NHS Integrated Care System Boundaries

Bernard Jenkin Excerpts

Tuesday 29th June 2021 Commons Chamber

[Sir Bernard Jenkin (Harwich and North Essex) (Con)]

I am sorry that this debate is unlikely to be the penalty shoot-out that some people may have been looking for.

We know that the Government are about to publish a new Bill on the NHS, but it is not widely known or understood that the NHS in England is being prepared for a major reorganisation. The clinical commissioning groups established by the Lansley reforms have gradually been subsumed into groups called integrated care systems. These ICSs are not legal entities, but single executive teams that have effectively merged the CCGs. Their boundaries are established according to the local health economies. For example, the North East Essex CCG has been merged with two Suffolk CCGs to form the Suffolk and North East Essex ICS, which commissions all NHS services across the whole area. This enabled Ipswich Hospital NHS Trust and Colchester Hospital University NHS Foundation Trust to be merged. I have to say that this is highly effective. In my nearly 30 years as a Member of Parliament, I can honestly say that the NHS in our area has never been better led.

[Sir David Amess (Southend West) (Con)]

I know that my hon. Friend will agree that we have had a fabulous football result this evening.

Going back to the days when my hon. Friend’s father was a Health Minister, when the noble Lord Fowler was Secretary of State and when the late Lord Moore was Secretary of State, would he agree that we have had far, far too many of these reorganisations, and that we need to halt the process in our area at the moment?

[Sir Bernard Jenkin]

I will come to that point later; I shall not want to repeat myself.

[Mr Tanmanjeet Singh Dhesi (Slough) (Lab)]

I congratulate the hon. Member on having secured the debate on changes to the NHS integrated care system boundaries on the night that England have beaten Germany and qualified for the quarter finals of Euro 2020. Does he agree that although these plans may satisfy the political ambitions of some, they do not deliver the best outcomes for our constituents, including my Slough constituents, who are already well served by the successful Frimley ICS, which should not be broken up? If something is not broke, why needlessly try to fix it?

[Sir Bernard Jenkin]

I was anxious to give way to the hon. Gentleman to show that there is cross-party concern about this matter; I am sure that his point will be enlarged upon by my right hon. Friend the Member for Maidenhead (Mrs May).

All this is being put at risk at a time when the NHS is still reeling from the impact of covid-19. The new Bill will place ICSs on a statutory footing, which is a good thing, but there is also a proposal that the ICS boundaries should be redrawn to be coterminous with upper-tier local authority social care boundaries, and that is what we are questioning.

I am most grateful for the way my right hon. Friend at the Dispatch Box has listened recently to MPs affected by these proposed changes and has consulted us. He therefore already understands why I and others remain so concerned, but I must put it on the record that the rest of the consultation process has been not just inadequate but in defiance of proper transparency and accountability.

[Sir David Amess]

Absolutely outrageous!

[Sir Bernard Jenkin]

My hon. Friend says that is outrageous.

A firm of organisational consultants, Tricordant, was instructed by NHS England and NHS Improvement East of England to host roundtables in recent months with all the stakeholders in and around the NHS in the east of England. For some reason, it was told to exclude the MPs. Tricordant has produced several drafts of its report, which have been shared among existing ICS leaderships, NHS providers and tier 1 local authorities, but not with MPs. A few of us were eventually briefed by NHS England at the Minister’s behest, but I am mystified as to why we were not positively engaged at the outset.

The White Paper produced in February 2020—incidentally, just as we perhaps should have been anticipating the pandemic, instead of planning an upheaval of the NHS—talks about this coterminosity of boundaries, but it also has a whole section on the primacy of place. I will explain this, but those two objectives are fundamentally incompatible. The consultation exercise then appears to have been driven by that dogmatic insistence on coterminosity, and has been further confused by a lack of clarity about the problem that actually needs to be solved.

