Health Services: Cross-border Co-operation

James Davies Excerpts

Tuesday 16th April 2024 Westminster Hall

[Virginia Crosbie (Ynys Môn) (Con)]

I beg to move,

That this House has considered cross-border cooperation on health services.

It is an honour to have you chairing this important debate on cross-border co-operation on the health service, Dame Caroline, and I thank you for the opportunity to hold it.

My constituents in Ynys Môn, like those of my colleagues here today, are served by the devolved Welsh NHS, which is managed and funded by the Welsh Government in Cardiff. Despite health having been devolved for 25 years, around a third of my most serious casework is for my constituents who are suffering, or perhaps even dying, because of failures in our local health board. I hear from patients, families and even members of staff who are deeply concerned about Betsi Cadwaladr University Health Board—BCUHB for short—and the effect that its failings are having on the people of north Wales. That is why my colleagues and I want the UK Government to help find a solution and why we desperately need the following: much better co-operation across borders on our health services; data that allows the direct comparison of performance across all health boards in the UK, regardless of whether they are devolved; a recognition that the UK Government have a moral, and arguably a legal, duty to take action where the wellbeing of their citizens is compromised; and a willingness to act on that duty where necessary.

I can best explain why we are so concerned by sharing the issues we face in north Wales. BCUHB is by far the largest health board in Wales; with a budget of £1.9 billion, it is responsible for a quarter of the Welsh population—more than 700,000 people spread across a huge area roughly four times the size of Greater London. BCUHB is currently in Welsh Government special measures for not the first but the second time; it has spent all of the last six years in special measures. Despite that, its performance seems to be getting worse, not better. It has been called “dysfunctional”, “chaotic” and a “basket case”. In February 2023, the Welsh Health Minister sacked its entire board. An audit of its 2021-22 accounts found £122 million unaccounted for, with senior executives accused of deliberately falsifying entries. It is now on its eighth chief executive in 11 years. All that is despite a devolution settlement that funds the Welsh Government with £1.20 per person for every £1 we spend here in England.

It is difficult to relate just how bad some of the stories I hear are: people discharged from hospital sicker than when they went in; hours spent waiting for ambulances, and hours spent waiting in ambulances outside A&E; errors in patient records; appointments lost; significant failures in the provision of medication; palliative patients dying in hospital because fast-tracking them home would take weeks; and medical appointments cancelled and rearranged for hospitals 60 miles away.

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

I congratulate my hon. Friend on securing this important debate. Betsi Cadwaladr University Health Board has, over the last decade, received the 11th highest number of prevention of future death reports of any organisation in England and Wales. To put that in perspective, organisations with comparable numbers of such reports are generally whole United Kingdom Government Departments. Does my hon. Friend agree that that is a damning indictment of the poor state of health services in north Wales and further emphasises the serious concerns about the adequacy of those devolved services?

[Virginia Crosbie]

I thank my hon. Friend for his intervention, which gives me the opportunity to thank him for his hard work in fighting not only for his constituents, but for everyone across Wales. They deserve a better service than they are getting, and it is only by working together that we can get action, so I am delighted that he is here today. He is a doughty campaigner and a doughty champion for his constituency.

Oral Answers to Questions

James Davies Excerpts

Tuesday 19th July 2022 Commons Chamber

[Steve Barclay]

On NHS pay, I expect to announce a response to the integrated pay review bodies shortly. We are putting more funding into the NHS, as I signalled in my statement yesterday.

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

T2. Making a diagnosis of dementia is important to allow appropriate treatment, support and time to plan for the future. Pre-pandemic, the diagnosis rate for dementia in England was meeting the two thirds target, but today it is 61.9%. In Wales, data capture and quality is poor, but the equivalent rate is thought to be just 50%. Will my right hon. Friend outline what steps he is taking to improve the situation?

[Steve Barclay]

My hon. Friend will be aware that the matter is devolved to the Welsh NHS, but I can say that in the last financial year, the Government allocated £70 million to NHS England to specifically address dementia waiting lists and increase the number of diagnoses. To further support recovery of the dementia diagnosis rate and access to post-diagnostic support, NHS England is funding two trusts in each region to pilot the diagnosing advanced dementia mandate tool, which will improve access to diagnosis.

Health and Care Bill (Eighth sitting)

James Davies Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Alex Norris]

I congratulate the right hon. Gentleman on his amendments and the case he made for them. I hope that he remembers with fondness his visit to the University of Nottingham and Nottingham Trent University when he was Universities Minister. He will have seen then the significant role that they play in our community, and I think they provide a good model for some of the things that we are talking about. I hope the Minister will address the points about clinical academics in particular. They were very well made, and I thought the right hon. Member for Kingswood also provided the basis for what will be a really interesting discussion on clause 33.

What attracts me to amendment 7 is that it is really important to send a signal to the leaders of integrated care boards that we want research to be central to their mission, as NHS Providers said in its evidence, and that we do not see them solely as administrators of health and care spending on a day-to-day basis, who every winter have to engage in collective crisis management to keep the lights on. We have much broader horizons in mind for them. If this is about new and enhanced models of more integrated care, we have to harness the expertise of academia. Hopefully, if this was effective and worked as a two-way process, with academics learning from inside the system and the systems learning from best practice from around the different footprints, that would be really powerful.

That relates neatly to the point about inequalities, from the beginning of our line-by-line consideration. The argument in favour of making that a priority was not about some sort of quixotic search for solutions or saying that something must be done, so let us just do something; rather, it is about taking evidence-based, high-quality interventions that work and putting them to work elsewhere. The sort of insights that amendment 7 proposes would certainly do that.

When I read amendment 8, my first instinct was, “I wish I had tabled it,” because I think it is great. We want to foster a culture where we invest in and develop our people. That is true whatever someone’s role is in the health and care service. Of course, that is really important in the NHS, and we all have a clear picture of what that looks like, but it is even more important in social care. We undervalue the role of social care in so many aspects, obviously and most tangibly in pay and conditions, but we also do not invest in people. Imagine how much more attractive a career in care would become if someone’s training prospects went beyond the limited ones offered by whoever their employer happens to be and instead a wealth of other opportunities and courses backed by top higher education providers in their community was opened up.

My family’s life was transformed by the impact that night school had on my mum’s skills. She progressed from being an unqualified person working in childcare and turned that from a job into a career. That was completely transformative, not just for her life but for mine and my sister’s. How terrific would that sort of picture be for people entering the care profession. It would be a wonderful thing. So there is a lot to go at here, and I am very interested in hearing the Minister’s views on how we can try to foster that culture, if not through amendments 7 and 8.

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

I rise to speak in support of the agenda raised by my right hon. Friend the Member for Kingswood in his amendments 7 and 8 and the need for integrated care systems to ensure that NHS organisations for which they are responsible conduct and resource clinical research.

I think all would agree that the UK life sciences sector is world-leading. That was evidenced during the pandemic by the way in which early PCR testing was brought forward for covid, by the recovery trial and by vaccine development and so on. In this country, however, the location of existing activity is all too often limited. We have world-renowned centres of excellence, often associated with teaching hospitals. I would do nothing to weaken that. The Government’s levelling-up agenda needs to extend involvement in such activity across the country. But at the same time, it can strengthen what Britain has to offer to patients and the world as a whole, bringing economic benefit to the country as well as to the NHS through increased income.

