that the safeguards and schedules will mean that NHS England has to sign them off. In that sense, there cannot be wide divergence, because the centre would not permit it. I reiterate that there should be commonality. I cannot see why it would be seven days in one place and five days in another. I do not know how we could explain that, so I hope that in those conversations the Minister stresses the need for uniformity. Perhaps the guidance might include strong encouragement on that. On the basis of the agreement that we have in principle, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I beg to move amendment 43, in schedule 2, page 123, line 2, at end insert—

“(5) An integrated care board must apply all relevant collective agreements for staff pay, conditions and pensions.

(6) An integrated care board must ensure that all relevant collective agreements for staff pay, conditions and pensions are applied throughout the area for which it is responsible.

(7) Any integrated care board which wishes to employ anyone directly on an annual salary greater than £161,401 must receive approval from their integrated care partnership before confirming the appointment.”

This amendment puts into primary legislation the current practice that NHS bodies honour collective agreements over staff pay and conditions and gives the integrated care board a role in ensuring this remains the case.

It is a pleasure to see you in the Chair, Mrs Murray. I would like to say that it is a pleasure to see the Minister, although when I saw the headline that two Ministers from the Department had been promoted to the Cabinet, I had expected that he would be among them—alas, not on this occasion. I am sure it is only a matter of time. Of course, if the Minister and other Members on the Government side want to keep their phones on in case a call comes through, we will not be offended if they have to pop out for a couple of minutes. I hope the Minister’s rush of blood and damascene conversion to the perils of privatisation at the end of the sitting on Tuesday have not blotted his copybook too much.

I turn to amendment 43, which plays into several points that have come up in the evidence sessions, particularly the anxiety that was mentioned by Sarah Gorton of Unison in her evidence to the Committee last week. She said that she wanted to see in the legislation confirmation of assurances that have been given verbally and in guidance. She referred to conversations that she had had—I am not sure with whom, but I assume with officials in the Department. Those conversations were to the effect that there was

“no intention for any new parts of the system to undermine the collective arrangements”.––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 96, Q129.]

and that the “Agenda for Change” agreement would continue to apply across the board and, indeed, to ICB staff. That is an important matter to seek assurance on. Anyone who has been involved in “Agenda for Change” will know that years of hard, torturous work were involved in getting that agreed. Certainly, on this side, we know the value of the staff and their trade union representatives, and the importance that collective agreements have in bringing issues to the fore and ensuring a universality in treatment and a common understanding of the basis on which the employer and employee move forward.

Of course, whatever the collective agreements say, the staff would like to be offered increases that actually keep pace with the cost of living, rather than the real-terms cuts that we have seen in the last decade. However, as an overall framework for ensuring staff are treated fairly and consistently, it is certainly not something that we want to be chipped away at.

I will not try to persuade the Minister of the benefits of collective agreements across other sectors—it would be well outside the scope of the Bill—but it is worth pointing out that there is plenty of evidence from across the world showing that where workforces have negotiated terms and conditions within sectors and across whole industries, they tend to enjoy better terms and conditions and, crucially, better rates of workplace satisfaction and staff retention. As highlighted in the report recently published by the Health and Social Care Committee, the NHS faces an enormous challenge in retaining its workforce.

We do not want anything to undermine “Agenda for Change”. Sadly, though, we have seen attempts to do that in recent years, with the creation of wholly-owned subsidiary companies. I will not return to the argument about whether those are a good thing, because we have said that they are not, but let us examine for a moment why trusts sometimes seem eager to set these companies up.

There are, of course, huge financial pressures on trusts. I will not rehearse the arguments on that, but they are always looking at ways to reduce their costs, and potentially with these subcos to boost their income. The VAT advantages have been a big part of that, but one of the big concerns—cash-pressed trusts may see this as a big opportunity—is that the subcos potentially have the ability to move away from “Agenda for Change”. That is the heart of it; it is not that the trusts have a major objection to “Agenda for Change”, but moving away from it allows them to set their own terms and conditions, which is really a euphemism for saving money and cutting pay. We think that that kind of approach is a false economy and, ultimately, self-defeating.

There are other examples of where the private sector will step in. We saw the news this week that King’s College Hospital Foundation Trust will transfer staff at its urgent treatment centre in Denmark Hill to Greenbrook Healthcare under a three-year contract, starting in October. Of course, staff will expect TUPE to apply, but, as we know, it is not a panacea. It does not protect terms and conditions for ever more, so it is little wonder that the news of that change has led the workforce to raise concerns.

Unison’s written evidence sought clarification from the Minister that

“it’s not the intention that ICBs depart from Agenda for Change”,

which the Minister gave on Second Reading. The written evidence also states that

“UNISON would support amendments to ensure that ICBs will apply the relevant collective agreements for staff pay, conditions and pensions, and be responsible for ensuring that these are applied within the wider system. In addition, further reassurances should be sought that nothing in the Bill will compromise the assurances already given in the Employment Commitment, the terms of which should endure beyond the point of staff transfer.”