In Essex and Suffolk, areas larger than single counties were ruled out so Ministers will be presented only with a choice between the boundaries as they are and two county ICS areas—one for Essex and one for Suffolk. Discussions concerning the future of the Suffolk and North East Essex ICS have been strongly weighted towards the county councillors and their officers. Not all relevant NHS stakeholders have been consulted, which is why NHS Providers, which represents NHS leaders across the country, has spoken out on their behalf. Individual NHS leaders are understandably reluctant to criticise proposals in public, but they are known to be against the change, including the leaderships of the acute trusts across the east of England.

I understand why the county councils want this change, and I completely respect their ambition. Essex has made clear to me its frustration at making time for meetings with three different ICSs. I can also see that the new boundaries are superficially attractive, because they align NHS commissioning with the boundaries for the health and wellbeing board and other statutory public services, such as the Essex police and the local resilience forum. Essex County Council acknowledges the extremely successful place-based working implemented by Suffolk and North East Essex ICS, which incidentally has been complimented by the Care Quality Commission, the King’s Fund and the National Audit Office.

The new legislation is intended to extend place-based working to all areas. None the less, the Tricordant report would be misleading if it did not express the clear preference of NHS leaders in Essex to retain the existing ICS boundaries, primarily in recognition of the long history of operating as a single health economy, the significant flow of patients across the county border, the strength of existing relationships in the system, and the progress that has been made locally in integrating health and care services.

There are practical difficulties with the changes for Harwich and North Essex, which are replicated in other parts of England. Enablers of effective place-based working—the leadership, the philosophy and having all the partners sitting around one table—are essential to build effectiveness. A place—I use that term advisedly—that has thrived as part of one system will not necessarily thrive as part of another. Superb progress has been made in north-east Essex in recent years and, more recently, in mid and south Essex. These systems are now working not just because commissioning reflects what is called place but because people have grown into their roles and developed relationships of trust across different organisations. All that will be discarded by the wholesale changes to NHS commissioning by imposing coterminosity.

[James Sunderland (Bracknell) (Con)]

Does my hon. Friend agree that, because Members of Parliament in Nottinghamshire, Berkshire, Hampshire, Suffolk, Essex and beyond have not been adequately consulted on these proposals, we should pause any decision with a view to looking more objectively at what is on the table?

[Sir Bernard Jenkin]

My hon. Friend anticipates what I might say later.

The foundation trust for the Ipswich and Colchester hospitals will have two different commissioners, or Suffolk will have to take over the commissioning role for Colchester Hospital, leaving north-east Essex GPs, mental health services and so on with a different commissioning authority from that of the local hospital. NHS England told the MPs:

“We still do not know how the funds will flow”.

We certainly will not have all the partners sitting around a single table. The constituency of my hon. Friend the Member for Waveney (Peter Aldous) will be reabsorbed into Suffolk, even though it is half of the wider Great Yarmouth and Waveney place.

[Peter Aldous (Waveney) (Con)]

My hon. Friend is making a very good point. The Waveney area of Suffolk has been in a health administrative area with neighbouring Great Yarmouth for a very long time, and with the rest of Norfolk for a reasonable time as well. Any change would be highly disruptive, a distraction and demotivating for hard-working staff. I have written three long letters to the Department of Health and Social Care and have had a meeting with the Minister for Health, my hon. Friend the Member for Charnwood (Edward Argar), but does my hon. Friend the Member for Harwich and North Essex share my concern that there is a perception among those working in health and care in the local area and East Anglia that changing the boundaries is a done deal? Can the Minister confirm in his response that that is not the case?

[Sir Bernard Jenkin]

I very much hope that my right hon. Friend the Minister will confirm the latter; I have been assured that it is not the former, which is why I thought it was worth having this debate. The problem that my hon. Friend the Member for Waveney has is that the local population will continue to have acute services commissioned and provided from Norfolk. The imposition of separate Norfolk and Suffolk ICSs would compromise place-level integration for that population.

