Health and Care Bill (First sitting)

Edward Timpson Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

Thank you very much. Members who wish to ask questions should please indicate that.

[Edward Timpson (Eddisbury) (Con)]

Q Good morning to you both. Having taken big Bills through Parliament before, I am aware that a lot of scrutiny goes into the detail on the statute book, for obvious reasons, but sometimes we also need to reflect on the implementation and how we can make the legislation turn into a reality. Based on the proposals in the Bill, what role do you think you can play to bring about that reality through the development of the workforce to meet the demands on the healthcare system that the Bill is trying to improve the prospects of meeting?

Dr Navina Evans: Thank you very much for the invitation to give evidence today. I am really pleased to note the prominence the Bill gives to the workforce, and the important focus on systems working together, and working together with social care. I think that implementation will work well because we can build on what we are already doing. There is a great deal of collaboration between all parts of the system, and I can give you lots of examples if you wish of how we have developed the workforce over the past few years, particularly through the pandemic. We can build on what we have done together with other parts of the system. HEE plays a unique role because we have relationships with educators, providers of healthcare, the regulators, the professional bodies and NHS employers and other partners, as well with NHS England and the Department of Health and Social Care. We play a convening role, and we have already used that experience, ability and capacity to develop the workforce so far. We think the Bill will enable us to build on that.

Danny Mortimer: Navina captures really well the work that is already going on, not least, as she has said, through the pandemic. My members, who are the trusts and ICSs around the country, are already trying to find ways of developing joint approaches to developing their workforce, not least with their colleagues in social care, but also by thinking about different ways in which they can recruit and perhaps make employment in the NHS more accessible to people from harder, under-served communities. Some fantastic work has been going on with the Prince’s Trust, for example, around the NHS, and that has increasingly been done through the organisations that are being formalised through this Bill.

I also think that the commitments that the Government are expected to make later today, not least around investment in social care, will help organisations to work together. We have a pressing need in the health service to invest in the longer term in our workforce, but that is even truer for our colleagues in social care. Again, that is a significant step forward today, which we hope will go even further in the spending review, in helping employers to ensure an adequate supply of people in the longer term, not least with the support of Navina’s organisation, and also by being able to innovate together in developing roles that better meet the needs of the communities they serve.

[Edward Timpson]

Q Do you see the principles set out in this Bill, along with the details in each of the relevant clauses, around integration and collaboration as a natural progression from a lot of the work that has already been undertaken by yourselves and others working in the healthcare system?

Dr Navina Evans: Yes, I do. I think they build on what we have already done well and strengthen our ability to go further.

Danny Mortimer: I agree with that. I think there are some risks. At the heart of the Bill, it is formalising organisations that can lead, innovate and perhaps do things differently from each other in local areas. We have a very centralised healthcare system in this country, and one of the risks is that the vision in Bill of integration and devolution to local areas is not realised, because the centralising impetus is very strong. However, the Bill absolutely captures what has now been many years of growing collaboration and integration between health organisations but also, importantly, with our colleagues and friends in local authorities and social care.

[Edward Timpson]

Thank you.

[The Chair]

I now call Mary Robinson.

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[The Chair]

Thank you. I believe Mr Edward Timpson indicated that he wanted to ask a question.

[Edward Timpson]

Q I did; thank you, Mrs Murray. I want to ask a brief question, if I may, about the proposed merger of NHS England and NHS Improvement. I assume, although I do not know, that this is part of the long-term plan that was set out by NHS England, but I hope it is a direction of travel that you are both comfortable with. Could you explain what you see as the practical benefits of the merger, in terms of both the working behind the scenes to ensure that we keep quality high in the health service and the experience of patients, who will be on the receiving end of those services?

Amanda Pritchard: This absolutely, again, falls into the category of formalising, in large parts, the way NHSEI already works, but removing some of the slightly more bureaucratic and legal barriers that we have in place at the moment. I came in two years ago as the chief executive of NHS Improvement and into Mark’s role as the chief operating officer of NHS England at the same time. Certainly, my experience over the last two years has been that, in practice, NHSE and NHSI really do work, to all intents and purposes, as a single organisation—but, as I say, with some of the bureaucracy that is still around that—and that has been absolutely essential over the last 18 months, particularly through the pandemic.

NHS leadership absolutely has to speak with one voice and has to be able to have consistent decision making. We have to have a way of managing, where this comes up, the tensions that sometimes arise between different parts of the system, but also leading in practice that integrated working and joined-up approach, right from the top. It was really only, I think, the 2012 Act that brought in the separation formally, legally, so in a sense what we are doing is stepping back to something that was always the way the NHS worked prior to that. As I say, we are really now just formalising the way things currently work, and have needed to work over the last 18 months or two years.

[Edward Timpson]

Thank you.

[The Chair]

Thank you. Now we will hear from Mr Chris Skidmore.

Health and Care Bill (Second sitting)

Edward Timpson Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Dr James Davies (Vale of Clwyd) (Con)]

Q Thank you. I have a general question about the key feature of the Bill: integration of services. What is the experience of your members with regard to that and have those views changed thanks to the pandemic? Perhaps we can hear from Saffron first.

Saffron Cordery: The experience of the pandemic, which is a seismic and far-reaching event, really put the frontline of the NHS and other local public services in the frame for delivering for their local communities, and for supporting each other and helping each other out with mutual aid. What we saw there was one very good and important example of how local partnership working, local collaboration and local integration was working in very different ways up and down the country.

We had some common features of all integration, something you would expect at a time of crisis, where there is a lot of command and control and procedures that go on in a state of civil crisis such as this one. We also saw different communities responding in different ways. That is one of the most important points that I want to make about this legislation. In terms of collaboration, we have to see a piece of legislation that is as enabling and permissive as possible. Obviously, legislation has choices. You go down different routes. Really prescriptive legislation will not help in this situation, though. We have to reflect the progress made in some areas and the need for encouragement and support in other areas to get where we want all ICSs to be: that is, really effective and delivering what local populations need. A permissive framework is critical. Going back to your question, it is right that the pandemic has shone a light on both the potential of ICSs and collaboration in particular and the challenges we face right now in implementing any new proposals due to the operational pressures facing the NHS, local government and other public services.

Matthew Taylor: I agree with Saffron. There have been some very good examples of local collaboration, such as the vaccination programme and reaching out to communities where initial take-up may not have been what we had hoped. There is some really impressive work there. That work presages the wider commitment within the health service to a strategy of population health, which addresses not only those people who express demand but those who do not. We wish that they would, because that is one of the things driving health inequality.

I have been at the confederation only three months, so I look at the legislation from the perspective of a wider interest in public policy over 30 years in government and outside it. This is a very interesting and innovative example of policy making. We have these integrated care systems in large parts of the country, so the policy has already been enacted ahead of the legislation. Though that may raise democratic issues, it enables us to see in practice how people are taking the principles of service integration and focusing them on population health. Despite the challenges of covid, a challenging funding context, and the issues around social care—which are hopefully being addressed in one way or another—we see across the country that there has been a whole array of interesting bits of innovative, collaborative work around issues of population health, prevention and addressing health inequalities.

I want to emphasise a point Saffron made. If you look around the country, you see some systems that are well advanced in their collaboration and other systems that are not. This is for a variety of reasons; in some cases there are issues to do with boundaries and such. Like Saffron, I think it is really important we have a permissive regime that allows these systems to evolve at a pace that is right for them and the places in which they operate. Over time, the systems will move forward, but it is actually a really effective way of working. It would be a mistake to try to impose exactly the same way of working on every part of the country. It would mean those who were ahead will be pulled back and those who are not quite ready to make integration work will be compelled to tick boxes, as it were, rather than work on the development of the relationships that we need.

[Edward Timpson (Eddisbury) (Con)]

Q I want to build on that point about permissiveness and take it a step further in terms of the specification in the Bill around ICBs and ICPs—the boards and partnerships. A lot of us on the Committee have been requested to look carefully at individual parts of the healthcare system. That does have a generality to it, covering mental health, children, palliative care and so on, and their representation is very clear within partnerships and boards. Based on your views around permissiveness and flexibility and the different paces ICSs are currently at, how do you see this? How do we reassure people that their views and the particular parts of the health system they represent will get a fair hearing and that the accountability structures will be in place to make sure they are able to come back if they feel they are not being addressed properly?

Matthew Taylor: That is an important point. Let me be completely open about the conversation within the confederation about this issue, for example. We have a mental health network representing mental health providers. Their preference would be to specify the need to have a mental health leader on the board. We as a confederation recognise that view and represented it, but that is not our view overall. Our view is that, partly because configurations differ from place to place—in some places, mental healthcare and community are together, for example—but for a variety of reasons, we would not want to specify further the membership of those boards. Again, that is to maximise local flexibility.