--- Later in debate ---

[Edward Argar]

No, because at the heart of ICBs is an enhanced integration and partnership-working model, which will be a significant step forward to facilitate improved patient care in our constituencies and localities.

The power to make loans is analogous to the power that exists for CCGs.

The hon. Member for Ellesmere Port and Neston touched on forward plans and health and wellbeing boards. The ICB will have an obligation to consult the health and wellbeing board, including in respect of whether it takes into account the latest joint health and wellbeing strategy and provides the HWB with a copy of its plan.

On Wales, I fear that I may have to write to the hon. Member for Arfon with some of the answers, but I shall try to give some now so that he has at least something today. We are seeking not to make a policy change or anything like that but to carry the existing situation for CCGs across into the new arrangement. We have been consulting and working closely with the Welsh Government. I suspect that, as we heard from the witnesses, some in the Welsh Government may suggest that we should consult more closely, while others will say the consultation is adequate. I believe I have a good relationship with the Health Minister in the Welsh Government—I spoke to her only yesterday about a number of aspects of the Bill—and at official level conversations are constantly ongoing.

The hon. Member for Arfon touched on joint committees, which will involve ICBs and their Welsh equivalents. We would not expect private providers to serve on them because they will in effect exercise an ICB function. On Tuesday, I made it clear to the Committee that it is not our intention that private providers should serve on ICBs, so they should not serve on joint committees either. We will have further discussions with the Opposition Front-Bench team and others as to whether we can find a way to make that clearer in the legislation.

Finally, accountability remains essentially unchanged. The NHS in Wales is accountable to the Welsh Government and ICBs will be accountable to NHS England and, therefore, to the Secretary of State. The hon. Member for Arfon touched on the challenge of divergence or disparity of provision. I suspect that, in a sense, it comes baked into a devolution settlement that when power is devolved down there is sometimes a divergence of approach or there are different services. That is in the nature of any devolution settlement where specific services or functions are devolved. For example, as we have seen in our exiting from coronavirus regulations, the devolved Administrations have the right, under the settlement, to pursue the approach that they deem to be most effective.

I hope that I have addressed a number of the points made by the hon. Member for Arfon. I see my officials frantically scribbling down his other questions; we will endeavour to check Hansard and write to him with anything we have missed.

I commend the clause to the Committee.

Question put and agreed to.

Clause 19 accordingly ordered to stand part of the Bill.

Clause 20

Integrated care partnerships and strategies

[Dr James Davies]

I beg to move amendment 55, in clause 20, page 29, line 7, at end insert—

“(2A) When appointing members to the integrated care partnership, the integrated care partnership must pay particular attention to the range of services used by children and young people aged 0-25.”

This amendment would require integrated care partnerships to consider representation from the full spectrum of services used by babies, children and young people, including education settings.

[The Chair]

With this it will be convenient to discuss amendment 54, in clause 20, page 29, line 32, at end insert—

“(c) include specific consideration of how it will meet the needs of children and young people aged 0-25.”

This amendment would require an integrated care partnership to specifically consider the needs of babies, children and young people when developing its strategy.

[Dr Davies]

I move the amendment on behalf of my hon. Friend the Member for Eddisbury.

These probing amendments would require integrated care partnerships to involve in their joint committee the key partners—including schools and colleges—responsible for meeting the needs of babies, children and young people. The intention is to understand how we can best ensure that children’s needs are given equal priority at ICS level. The Bill provides a genuine opportunity to reduce child health inequalities and improve children’s health outcomes, which is all the more pressing following many children’s severe adverse experiences over the past 18 months.

The Government’s drive towards integrated services and greater collaboration, both within and beyond the health and care system, is very much to be welcomed, but if ICSs are to achieve their aims of improving population health and reducing inequalities, they must give equal weight to the needs of children when they plan and commission services. Why? Because children are a distinct population with their own workforce, infrastructure, developmental needs and legislation. Children’s health is affected by a complex ecosystem of factors, with many interrelated systems encircling the child. Their health is determined not only by primary and secondary health services, but by their nursery or school, children’s social care teams, the local authority SEND workforce, school nursing, health visitors and many other partners.

--- Later in debate ---

[Edward Argar]

I am grateful to my hon. Friend the Member—I cannot pronounce that—and to my hon. Friend the Member for Eddisbury, on whose behalf my hon. Friend for Vale of Clwyd spoke. I also wish to put on the record my gratitude to Lord Farmer and his team for the work that they have been doing in this space. I have had the pleasure of meeting them, and—to reassure the shadow Minister—I have already met once, or possibly twice, with my right hon. Friend the Member for South Northamptonshire (Dame Andrea Leadsom) to discuss her review. I know that my hon. Friend the Member for Bury St Edmunds has also worked with her on it, and we continue to work together to try to find ways to move that forward.

I hope that all Members agree that the creation of integrated care boards and ICPs represents a significant opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people. We acknowledge that these amendments understandably intend to ensure that the needs of children and young people aged 0 to 25 are represented on the ICP and are considered by the ICP when developing its strategy. While we entirely agree with the intentions behind the amendments, we come back to the point that we wish to provide local areas with the flexibility to determine what will work best for their systems, their priorities and how they develop their plans and membership. Overly prescriptive approaches in the Bill would risk making it harder for systems to design the approaches that will work best in their area.

Turning to amendment 54, we would not want ICPs to create plans for children disconnected from the wider healthcare system. We know that the very best systems consider how their health systems are meeting everyone’s need, including where there are transitions between different stages of life. However, I do hope that I can provide some further comfort for my hon. Friend the Member for Vale of Clwyd. We are working on bespoke guidance for babies, children and young people, which will set out clearly how ICBs and ICPs are obliged to deliver for them. This will cover the importance of the ICB forward plan and the ICP strategy and how they can set clear objectives for babies, children and young people. The Department is working closely on the drafting of this guidance with NHS England, the Department for Education and, indeed the relevant Minister, my hon. Friend the Member for Chelmsford (Vicky Ford)—I presume that she is still the relevant Minister as we speak. We will also be working with all stakeholders, including the National Children’s Bureau, in the coming months. I suspect that this is a theme and an issue that we will return to at various points both in Committee and indeed in the further passage of this legislation.

I hope that I can reassure my hon. Friend the Member for Vale of Clwyd on this matter. I entirely understand where he is coming from, but ask that, on this occasion, he does not press his amendment—or the amendment of my hon. Friend the Member for Eddisbury—to a vote.

[Dr Davies]

I thank the Minister for that response. I know that my hon. Friend the Member for Eddisbury is particularly keen that these matters are covered within statutory guidance, but, with the leave of the Committee, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Justin Madders]

I beg to move amendment 47, in clause 20, page 31, line 31, at end insert—

“(3) The Secretary of State must make regulations which set out the procedure to be followed should an integrated care partnership believe that an integrated care board has failed in its duty under this section.”

This amendment would require the Secretary of State to establish a procedure for the resolution of any dispute between an integrated care partnership and an integrated care board concerning the implementation of a strategy produced by the integrated care partnership.

Health and Care Bill (Fourth sitting)

James Davies Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Jo Gideon]

Q How might we implement the changes that you suggest?

