Integrated Care

Diana Johnson Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

I beg to move,

That this House has considered the Seventh Report of the Health and Social Care Committee, Integrated care: organisations, partnerships and systems, HC 650, and the Government Response, Cm 9695.

It is a pleasure to serve under your chairmanship, Dame Cheryl. I thank all those who contributed to our inquiry in writing and in person, my fellow Select Committee members, and the Select Committee team, which was ably led by our Clerk, Huw Yardley, with special input from Lewis Pickett. I also thank our special advisers, Professor Sir Chris Ham, Dr Anna Charles and Professor Pauline Allen.

We are all immensely grateful to the South Yorkshire and Bassetlaw sustainability and transformation partnership, the Doncaster Royal Infirmary and the Larwood practice, not only for allowing us to meet them and their teams, but for facilitating the Committee’s meetings with local and national leaders from across the healthcare system, the third sector and many other providers to hear evidence during our inquiry. Without them, the report would not have been possible.

I will start by setting out what we are talking about, and why it matters. It is one of the greatest triumphs of our age that we are living longer but, as that happens, many more of us are living with complex, long-term conditions that require support and input not only from dedicated family and formal carer networks, but from across the health and social care system. If those systems do not join up, if they do not share information, or if they are poorly co-ordinated or inaccessible, patients’ care is poorer and everyone has a worse experience. Don Redding from National Voices said that patients and the public

“want to feel that their care is co-ordinated, that the professionals and services they meet join up around them, that they are known where they go, that they do not have to explain themselves every single time, and…that their records are available and visible.”

That is essentially what we mean by integrated care.

Integrated care can happen at three levels. It can happen directly, in the teams around the patient who deliver care in the patient’s home—for example, through joint assessments. It can happen at the service level—for example, with services brought together in a one-stop clinic. It can happen at an organisational level—for example, in commissioning or the pooling of budgets. We should all be clear, however, that none of that matters unless we keep the patient at the front and centre of those discussions. If the result is not delivering better care for patients and their families, it is not worth doing.

Integration does not save money in the short term or, sometimes, in the medium term, which acts as a key barrier to putting in place integrated systems for the long-term benefit of patients. Unfortunately, particularly with the current financial pressures, we have a system that is sometimes dictated and hampered by short-term pressures to deliver financial savings—I will come on to that later. In essence, we have to keep sight of the fact that integration is about people and families. Although our report focuses on organisations, partnerships and systems, we have tried to relate it back at every stage to why it matters to patients, rather than it being a dry discussion about systems.

[Diana Johnson (Kingston upon Hull North) (Lab)]

We are very ably led by the hon. Lady on the Health and Social Care Committee. The Committee’s approach to the public was the right one, and I hope that, in its future communications with the public, the Department of Health and Social Care might learn that lesson about having the patient at the heart. That is what this is about, because it is so complicated and difficult for the public to understand.

[Dr Wollaston]

I thank the hon. Lady, my fellow Committee member, for her input. We on the Committee heard that there is a complex spaghetti of acronyms—STPs, ICPs, ACOs—and nobody knows what they mean. Even those working in the system struggle to keep pace with them and with the changes. We have to keep bringing it back to plain English and why it matters to people and hold our attention there.

The integration of health and social care has been a long-term goal for successive Governments for decades, so we might ask why it is not happening everywhere if we have been striving for it for so long. We saw and heard about many fantastic examples of good integrated care, but they sometimes felt like oases in a desert of inactivity. It is also possible to have an area that does some things very well but others not so well.

--- Later in debate ---

[Dr Wollaston]

I thank the hon. Member for that intervention and for her own service to the Committee previously—she is very much missed. Her remarks are typical of the constructive input that she has always made to the health debate in emphasising the need to take the long view. Financial pressures so often force us into short-term solutions, not only in the way she set out but through the salami-slicing of services.

One of the points that our Committee feels strongly about and that I was going to make to the Minister is the need to ring-fence transformation funding, because it is so easy for that funding to get lost. I welcome the uplift in funding—a 3.4% increase will be very helpful—alongside a 10-year plan. However, we have to be realistic about what that uplift can achieve, because there are very many demands on that budget, as the Minister will know and as we have seen in the past. We saw it with the sustainability and transformation fund, which tended to get sucked into sustainability and not into transformation. That has been the pattern of recent decades. There is good intention to ring-fence money for transformation, but that money disappears because of other priorities around deficits and, as I have said, the many other calls on the funds available.

That is why we feel that, in order to prevent the continuation of that cycle of past mistakes, it is important that the pattern is recognised and that funding is earmarked for transformation—not only for capital projects but for things such as double-running.