If people feel their voice is not being heard, then that is something they are going to say. We will have to see how this system evolves, but let us start with—going back to a word used earlier—the permissive regime and see how that goes, because after all it is in the interests of everybody in the local health system that they hear the voices they need to hear.

Saffron Cordery: I agree. This is a thorny issue but I suppose it is one of either, depending on how you look at it, the opportunities or the casualties of creating another level of governance in a local system. When you are thinking about putting collaboration on a statutory footing, you have to surround it with some kind of governance to ensure the effective operation of that body.

It is a tricky issue. You cannot have an integrated care board—the board that will govern how funding flows through and how priorities are agreed, decided and implemented—that is so enormous that it becomes unworkable, but there has to be a clear balance between making sure it is not only the big and the powerful who are represented there, but also all the rights and appropriate interests. There are a number of positions specified in the ICB board arrangements, and it will be interesting and important to see how different ICSs use those roles, particularly the non-executive or wider partnership roles that are specified, in order to have a broad range of voices around the table.

It is worth remembering that many other organisations and structures will be taking part in the ICS arrangements. You will have things like provider collaboratives, which are not in the Bill but feature heavily in the guidance that comes from NHS England and NHS Improvement, which are precisely about organisations working together to deliver on local priorities. Many of those are led by mental health organisations focusing on what they need to deliver.

There are other structures within these arrangements, but no one would say it is ideal. It is not the most ideal solution, but it is very difficult to get to a final configuration that is both workable in terms of numbers and reflects the multiplicity of voices in a locality. It is important to have the right engagement at every single level and the right channels feeding up information and priorities, and to understand what is really important in a system.

Matthew Taylor: Today the Government have been talking about the importance of integration in the context of its announcement on health and social care. One of the big questions is going to be about the powers that are devolved within systems to places, and I think it will be at the place level that we will see service integration. The evolution of place level forms of accountability is an important part of that, and again a reason why it is really important to allow these structures to evolve locally. I suspect that in some areas more power will be held at the system level and less at the place level. In other places, it will be the reverse, with most of the action taking place at place level. That reflects the nature of places, the legacy of those places and the relationships that have built up.

[Chris Skidmore (Kingswood) (Con)]

Q I wanted to turn to workforce planning and your views on clause 33. The NHS Confederation, in its written evidence, has suggested that the five-year period for a strategic review on workforce planning is too long. That mirrors my amendment, which has a crack at this. I have suggested an annual review. It was suggested this morning that two years might be the right time length. I see that the NHS Confederation has suggested three years. I want to get your organisations’ views on what a strategic review should look like, but also on the format and how a strategic review should be undertaken so that it actually works as an act of co-creation, rather than being directed centrally by the Secretary of State on to Health Education England.

Matthew Taylor: My area of expertise before coming to the NHS Confederation was work and the future of work, on which I advised the Government, and one of the things I know from that work is how quickly the world of work is changing. It is impacted by a whole variety of things—not least, of course, substantial technological change. In a world where work is evolving very quickly and population needs are evolving, five years is simply far too long. If it were one year, we would be happy. We have fastened on to two years. That would be the minimum that we would want as a gap between assessments of workforce need.

It is also—to emphasise the point that I think you are making—important that this review gathers evidence from a whole variety of bodies, because an enormous amount of extremely good work is taking place around work. Predictions of workforce need are imprecise, so hearing from a variety of voices is important. This should be an independent process, in which independent expertise is brought to bear; there should be wide consultation with those who think about these issues; and a two-year plan would, I think, be an improvement on what is in the Bill.

Saffron Cordery: We also support this amendment and the work that has been done by the confederation and others on this. There is one other element that I would add to this that supports this perspective. It has been really hard, across NHS workforce planning, to light upon one version of the truth, in terms of workforce numbers. Anything that starts to move towards a collective perspective on workforce needs and workforce planning will be absolutely critical.

Getting an agreed perspective on how we create that figure will be fundamental. In my time working across the health service, there have been many different perspectives on workforce—on the gaps, the numbers who are in roles, and what those roles need to be. It is important to have lots of views, but I think this is also important. Although, as Matthew says, it is not a precise science, we need to light upon a version that is independently agreed, but that we all sign up to as the numbers we are working to.

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[The Chair]

Do you have anything to add to that, Mr Conradi?

Keith Conradi: I think that is outside the HSIB’s experience.

[Edward Timpson]

Q Just to follow up on the answers that we had about the healthcare safety investigations branch and putting it on a statutory footing, I am speaking as someone who chaired the first national child safeguarding panel, which was looking at investigating what were then called serious case reviews and trying to understand how you get to the bottom of the why question, as opposed to simply what happened. In fact, we used the air accident investigation branch as an exemplar of that. It would be helpful to understand how you think these new powers, and the statutory footing that you will have, will help enhance your ability to answer those all-important why questions within the health system, and get away from the potential for it to become a finger-pointing exercise that does not necessarily improve the outcome for patients.

Keith Conradi: Having come from the air accident investigation branch as my background, the whole idea of these investigations is that we do not apportion any blame or liability, and that we are really looking at why an event took place when somebody came into work planning to do a good job, and what the circumstances around the environment were that allowed a tragedy to occur. We use a lot of investigation science methodology to ask those why questions, really looking at systems-type thinking, so we do not mention anybody’s names in the reports. We do not, at the moment, mention where the actual occurrence took place, because in our view that is almost irrelevant. It is the system that we are trying to change, and the safety recommendations that we make are, by and large, to the national bodies—often the regulators—because we think they are best placed to make the changes that we think are necessary.

[The Chair]

Do you want to add anything to that, Mr Trenholm?

Ian Trenholm: No, thank you.

--- Later in debate ---

[The Chair]

Please do.

Professor Maggie Rae: Just building on those comments from Councillor Jamieson on what I think is a very important question, there is a line in the Bill saying that the ICSs have to take note of advice from directors of public health. If we want ICSs to be population health organisations, we have to make sure that the legislation is strong enough to ensure that the advice is acted on. Our directors of public health have been highly trained and are able professionally to identify the needs of the population, identify where the health inequalities are and make sure that they can provide the ICSs, in terms of both the NHS-side board and the partnership board, with all the evidence they need about what will make a difference. It is the action that will make a difference and improve those outcomes that we all want. It would be very helpful to ensure that the Bill, if possible, is more explicit about that advice and which source it is coming from. We have worked very closely with the legislative team and the Bill team. I do not think anyone could fault the amount of hours they have spent discussing with stakeholders the details of the Bill, and Councillor Jamieson is also right that we cannot have everything in the Bill, but we want a true population-focused organisation.

That has to be the change that this legislation brings; it has to be an enabling legislative framework. We then need to ensure that the guidance, and, most importantly, the assurance process, allow some of the public health expertise to determine whether it is fit for purpose. It is possible that these organisations, and the excitement of the changes, could result in our having a more place-based population focus, but that will only be the case if we get it right and take account of those wider determinants such as education and housing—all the things that contribute to good health.

[Edward Timpson]

Q This is principally for Councillor Jamieson, if I may, in relation to the role of local government in the new integrated care structure. As you will be aware, there was initially a one-part structure, and partly through the input of the LGA, I think, we have ended up in the Bill with a two-part structure, with both the board and the partnership. For the first time, in many respects, that puts local government very much at the heart of NHS decision making. How do you think that that will assist in addressing both health inequalities within the local area and—I note your point about the flexibility of the board and the partnership—what barriers do you think it will help remove, so that we get a truly integrated system and service that the local government level will have a positive influence on?

Cllr James Jamieson: Looking at the current situation with health and wellbeing boards and so forth, that has worked well in some places and not so well in others. That is largely down to local factors, relationships and the willingness of the NHS to participate in a place-based approach. Our hope and expectation is that this formalises it, not in absolute terms, but in emphasising the role of local government and other partners that the NHS has to take account of. In essence, it is strengthening our ability to influence the NHS.

Why is that so important? I come back to the comment that I made earlier about how much health outcomes for an individual are based on non-NHS factors. I have forgotten who raised the question of health inequalities, environment and so forth, but those are all place-based factors. Getting more investment in public health, less pollution, better community health care, a better GP service and better occupational therapists will make huge differences to people.

At the end of the day, nobody wants to go to a hospital; they would far rather be healthy and not need to. Therefore, empowering local councils and partners to have a greater say in how we improve the health outcomes of our whole population has to be a good thing.

Professor Maggie Rae: To add to what Councillor Jamieson has said—he is making some excellent points on that agenda—it is important to get the balance right. In England, we had the legislation on health and wellbeing boards. One of the principles should be not to ride roughshod over legislation we already have just because we like the new bright and shiny legislation. On the commitment to stakeholder engagement, we managed to get the Bill team to understand that we have legislation already.