Richard Murray: I would really ensure that local government is part of this. It is an independent voice, and has already been a useful counterweight to some of those centralising forces, as local government comes closer to the NHS. Ensure that people from the voluntary sector are there. They do not follow the orders that come out of NHS England, so you are putting people directly into the system who carry some of that independence and are looking out fundamentally to their local communities. That really is the strength of some of the ICP structures—that you have those people round the table and, indeed, some of them on the ICB itself. Really invest in that place-level work. That is where a lot of the excitement will come from working with local government, and again with the voluntary sector and primary care. Do not get too focused on the ICS as this interim middle step, because it is quite distant from where a lot of the action goes on.

Nigel Edwards: It is not just upper tier local authorities that have an important voice in this. I think that Richard is right: a lot of the most interesting and bigger changes are likely to happen at the place level. It is probably the case that quite a lot of legislation has not really affected how patients are cared for or how professionals work. In some senses, that is not a bad thing. I think this does remove some of the behavioural oddities of the hybrid market and other systems that we had.

It will introduce some other hazards, in particular—Richard sort of referred to this—the slight danger of ICSs becoming inward looking, and some organisations, and the independent and voluntary sector, being excluded and not feeling that they have a voice. The challenge that local authorities can bring to that will be important, as will behavioural change from NHS England and some of the regulatory machinery, but you cannot legislate for that. That is a cultural change that is probably beyond the scope even of legislators.

Nick Timmins: Yes, and you can see that in evidence that you have already heard about the construction of the board and the partnership. It seems clear to me—you have heard from the Local Government Association—that some local authorities were happy to join a single board and others felt that that was too much of a loss of sovereignty, which is why we have ended up with this slightly complicated system of an NHS board and a partnership board. Probably, in an ideal world, it would have been better if it was one, but you have to live with what people are prepared to do.

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

Q Nigel Edwards, you mentioned the word “reconfiguration” earlier. In an ideal situation, from your point of view, how would you see a reconfiguration decision being reached, and how do you balance that with the need and expectation for ministerial accountability?

Nigel Edwards: The current system dates back to Andrew Lansley, who set up four tests. Do not ask me what they are. I can look them up, but I cannot remember them. However, they were good. They involved local people and clinical support. You had to make an evidence-based case. Then there was a process that involves local stakeholders, and then there was the opportunity for review by the Secretary of State and referral by local authorities and the independent reconfiguration panel, which has been a remarkably longstanding innovation, given the way that NHS organisations are formed and then abolished. It has done, I think, a very good job.

The current system seems to me to work quite well. The Secretary of State still has a say, particularly around controversial decisions, but they do not get sucked into every small reconfiguration and change. You also do not have a point where there is an opportunity for local participants to say, “I’m not going to contribute to this conversation any more. I’m going straight to the top,” and undermine people working together locally. I am of the view that the current system works quite well. I think we said to the previous Secretary of State, “You need to be really careful what you wish for. You may think that your intervention is going to help to move things along and improve innovation. It’s quite likely, from both previous experience and experience in other similar types of systems, to have the opposite effect.”

Richard Murray: I would not disagree with anything that Nigel said. Also, the clauses in the Bill as they stand at the moment are really, really unhelpful. There may be things you could do to make reconfiguration easier, but I think they would be working around the margins of what Nigel said. It would not be wholescale intervention without limit by Ministers in local decisions—that would mean any change, of any service, could go up to the Secretary of State. Also, if you need to make an emergency move for an operational reason, you would need to write to the Secretary of State in advance—you kind of think the clue is in the fact that it is an operational crisis. I think that the legislation as drafted would not give Ministers what they want, so I really think it is not helpful at all.

Nick Timmins: Can I just add to that? I think it is really dangerous for both Ministers and the NHS. Not many people know about the Independent Reconfiguration Panel. It has worked very well. It has dealt with about 80 controversial cases. It quite often suggests some amendment, and the Secretary of State does not have to take its advice, but the Secretary of State almost invariably does take its advice. I think that if we end up with lots and lots of reconfigurations hitting Ministers’ desks, Ministers will come to regret that. If you listen to the views of previous Secretaries of State, they almost always say, “It’s ludicrous we ended up having to make a decision about what was going to happen”—in Nether Wallop or wherever—which was the case before the Independent Reconfiguration Panel was around.

[Chris Skidmore (Kingswood) (Con)]

Q I want to touch on the King’s Fund’s comments in its own white paper in which it welcomed the Bill’s removal of the “cumbersome competition rules” that were introduced in the 2012 Act; and to discuss some of the consequences of competition and why it is welcome that we remove that; and to ask this question. Are there are any unintended consequences from also introducing the duty on the triple aim in commissioning decisions?

Richard Murray: There are a couple of things around competition. Probably the most obvious one is that it never really worked. A lot of care, particularly urgent or emergency care, is not an area for choice in the first place, so you are already dealing with a fairly specific part of the health service and drawing an awful lot of attention into that one element of the service when a lot of the interest is in care for people with long-term conditions and how you stop overuse of A&E and emergency services. There are lots of examples of things, particularly uncertainty around competitive procurement. Commissioners were anxious about where they stood in law so they used, and probably overused, competitive procurement.

I know from speaking to some commissioners that they sometimes felt slightly powerless to influence the provider side so they would put it out to procurement instead. There was very little sign that all the effort and bureaucracy that went into that really did any good at all. Let us step away from that and enable more co-operative working, to try to get the kind of change that we need for long-term conditions, for the real health conditions that this country faces. I should say that a lot of the academic evidence has found no benefits of competition, so not only was it not a helpful thing, it just did not seem to work—probably reflecting the fact that we have such shortages in this country. Competition works only when there is a meaningful choice.

On the triple aim, you would not want the system to get tied up in a new round of bureaucracy, form filling and ticking boxes, to show that it has duly considered the triple aim. I think it is also important to make sure you do not lose the issue of inequalities from the triple aim. I would not want to exaggerate: does legislating a grand vision make people do things differently on the ground? I think it is helpful to remind NHS providers and others that absolutely they should be thinking about the quality of care; absolutely they should be thinking about value for money and making sure they are efficient. But they also have a duty to the health of the wider population. You can then, through that triple aim, bring the different parties in this system closer together, and I think that for some non-executive directors and for governors, it is quite helpful to know that they are all working in the same direction. So I would not exaggerate the kind of change it would bring, but I think it is a move in the right direction.

Nigel Edwards: Can we just nuance the competition point? Actually, there were two elements to the competition regime. One was the very formal going out to tender and big, bureaucratic procurements—often resulting in the reappointment of the previous provider at significant expense. But the other component was patient choice—for diagnostics, for maternity and for elective surgery. I think that dynamic has benefits. One of the slightly worrying things in some of the plans produced by the ICSs’ predecessors—the STPs or strategic transformation partnerships—was a wish to “repatriate” work, as they called it, which meant to bring work back from providers outside their patch into their own. That was not necessarily a good thing; patients should have the opportunity to have a choice of provider and, particularly in the case of specialised services, one would be concerned about people saying, “Let’s grow our own services locally,” rather than, “Let’s use centres of excellence.”

The maintenance of patient choice, and ensuring that ICSs do not act to limit patient choice, particularly for those patients living on their margins, is quite an important dynamic; almost all ICSs have borders with someone else, and patients naturally flow across them. People want to be able to make choices, because they have an existing relationship with a provider or because they have a relative who lives nearby and could care for them while they are there. There is international evidence that that dynamic has a beneficial effect on providers’ behaviour.

