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.

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[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.

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[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.

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[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.