Some of that legislation is still there—we still have directors of public health and the powers in local government—and those things are important, but we also know that if we do not get this legislation right, we will not be able to get right the ambitions on health inequalities and on improving health either. The detail of this is really important. As I think was indicated in what Councillor Jamieson was saying, we know that legislation alone does not always fix problems. I do not know how we can get good relationships just through legislation. We can enable things to happen, but we need to ensure that the legislation is enabling and that there is some holding to account for the standards that the legislation is trying to set.

We cannot afford for the health of our populations to be affected by unhelpful variations. I am very supportive of place-based—action happens at the local level and it can be effective at the local level. We need good national legislation, but if we want to do justice to the population in this country, we cannot have unhelpful variation, because that is what will undermine this legislation. We have to make sure that everyone is working for the same aims and that at the heart of everything is the commitment to reducing health inequalities and improving health outcomes, regardless of where you are. Whatever your own organisation, whether a hospital, a local authority or a mental health trust, we have to have something that overrides loyalty to the organisation—to put the population first.

[Karin Smyth]

Q Following up on that point, I do not know whether our witnesses heard our earlier session, but I asked them about this very issue of decision making, governance and accountability. Professor, I hear what you are saying and I understand that you had lots of discussions with the Bill team, but I am not entirely clear what your ask is for the legislation. It would be very helpful if you could spell out what could be added into the Bill to achieve the outcome that you are seeking and the assurance that the drive and logic of the Bill around place-based commissioning, which I support, are made reality somehow.

My point to Councillor Jamieson, which I made to earlier witnesses, is about the integrated care boards, which are the decision-making and accountability bodies locally—the ICPs are essentially a committee of these boards. The accountability, responsibility and decision making lie very clearly with the integrated care boards, which are essentially, as I have called them, a cartel of local healthcare providers—largely the acute sector trusts, which are responsible for vast sums of money. Councillor Jamieson, you have gone to the effort of putting your name on a ballot paper and persuading local people to put their cross by your name. Should you fall foul of them, or make decisions that they do not agree with, you will soon no longer be Councillor Jamieson. That is very clear accountability. With that hat on, can you talk us through your understanding of the role of local government status wise—beyond “Let’s all work together in partnership”—when we reach that real decision-making, push-comes-to-shove crunch about where accountability to local people could lie for decisions if we improve this Bill?

Cllr James Jamieson: In the ideal world, one would probably like one board. However, that would mean that all members of that board had equal status and so forth. Obviously, the NHS partnership would have budgetary responsibility for hospitals, and there is a technical issue with, “Can you have a bunch of non-NHS people having budgetary responsibilities for the NHS?” We understood the difficulty, and that is why there is the need for two boards. The clear point here is that this legislation provides us with a framework that enables that to have real traction.

But I come back to my earlier point, which is that this is a framework; this is not a solution in itself. Legislation does not solve all the problems. This is about how budgets are managed; it is about all the guidelines and regulations that come out. One of the big requests that we have as local government—I am sure Maggie will have it as well—is that we are deeply involved in those guidelines to make sure that they work. I have to say that, so far, we have been, but many more bits of guidelines will come out. That is the crucial bit.

There are some changes we would like to the legislation, but they are not that great—I will come to them later, because they do not refer to this point. We want statutory and non-statutory guidance around things such as the implementation of the Bill, a comprehensive list of guidance that will be issued and clarity about the flexibility. We want some statutory guidance on health and wellbeing boards to ensure that they are at the heart of this. So there is a lot going on, and I am pleased to say that we have been involved in some of the guidance that has already been issued, such as “Thriving places”. As Professor Rae said earlier, engagement has been very good so far, and we would like that to continue, because this is our chance to get this right. We will do that through getting the statutory and non-statutory guidance correct and making some changes, no doubt, to the Bill. But I do not think that this Bill can accomplish everything, so the LGA would certainly not be in favour of significant change to the Bill.

Health and Care Bill (Third sitting)

Edward Timpson Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

Thank you. Will Members indicate whether they have any questions?

[Edward Timpson (Eddisbury) (Con)]

Q112 Good morning, both. My name is Edward Timpson. I am the Member of Parliament for Eddisbury in Cheshire. This question is for both of you, but I will start with Sara. You were a signatory who supported NHS England’s original proposals for legislative change back in 2019, I think. How much in the Bill before us reflects what you signed? What do the changes proposed bring for your members and to the health and care system, based on the proposals that you were in favour of back in 2019? That is probably something you will be able to answer as well, Dr Chaand Nagpaul, but Sara first.

Sara Gorton: I hope you have had our Bill submission, which makes clear the areas where we feel the new Bill needs some amending. You are right that Unison was a signatory, along with the BMA and other colleagues, to the letter in 2019, so it is a matter of concern that, after all this time and with such broad consensus, we are still awaiting the legislation.

The Select Committee process that followed that letter clearly identified that the changes that have been added would be contentious, so that is adding further delay. There are a variety of elements that stray outside the clear consensus that was set out in the 2019 proposals. However, we are committed to seeing an end to a system that holds lots of unnecessary cost implications for the NHS. There is an urgent need to stabilise and give clarity of employment, particularly for the 27,000-plus people who are currently in a state of flux, moving between the clinical commissioning groups and the proposed new ICSs.

There are some clear areas where we would like to talk to you about amending, improving and strengthening what is in the legislation at the moment. There is very, very clear support for following through on the commitments in that 2019 letter, to strip away the unnecessary procurement and competition regime.

Dr Chaand Nagpaul: The BMA was very opposed, and I believe rightly so, to the changes in 2012. We felt they introduced unnecessary competition in the NHS that did not work, has not worked, was not good for the taxpayer, fragmented the service and increased private sector involvement, which we can talk about later. We were very supportive of any changes that would reverse that legislation and have a duty of collaboration. In fact, I led a piece of work at the BMA called “Caring, supportive, collaborative: a future vision for the NHS”, where we spelled out the sort of arrangements we believe would be right, in keeping with the principles of the national health service, and be right for patients, right for the workforce and right for the taxpayer.

In principle, the idea that the Government were relooking at or reversing the 2012 Act was something we supported. In one way, you could say that the repealing of section 75 is an element that we are supportive of. However, in doing so there are not sufficient safeguards and we believe there are many consequences that would actually do the reverse, in particular with regards to a lack of assuredness around national health service providers being supported, in terms of the continuation—we can talk about this later—of unequal arrangements for the private sector provision of care compared to the NHS, and in terms of the lack of clinical engagement that would ensue. Of course, we are getting rid of a whole tier of local commissioning organisations, CCGs, and moving them at a more distant level, called ICSs. We are very concerned about that.

We are also concerned about some of the Secretary of State’s powers and the balance between political accountability and political influence. There is a range of issues here that we think need to be addressed.

The other thing I should say is that we are in the midst of a pandemic. It is by no means over. It is hard to grasp the scale of the backlog of care. These changes have occurred when the profession has not been able to engage. I have not had the time to properly be involved in the input. With the BMA I have, but my colleagues have not. We believe that this is the wrong Bill at the wrong time. We should really address what the NHS needs and get the right Bill at the right time, in due course.

[Edward Timpson]

Q May I have one follow-up question, Mrs Murray? Picking up on your answers and accepting that you will have some aspects of the Bill that you will want to challenge and some amendments that you will want to put forward, the general thrust of the Bill, which is moving from a competition to a collaboration approach, is one that you both welcome. In that endeavour, and touching on some of the issues around procurement and the section 75 regulations governing NHS procurement, what benefits do you see in the changes to the role of the Competition and Markets Authority, which will change the current procurement regime? You touched on some of your concerns, but what are some of the potential benefits?

Sara Gorton: When we set out our support along with other parties in 2019, we saw huge benefits from not wasting unnecessary time, process, money and oversight on unnecessary competition, particularly where no provider other than the NHS was capable of providing the service. We support the removal of the role, as set out in that consensus letter, and that has travelled through to the legislation.

Where we think this could be more robust is the so-called provider selection regime that backs up exactly how the process will be carried out. We think that needs to be extended to make it absolutely explicit that the NHS is the preferred provider where there is an NHS service, that there need to be limits placed on roll-over without scrutiny from external providers and that that provision should be extended to cover non-clinical services. I think that earlier in the week you heard from employers how important the whole-team—the one-team—approach had been during the pandemic and how crucial that had been to tackling the spread of the virus and the work that the NHS had done. We think that principle should be extended and placed in the provider selection regime as well.

Dr Chaand Nagpaul: We absolutely agree that repealing section 75 is something the BMA has called for since 2012. It has been a nonsense that every single contract up to this point has to be put out to tender: huge amounts of waste of taxpayers’ money and of time. As a GP, we were not even able to provide our own phlebotomy services without it going through a process, so in that sense, that is a good thing. However, just repealing section 75 without complementing it with the right tools to ensure collaboration will not work. In fact, the current arrangements repeal section 75 but do not provide any safeguards, or rather structural processes, that will, in our view, allow the NHS to work as a collaborative system.