The west Essex population, which may be close to your heart, Madam Deputy Speaker, has acute services commissioned and provided predominantly from Hertfordshire, London or Cambridgeshire, and very little from the rest of Essex. That means west Essex will become part of an Essex ICS when it does not even include many of the key partners responsible for delivery of acute services to that population, and of course there is to be a new hospital, which may well be outside the Essex border. The proposed county-based arrangements would fragment NHS commissioning for places in north-east Essex, Waveney and west Essex. There might be different commissioners for acute, community and primary care. These places can only fully realise the benefits of integration if they have the flexibility to align all NHS commissioning. Other parts of the country will be similarly affected.

The idea of coterminosity for the administrative convenience of county councils is, I am afraid, a bit like the tail wagging the dog. In 2018, across the UK as a whole, we spent £149 billion on the NHS, but only £22 billion on social care. How can it make sense to align NHS commissioning with social care boundaries? That is not integration with social care; it is disintegration of NHS commissioning, and why do it now, of all times? We would be destabilising our health and care infrastructure while we are not yet out of the pandemic, let alone free of the aftermath.

The focus needs to be on the recovery of services. Elective treatment waiting lists increased to 5.12 million in April—a record high. There are other options for Essex and Suffolk, and I dare say in other parts of the country as well, such as a two-county proposal, as many Essex and Suffolk MPs set out in our letter to the Secretary of State two weeks ago.

In conclusion—I want to give time for others to contribute—the new legislation could provide the opportunity for ICSs to build on their successes, but that will be impossible with the level of disruption that a change of boundaries would bring about. Conservatives should have learned the lesson that NHS reorganisations usually fail to deliver the benefits promised. That will be especially true if reforms are rushed through again, tearing up what has been so recently established. Boundaries are the contentious part of the reforms. It would be better to allow the current ICSs to implement the new legislation and then look at whether boundary changes are necessary, rather than trying to do both at the same time.

So often I have seen it happen: structural and organisational reform is imposed from above as a substitute for a full understanding of what is really going wrong and why. It is always hard to improve leadership and to promote the right attitudes and behaviours in large and complicated organisations, particularly the NHS, but the slowest way to achieve this is to have another structural organisation. Everyone stops thinking about the job they are doing and thinks only about what new job they are applying for. After the reorganisation everyone has to re-learn how their job works and to re-establish new relationships, but nobody has challenged the attitudes and behaviours, which are still holding the organisation back. So often the problems are about poor leadership, poor employee engagement and lack of stability, which yet more structural change just makes worse. I therefore urge my right hon. Friend to delay the decision concerning future ICS boundaries until after the pandemic, and to consult and explore alternative boundary proposals after the legislation has settled down.

--- Later in debate ---

[The Minister for Health (Edward Argar)]

I congratulate my hon. Friend the Member for Harwich and North Essex (Sir Bernard Jenkin) on securing this timely debate about potential changes to ICS boundaries—and indeed on elevating me to the Privy Council, for which I am grateful. He and I have known each other for a long time and I always listen carefully to what he says. When there was the prospect of extra time, our friendship might have been in doubt had I been in here and unable to see the final result, but we got the result we all wanted just in time, so it is a pleasure to be here today.

The subject is important, not only for my hon. Friend, who works tirelessly for his constituents, but for all hon. Members who have spoken. The provision of healthcare goes to the heart of what many of our constituents care passionately about.

In his remarks, my hon. Friend expressed his concerns about the future of Suffolk and North East Essex ICS as one of the areas included in the NHS England ICS boundary review. I am grateful that he has called the debate, not only to allow fellow parliamentarians to express their views before any decision might be made on the Floor of the House, but to let me listen once again to them. I am equally grateful to my right hon. Friend the Member for Maidenhead (Mrs May). She and I have known each other a very long time and she knows that I have huge respect for her opinions. When she speaks, I always listen carefully.

As has been said, in the recent White Paper, we set out proposals to place integrated care systems in statute. We are working with NHS England and the Local Government Association to deliver and develop those proposals. At the outset, it is important that I highlight a key point. Members alluded in their remarks to the feeling that something here is predetermined. If there is such a feeling, that is a challenge for us to overcome because I want to reassure hon. Members that nothing is predetermined in any of the specific situations that they have outlined.