I will give an example from my area. There will be a complete destruction of public trust in new models of care if money is not set aside for double-running. The community was prepared to accept that there would be a new facility—nobody wanted the closure of the local community hospital in Dartmouth, but there was an assurance that there would be a new facility. Unfortunately, despite many of us opposing the closure of the old facility, what happened was that it was closed and then there was a breakdown in the arrangements for the new facility. The community was left with nothing and there has been a huge destruction of public trust in the process, which unfortunately will have ripple effects across other communities. Had we received the money to keep the existing service while the new service was built and got up and running, it would have left us in an entirely different situation. I am afraid that we see that too often across health and social care. There is good intention, but without double-running, which is part of having a ring-fenced transformation fund, I am afraid that the system has broken down too often in the past. I would like the Minister to focus on that when he makes his remarks.

The Committee is also looking forward to the 10-year plan—we look forward to working alongside both NHS England and the Department of Health and Social Care to examine how that plan emerges—but is important to draw attention to legislative changes. Our Committee made a recommendation that legislative proposals should come from the service itself rather top-down from the Department, which would immediately run into difficulties. However, as a Committee we also offered to subject such proposals from the service to pre-legislative scrutiny.

As the hon. Member for Kingston upon Hull North (Diana Johnson) pointed out in her intervention, we need to build cross-party consensus at every point. As it has not been covered in the formal response to the Committee’s report, will the Minister say in his closing marks whether the Government would support the Committee conducting pre-legislative scrutiny?

I am pleased to have had a conversation with Simon Stevens, the chief executive of NHS England, who has confirmed that, as it emerges, the NHS assembly will consider that within its remit—NHS England hopes to produce proposals in draft form before Easter 2019. Nevertheless, as I have said, it would be helpful to receive the Minister’s assurance that proposals will come to our Committee for pre-legislative scrutiny as part of the process of building consensus.

[Diana Johnson]

Like me, the hon. Lady was in Parliament when we went through the 2012 reforms. We had to have a period of pause because of the complexity of the legislation. Pre-legislative scrutiny is absolutely essential and I wholeheartedly support what she has said as the Chair of the Committee.

[Dr Wollaston]

Hon. Members know that a lack of proper pre-legislative scrutiny that responded to concerns expressed led to many of the barriers. We have to go back and address them when they could have been addressed in a more collaborative process during the passage of the Health and Social Care Act 2012. I am thinking of the need to reconsider the legal basis for merging NHS England and NHS Improvement, and how we establish a better statutory basis for the process so that provider partnerships do not always have to go back to separate boards to gain their approval. It is about considering how we address issues such as geographical arrangements so that they make more sense to local communities. The Committee could play a constructive role in a host of areas but—I say this to the Minister—unless proposals are subjected to pre-legislative scrutiny and unless a cross-party consensus is established, proposals are likely to fail.

My final point—other Committee colleagues will probably want to develop it further—is this: what will happen around establishing a legal basis for integrated care providers? For two reasons, the Committee welcomes the change of name from “accountable care organisations” to “integrated care partnerships”. First, the original name confused the debate about Americanisation. The “accountable care organisations” proposed were not the same as those organisations in the States, and the original name caused a great deal of unnecessary anxiety. We do not see the process as Americanisation.

A concern raised with the Committee was that the process will be a vehicle for privatisation. We did not agree. In fact, we thought the opposite: we agreed with the witnesses who told us that the process provided an opportunity to row back from the internal market and away from endless contracting rounds, and move towards much more collaborative working. We would like that change to be properly reinforced within the legal status of health bodies, and are disappointed that the Government have not agreed to say categorically that these bodies would be classed as NHS bodies. When the Minister sums up the debate, I would like him to reflect on whether any form of wording can put the matter beyond doubt and ensure that these health bodies will not be taken over by large, too-big-to-fail private sector organisations.

It is not a concern that groups of GPs might want a leading role in the bodies. The Minister will know that the public concern is more about them being taken over by very large too-big-to-fail private sector organisations. It should be possible to come up with a solution. The Committee heard—the Minister knows this—that those working in the service have the view that the bodies are not likely in practice to be taken over by private sector providers. However, that public concern exists and is a barrier to change. If we can put this matter beyond doubt, we should try to do so.

--- Later in debate ---

[Dr Whitford]

It is not a particularly formal term. I simply mean that there has been a tendency to think that, because community hospitals cannot provide the full range of acute healthcare, they have no place, whereas someone might require only a low-level of in-patient care, such as an elderly person who has a urine infection and lives on their own may need intravenous antibiotics, fluids or extra care. Such hospitals allow us to have much more healthcare—things such as minor injury units—close to the public. The more we take forward to people, the less worried they will be about the fact that we are coalescing specialist services. If they see services coming towards them, they will not have the sense that everything is being taken away. We have utterly failed to impress on the public that healthcare is not about buildings, but very much about people and services. That is what integrated care should be about.