--- Later in debate ---

[The Chair]

Q We will hear next from Ed Hammond, who is the deputy chief executive at the Centre for Governance and Scrutiny, who is appearing in person, and from Andy Bell, who is the deputy chief executive at the Centre for Mental Health, who is appearing remotely. I will just remind Members: if you are directing your question at Andy, can you make that clear, so that he is aware of it?

Good afternoon, both. Can you both introduce yourself for the record, starting with Ed?

Ed Hammond: My name is Ed Hammond and I am the deputy chief executive at the Centre for Governance and Scrutiny.

Andy Bell: I am Andy Bell and I am also a deputy chief executive, but at the Centre for Mental Health.

[Dr James Davies]

Q Andy Bell, how do you think this legislation can help to address current mental and physical health inequalities in this country?

Andy Bell: It is a really good question and I think that, on its own, the legislation certainly has some potential to assist with that. Of course, there also need to be a number of other things and I can talk about those if that would be helpful.

The first positive thing to say about this legislation is that the idea of integrated care—the practice of providing care that actually links across between mental and physical health, NHS and social care, and prevention and treatment—undoubtedly is the way to go. I think we have a number of areas within the system where we know that people at the moment get very poor support for their mental and physical health, as a result of the lack of integration in the system.

Examples would be people who have both alcohol and mental health difficulties at the same time; people living with long-term physical illnesses, such as diabetes or kidney disease, who get really inadequate and often very poor emotional support, if indeed they have any emotional support at all; and, indeed, people living with long-term mental health conditions, whose physical health is very often very badly neglected, and they have very little support. Integrating care—actually doing that on the ground—and achieving a real change in the way that services are organised around people’s needs would undoubtedly make quite a significant difference and reduce some of those inequalities.

I think the way that the Bill and the various bits of guidance are written gives us some hope that that may happen; it certainly does not answer all of our questions about it. In and of itself, I think it is potentially a step in the right direction, but we need to give some thought to a number of caveats around that.

[Dr Davies]

Q That is very promising. Can you just give an indication of those caveats, if that is possible?

Andy Bell: Yes, sure. Again, “integrated care”—we like the words; they are good—but the difficulty in a way is, first of all, the fact that this is very much an NHS-dominated set of proposals. It was written by NHS England for NHS England. I think that if we have a genuinely integrated system, where people will get support across the whole range of services, we need this to be an equal partnership between the NHS, local government, and voluntary and community organisations.

If you look at the proposals, in a sense what they are doing is taking decision making and power within the health and social care system further away from local communities into what are effectively sub-regional groupings. There is not anything very local about integrated care systems in many places, and that gives us some pause for thought. It is very much NHS dominated. If we look at the current health and care system, public health and social care are often the less well-funded and less well-resourced parts of the system. From what we see from the spending plans, it looks like that will become even more the case if you have legislation that, in a sense, reinforces the power of the NHS over other partners. I worry we are not going to get that real shift.

[Dr Davies]

Q Ed Hammond, on the same agenda of scrutiny of outcomes, how do you think those are best measured, and how does the Bill assist with that?

Ed Hammond: In terms of scrutiny generally, it is a challenging picture, as Andy said. There is a challenge around the need for effective local accountability. That scrutiny is best exerted at a local level. Local scrutiny is much more able to assess and make accurate conclusions about what outcomes have been reached. We do a lot of work as an organisation supporting local councils in their formal health scrutiny functions. The past 20 years of that has demonstrated a significant degree of success in local government being able to lead with local healthwatch in, alongside and on behalf of local people, seeking to understand how local health services design and deliver effective outcomes, challenging, where necessary, through the referral power for substantial variations.

My worries echo Andy’s in that the Bill as it stands moves a lot of decision making, commissioning and direction activity up to system level. Depending on the character, relationships and personalities of the key individuals involved, there is a risk that decision making therefore becomes remote from local accountability, making effective scrutiny of outcomes more challenging to achieve.

[Karin Smyth]

Q That leads neatly on to my point. We have just heard a great defence of ICSs as the system of accountability, and you have said that system level is where decision making is happening. The chief executive told us very clearly on Tuesday that accountability for decision making was clearly located in the ICB. The ICP—the partnership—is formally a committee of the ICB. I think each of our witnesses—very experienced people—have actually confused those three acronyms. They have also confused the accountability, which NHS England has told us is very clearly in the ICB. The finance director, the accountable officer at the ICB, carries the can. The other person will ultimately be fired, should the accounts not balance and there be some sort of health and safety patient scandal. I think that is clear. First, do you think that is clear? Secondly, how can we encode the good direction of travel in the Bill around local accountability to somebody who could oversee it in a more independent way and better hold that accountability locally?

Ed Hammond: In answer to your first point, I think it is clear. As we become more familiar with what is a complex system—and health governance is complex—some of this confusion will dissipate. As we start to operate practically within these systems, familiarity will breed a degree of confidence in understanding whose roles relate to what. As with all complex systems, it is vital that everybody understands their individual and collective responsibility for governance within those systems and accountability.

It is great when you have a partnership-led framework, in which everybody in the system is working together, and everybody has some stake in the system and in decision making. It is not a hierarchical, dictatorial system; it is one based, hopefully, on dialogue and, to an extent, consensus. The risk of that is that it necessarily dilutes accountability. Where everybody has a stake in decision making, you need some kind of external source of local accountability. That leads on to a second question. I think there is a need for a distinct and separate form of local accountability within these new arrangements at system, place and neighbourhood level. That role is currently performed at a local level in two main places: through local Healthwatch, from whom you will be hearing later, and through local health overview and scrutiny committees.

For me, the risk of these new arrangements is that, first, the removal of the power of referral to the Secretary of State by health overview and scrutiny committees on matters of concern relating to substantial variation of local health services is a worry for us, as it is for NHS colleagues. Also, the focus on system-level decision making will, by definition, make it more challenging for local health overview and scrutiny committees to co-ordinate to form, where necessary, joint committees to effectively oversee, scrutinise and hold to account ICS, ICB and ICP activity at system level.

--- Later in debate ---

[The Chair]

Dr Davies.

[Dr James Davies]

Q My point is also about patient choice. I work as a GP in England and know that many patients enjoy being able to access secondary and tertiary care throughout England, if they wish to do so—something that my constituents in Wales do not generally have the opportunity to do. Are you satisfied that the Bill protects that opportunity to its maximum?

Sir Robert Francis: I do not think it prevents it, but the extent to which it allows for it will depend, as I understand it, on the strategic decisions being made locally within the system. The answer is that I am not quite sure.

[The Chair]

Karin Smyth.

--- Later in debate ---

[Karin Smyth]

Q But, clearly, accountability is with the ICB and not with the partnership. We have heard that very clearly from NHS England.

Stephen Chandler: Yes, indeed. Without giving away too much personal information, my wife and I have a joint account. We each have our own accounts. She is not here, so I will say that I think I have the authority on the joint account, but if she was here she would probably say that she has.

The point I am trying to make is that a lot of this works on the formal agreement, but as much of it also works on the trust and confidence you build in those relationships. However, you cannot take away the facts, as you said. Equally, my elected members are very clear with me that I am responsible for ensuring that Oxfordshire County Council’s resources are being managed and used in the way that they have approved.

[Dr James Davies]

Q Stephen Chandler, what are the principles that underlie the successful discharge of a patient from hospital, and does this Bill support that?

