Integrated Care

Cheryl Gillan Excerpts

Thursday 6th September 2018 Westminster Hall

[Luciana Berger]

I am listening closely to my hon. Friend’s remarkably informed remarks. Taking him back to his second priority, prevention, does he agree that the Minister should be thinking about what he should be doing beyond his own Department? The Minister and his colleagues in the Department of Health will not on their own be able to do what is needed on prevention as well as tackle this country’s mental health crisis and increasing lifestyle-related disease. If we are to address those challenges seriously, it will also be about what happens in our communities, our schools and our workplaces. That comes from local government and is what will ultimately make the difference.

[Dame Cheryl Gillan (in the Chair)]

I remind colleagues that interventions are meant to be short. I hope Members will be able to keep them a little briefer.

[Dr Williams]

I thank my hon. Friend for her informed comments. I agree with her. We need a cross-governmental approach, particularly for children. There is a glaring absence of a cross-governmental strategy that would enable us to focus on all the things that have an impact on children.

The third area I want to mention is legislation. Under current rules, clinical commissioning groups will remain the statutory accountable bodies, even as the relationship between commissioners and providers starts to evaporate. At the moment, STPs, where the providers and commissioners are getting together, are making decisions—often behind closed doors—which are then rubber-stamped by the accountable bodies, which are the CCGs. That does not feel to me like particularly good governance. Legislation needs to follow the new provision arrangements.

We might also need to consider legislation to improve information sharing. The duty to share information—the eighth Caldicott principle—is often forgotten. In my experience the biggest barrier to integration is the fear that NHS providers have about sharing information with other parts of the system, and their resistance to do so. We are not necessarily doing enough in legislation to protect that duty to share information in the interests of providing good-quality clinical care.

The current situation on procurement is very difficult for CCGs. The law says that many services have to be procured if they are over a certain value. CCGs, as small organisations with accountability for their local pot of NHS funds, genuinely fear legal challenge. When they ask lawyers they are, unsurprisingly, advised that they have to follow the law, but the political and NHS England leadership strategy is to integrate care, which often cannot be achieved when care is fragmented by putting services out to tender, and provided by numerous different organisations. Many CCG governing bodies want and need to be cautious. They are just not going to take the risk given the current legislative framework.

Quite simply, if we, as elected politicians, want the NHS to collaborate, we should legislate for collaboration. In my view, the Health and Social Care Committee should be an enabler of that process. We would like to provide pre-legislative scrutiny, but we would like first to ask the health and care community what changes in the law would enable them to achieve their goal of providing integrated care to patients. I would like to know whether the Minister agrees with that proposition.

My fourth point is that integrated care providers should be NHS organisations—a recommendation the Committee made in its report. There is a well-founded concern in the health and care community that, under current legislation, private companies might bid to win contracts to provide significant chunks of our health services. That concern could be alleviated if it were made clear that integrated care partnerships need to be NHS bodies. In their response to our report, the Government did not accept that recommendation, arguing that ICP contracts could be held by GP-led organisations. It would be a very good thing to have GP-led organisations running primary and community care and other parts of the health service, but I see no reason why those GP-led organisations cannot be NHS organisations.

It is a barrier to progress in the NHS that there are not community-based NHS organisations that GPs can lead and work for. I urge the Government to look seriously at the recommendations in the Institute for Public Policy Research report “Better health and care for all”, published in June, which suggests the creation of integrated care trusts in communities and a right to NHS employment within such organisations, which would provide all non-hospital care in an area.

My final point is about leadership. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is a member of the Health and Social Care Committee but cannot be here today, has done significant work shining a light on leadership failures within the NHS. Integrated care is possible only if we have the best and most talented managers in the NHS. As was evident in the failure of management in Liverpool Community Health NHS Trust highlighted by Dr Bill Kirkup, we are far from achieving excellence and need to be certain we have the right mechanisms in place to ensure that we have only the best and the brightest. Will the Minister assure us that the Kark review will be expansive in its remit and that those NHS leaders charged with fixing the mess in Liverpool have been consulted for their expert views?