As has been set out, ICSs aim to strengthen partnerships and joined-up working between the NHS and local authorities. Local authorities therefore have a key role in ICSs. We know that coterminous boundaries can support more joined-up working between the NHS and local government, but I take on board entirely from my time as a local councillor—indeed, as a cabinet member for health and adult social care—the point that my right hon. Friend the Member for Maidenhead made that sometimes natural geographies of place can mean a lot more to our constituents than administrative boundaries to which we as politicians might pay a lot of attention.

For the reasons I have given, earlier this year the former Secretary of State, my right hon. Friend the Member for West Suffolk (Matt Hancock), asked NHS England to conduct a boundary review to understand what the options—I emphasise options—were to achieve alignment in the small number of areas where coterminosity was not already in place. He set out to do that in two stages: NHS England and its regional teams have led on the review at a local level, engaging with local NHS and local authority stakeholders to determine options for alignment, local views and concerns, and to put forward a fair reflection of what they had heard, while in parallel I, as a Minister of the Crown, have held multiple meetings with parliamentary colleagues. I think I have met well over a dozen colleagues in person or virtually—in this day and age—and held almost 10 different meetings.

I thank NHS England for all its engagement and work on the review. As I say, over the past six months its regional teams have worked closely with local NHS and local government stakeholders to consider, with an open mind, the options available for the areas identified in the review.

As right hon. and hon. Members have made clear, it is important to recognise where things are working well irrespective of coterminosity and serving Members’ constituents well. As I say, the review is without prejudgment and I would not wish to pre-empt what may be either recommended or even just set out as options. In that context, keeping the current arrangements would of course be an option to consider. I reassure Members that the Secretary of State and I do have at the forefront of our minds the need primarily to ensure the best health outcomes for local people when any decision is taken. I hope that my hon. Friend the Member for Harwich and North Essex will recognise the sincerity with which I say that.

Before I conclude, let me turn to a couple of specific points that my hon. Friend mentioned. I wish to clarify that were any changes made to ICS boundaries as a result of the review, they would not impact on the patient’s right to choose or use services outside of their ICS or current patient pathway flows.

On funding, I wish to try to reassure my hon. Friend a little more than perhaps he was reassured in the meeting to which he alluded. Once ICSs are placed on a statutory footing, the allocation of resources to each integrated care board will be determined by NHS England based on the long-standing principles of ensuring equal opportunity of access for equal need and reflecting the considerations that currently inform how moneys flow to areas when following the patient.

[Sir Bernard Jenkin]

Will my hon. Friend allow me to intervene on one point?

[Edward Argar]

Briefly, because I want to give my hon. Friend the reassurance that he seeks before the time runs out.

[Sir Bernard Jenkin]

What my hon. Friend has said does not address how Suffolk would be funded to commission services for Essex patients at an Essex hospital, and it does not address what will happen to the distribution of deficits, which is uneven across the existing ICSs.

[Edward Argar]

I would try to address that point briefly, but I think my hon. Friend would rather have the reassurance that I can give him. Perhaps I can pick up that point separately with him, because I do not want to run out of time.

Finally, and most importantly, I reassure my hon. Friend and other Members that no decisions have yet been made regarding the outcome of the ICS boundary review. As he would expect, the newly appointed Secretary of State will want to consider carefully the background to this issue, the options before him and, indeed, the views of right hon. and hon. Members before any decision is made. I have discussed this matter with the new Secretary of State and wish to extend his clear commitment to meet my hon. Friend, my right hon. Friend the Member for Maidenhead and other Members before he makes any decision and decides how to proceed in this matter.

My hon. Friend knows me well, and my preference is generally for evolution, not revolution. I hope that, him knowing me well and in the light of what I have said today, he will recognise the sincerity of what I say. I also hope it is helpful that I have put on record, once again, that no decisions have been made and that Members will be consulted and have the opportunity to speak to the Secretary of State. I hope that commitment reassures my hon. Friend, at least in the short term, that nothing will happen without him and other Members having their say clearly on the record.