[Diana Johnson]

I am very interested in what the hon. Lady is saying about Scotland. Does she know that areas of England have integrated financial plans involving local government and health to try to bring together that continuity and put patients at the centre?

[Dr Whitford]

That is exactly what we have in Scotland—it was introduced in legislation in 2014, and all areas were up and running by the beginning of 2016. More than 60% of the budget goes to what are called integrated joint boards, which use innovative solutions to deal with all sorts of local groups to try to prevent people who do not need to be in hospital from ending up there, and to try to allow people to come out of hospital when they are ready. It has led approximately to a 9% per year decrease in things such as delayed discharges. Those two measures—acute admissions that could have been avoided and delayed discharges that lead to people being stuck in hospital—are very much looked at. In my early career, if someone was in a bed and ready to go home, they would be told, “Well, it’s your problem. We don’t have room.” There was always friction between secondary and primary care, and between health and social care. That is where we are, but it is not easy—it is not even as easy as integrating within health.

There is no escape from legislation. Some legislative change is critical for NHS England to be able to take the barriers out of the way. At the moment, as the hon. Lady mentioned, people are trying to work around those barriers, but when things change in an informally integrated care system, the acute hospital is put into financial difficulties. It is being asked not to admit people, but the existing tariff system rewards the hospital only when it admits people, so when it starts to get into difficulties, we are asking it informally to sacrifice its budget line for the greater good. I am sorry, but tariffs need to be reformed. It is a bizarre system if the aim is not to admit. Hospitals make money on the people who almost do not need to be there and lose money on the sickest, who do need to be there.

[Diana Johnson]

Again, that is very interesting. A good model of that, which is already happening in England, is in my own backyard: Hull. The hospitals have agreed that they will take a sum of money and will not look for additional money from the CCG if they need to treat more people. That is an integration of social care—the local council—and the acute sector, which is important in making this work. It can be done without legislative change, but overall I agree that change is vital.

[Dr Whitford]

That is fine in one place with good leadership and good relationships, but if things got tight it would be very difficult for one chief executive to accept the failure of their budget in order to keep the whole system going. Legislative change is crucial, towards more per-capita funding and away from tariffs, and towards more area organisation of that integrated care partnership.

Reform of section 75 of the Health and Social Care Act 2012 is crucial, because it pressures CCGs to put out to tender all possible contracts. In Surrey, six CCGs were sued by Virgin not for breaking a contract but for not renewing one. We estimate—actual figures are hidden behind commercial confidentiality—that more than £2 million ended up away from the frontline, instead going into Virgin’s pockets, which is not helpful.

In fact, the administration of the bidding and tendering market is estimated to cost between £5 billion and £10 billion, which contributed to the debt that NHS England got itself into by 2015, a mere two years after the changes in the Act came into effect in 2013. Before that, by looking down the back of the sofa and scraping around, and with a little bit of moving money around, the NHS in England usually managed to get to the end of the year in balance.

Moreover, that debt has led to rationing. The problems are not hypothetical ones on a piece of paper. They result in older citizens—we will be having a lot more of them—being held back from hip or knee replacements, cataract surgery and other things that allow them to see or walk, get out and meet friends and keep active, which is crucial.

Finally, it is critical for the accountable care organisations or whatever they are called now to be statutory. The model contract published last August would still allow a private company to bid for and run an entire integrated area. The report states that that is unlikely, but it should be simply ruled out in order to get rid of a huge amount of concern about a threat that might lie around the corner or down the line. Without that statutory basis, a company could hide from freedom of information requests and use its commercial sensitivities even though it is being handed billions of pounds of public money and getting to decide what is delivered to the population in its area. I am sorry, but that cannot be a private company and has to be a statutory body.

There are challenges ahead and we all face similar ones—increased demand, workforce and tight budgets—but we have talked about that before. At the moment, however, the structure for NHS England is hampering the staff on the frontline who are trying to look after people. The challenge of merging a free system with a means-tested system will not go away; it will have to be addressed. In Scotland, we have a slight advantage because we have free personal care, which takes away one of the problems, because it allows us to keep more people at home—in their own home, where they want to be—rather than in hospital.

Even though it is only five years since the last big reorganisation, NHS England is at another major crossroads, so there will be a lot of upheaval. It is important to get that right and to do it in a measured way in the House. Legislation should allow innovation in different parts of the country but get rid of the barriers. We should be radical and, as Members have said, to put the patient or the person right in the middle of the design. That involves more than just the delivery of treatment. Health is not given by the NHS—the NHS catches us when we fall and ought to be called the national illness service, but we would have even worse workforce challenges if we called it that. I echo the call for health in all policies, within the integrated systems and in the House, so that we are actually investing in the health of our population.