The evidence continues:

“Recently published guidance lists 10 ‘outcome-based people functions’”—

perhaps that phrase could be translated into plain English at some point—

“that ICSs will be expected to deliver from April 2022… In addition, the guidance suggests that the responsibility for engaging with trade unions will rest with the regional teams of NHS England / Improvement rather than with ICBs”.

That runs the risk of depriving unions of access to those who might be making strategic decisions in their area—or perhaps it just speaks to a larger truth about where power will lie in all this. We have covered those concerns in our amendment to some extent, but we would like reassurance from the Minister on some of the points we have raised about how this will all work in practice.

In particular, we need reassurance that the system will not undermine existing provider responsibilities on engaging with trade unions. As hon. Members will know, the vast majority of NHS staff will not be employed in commissioning bodies such as ICBs. The strong relationships with individual provider organisations should be a supplement to existing national and regional partnership forums. The concern is that the new kids on the block, the ICBs, will in some way disrupt those arrangements.

If, as we are told, the new ICSs—to use the correct terminology—will be system leaders themselves, it is not impossible that some of those leaders will want to set their own path in tweaking employment matters. We might see circumstances in which some agreement about staff mobility within ICSs comes to the fore, particularly for those whose duties cross organisational boundaries. In principle, that is no problem, as long as no ICB thinks that, as a result, it can move outside existing collective agreements. Our amendment would rule that out.

It is essential that ICBs have a positive role in all this and that they follow existing practice by referring to collective agreements. We would not want a re-emergence of what we saw some five years ago, with certain trusts trying to undermine collective terms and conditions. Those attempts failed, but we never know when that might re-emerge. We also believe that the ICB should honour national agreements for the staff it employs.

That should not need to be said—as we have heard, assurances have been given—but it needs to be made explicit in the Bill to give us the cast-iron lock that both we and Unison would like. We would certainly like some further assurances about whether the ICBs have the potential to circumvent or destabilise existing arrangements, should they seek to forge their own path at some point. We see this amendment as bolstering the commitment to “Agenda for Change”—I hope that the Minister will confirm that commitment when he responds —so that ICBs’ broad powers are not seen as an attempt to undermine or conflict with the hard-won terms and conditions that have been collectively agreed.

Turning to sub-paragraph (7) in the amendment, which relates to pay limits, hon. Members will have seen headlines in the paper, on Tuesday, I think, about the highest-paid NHS managers being “cleared out”; I think that was the term that was used. I am not quite sure what that means, other than redundancy. The story refers to a Government-inspired audit, which was—at least on Tuesday—going to be led by the then Chief Secretary to the Treasury, the right hon. Member for North East Cambridgeshire (Steve Barclay), who has since moved on to other matters. That is a shame, because he used to hold the same role as the Minister does now, and he would know exactly where to look if there were indeed examples of unnecessary management and bureaucracy in the NHS.

That news follows the headlines we saw last week about some ICB executives potentially receiving salaries of £270,000. Let us be clear what we are talking about here: that is the pay of 10 nurses. It seems that someone somewhere in Government is exercised about the number of managers in the NHS, but according to the King’s Fund, the actual figure is somewhere below 5%, and many of those managers hold dual clinical roles. If the Government think there is a problem here, I am not entirely clear what they think the scale of it is, or what the consequences would be if thousands of managers in the NHS were made redundant. I am sure that was not covered in the impact assessment, but we have the benefit of that now.

To be clear, the amendment is not about bashing managers at all. Every organisation needs managers if it is to be effective, and they play an important role in enabling clinicians to get on and do their jobs on the frontline. I am sure the Minister would not want to leave managers in the NHS with the impression that has unfortunately been left by some of the headlines this week, namely that there is no role for managers in the NHS. One could be forgiven for concluding that from Tuesday’s headlines. If the Government think layers of management, bureaucracy or management costs have got out of control, we can do something about it.

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[Karin Smyth]

I agree, and we will probably all have examples through the primary care networks of practices that were not in old houses but that had perhaps had a LIFT scheme or another new development. In my constituency, the Bridge View Medical practice was able to have a flow through the building and move patients downstairs because it had a large, fairly new building. The pandemic has shown that in an emergency we need to make sure that the community-based estate is brought together in some way. Actually, that applies not just to the health service, but to ex-local authority or even Ministry of Defence or other Government Department estates. The place-based aspect of the Bill should be encouraging people to do that locally. Because estates are not part of it, they will struggle to deliver on the service intent of the Bill.

[Alex Norris]

I am grateful for the opportunity to comment on amendment 17 and the insight that my hon. Friend the Member for Bristol South brings from her long period of working in the NHS. What is at the crux of this point is quite important. We have spoken quite a lot about integrated care and revenue, but the capital component is as important, so I am glad we have the opportunity to discuss it.

I have great affection for the Bulwell Riverside facility in my community, which co-locates two GP surgeries, community services and pharmacy services with local authority neighbourhood services, the local library and youth services. Pre-covid, I and the local councillors would be there every week for an event. Every year, my annual jobs fair is there—it is today, but we are not inside because of covid, so it is out in the marketplace. If any of my constituents are watching, we are there until 2.30 pm.

