Integrated Care

Debate between Diana Johnson and Philippa Whitford

Thursday 6th September 2018 Westminster Hall

[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.