The example I will give is that we believe the NHS should be the preferred provider of care wherever it is capable and wherever it is available to do so. There is so much evidence. People say: “Does it matter who provides?” Well, it does matter, and all the evidence in the last few years has shown repeated examples. Some of you will remember Circle taking over Hinchingbrooke Hospital. It is very easy for the private sector to say: “You know what? We will really run the NHS efficiently. We will use all the market skills we have.” The NHS does not work like that. We forget at our peril the added value, the accountability, the loyalty and the good will that the NHS provides. We really do.

We only have to look back at the last year. Compare the vaccination programme run by the NHS and delivered by NHS staff to Test and Trace. Even with Test and Trace, compare the £400 million that Public Health England had to the billions that went to the private sector, and local public health teams reached 97% of contacts compared to 60% for the others. I am saying that it does matter. Your local acute trust is not there on a 10-year contract, willing to walk away after two years. It is there for your population; it cannot walk away. I think that given those things, we need to make sure the NHS is the preferred provider.

[The Chair]

Could I just ask you to keep your answers to within the scope of the Bill, please? Also, I ask if we could perhaps have more succinct answers. I still have several people who want to ask questions and we do not have a lot of time to get them in. I intend to call the Front Bench spokespeople at about 10 minutes to 12. I now move to the hon. Member for Arfon (Hywel Williams), but if we could keep to the confines of the Bill, that would be good.

--- Later in debate ---

[The Chair]

Thank you very much, Mr Williams. I now turn to Edward Timpson.

[Edward Timpson]

Q Thank you very much, Mrs Murray. This is directed to Martin. Perhaps unsurprisingly, there is a lot of demand on representation or membership of the integrated care boards, and I think we heard evidence earlier that in my own area of Cheshire and Merseyside, if everyone who wanted to sit around the table was sitting around the table, there would have to be 63 seats, which is clearly unwieldy and unworkable. Specifically thinking about the organisations that you represent, when it comes to clinical representation, moving from the CCGs to the ICS, what do you think should be specified about clinical representation on these new ICBs?

Professor Martin Marshall: We have pushed very hard for clinical representation on the board, and I think that the acknowledgement that a primary care representative is required is absolutely right. Of course, one representative is not going to change the world, but there is something symbolic about it, and there is something about having a primary care voice that is really important. The nature of that primary care voice is interesting, because of course, general practice is a multi-disciplinary specialty, and we work very closely with our nursing colleagues, our pharmacy colleagues and a whole range of different clinical disciplines. I think that in most localities, it is likely that a GP will be the representative of primary care, most obviously because general practice has a long track record of being involved in the management of the NHS, and the onus will then be on that general practitioner to represent all of the primary care voices. As a college, just last week we had a very productive workshop involving all the different specialties in primary care, and a strong sense of consensus that we must and will work together to drive this forward.

I have a particular focus on the primary care voice—I guess that is my job; Helen might refer to other clinical voices—but it is particularly important for primary care, for the simple reason that in primary care, we deal with about 90% of the presentations that come to the NHS every day. We live in, and are closest to, the communities that we serve. We are trained to address the broader determinants of health. We are trained as doctors, as GPs, for example, but we are trained to understand the social determinants of health and health inequalities. Everything that is important about this Bill is stuff that general practice is expert in, so we feel the general practice voice is really important.

One of our biggest concerns—not so much with the legislation, but the way that this is likely to play out on the ground—is that the general practice voice threatens to be diminished as a consequence of the change in legislation around CCGs. If you look at what the boards will look like, we know that the acute trusts will still have their governance arrangements and their budgets. CCGs are going to disappear. We are not necessarily saying that that is the wrong thing, but it means that a lot of the experienced clinical leaders in CCGs risk getting lost, and we know that that is not happening in some of the ICSs around the country, but it is happening in others. The CCG staff are just being transferred into the ICSs, but there is a real risk that the leaders who have been around for a decade or two decades, who understand the nature of organisational change and understand what the Bill is trying to achieve, will get lost. We know from the evidence that the most successful integrated care organisations around the world are the ones that are primary care led, so if primary care does not have a dominant voice, the ICSs are much less likely to achieve their potential.

[The Chair]

Thank you.

Health and Care Bill (Fourth sitting)

Edward Timpson Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

We are going to hear from Richard Murray, chief executive of the King’s Fund, Nick Timmins, senior fellow, policy, at the King’s Fund, and Nigel Edwards, chief executive of the Nuffield Trust. Thank you very much for coming. Could I ask each of you in turn to introduce yourself for the record?

Nigel Edwards: I am Nigel Edwards. As previously stated, I am the chief executive of the Nuffield Trust.

Nick Timmins: I am Nick Timmins, a senior fellow at the King’s Fund.

Richard Murray: I am Richard Murray, chief executive of the King’s Fund.

[Edward Timpson (Eddisbury) (Con)]

Q155 Good afternoon, Mr McCabe, and good afternoon to each of our witnesses. I am Edward Timpson, the MP for Eddisbury, in Cheshire. I want to start by contextualising the discussion about the Bill, particularly off the back of the pandemic and with regard to the timing of the Bill and the issues that it is trying to resolve, which perhaps have been highlighted even more by the demands and pressures that have come through over the last 18 months. Do you think that this is the right time to be taking forward the principal measures in the Bill, particularly around moving from competition to a more collaborative approach and the integration that it is looking to achieve through many of the measures that we have seen with the integrated care system, board, partnership and so on? I will start with you, Richard, and then we will move along the panel.

Richard Murray: There is obviously a risk with any large-scale transformations, and particularly ones in the NHS, that they will cause too much disruption, and they distract people from the day job. I think that is the clear case against. If I may, I will just say a few words, though, on the case for. The existing system already causes disruption, so there are complicated workarounds; there are procurements being done that do not really need to be done. I would not underestimate the fact that there is a headwind in the system from trying to apply the 2012 legislation. There was a real head of steam, coming through covid, of people working together, trying to make this system work, still having to deal with some of those workarounds and still having to deal, sometimes, with doing things in an emergency that you probably would not be able to do in peacetime, so to speak.

The key thing is to try to keep the disruption to a minimum—wherever possible, and particularly for staff, to keep that degree of unnecessary churn down. I have to say, unfortunately, the NHS is quite good at doing large-scale churn without too much benefit. But I think on balance that as these changes are already under way and there are problems with the previous system, stopping now would be more disruptive than simply carrying on.

Nick Timmins: I do not want to take up a lot of time. I particularly agree with that last remark: stopping now would be worse than carrying on. A lot of this is already happening. We have been merging clinical commissioning groups ever since the new system came in in 2012. It is sort of completing a journey. You may not be entirely happy about all the arrangements around the different sorts of board and what have you, but to stop now, I think, would be not sensible.

[Edward Timpson]

Q So it is a natural progression from what is happening practically.

Nick Timmins: In large measure.

Nigel Edwards: I do not have anything to add, given the time. I agree with everything that has been said.

[Mary Robinson (Cheadle) (Con)]

Q Do you have any thoughts on the new HSSIB and its powers, which are set out in the Bill? I know that you are likely to be probed further on this later, but do you have any thoughts on how it will be implemented, the investigatory powers it will have and the safe spaces and protections it can give? Do you have a view on how it will sit with existing legislation on the protection of whistleblowers?

Richard Murray: I am afraid that is not an area we have focused on—sorry.

Nigel Edwards: Likewise.

--- Later in debate ---

[Karin Smyth]

Q I broadly agree with the direction towards permissiveness and the logical direction of the Bill. I am profoundly disturbed, and most of the NHS representatives are making me feel more disturbed, about the lack of local accountability and scrutiny that local people will have of the power that we are giving, with due respect, to people such as you, designated within and by the local health service to police and manage itself. In your drive for permissiveness and power within the system locally, how does a local patient hold you to account for, in my area’s case, the £1.5 billion-worth of decisions that you are going to be making? How do we break the national power and make the local power better?

Dame Gill Morgan: What is different about this Bill is that it is the first time that local government will be very actively involved in those decisions. It has always been involved in scrutiny and big changes, but it will be heavily represented on our partnership board. We have four local government people, including two elected members on our ICB—integrated care board—so we are bringing in the local government elected people.

We intend our partnership board to meet in public and we are looking at exactly how many of our meetings of the ICB should be in public. Clearly, when talking about quality and clinical stuff, the actual deliberations need a private bit—[Interruption.] When talking about named individuals, yes, they do; but when talking about the quality of the service in general, that is something that needs to be clear and in the public domain. We need to get the balance right between what we need to do publicly and what we need to do privately—as we will, because we will have so much local government involvement, with elected members, as well as Healthwatch and other people like that. They are all intrinsic parts, in a way that they have never been before. It has never felt as engaging to me as it does now, certainly in my patch.

Louise Patten: From my point of view, having experienced health overview and scrutiny committees as an accountable officer, the patients and public certainly feel that there is the voice of that local place. It is important to NHS leaders that that continues—that ability to have local scrutiny at local level, which is very much where patients and service users feel is the right place to do it.