Stephen Chandler: The principles that underpin successful discharge are, quite simply, a person-centred, strength-based approach to enabling that individual to get back, preferably and ideally, to their own home, in a timely manner, with the level of support that they need to continue the recovery that will have started in the hospital but will not have finished in the hospital.

Where we have got that process right—I think the discharge to assess arrangements have really helped us in this—is by clarifying that the destination for discharge, for the majority of patients, has to be home. It is pathway 1—“Home First”, as it is often described—with the appropriate reablement support to maximise the recovery. That is good for the patient; it is good for us in local government, because it reduces the level of ongoing care needs in many cases; and it is good for the NHS, in that it frees up acute hospital beds. Those are the principles.

The way you successfully do that is by ensuring that the focus is on the patient and getting the patient—the citizen—to their home, not on the organisational form and who is responsible for it; in fairness, we all are. Discharge to assess has helped us to clarify “Home First” or pathway 1, and it has provided for some of those systems where one of the stumbling blocks was the resources to make that happen.

The challenge we have, though, is that we have introduced “Home First” at a system level nationally at a time when demand, linked to covid and the unintended consequences of covid, has really impacted. I reference my first meeting this morning, looking at acute pressures in Oxfordshire. We pride ourselves on getting people home, and “Home First”, but when I was chairing that call I heard myself saying, “We need to move people into some interim beds”, because I needed to create capacity in the acute system. I am hearing that coming through from director colleagues up and down the country; we are making less than ideal decisions for people because of just how much demand there is in the system. Let us be very clear: good discharge is discharge home, to your bed, with the support to enable you to maximise your recovery.

[Dr Davies]

Q Gerry, do you have any comments to add?

Gerry Nosowska: Yes, please. I completely agree with Stephen on the principles behind discharge to assess, and we have good experience within social work of it working when there is clear shared responsibility and the person is kept at the centre of it. We also have evidence from our members of the potential for rapid discharge to assess, without real advocacy and potentially without the involvement of social work, to lead to some undermining of people’s rights around potentially being placed in a more restrictive environment and potentially struggling to have access to their family. It is partly about resourcing, but it is also about the ethos of human rights and people’s right to be heard and to have choice, and then having the practical backing to follow things up well.

I think that people with experience of social care and health want to have a really clear and transparent process. For that to happen well, we still need some safeguards around that transition. It is a complex moment in people’s lives, and I would want to see social work involvement in the guidance around that. But we also need to be thinking, if we want people to have more of their care closer to home, about how we rebalance resources—this relates to the previous question—by making sure that there are incentives for the resource to be put into community and local support and not just into the most urgent matters.

Stephen Chandler: Could I come back in? One thing that I omitted—it was remiss of me—was that we also need to never forget the importance of the support for carers, particularly around hospital discharge. All too often we are focusing on the individual in the hospital bed and the need to get them out, but we also need to ensure that we are not overlooking or not giving due regard to the role of the carer in that. If I could ask you to do anything, it would be this. Can you just ensure that the emphasis on the role of carers and how all of this is going to help the role of carers is brought through? Without carers, the health and care system would disintegrate rapidly.

[Chris Skidmore]

Q What confidence do you have in the discharge to assess model? Obviously, there have been pilots since 2016, but a lot of this was accelerated through the pandemic. That may be a good thing, but it might also be a bad thing, in that we have now to look at data in a very short timeframe. I served on the Health Committee over a decade ago, and during those discussions around tables like this, we used to talk about the Liverpool care pathway and how that was a good model to be following, until it unwound spectacularly and its local delivery was not as was thought in Committees like this. I wanted to ask what your view is on discharge to assess. You have mentioned carers and ensuring that we take into account the need for carers to be able to cope with any rapid discharges. Are there any other concerns that you might have about the model that should be taken into account?

Stephen Chandler: You are right: discharge to assess and, indeed, the “Home First” model of three pathways is not new. It has been around and used up and down the country for a decade or so now, so there are some well established services that you can draw some really good data from. Before I was in Oxfordshire, I was in Somerset, and we did a lot of work in the Somerset system to develop “Home First”, because our delays were really poor. We saw significant improvement in the outcomes for patients in the first instance. We then saw significant improvements in the flow from the acute hospitals, and I would say we also saw some significant benefits to the local authority in relation to the commitment it had to individuals on an ongoing basis.

I have been out of that system for over two years, but the work that it has done since then to take that even further is phenomenal, and I would encourage you to talk to some of the health and social care professionals in that system. One of the hallmarks of the system is that it does not rely solely on health and social care professionals. It has brought what it refers to as community agents and village agents into the hospital to help with discharge. It has got the voluntary sector as an equal partner. It is helping the individuals beyond the health and care needs that they have in leaving hospital.

I personally believe that discharge to assess is a robust and positive model, and I am hearing nothing to the contrary from director colleagues. What I am hearing from director colleagues, though, is real anxiety about conclusions that might be being drawn from the very point you made, which is that we have tried to evaluate discharge to assess in a very short period of time, and at a time when demand and pressure on the service has been at its most acute. Remember that it is not just the physical demand on those services that we have been experiencing; we have been working on an assumption that there is likely, at any point, to be an immediate surge in the demand for acute services, so we have been working to try to ensure that there is always capacity behind us should a further wave—either a local or a national wave—occur. We have been, up and down the country, operating systems at a pace that I have never seen before, as a result of covid. I would be cautious about drawing out any strong opinions around discharge to assess from an evaluation that was done during that covid period. For me, it is the only model that really helps people leave hospital in a timely manner.

I do not know about any of you, but as I get older and hospital admission becomes more likely, I want that hospital admission to deal with the acute need that requires it, but I want to go back home as quickly as I possibly can and to be able to continue to regain the independence I had. I do not want to become reliant on the local authority for all my support, which is why that reablement support at discharge is so critical.

Gerry probably wants to add to this, but the multidisciplinary approach that has a social worker and the local authority at its heart, building upon not just the professional expertise we bring but the relationships with our communities, our voluntary sector and our social care providers, is critical to that success.

Health and Care Bill (Third sitting)

James Davies Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

All our witnesses are appearing in person. It is helpful if Members direct their questions to specific witnesses.

Before calling the first panel of witnesses, I first remind all Members that questions should be limited to matters within the scope of the Bill and that we must stick to the timings in the programme order the Committee has agreed. For the first panel, we have until 12.15 pm.

Secondly, do any members of the Committee wish to declare any relevant interests in connection with the Bill?

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

Chair, I am still a member of the British Medical Association.

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

I remain a member of the BMA.

--- Later in debate ---

[Hywel Williams]

Thank you.

[Dr James Davies]

Q I am interested in Unison’s position on the social care aspects of the Bill, and in particular the CQC inspection that is proposed, and also the data collection powers, please.

Sara Gorton: That is not an area of the Bill that we focused on. Our main focus is on extending the provisions of the provider selection regime—the procurement. I can do some more work and send in something.

[Dr Davies]

Q That is fine. In that case, I will turn to Dr Chaand about a fit and proper persons register for those on NHS boards, or wishing to be on NHS boards. Do you have any views on that, and how legislation might expand?