That joint service centre has driven a culture of integration and collaboration, exactly in the spirit of everything we have been discussing on the Bill. It is a very practical example of integration in practice. It was funded on the LIFT model because, at that point, more than a decade ago, that was the way to get money into the system. The logical consequences on the ground of the legislative direction that we are told is intended here will be more need for this sort of joint service centre model. We need to give that proper consideration.

As my hon. Friend the Member for Bristol South said, this element is one of the few bits of the 2012 Act that is not being removed to take us back to pre-2012 status. Then, primary care trusts could enter into these arrangements locally, whereas their successors, clinical commissioning groups, could not and, at the moment, the successor ICBs cannot either. The amendment would remedy that.

Why is that provision not being added back in? It looks a bit like a wheeze. Originally, PCTs would have had a 40% stake in the arrangements and would have benefited exactly as my hon. Friend said. Now, that stake is owned by community health partnerships. Who owns 100% of community health partnerships? That is the Department of Health and Social Care. It is not that nobody benefits from these arrangements—it is that the Department does, rather than local communities. We are told this Bill is about localisation and devolving resources and powers to local communities, so why on earth is this bit not going back in? It is definitely a point of interest, particularly with existing LIFT models.

On LIFT models, it may be that the Government do not think that they are in vogue now or that they are the right model. I would be interested to hear what other methods the Minister might prefer.

How to get capital back into the system is a significant point. The NHS backlog is now £17 billion, as the bill for austerity becomes due, so we will have to address it by one means or another. If that is not to be done through this system, I am keen to hear from the Minister how it is to be addressed.

Health and Care Bill (Fifth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[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).”

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[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.

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I therefore encourage the shadow Minister not to press his amendments to the vote and commend clause 4 to the Committee.

[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 Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[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?

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Division 4

Ayes: 4

Noes: 9

[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.

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[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.

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Division 5

Ayes: 5

Noes: 9

[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.

--- Later in debate ---

[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 Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Dr Whitford]

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

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

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

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

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

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

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

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

[Alex Norris]

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

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

[Alex Norris]

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

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

[Alex Norris]

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

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

[Alex Norris]

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

Louise Patten: It is both/and.

[Edward Argar]

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

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

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

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

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

--- Later in debate ---

[The Chair]

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

[Alex Norris]

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

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

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

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

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

[Alex Norris]

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

Sir Robert Francis: Yes.

[Alex Norris]

Q Thank you.

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

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

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

[Edward Argar]

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

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

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

Health and Care Bill (Third sitting)

Alex Norris Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

Thank you. I now turn to the shadow Minister, Alex Norris.

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

Q Thank you, Chair. Thank you to all three of you for joining us this afternoon, and thank you for everything your members have done for us in such difficult times in recent months. Collectively, you speak for tens of thousands of NHS staff and allied professionals, so a simple first question from me. Pat, you might go first: how do staff feel at the moment?

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—

--- Later in debate ---

[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 With that in mind, given the quite challenging picture that all three of you describe there, do you have any anxieties that this is not the right time to have the Bill and that, with staff anxious, demoralised and tired, a reorganisation might add to those anxieties and concerns for the future?

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 I will just ask a final question in my last couple of minutes. Martin, notwithstanding what you said about a greater GP voice on boards, and similarly Pat regarding directors of nursing on integrated care boards, what else could we do to get the voice of the staff really heard in the plans generated by the integrated care partnerships and then executed by the boards? What mechanisms do you think are effective ways of hearing from the frontline what is happening day in, day out? Perhaps, Martin, you could go first.

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.

[Alex Norris]

Thanks, all three of you.

[The Chair]

Thank you. We now go to Minister Argar.

Health and Care Bill (First sitting)

Alex Norris Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[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 I have a very quick question for Danny Mortimer. You have the unenviable task of negotiating with the staff and their representative unions on all sorts of issues—pay, terms and conditions, safety. When you have such negotiations, how high up on the list does a commissioning restructure come in terms of the things that our front-line staff are really after?

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.

[The Chair]

I call Dr Phillipa Whitford, the SNP spokesperson.

Health and Care Bill (Second sitting)

Alex Norris Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

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

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

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

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

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

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

[Alex Norris]

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

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

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

[Alex Norris]

Building on that point—

[The Chair]

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

--- Later in debate ---

[Edward Argar]

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

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

[Alex Norris]

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

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

[Alex Norris]

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

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

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

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

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

--- Later in debate ---

[The Chair]

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

[Alex Norris]

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

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

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

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

[Alex Norris]

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

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

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

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

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

[Alex Norris]

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

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

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

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

[The Chair]

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

--- Later in debate ---

[Dr Whitford]

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

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

[Alex Norris]

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

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

[Alex Norris]

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

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

Lyn Summers: No, we have not.

[Alex Norris]

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

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

[Edward Argar]

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

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

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

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

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

Cervical Screening

Alex Norris Excerpts

Monday 19th July 2021 Westminster Hall

[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

Thursday 15th July 2021 General Committees

[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

Wednesday 14th July 2021 General Committees

[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.