At the strategic level, we must not forget that ICSs comprise both the integrated care board and the partnership. This is a real opportunity to tether the NHS to always thinking about the wider determinants of health, social value, public health and, again, patient experience.

[Edward Timpson]

Q I am Edward Timpson, the MP for Eddisbury in Cheshire, so coming into the Cheshire and Merseyside ICS, which is a very different proposition from Gloucestershire’s. In that context—it is encouraging to hear how engaged you feel in the process to date, so reflecting on that engagement—what do you think you have discovered already from the preliminary work in Gloucestershire? You have used that example in our evidence sessions. How has that helped to inform the way in which collaboration can best work, bearing in mind that there will be different political, social and economic geographies in each area? In doing so, where do you think clinical representation needs to fit within an ICS, or even within the ICP or the ICB, to ensure that the decisions made are the best for patients and their outcomes?

Dame Gill Morgan: Our big learning about all of this is that, at the end of the day, many of the structures do not matter; what matters is people being in the same room, having the conversation about common purpose, and getting to know and trust each other. The reflection on that has been why we now have such an emphasis on place. If you have a really large ICS and you are trying to do it all, you are so distant from patients, citizens and clinicians that you will never have the contact. Place, in those bigger systems, has to be where you begin to pull those things together, by getting the right people to engage and developing the right level of trust.

As far as clinical engagement is concerned, the ICS is about three things—the triple aim, which is, basically, how do we get better health services today, which are responsive, high-quality and all those things we want; how in the long term do we create populations that are healthier than they are today, which means thinking about employment and all those bigger things; and, in the middle, how do we take services that we deliver today and transform them to be more community-orientated, better for citizens and delivered where people want them? In each of those three boxes, clinicians are absolutely fundamental.

A lot of our effort—in particular around covid and some of the successes—has been in getting that synergy, with clinicians in the transformation box feeling that they can not only write on what the hospital does, but define what the community does and what the GPs do, because they are all working collectively. That has been transformational. Certainly, we would not have managed covid as effectively as we have without those sorts of relationships running all the way through the system as a thread.

Louise Patten: The clinical leadership has to be multi-layered, right the way through from the strategic level to place. We have to have clinical advice and we must heed it when we are talking about planning clinical services. That is fundamental. I think it will involve different groups of people. If it is a care pathway about cardio-vascular disease or a professional pathway about social care, we must heed clinical and professional advice when we are planning these services, so it is multi-layered.

[Edward Timpson]

Q All the way up to the board?

Louise Patten: From strategy right the way down to grassroots implementation.

[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.

--- Later in debate ---

[Mary Kelly Foy (City of Durham) (Lab)]

Q This is for Andy. It is noted that mental health provision has for far too long been seen as the Cinderella service of the health system. Indeed, there is very little in the Bill specifically around mental health. Given the growing number of people suffering with mental ill health and the shortage of services, is there enough in this Bill to satisfy you that mental health will be given parity of esteem alongside physical health?

Andy Bell: It is difficult to tell; the Bill is largely silent on mental health. If we had a system where there was genuinely equal regard for both mental and physical health, we would not have to worry about that, because we would know that the system would treat mental health fairly and equally, and there would be no disparity in the way it was thought about. Unfortunately, all our experience tells us that that is not what happens within many health systems at different levels, from very local to national, so we would like to see some assurances in the Bill.

From our point of view, that could happen in one of two ways. Legislation only gets you so far, but it could place specific duties on both NHS England and integrated care boards—I am being very careful in specifying integrated care boards here—that they must take action to ensure that mental and physical health are given equal regard in their decision making, particularly on resource allocation. We feel strongly that there needs to be a voice for mental health within integrated care boards. That is highly likely to happen within integrated care partnerships, but within integrated care boards we do not have confidence that mental health will be properly represented at the top table where important decisions about resource allocation are made.

We think that would help. There are no 100% safeguards in legislation, but one positive thing we have seen with the 2012 Act is that a clause at the very top of the Act talked about mental and physical health as one of the key purposes of the NHS, and that has been used positively and helpfully to make the case for parity in health systems up and down the country. A few simple words can sometimes make quite a big difference.

[Edward Timpson]

Q This is a question for Ed, building on the fact that you have, I think, fairly extensive experience of working with local authorities and supporting them on governance and scrutiny. Having direct involvement in NHS decision making on funding and so on is a fairly new role for local authorities, and different ICSs will have different sizes and geography; for instance, mine is Cheshire and Merseyside, which is one of the largest—I think it is three or four times the size of some other ICSs. Over and above being involved in the board, for local authorities in larger ICSs, where the emphasis on place could be lost if they are not more fused into the system, how do you think the Bill could help to ensure that that is the case, so that we get the right balance between their involvement in the decisions, based on their knowledge of their own population, and the wider regional decisions?

Ed Hammond: For me it starts with an understanding of what decisions are best made at system level and what decisions are best made at place level. Certainly, I would imagine one of the first things that ICBs and ICPs would need to do, once established, would be to determine how to set up a system-wide framework for ensuring equality and equity in terms of how its health and care service is delivered, and then determine how and where it is most appropriate that more detailed decisions come to be made at place level. Otherwise, the system simply becomes too unwieldy.

There are risks that those partners sitting at that system level will draw decision making into those spaces, rather than pushing it back out to localities, because it is the simplest, in many ways the most efficient and apparently the most co-ordinated way of doing it, but in practice it will not serve the interests of local accountability or better outcomes. That raises the prospect of certain services being delivered in different ways in different localities, depending on the political priorities of different councils, but that is local democracy—that is local government bringing its understanding of the demographics of the populations it serves into the conversation.

I think this can all be made to work if there is sufficient transparency in the system, so that those within and those outside it understand how decisions are being made, on what subjects, and by whom. When you have that clarity, it becomes easier to unpick what is happening at place level. Are decisions being made at system level that would be more appropriately made at a lower level? Is there consistency across the entire system? What does the geography mean for decision making and commissioning, and these kinds of things? It provides assurance, and it provides everybody with more confidence that decisions are being made properly in the interests of local people.

Going back to the point I made before, that is also why some external local accountability is so important, because effective local external accountability can challenge the system on whether the right decisions are being made at the right level, and whether they reflect and are responsive to what the local needs are. Local scrutiny committees are, at the moment, anchored at place level within local authorities. They are well able to publicly draw in the voice and concerns of the public about those kinds of issues, and transmit them to health and care partners so that there is a clear way for those concerns and issues to be responded to.

[The Chair]

Thank you. Dr Whitford.

--- Later in debate ---

[Jo Gideon]

Q Thank you, Mr McCabe. How do you think the public voice should be represented across the integrated care system at board and partnership level?

Sir Robert Francis: Healthwatch England welcomes the requirement for Healthwatch and representatives of the public to be “involved”—that is the word—in the strategy, but we would like to see that enhanced, as I am sure many people would, and we just heard that expressed very articulately. In order for these new reforms to work, it is absolutely essential that the public whom the system serves are able to engage with it and participate in the design of the services that they are going to receive. In order to do that, in our view, they need a visible presence on the ICB board and the ICB partnership. Although that can of course be done by local discretion and local arrangement, we think it would be a powerful boost to the importance given to the people’s voice if there was a representative on the ICB—not as a voting member but, in NHS England’s parlance, as a “participant”. It would be a requirement that one of the participants be such a representative, and you will not be surprised to know that we would advocate that person being a representative of Healthwatch.

That can be done through a coalition of local healthwatches—in many places there will be more than one—so that they have a presence on the board and are able to raise things. It is not just a question of the ICS deciding what to ask people about; they need to have a flow of intelligence coming in about what people are actually concerned about, and those two things are often different. It should be someone who is able to question what is happening in a constructive way.

Of course, part of that is done by local government representatives, and this is not a substitute for local democracy, but we consider that Healthwatch has a local and national ability to reach out to groups who do not often get considered, for instance, and that is particularly relevant if you are seeking to tackle health inequalities. Through the relationships that a good local healthwatch has with groups who feel—rightly or wrongly—that they have often been ignored, the questions that they pose can be put and the answers given back to them. That is a two-way process; you need someone who is independent from the system but in the room, and they also need to be able to transmit into the room information from patient services and the public, and transmit information back. They are part of the mechanism for explaining to the world at large this extremely complicated new concept—namely, a system of which the public has no understanding at all at the moment. A lot of professionals do not either.

[Edward Timpson]

Q Sir Robert, a shift away from competition towards collaboration and integration is very much at the heart of the Bill. We heard earlier that competition is not just about the constant tendering for services but also has the element of patient choice. From the evidence you have gathered from your local healthwatches and more generally across the country, where do you think patient choice needs to sit within these reforms? I am particularly interested in children and young people from the ages of nought to 25, because we are talking about all our health system’s service users.