To conclude, the purchaser-provider split has not always achieved the best NHS care for patients. I welcome the step towards integrated care, but I do not think it will succeed when the legislation promotes, and sometimes mandates, competition. There is political will—certainly from the cross-party Committee—to work with the NHS and care system, including the NHS assembly, on proposals to change legislation, keep integrated care providers within the NHS, improve governance and remove mandatory competition. I hope the Minister will respond positively to those concerns. Integrated care has the potential to transform the lives of millions of patients in our health service. I commend the Committee’s report, and I thank the Government for the changes they are making.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I congratulate the hon. Member for Totnes (Dr Wollaston) on her knowledgeable and measured introduction to this extremely important debate. I also thank the Health and Social Care Committee for an extremely useful and detailed piece of work on a rapidly changing area. In her speech, the Chair of the Committee set out from a patient’s perspective why it is so important for us to have a more co-ordinated approach than we do. “Having to tell the same story over and over again” was a phrase mentioned by not only the Chair but a number of other Members, and we all recognise the frustrations that we and our constituents have when that occurs. She was right to say that it is important that we look at the subject primarily from the point of view of patients. Their experience has to be at the very front and centre of all our plans for the future.

The hon. Lady articulated clearly how the financial pressures in the existing legislative framework, which we have all talked about many times, can inhibit transformation. She was right to say that an earmarked fund for transformation has to be protected, and it should not just be a capital pot. She set out clearly the need for a degree of flexibility.

As always, it was a pleasure to hear my hon. Friend the Member for Stockton South (Dr Williams). He made a pertinent point about the challenge for integrated care partnerships: to be considered successful, they should make a difference for those with the greatest health needs. He is right that we need to do much better as a nation on health inequalities, but how we approach prevention and health generally in this country does not necessarily lend itself to that. It would be most welcome if we can tackle that as part of integrated care.

My hon. Friend also expressed the genuine concern about the risk that changes could affect performance quality and safety, which are the pillars of an excellent health system. He made a strong point about governance and how existing decision-making processes are probably the wrong way round. The report acknowledges that they are certainly cumbersome and do not lend themselves to streamlined decision making. He highlighted well the dilemma faced by CCGs when tackling that agenda. This place needs to take a lead on that. He concluded by saying that integrated care has the potential to transform the lives of millions of patients—that really underscores why it is so important for us to get the integration right.

The hon. Member for Strangford (Jim Shannon) made a typically thoughtful contribution. I agree with him about the need to bring people along with us when we set out our vision for the health service. The report touches on how that has not been as successful as we might like in recent years. His comments on the use of acronyms were particularly perceptive—they may initially save time, but they actually increase complexity. Although I agree with the sentiment that we should keep things simple, anyone who looks at the Health and Social Care Act will realise that at the moment we probably cannot achieve that readily.

The hon. Member for South West Bedfordshire (Andrew Selous) made an important contribution. No one will disagree with what he said about putting patients at the centre of all this and the quote he gave about the kind of care they want. I was very interested to hear about his visit to the Larwood centre in Worksop; that sounds like the kind of model that we need to showcase what a good new procedure looks like.

It is clear from reading the report that I am not alone in being critical of the way some of the proposals in the past few years have been communicated. I do not underestimate the damage that has done to public confidence in the aims of the policy.. Releasing the new draft ICP contract in the middle of the summer with no publicity has not increased transparency about the Government’s agenda. It was interesting that the report described how public understanding of the proposed changes has been seriously compromised by the “acronym spaghetti,” which a number of Members mentioned. At another point in the report there was a reference to the acronym soup of

“changing titles and terminology, poorly understood even by those working within the system.”

That highlights well the difficulty we all get into sometimes when acronyms can take over—that will resonate with anyone who is a member of a political party. The use of food terminology in the report shows that perhaps the author was a little hungry when they wrote it.