Dr Chaand Nagpaul: I can tell you, just from the personal experience of being a GP over 30 years and speaking to doctors and representing doctors, that clinical engagement is vital. None of us can have any workplace that functions well until those who work within it feel engaged—feel that their voice is heard and their experience is understood. One of my biggest concerns about the current arrangements is that at the moment, for example, we have clinical commissioning groups. We have had seven GPs in my local area representing me and my colleagues. That is going to whittle down to no one, except one primary care doctor—we think—on an ICS board, which will be more remote, so we are diluting that local accountability. We vote for those doctors who sit on the CCG boards; we will not have any voting, so you are reducing the numbers who are influencing.

The second point is that we believe that those who sit on ICS boards should be facing the reality of the clinicians they represent. In the medical profession, we have two statutory bodies—the local medical committees and the local negotiating committees—that represent hospital doctors and GPs, and we believe that they should be there because of their motive: they will be clinicians representing clinicians, as opposed to what sometimes happens, which is doctors becoming managers. We know that that just disconnects, and if you have a disconnect, you will not be able to deliver your aims as a health service.

The other notable omission in the Bill, we believe, is the lack of public health presence. There is no place for a public health doctor. Again, I know that it is not in the scope of the Bill, but I think we have to learn from the past year. Public health is vital.

[The Chair]

We should stick to within the scope of the Bill.

Dr Chaand Nagpaul: The scope of the Bill should include a public health doctor who is independent, who should be an advocate. Those of you who were present in the 1990s will know that is exactly what we had. An independent public health voice on ICS boards can provide proper independent advice on population health. These are meant to be population commissioning bodies, in the interests of the public. Those are the things that we think should be changed.

[Dr Davies]

Thank you.

[The Chair]

Would anybody else like to ask a question from the Back Benches before I move to the Front-Bench spokespeople? Okay, that means that the SNP and Labour spokespeople have around 10 minutes. If they could keep it between nine and 10 minutes, that would be appreciated. I call Dr Philippa Whitford.

--- Later in debate ---

[The Chair]

Thank you. We have until 1 pm for this session, so I propose the same timings as for the last one. I call on Back-Bench Members to indicate if they have any questions.

[Dr James Davies]

Q Good afternoon and welcome. I would like to ask all three panellists about the workforce projection elements of the Bill and the adequacy of those, starting with Pat.

Pat Cullen: We have yet to submit our evidence in relation to the Bill—we are currently doing that. It is very clear to us and our members that the Bill does not go far enough on accountability for the workforce. We are very clear that the workforce shortages in nursing are not addressed properly through the Bill.

[The Chair]

Could you speak up a little bit, please? We are finding it quite difficult to hear you.

Pat Cullen: That is not normal, mind you, for a woman from Northern Ireland! I will try again. Principally, our response to the Bill is that the accountability issues do not go far enough in the Bill. We are asking for the Secretary of State for Health and Social Care to not only clearly have full accountability and responsibility for the assessment of workforce planning, but ensure accountability for the delivery of the workforce. It is not just about the assessment. We are all clear about and know about—it has been played out well—the shortages of nursing staff. We had 40,000 vacancies heading into the pandemic. We make up 26% of the workforce. Everywhere you see a patient, you see a nurse, and we need nurses. That is the only way to provide the best care for our patients. We say that the legislator at the highest level must have that accountability and responsibility for the assessment and the delivery of the workforce shortages in nursing.

Professor Helen Stokes-Lampard: The Academy of Medical Royal Colleges has worked very closely with the Government on the development of the Bill, and we have been very grateful for the opportunity to collaborate so far. We have been largely supportive of the direction of travel, but the workforce, in clause 33 particularly, is the one area where we probably still have the greatest concern. We feel that it needs to go further. That builds on exactly what Pat has said. Along with other organisations such as the RCN, we have co-signed an amendment that goes further on that.

We feel that workforce planning needs to be very transparent and collaborative across multiple organisations and agencies, but ultimately owned by the Secretary of State for Health and Social Care. It needs to take on board both the projected supply of workforce already in the pipeline and projected demand. We anticipate that the line representing workforce supply going upwards, and the line representing the demand for need and care climbing even more steeply. There is a gap between them that, at the moment, we cannot quantify. It needs to be quantified and made transparent. Even if the state does not feel it can fund for that gap, we should not be afraid of knowledge. Without knowledge, we run into the risk of repeating historical cycles of boom and bust when it comes to workforce planning. That would be our big plea to you: try to strengthen that, and please do not fear knowledge—it will help us in the end.

Professor Martin Marshall: The Royal College of General Practitioners, as members of the Academy, are completely in line with Helen’s position. There is a marked workforce crisis relating to general practitioners and other health professionals who work in general practice. Without an adequate workforce, it will be very difficult to deliver any of the ambitions of the Bill, so we are absolutely in favour of a much stronger emphasis on workforce. I think workforce planning is an oxymoron and has been for many years in the NHS. This is an opportunity to do something about it.

Health and Care Bill (First sitting)

James Davies Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

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

I want to declare an interest as a medical practitioner, although not commonly practising, and as a member of the British Medical Association.

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

Likewise, I declare an interest as a serving general practitioner in the NHS, a member of the BMA and as a member of the Royal College of General Practitioners.

[The Chair]

Thank you. I am very keen that we continue this session as quickly as possible. We will now go to our witnesses. Good morning and on behalf of the Committee, thank you very much for agreeing to give evidence. Please introduce yourselves for the record.

Dr Navina Evans: Shall I go first?

--- Later in debate ---

[Dr James Davies]

Q I am interested to hear your views on the adequacy of the requirements for workforce projections within the legislation as it stands, in relation to both the NHS workforce and social care, potentially, and how you think the devolved Administrations should be brought in. Dr Navina first, please.

Dr Navina Evans: HEE has recently been given a ministerial commission to lead on developing a strategic framework for future workforces planning. We think that this is really timely in relation to the Bill. What we feel really matters in workforce planning is driving actions and solutions. We need to be able to identify future needs and shortages, and then ensure that the systems develop plans, but these plans need to be able to access all levers at all levels. It is quite a complicated business, but we feel that it is timely for us to pay particular attention to it.

There are a number of areas to consider. We need to look at service redesign; workforce redesign and transformation; employer roles, in terms of retention and recruitment; other supply interventions, such as international recruitment; and then—this is particularly relevant for HEE—future supply through education and training. We then want to pull the system together, through our convening role in HEE, and to have two principal ways of thinking about this: the future needs more and different, in terms of workforces and people; and we want to focus on skills, not necessarily just roles. The really critical point about this commission is that it asks us to ensure that we include the regulated social care workforce in our planning, which is a real step forward. We are looking to ensure that planning should track long-term trends in demand, that we should not be too tied to short-term fiscal cycles, and that we are prioritising supply for the whole health and care workforce.

Danny Mortimer: It is very welcome that the Department has commissioned HEE to do the work that Navina has described, but the NHS Confederation is clear, alongside a whole range of other organisations that work on behalf of the health service in particular, that clause 33 is insufficient for the task that the NHS faces in workforce planning. What it sets out, as Committee members will know, is a requirement for the Secretary of State to describe the process of workforce planning every five years. We have proposed to Parliament that that needs to move from setting out the process to actually setting out the requirements that health and social care have, and to do that much more regularly—we propose every two years.