Sir Robert Francis: Clearly, patient choice and view include information about people’s experience of the service they have had, where they think the gaps are, and their needs. The less you have a competitive exercise with different organisations coming in and saying, “We can provide this better than X or Y,” the more you need to know what people think about what you are proposing, or indeed the more you need to know to inspire creative thought about how you meet the needs that people are telling you they have.

Our view is that while we actually welcome the removal of the requirement for tendering and all the bureaucracy that, quite often in our healthwatches’ experience, interferes with and delays getting solutions to things, that should not mean that we do not have a concentrated effort to involve patient services and the public in the design of what they are being provided with. In effect, that would include how you commission the service that they are going to be provided with. You then need a constant flow of information and dialogue about whether that is working. Frankly, I do not see a great deal of clarity in the Bill about how performance will be monitored after having commissioned services and worked out your strategy and so on.

[Edward Timpson]

Q Is my point about children and young people one that you look at and factor in?

Sir Robert Francis: Definitely, and it would be quite wrong to think that children and young people cannot be fully involved and consulted in the design of the services that are required for their benefit. Many local healthwatches have been very good at doing just that.

[The Chair]

Dr Davies.

--- Later in debate ---

[The Chair]

Q We now come to our final witness session of the day. We will be joined by Stephen Chandler, who is the president of the Association of Directors of Adult Social Services. We will also be joined remotely by Gerry Nosowska, who is the chair of the British Association of Social Workers. We have until 5.15 pm for this session. I remind Members, because one of our witnesses is joining remotely, to be clear about who they are directing their questions to. May I ask both witnesses to introduce themselves for the record?

Stephen Chandler: Good afternoon, everyone. I am Stephen Chandler. As you said, I am currently the president of the Association of Directors of Adult Social Services. ADASS is a small charity that represents directors such as myself. My day job is director of adult services in Oxfordshire—up and down the country. It is probably important to say by way of context that I have only worked in the public sector. I left school and started my training as a nurse. The first 20 years of my career were in the NHS. I reached trust board level via a route of joint commissioning. The second half of my career is in local government, so in a way I am living proof of integration, if there was one.

Gerry Nosowska: I am Gerry Nosowska, and I am the chair of the British Association of Social Workers, which is the professional body for social work in the United Kingdom. We have around 22,000 members. I am here to represent the voice of social work, and our experts by experience who have worked with us.

[Edward Timpson]

Q May I start with you, Stephen? This may start to build on your dual professional career in both local government and the national health service. The Bill tries to ensure that much of the important data that flows between the two, and other services within the health and social care system, is more effectively and efficiently used for the benefit of patients and their outcomes, so how could a new provider dataset best meet the needs of local authorities in particular in meeting their Care Act duties?

Stephen Chandler: It is a really good question. We see the importance of bringing that collective data together in one place at every level in the stratified system. If you take the integrated care system, at the macro level it is really important for population-based planning. My local integrated care system covers Buckinghamshire, Oxfordshire and Berkshire—colloquially, BOB—and for some conditions dealing with it at that footprint is really important. Having data, for example, around cancer care and some of the specialist mental health services is really important.

The first thing that I did this morning was to chair a call looking at urgent care activity in our local system, and it was really important for the staff from the community trust and social care, as well as the acute staff, to be looking at a single view of the citizen—the patient—in that instance. We have done a lot of work to get there already. Again, this is about building on some good foundations, but it is critical for practitioners to do their job to have that data there, flowing readily, as well as for us in the planning and commissioning sense.

[Edward Timpson]

Q Gerry, I do not know whether that is something that you, from a social work perspective, would like to comment on.

Gerry Nosowska: Yes, please. The link between health and social care data is obviously essential, because health care impacts on people’s lives and social lives, and social determinants impact on health. Joining those things up will help us to have a much more holistic picture, which is what social workers are interested in. For social workers, what we really want to understand are the trends, the gaps, and the barriers to wellbeing. In practice, having that data and that understanding—ideally a really local understanding—is important.

We would want to see social workers and experts by experience input into the kind of data that is collected, with an understanding in particular of under-met or unmet need, so that we can become more preventative, which is another aim of integration, and we have information about people who might fall outside of statutory responsibilities—self-funders, for example. We know that there is a real need to understand much more about the pressures on carers. This is an opportunity to think about how we can build more fairness locally through understanding the inconsistencies in people’s experiences and outcomes. We also have a need to understand the impact of digital developments on people—how to ensure equity as we move into a wider range of working. Another hope would be that, ultimately, our health and social care leaders will be able to be more proactive using the data, because very often it feels like we are on the back foot.

[Karin Smyth]

Q I, too, did joint commissioning roles in Oxfordshire at one point—so, only the best.

Every project that I have seen or witnessed on integration—joint commissioning; joint collaboration—has fallen apart in the end because of accountability for the money. A finance director in a local authority has to account for its budgets, and the finance director and accountable officer of a health authority ultimately has to account for their budgets. If agreement cannot be held at that point, those projects fall apart.

We heard earlier that we still do not know any detail on the tariff or money flows as a result of changes in the Bill—changes that will come into place in April. We also have the better care fund outwith the Bill, and this week’s announcement of a major change in funding is also outwith it. I wonder, with your ADASS hat on, how can you now help the Government to get around the problem for organisations regarding accountability for the money so that they do not fail?

Stephen Chandler: Again, that is a really good question. To be honest, a real challenge for those of us working in both health and social care is that uncertainty and delay in knowing the financial envelope we are working with. The announcements this week help to provide some clarity of what the future funding arrangement is likely to look like but, of course—from a local government point of view—until the spending review confirms the final settlement later this year, we will not know.

Some practical examples of how to mitigate or manage some of that uncertainty clearly come down to how much you are able to put together—and feel confident to put together. I suspect it was probably there in your day in Oxfordshire, but Oxfordshire has a large pooled budget arrangement—some of it completely risk-shared, but some of it not. That reflects the confidence and experience we have in using that money together. If I were not here providing testimony to you, I would be chairing a joint commissioning executive. In Oxfordshire, across health and social care, we have responsibility for more than £500 million in health and social care expenditure.

We are talking about continuing to build on some really good relationships and experiences that have existed but, rather than allowing them to evolve because individuals—either at a system level or a personal level—believe it is the right thing, it becomes policy and direction. I think that the success for us has to be looking at where systems have been able to resolve some of those challenges. I am still working with my CCG colleagues in Oxfordshire around what we believe the better care fund will look like, having signed the agreement at the beginning of the year. That is about us becoming much more involved and therefore much more confident in each other.

You will appreciate that ADASS members are constantly providing reassurance and at times caution to our elected members on how far we could and should go in relation to sharing and using our resources. Some of the developments in the Bill around the establishment of integrated care partnerships fully provide a vehicle for some of that greater transparency and greater opportunity to look at the problem, the challenge and the opportunity from a place, and then from a system, point of view.

Health and Care Bill (Sixth sitting)

Edward Timpson Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Edward Timpson (Eddisbury) (Con)]

It is a pleasure to serve under your chairmanship on this Bill Committee, Ms Elliott. I rise to speak on the amendment, not to support it, I am afraid, but I do want to show some sympathy with the arguments the Opposition have raised about the way ICSs have come into being and particularly about their size and population.

As was hinted at by the shadow Minister, the hon. Member for Ellesmere Port and Neston, this is where we have a shared experience of the shadow integrated care system in Cheshire and Merseyside, which has, I think, been through four different leadership teams in the last five years. Concerns have been raised with us, by local government but also by many working in the health service in and around Cheshire and Merseyside, about how the construct of this ICS will impact on their ability to deliver local place-based healthcare.

On size, the majority of the evidence we have had in the sessions to date has suggested that the formulation of ICSs needs to have a level of flexibility and permissiveness. However, we also need to be cognisant of the fact that there are populations that will need to be served differently, based on past experiences of borders that already exist. Cheshire and Merseyside will to cover 2.6 million people—that is over eight times the size of some ICSs. It will incorporate 9 CCGs—more CCGs than that, but in Cheshire itself it has moved from four to one as recently as April 2020. There will be 19 NHS provider trusts and 51 primary care groups. It is going to be an almighty body trying to make sure we deliver healthcare at the very local level as best we can.

If that is not done well and there is not the right level of scrutiny, transparency and accountability, the number of bodies on the Cheshire and Merseyside board, for example, could end up being 63 if every body that falls within that geography and that has asked to be on it has a place at the table.

We contrast that with the example of Gloucestershire. We had evidence from Dame Gill Morgan, who is the chair of that ICS, which is one of the much smaller ICSs. In one of our evidence sessions, she was very clear from the experience that she had had:

“If you have a really large ICS and you are trying to do it all, you are so distant from patients, citizens and clinicians that you will never have the contact. Place, in those bigger systems, has to be where you begin to pull those things together, by getting the right people to engage and developing the right level of trust.”––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 129, Q177.]