To reinforce the point, since the report was published we have ICPs on the horizon—yet another acronym. Although I appreciate that the change was made to avoid conflation with the American model of ACOs, it is clear that we do not need new acronyms, but a clear explanation from the Government along with a timeframe for what they are seeking to achieve and, importantly, the criteria they will use to determine whether those objectives have been achieved. The chief executive of the Nuffield Trust, Nigel Edwards, described this as

“perhaps the biggest weakness, not just with the STP process but arguably with the ‘Five Year Forward View’.”

It is clear from both the evidence sessions and the report itself that confidence in the Health and Social Care Act 2012 is at an all-time low and that the current direction of travel is really an admission that the Act has not worked. As we know, the last top-down reorganisation put in place a siloed, market-based approach that created statutory barriers to integration. Now, there is a lot of tiptoeing around the current legislation but we need an admission that that legislation has had its day. We need new proposals that are properly scrutinised.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. The Government acknowledged in their response to the report that perhaps that was done rather too quickly. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others there was a vast and unwieldy network of commissioners and providers with completely different approaches put together at very short notice. They were told to produce plans in private, again very quickly, which were focused not on integration but on organisations balancing their budgets. The only beneficiaries of this process seem to be the private consultants who were drafted in to complete those hastily arranged plans. As Professor Chris Ham pointed out,

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Will the Minister set out what his plans are for those areas, as the local bodies appear to be working in a vacuum? They want to work together, but at the moment they have a legal duty to compete.

The report makes it clear that being asked to solve workforce and funding pressures caused by national decisions exacerbates tensions and undermines the prospect of each area achieving its aims for its patients. The report also makes it clear, as my hon. Friend the Member for Stockton South said, that where support has been provided towards integration, it has been directed at those who are furthest ahead. Those at the bottom of the curve, sometimes through no fault of their own, have lost potential funding that they need to work together to improve services. The chief executive of the NHS Confederation, Niall Dickson, told the inquiry,

“There is a sense in which some organisations find themselves in a really difficult position. Just taking their STF money away…is like somebody digging a hole. Instead of…helping them to get out of the hole, they jump in with a larger spade and dig even faster.”

That is a colourful and alarming analogy.

Where local areas are able to proceed to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean. The integrated care provider contract has the potential to radically alter the entire health and social care landscape, but is continuing without any parliamentary scrutiny. Despite assurances that it is unlikely that a private company will win the contract to be an ICP, it remains the case that it will be possible, as a number of Members have said. As we heard, not long ago the NHS was forced to pay out millions of pounds to Virgin because it lost out on a contract. I am concerned that we will face similar challenges if this process continues without legislation.

It is not scaremongering to say that the Government are introducing a contract whereby a private company could be responsible for the provision of health and social care services for up to 10 years—it is a fact and a possibility under the legislation. The Chair of the Select Committee was right to say it would be extremely helpful to have a clear statement from Government to rule that out. It is within the gift of Ministers to say there will be no private involvement in those bodies in future. Will the Minister make such a commitment today?

It is clear in the report that staff are concerned about the lack of engagement in a process that in some areas has excluded them completely. They are also concerned about their jobs being transferred to non-NHS organisations; hopefully the Minister will deal with that today. Almost half all NHS providers were in deficit last year and we are entering uncharted territory in budget setting, so what steps will be taken in the event that an ICP reaches a significant deficit position that it is unlikely to be able to resolve alone? Given the recent news that loan repayments to the Department of Health are now a bigger financial burden to providers than private finance initiatives, will the Minster confirm that deficits caused by structural funding issues will not be resolved through further loans being issued?

It is also clear from the draft contract that the ICP rather than the CCG will be responsible for managing demand. That raises questions about accountability and transparency. What safeguards are in place to prevent further rationing of services and who will be accountable in the event that patients want to challenge such a decision? These are important questions that I hope the Minister will respond to. Will he also commit to set out in full the direction of travel, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for primary legislation, which just about everyone across the sector believes is needed?

[Dame Cheryl Gillan (in the Chair)]

Before I call the Minister I remind him, although I am sure he knows, that we like to leave two minutes for the Member leading the debate to make her closing remarks. I call the Minister.