For us, what is in the Bill is positive, because it is good to have the process described for the first time, but actually, as Dr Evans has just touched on, we need to spell out what the health and social care systems need in the longer term, but also in the immediate term. In some ways, that would mirror the work of the Office for Budget Responsibility in terms of advising the Government and Parliament about likely health and social care spending. We then need a corollary that sets out what is needed to respond to that in terms of people. Health and social care is fundamentally made up of the 3 million people who work in it. We sometimes fixate on the buildings and the technology, but it is fundamentally, in its essence, a people business. We think that that is a pressing issue, not least because of the pressures we face. That is not to say that the Government have not and do not invest in workforce numbers—significant decisions have been made in recent weeks around expanding medical school places, for example. But what we do not have is one coherent, single plan that is presented to the country and particularly to Parliament, which sets out what the NHS and our friends in social care will need to meet the demands that are being placed on us by the population, their health needs and quality of life, and also of course any priorities that the Government might set for social care and health services.

[Dr Davies]

Thank you.

[The Chair]

Thank you. I call Karin Smyth.

--- Later in debate ---

[The Chair]

Thank you. I call Dr James Davies.

[Dr James Davies]

Q Thank you, Mrs Murray. To follow on from the discussion about special interest groups and particular clinicians on the ICS boards, are you saying, therefore, that you do not think the legislation should specify, for instance, that there is a representative for mental health in relation to children, or in relation to social care? How do we explain to the representatives of those very important subject areas that it is down to local flexibility? What happens if local flexibility results in a lack of attention to those issues?

Amanda Pritchard: On a positive, it is great that so many people want a seat on the boards, because I think that actually shows the level of engagement in ICSs. In practice, this is a very organic development from where the NHS has been since 2016, when we first started talking about STPs, as they were known then. This has been very pragmatic, bottom-up and testing as we go, and it now feels as though it is very much with the grain of where the NHS is.

I am not surprised, but I am really pleased, that so many different groups want to be involved. The balance that Mark has just described, which I think the legislation gets right at the moment, is in recognising that to be functional, we have to have the right number of people around the table. At one point we added up how many there would be if you allowed everybody who wanted one a formal seat at the table, and I think Cheshire and Merseyside ended up with 63 people who would be formal members of the board. That is completely unworkable.

It is about trying to find a balance that says, “Let’s be clear what you must have. Let’s use the opportunity that we have through NHSEI to introduce both mandatory guidance—things that people have to do—and guidance that sets out what we would consider to be best practice.” We have been very clear about, for example, the need to have arrangements in place to hear from all those terribly important stakeholders, and indeed for some of the duties, as I have mentioned already, that CCGs continue to carry around engagement with patients and the public, which is the other critical voice that we do not want to lose in any of this. That is the right balance, because it allows us to use some of those tools to keep some safeguards in place to give some clear direction, but it does not try to end up with either a one-size-fits-all solution for ICBs or something that is just unworkable because of the scale.

[Dr Davies]

Thank you.

[The Chair]

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

Health and Care Bill (Second sitting)

James Davies Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

I will come to you if there is time, but I want to move on. Dr Davies.

[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.

--- Later in debate ---

[Karin Smyth]

Q Mr Conradi, could you talk a little about what the branch will be doing in relation to maternity cases and how that is seen to be investigated? You have talked about systems, but will there be a look at all maternity cases in a system? Could you elaborate a little on that? If I may have a second bite, you could also talk a little about discussions now as to where we think the relationship lies with the health service ombudsman and being clear on the roles within this Bill and how that might look in the future.

Keith Conradi: We currently have a maternity programme that investigates about 1,000 cases a year, based on quite specific criteria. At the moment, the Department is deciding what it wants to do with that programme—where its future lies. As far as we know, it will stay with us, certainly until the HSSIB—the health service safety investigations body—starts, but I think a decision has yet to be made on whether it will actually just fall into the work that the HSSIB does, or whether it will do something separately with it, so I am not aware of that at the moment.

On the second point, I am aware that the ombudsman would like the same power to access the statements that we take under safe space. I think that is a major concern. Over the last five years, the ombudsman has been able to investigate any complaint brought against us in our current guise. It has not seen fit to do so, so I would suggest that on the rare occasion that might be necessary, the provision for the High Court to carry out the balancing test and decide whether to disclose information or not is the appropriate way ahead.

[Dr Davies]

Q Mr Trenholm, you referred to the fact that the CQC will be assessing ICSs in future, which was a recommendation of the Health and Social Care Committee. You also referred to oversight of social care provision. Can you clarify whether that is by virtue of your assessment of the ICSs as a whole, or is it through a local authority-targeted assessment that the Health and Social Care Committee has also called for in an Ofsted-style rating?

Ian Trenholm: Can we not call it a CQC-style rating? There are two separate things. The Bill currently contains an explicit provision about providing assurance on how a local authority is discharging its responsibilities in relation to the Care Act. That is important because the way in which care is commissioned is as important for outcomes as the way in which it is delivered. That is one part and that is a discrete piece of work. There is a broader piece of work that we are expecting Government to ask us to bring forward on assurance on ICSs. It will look at the ICS partnership board, how that works, the ICS strategy and so forth. They are two complementary pieces of work, but they are separate, as you describe.

[Dr Whitford]

Q Mr Conradi, you have talked about this coming from Air Accidents Investigation Branch, where the safe space is very tightly protected. That is very much as has been put forward. The key concern is the fact that coroners are listed in the Bill. The ombudsman is already lobbying and many of us are being lobbied to get access to safe space testimony. The Campaign for Freedom of Information is also lobbying for that. Will that not just kill it dead, in that you can compel people to come and give you testimony, but you cannot compel them to talk about all the soft weaknesses within a system that contributed to that tragedy or failure? Should it not be that maybe we need to define more tightly what is protected? All these bodies should be able to investigate as they do now. They are not losing anything because you would have safe space.

Keith Conradi: I totally agree with you. I think it will have a major impact on people’s wish to speak to us. It is not just me that thinks that; the medical unions have said that their members are concerned. The whole idea is that you want people to talk about, as you say, the “soft” things. They tend to be things like the culture of an organisation and the pressures that are brought upon them to do various pieces of work. In the past that has been a bit of an Achilles heel in terms of safety in the NHS. People have often been blamed for these things. They have been disciplined for speaking out—we talked about whistleblowers earlier.

Anything that we can do to bring that information up to an investigation body, which is not about blame and liability, is going to help patient safety in the long run. They will find their way into our final reports—that is the whole idea of getting this information. We want to encourage that as much as possible. I do not think this helps. I think a previous Joint Committee looked at a similar piece of legislation, and that came to exactly the same conclusion. As you say, what is the problem with other bodies such as coroners conducting their own interviews to get the same piece of information or any information they require?

--- Later in debate ---

[The Chair]

Thank you.

[Dr James Davies]

Q First to Councillor Jamieson on the changed procedures during the pandemic for the discharge of patients into social care, do you welcome the embedding of those changes into legislation for the future?

Cllr James Jamieson: Certainly, we are very pleased that we have repealed some of the legislation, which basically made people focus on targets rather than what is best for the patient. Focusing on discharge to assess at hospital led to some at times frankly perverse incentives just to get people out, often into care homes, when the right solution was to assess after they had left hospital, in their normal setting, not in the setting where they were in maximum need. That change has given much better solutions and outcomes for our residents, which is what we want.

[Dr Davies]

Q Very good. Thank you. As a follow-up question to both panellists, could you comment on the benefits arising from the preventive measures in the Bill on the fluoridation of tap water and obesity?