Where that will be vital in an area such as Cheshire and Merseyside is on my second point, around population. The ICS will incorporate a huge and diverse population across the Liverpool city region and Cheshire. Those who have only a cursory knowledge of that part of the world will not be surprised to hear that, within it, there are very different health populations, needs and inequalities. The concern that has been raised with myself and other local representatives is that, over time, there is a risk that that might have an impact on some of the priorities, and where they sit within that large area, as well as on what allocations that might bring to deliver the right level of healthcare.

In one of the unitary authorities in Cheshire—Cheshire East Council—somewhere between 55% and 70% of its overall budget is spent on social care. It is so important that these bodies have an integral role in making sure that the place-based services match what they know is needed within their own budget.

There has been some amelioration of that issue, by virtue of the local authority representation on the integrated care board—I think it has two representatives. I was pleased to see in my hon. Friend the Minister’s written statement on 22 July that as part of the boundary review of the ICSs, which has been referred to, Cheshire and Merseyside will have a period of two years where the current arrangements will be reviewed. I seek assurance from the Minister that that review will have veracity and deep-rooted scrutiny of the performance of the ICS during that period, to ensure that it does not fall into the trap that some of the larger ICSs could do unless we have the balance right between the role of local government and local healthcare providers, alongside this larger organisation, which will have to encompass a huge range of demands and pressures on its time and resources.

I have every confidence that my hon. Friend will ensure that the exercise is fruitful, that in Cheshire and Merseyside—particularly in Eddisbury and in Ellesmere Port and Neston—we end up with a better system than we have, and that our patients and residents will be able to get the healthcare that they need when they need it, irrespective of where they live.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is important to recognise the changes that the NHS in England has been through over the past 20 years, moving from about 100 strategic health authorities to primary care trusts, too more than 200 CCGs, to STPs and now to this. Witnesses in the ICS session said that although some were making great progress, it was those with boundary difficulties that were falling behind. The Bill talks about population health and wellbeing, but local government drives a lot of those things: housing, active transport, social care or what the town centre looks like. It is therefore important to get the boundaries right, or in a few years’ time there will be yet another upheaval.

In Scotland we got rid of trusts and went to health boards in 2004, and we have had 17 years of stability since then. If people keep moving around who they are connected with, the Government are breaking relationships and expecting people to form new ones. This is not a minor thing. I would like the Minister to explain what the basis was for deciding the number, the size and the geography of the boards. Was some formula used? Trying to get that right will be a major influencer of the outcome of the whole policy.

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[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.

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[Edward Argar]

The hon. Lady and I have spoken about “Learning from Scotland’s NHS” before; as she will know, we are not dogmatic and are always happy to learn from Scotland’s NHS—as, I am sure, it is happy to learn from England’s NHS. That is to the benefit of everyone, and I am very grateful to her for inviting me on Second Reading to come and visit Scotland and see it on the ground, which I hope to do.

The reality is that the ICSs at the moment, on a non-statutory footing, are at different stages of development, different stages of evolution and reflect different approaches. One of the things we are seeking to do here is to put a non-restrictive degree of prescription around this—if that is possible—to get a degree of consistency, but not to be too prescriptive.

Dame Gill Morgan leads one of the more developed ICSs. I do not think what she is saying would be unrepresentative of the attitudes and approaches adopted by ICSs more broadly. I should say ICBs, as the hon. Member for Bristol South rightly highlighted the importance of reflecting careful use of the terminology in the evidence sessions—she caught my eye, and I have corrected myself now. I think we strike the appropriate balance here, and I suspect we will see ICBs going further in their membership, but that flexibility is able to reflect local circumstances.

[Edward Timpson]

I wonder whether my hon. Friend the Minister could assist the Committee with a question on the evidence given by Louise Patten from the ICS Network, who said that, on top of the five mandated board positions in the Bill,

“a further five will be in the mandated guidance from NHS England.”––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 134, Q186.]

Is that something that the Minister has been sighted on? If so, do we know what those positions are? I fear that the hon. Member for Nottingham North might have to start to move to a substitutes bench to get enough people around the table, based on his amendment.

Health and Care Bill (Eighth sitting)

Edward Timpson Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Edward Timpson (Eddisbury) (Con)]

On a point of order, Ms Elliott. I apologise for interrupting the flow of the sitting, but it will not have escaped your notice that my amendments 55 and 54 to clause 20 are coming up soon. As luck would have it, the debate will coincide precisely with the time at which I am due in Westminster Hall to discuss the progress of the Government’s implementation of the recommendations of the Timpson review. It is very difficult for me to avoid being present in Westminster Hall. As luck would further have it, my hon. Friend the Member for Vale of Clwyd is happy to move the amendments on my behalf, as well as speak to them. I hope that is acceptable, and I apologise for having to absent myself for a short period in order to fulfil my duties in another part of the House.

[The Chair]

That is absolutely fine. I thank the hon. Member for advising the Committee of that.

Health and Care Bill (Fourteenth sitting)

Edward Timpson Excerpts

Committee stage
Tuesday 19th October 2021 Public Bill Committees

[Edward Argar]

During our debate on amendments 101 and 122, we discussed a number of the key themes that run through clause 95. This clause sets out that, as an independent body, HSSIB will be able to decide its own priorities and determine which qualifying incidents it investigates. We would expect this to be the result of referrals it receives, but also its own intelligence. The clause also gives the Secretary of State powers to direct HSSIB to carry out an investigation when, for example, there has been an incident that has caused a particular concern, and it allows the Secretary of State to request a report to be produced by a specified date.

I appreciate that, as we have heard today, some could argue that the clause could be perceived to encroach on the independence of HSSIB. I hope I set out in my earlier remarks why I do not take that view, and why I believe it is right that the Secretary of State, who has responsibility for the health of the nation, has such a power and is able to respond to emerging, ongoing safety priorities or issues of concern. I believe that this measure strikes the right balance, providing the Secretary of State with that flexibility while ensuring effective and proportionate accountability. HSSIB is not bound to follow the instruction, but it is bound to explain why it deems it unnecessary, or why it has determined it should not pursue a particular investigation request.

[Edward Timpson (Eddisbury) (Con)]

As a point of clarification, I notice that clause 95(2) gives the Secretary of State the power to direct both an individual investigation and

“qualifying incidents that have occurred and are of a particular description”,

but I wonder whether HSSIB, off its own bat and as part of its independent investigation, is able—as we were when I chaired the national Child Safeguarding Practice Review Panel—to look at a number of incidents in which there is a theme that it would want to investigate. For example, we looked at a number of cases of co-sleeping with babies, which gave us an opportunity to look at that issue in the round, rather than individual cases. Is that something that HSSIB will also be able to do?

[Edward Argar]

I am very grateful to my hon. Friend for making that point, and I put on record my gratitude—our gratitude—to him for his work, which he alluded to. He is right: one of the key things we would hope HSSIB would seek to do, where it was supported by the evidence, is to join the dots where there is a systemic issue—not just in an individual trust, for example, but an underlying issue for the Department or the NHS as a whole—and be able to reflect that in its decisions on what to work on and how to broaden the scope if it deemed that to be necessary.

Clause 95 provides that whenever HSSIB decides to undertake an investigation, it is required to make a public announcement, setting out briefly what it will be investigating and what it expects to consider during the investigation. I take the point made by the hon. Member for Central Ayrshire: that announcement should give the public an indication of the fact that something is being looked at, but it should not limit which leads—for want of a better way of putting it—HSSIB decides are worthy of investigation and of following. HSSIB will also be able to get in contact in advance with anyone who it thinks may be affected by the investigation. This may, for example, include patients, families or any individual who has referred the incidents to HSSIB, a trust or other healthcare provider.

Finally, there may be occasions when HSSIB decides not to investigate an issue or to discontinue with an investigation. Clause 95 covers those scenarios. If HSSIB decides to discontinue the investigation of an issue, we have set out that it should make a public statement explaining the reasons for doing so. If HSSIB decides not to investigate a qualifying incident, it will be able to give notice of the decision to those who it considers might be affected by it and to explain the reasons to those who have an interest in it.

I hope colleagues on the Committee will agree that the provisions are necessary for HSSIB to be in control of the qualifying incidents and to investigate and to ensure transparency about what investigations are being carried out or discontinued by the agency. We expect that the Secretary of State’s power of direction will be exercised extremely sparingly but it can ensure that crucial patient safety issues can always be focused on where appropriate. I therefore commend the clause to the Committee.

Health and Care Bill (Seventeenth sitting)

Edward Timpson Excerpts

Committee stage
Tuesday 26th October 2021 Public Bill Committees

[Edward Argar]

We tabled the amendments following the publication of recommendations by the Health and Social Care Committee on the Bill. The Committee recommended that the Care Quality Commission be given a role in assessing integrated care systems—the umbrella term, of course, for integrated care boards, local authorities and their system partners working collectively. We agree entirely; indeed, I thank the Committee for championing that agenda. The intention is for those reviews to provide the public and the system with independent assurance of how their ICS area is performing, and in particular the effectiveness of joined-up working and integration. Those reviews will be a valuable way to improve the services provided and encourage the effective joint working that the Bill enables.

[Edward Timpson (Eddisbury) (Con)]

I welcome the involvement of the CQC in reviewing the work and impact of the new integrated care systems, but other parts of public service provision, particularly children’s services, are regulated by other bodies—Ofsted, in the case of children’s social care. Can the Minister reassure me, either now or at a later stage, that those bodies will be involved in the initial discussions about what the reviews will look like, and how Ofsted may be able to provide input to ensure that the review encompasses all aspects of regulation and inspection that will touch on the ICSs.

[Edward Argar]

I am grateful to my hon. Friend for his comments. He is right that we must not at any point forget the interest of children and families in the context of the services being provided. I hope that I can give him the reassurance that he seeks. I certainly envisage that, as we draw up the system, and as what we are proposing becomes designed and operationalised, the process would encompass close co-operation with Ofsted and other relevant bodies to ensure that it does the job that it is intended to, and that no one falls through the cracks—for want of a better way of putting it—in that regime.

Our approach builds on the existing role of the CQC as the independent regulator of health and adult social care in England. Under the Health and Social Care Act 2008, it already reviews individual providers of health and social care. This Bill expands its role, as under clause 121 it will also have a duty to review and assess the performance of local authorities in delivering their adult social care functions under part 1 of the Care Act 2014.

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[Alex Norris]

It is a pleasure to speak to this important clause, which sets out restrictions on advertising less healthy food and drink. I echo what the hon. Member for Central Ayrshire said about its importance and the general commitment to it across the House. Importantly, it also gives me an opportunity to put on the record a message of thanks to the hon. Member for Bury St Edmunds (Jo Churchill) for all the work she did in this area while a Health Minister. She has moved to a new post during the Bill’s consideration, but she championed this provision for a long time and fought very hard for it, so I have no doubt that she will be glad to see it included in the Bill.

These measures form part of the Government’s obesity strategy, which is coming through the system bit by bit. The strategy has largely come through in secondary measures, so I welcome the fact that this provision has been included in the Bill, because it gives us an opportunity to propose improving amendments. Is the Minister able to explain why other provisions in the strategy have not been brought forward in this way? For example, we have considered a statutory instrument on showing calories on menus, which I dare say all Members will have received something about in their mailbags, because it is a contentious and emotive topic, with many shades of grey. That provision would have been improved if we had had a chance to amend it, so I am sad that we instead got a “take it or leave it” measure. I do wonder why the entire obesity strategy was not put through in this way.

Turning to what is before us, ensuring that we do not see the aggressive promotion of products high in fat, sugar and salt, particularly to our nation’s children, is an important step in reducing the obesogenic environment we live in. We know that one in three of our children leave primary school overweight and one in five are obese, and we know the lifelong impact that that has on physical and mental health, such as the links to diabetes, musculoskeletal ailments and depression. We also know the impact on children’s education, as they go to secondary school and beyond, and on their prospects in the world of work.

It is a well-established and long-standing precedent in this country that we try to protect children from exposure via the television by using a watershed, so it makes sense to consider these products within that scope. Of course, the nature of the content we all consume—children are no exception—has changed beyond all recognition in my lifetime. The explosion of the internet and its pre-eminence in our lives has provided new advertising space for traditional means—banner ads, pop-up ads and similar—but there is also a much broader platform. Today is probably not the day, certainly not in the witching hour of this Committee, to get into the influence of culture and how the entertainment landscape is changing—not least because I feel woefully underqualified to talk about it—but the point is that there are extraordinarily novel ways of connecting with people, especially young people. It is therefore right that we in Parliament enter this space to try to create the safest possible environment.

I will say, alongside this, that I am surprised that we have not yet seen the online harms legislation—it seems to have been coming through the system for a very long time indeed—because it would sit very neatly with this. I hope there will be a sense of trying to weave this in with that in due course.

The Government’s answer here goes beyond a watershed and into full prohibition. I hope that the Minister will take us through how that decision was reached. I understand from my conversations with industry, particularly those working in digital media, that they have offered a solution that would act as a de facto ban for children without being an outright ban. Given that we genuinely lay claim to being world leading in advertising in general, and in digital media in particular, we ought to listen if there are more elegant ways of doing that. I hope the Minister can cover the conversations being had with the sector and why this approach was chosen, not a slightly more nuanced one. Perhaps it was considered too complicated, but we need to know that.

As the hon. Member for Central Ayrshire says, clause 125 inserts schedule 16 into the Bill. As that is where the meat is, I want to probe the Minister on a couple of points. First, on the fines regime, what are the sanctions in the Government’s mind? Secondly, the schedule provides for regulations to follow. I suspect we will see a full regime, but when are we likely to see it? How far along are we, and what sort of consultation will there be? Thirdly—again, this will be a matter for regulations, but I hope the Minister might be drawn on it now as a concept—who does the burden fall on? Is it the advertiser or the platform? It might be both, and obviously it could not be neither. That will be a very important point going forwards.

Adding to the case the hon. Member made about small and medium-sized enterprises, we supported that conceptually in the statutory instrument on calories on menus because there was agreement that it was reasonable to say that these things would be a significant burden for a small operator, which might have only one or two members of staff. I do not think that applies in the advertising space. Again, we would be keen to understand how the Minister and his colleagues reached the conclusion they did.

Amendments 139 and 141 deal with alcohol. One of the few parts of the obesity strategy where we have departed from the Government’s view is the curious decision to remove alcohol, particularly with regard to calories and labels. We all know that alcohol is a less healthy product—I may well be the billboard for that, certainly when it comes to weight—so why has it been left out? Our amendments are more probing than an attempt to actually change the Bill, because I hope that alcohol has already been covered. However, in the obesity strategy in general, it seems to have disappeared, which seems very odd. I hope that the Minister can explain his thinking on that.

New clause 55 seeks to protect the nutrient profiling model. According to gov.uk, the NPM

“was developed by the Food Standards Agency in 2004-2005 as a tool to help Ofcom differentiate foods and improve the balance of television advertising to children. Ofcom introduced controls which restricted the advertising of HFSS foods in order to encourage the promotion of healthier alternatives.”

So far, so good. We would say that that principle is sound today and will be sound going forward; that is why we are keen to see it in the Bill. It is crucial that we continue to uphold those standards, but we know that foods change. We know that our understanding of what different nutrients mean for us or our children changes over time. We know that the biggest prize in this space is about reformulation, as much as it is about anything else, which would put more stresses on the NPM. I am keen to hear a full commitment from the Minister today that before meaningful changes are made to the NPM, they will be put out to proper consultation and that industry and consumer groups will be properly engaged, along with anyone else who may have an interest.

I will finish with amendment 113, in the name of the hon. Member for Central Ayrshire. I have made the arguments around engagement through consent, mutual good faith and co-operation from Ministers multiple times, and I hope to hear that in closing.

Clause 125 is very important, and we would like to know a bit more about schedule 16. I would be keen to hear that the issues raised in our amendments are covered elsewhere or at least to have a commitment to that. Finally, I would like to hear a bit about the nutrient profiling model.

[Edward Timpson]

Briefly, on clause 125 and schedule 16 in particular, I want to pick up where the hon. Member for Nottingham North left us, on the issue of obesity. I think we all share concerns that a rising number of children continue to leave primary school either overweight or obese. Much of the answer to tackling that lies in making physical education and sport part of the core curriculum in schools, but we need to look at all measures, including on what children look at and are exposed to in the changing and more digital age in which we live. I welcome measures to tackle that head on, particularly in primary legislation, although I recognise that regulation will flow from that.

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[Alex Norris]

The Minister and I have had these Brexit-type statutory instruments time and time again, so I am not going to get too involved in the conversations that we have had. As we said in the discussion on clause 146, we would like to see greater safeguards. We are glad about the use of the affirmative procedure but we do not think that there is a strong mandate for Ministers to march across the statute book. I hope to hear that this power will be used to the minimum extent necessary to implement the decisions that we have taken.

[Edward Timpson]

I want to put on record my support for the clause and for the opportunity that it presents for our domestic market and the promotion of locally grown produce, the high standards of animal welfare across the UK and our eco credentials. We do not want to make labelling too complicated for people––we want to make it accessible and simple to decipher––but this power is a chance to put that to the forefront so that consumers get produce that is good for them but also good for the UK market.

[Edward Argar]

I just want to give the shadow Minister the assurance he seeks that I believe that the powers under this clause would be used sparingly and proportionately.

Question put and agreed to.

Clause 127 accordingly ordered to stand part of the Bill.

Clause 128

Fluoridation of water supplies