Professor Maggie Rae: Obviously, from my position as president of faculty, I want more emphasis on prevention, so I am very pleased to see that focus on it, but I do not think it is quite enough yet. I think we would all recognise that part of the reason why we seemed to take the biggest hit on covid in terms of deaths and the effects of the virus was the ill health of our population. We are recognised as having one of the most unhealthy populations in Europe now, and that was not always the case. Yes, it is very pleasing to see the measures on obesity, but we need to recognise that most of the influence could come from the very local level.

I am sorry to say to colleagues and this eminent Committee that we could probably spend the whole meeting talking about fluoridation. I recognise the attempt to tackle the problems of oral health. Children’s teeth being extracted under general anaesthetic is a national disgrace; that money is so wasted in the NHS when we desperately need it to be spent on other health matters, and the time it takes for that operation is so dangerous for children. It is good to have this recognised, but I think it will be quite a slow burn, even with the legislation.

Some areas have tried to implement fluoridation. It has taken them years and they still have not succeeded. Could we perhaps persuade people? As well as focusing on fluoridation, could we have just a small investment in other methods to tackle oral health? One that is really effective, which I used myself as DPH, is simple toothbrushes and toothpaste. Sometimes we think public health measures take a long time, but I can guarantee that if that measure were implemented effectively you could see the changes within 12 months and would also end up saving the NHS a lot of money. I work closely with Councillor Jamieson in his role at the LGA and I hope that he would agree with me.

Cllr James Jamieson: I am going to agree with Maggie. I think that that is a general point we would make. Better healthcare does not start in a hospital; it starts in the community and it starts before you are born. It is about prevention, early intervention, public health, good food and all those things. We welcome measures to support that.

On the point about obesity, I would particularly say that although, yes, it is nice to be able to produce advertising, there is so much more we would like to do. This is not necessarily within the scope of the Bill, so I am not suggesting that, but, for instance, in licensing legislation, being able to take account of public health, which at the moment is specifically excluded, as well as being able to do so in planning legislation as regards where fast food places are and so forth, would be immensely helpful. This is a start; it is a small but positive step.

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

Q One of our earlier witnesses touched on the social determinants of health—housing, green spaces, good jobs—being the greatest factor in a person’s healthy life and life expectancy. I am disappointed that there is nothing in the Bill that addresses those fundamental issues. Do you think that there is scope for them to be touched on, as well as in working with local authorities?

Even more remarkable as regards reducing health inequalities is the absence of any detail, duty or provision to tackle alcohol harm and tobacco control, which of course are the greatest factor in determining a person’s life expectancy—and further down the line they have the greatest impact on local authorities’ social care bills. Do you think they should be included in more detail in the Bill, with a duty to reduce health inequalities rather than just having “regard” to reducing them?

Cllr James Jamieson: I think we need to be cognisant of the fact that this is a Bill providing a framework. I completely agree with the comments made about health inequalities, good housing, green space and all those things—absolutely. I am a full advocate of the idea that health is three quarters determined by somebody’s environment and choices, and probably only a quarter by what the NHS does. That is really important. My slight concern is that if we get very prescriptive in legislation, it limits the ability to do the right thing.

The really important thing about this legislation is all the guidance and so forth that will come out of it, and where the funding goes. Our preference is to say, “Try not be too prescriptive in the legislation, but really engage with local government and public health on the guidance that comes out of this legislation.” A real priority has to be better places, better communities, better jobs, less pollution and all those things, but I do not think that that is something for legislation; I think it is very much about getting the guidelines right, and they will be different in different parts of the country. The issues that might be faced in a rural area are very different from those faced in an urban area. I do worry that if legislation is too prescriptive, it hampers rather than helps.

Professor Maggie Rae: Would you mind if I added some comments please, Chair?

--- Later in debate ---

[The Chair]

We will now hear from Eluned Morgan, who is the Minister for Health and Social Services in the Welsh Government. I hope that I have pronounced your name properly. We will also hear from Lyn Summers, head of health and social services central legislation team, and Mari Williams, senior lawyer (health)—both from the Welsh Government. All witnesses are remote, and we have until 5.15 pm for the session.

[Dr James Davies]

Q Minister, would you outline your understanding of how the Bill will impact the people of Wales? I believe the areas to be the UK-wide medicines information system and social care discharge to assess measures, which may well be relevant in border areas, but there may be other points.

Eluned Morgan: Thank you very much for inviting me to give evidence this afternoon. Obviously the Bill mainly relates to England, but I want to say that I understand what the Bill is trying to do and achieve and I am pleased that it represents some moves towards removing market competition from health and care. I am very pleased to say that we have never had that in Wales because we have our system of unitary health authorities.

There are a number of areas of the Bill that impact Wales. I have set out the significant concerns I have in a letter to Minister Argar. I would be very pleased to present the letter if that is helpful to the Committee. To summarise that letter, there are nine areas of the Bill that I think require the legislative consent of the Senedd. I have set out these areas in a legislative consent memorandum, which has been laid before the Senedd. We are currently in a disagreement with the Department of Health and Social Care UK regarding some of the clauses that the Welsh Government consider to fall into the areas that require the legislative consent of the Senedd. There are a few where we both agree that legislative consent is needed.

In response to your question, Dr Davies, the aspects of the Bill will impact Wales are special health authorities; accounts and auditing; clause 78 on hospital patients with care and support needs—that is the one you referred to, I think, with the border issue; clause 85 on a UK-wide medicine information system; clauses 86 to 92 on transfer of functions between arm’s length bodies; clause 120 on international healthcare agreements; clause 123 on regulation of healthcare and associated professions; and clause 127 on food information for consumers. We consider clause 125 on advertising of less healthy food and drink an important point for us. Clause 130 is also really important to us. The power to make consequential provision also falls within the legislative competence of the Senedd. I think that is something that is worth looking at. I am happy to go through some of the detail on those if that would be helpful to you. Should I continue with that, Dr Davies?

[Dr Davies]

Q Is it a fundamental objection to the content of those elements of the Bill or is it a procedural matter?

Eluned Morgan: Interesting. We do not necessarily have an issue with the policy of some of them, but we are very concerned with some aspects of the constitutional shift and power grab that is happening here from the UK Government’s point of view. For example, the provision on arm’s length bodies is going to impact Wales in several ways. The UK Government are suggesting a requirement to consult the devolved Administrations before those powers are exercised. Frankly, that is just not good enough, because that memorandum of understanding, which the UK Government offered to present to alleviate some of our concerns, is a passing thing. It cannot be enforced by law and it does not bind future Governments, so we are very keen to see all the areas that impinge on our powers move from a duty to consult to a duty to get the support of the Senedd. There is a fundamental shift that we would like to see because we feel that our powers are impinged on.

The other point, which is quite interesting in the context of what is happening with Brexit, is that a number of clauses contain powers that enable the UK Secretary of State to make consequential amendments to provisions in a Senedd law. That is absolutely constitutionally unacceptable. It is fascinating when you think that part of the reason for the UK leaving the EU was to remove an outside institution’s ability to legislate in relation to the UK, yet the irony seems to be completely lost on the UK Government when the same consideration is not applied to legislation in the devolved Administrations in areas where it is absolutely clear where the power should lie. Those are the two fundamental issues that I am concerned about.

[Dr Davies]

Can I have one further question?

[The Chair]

Why not?

[Dr Davies]

Q Thank you very much. Minister, we met recently about the NHS in north Wales and you very kindly sent a detailed response. I am very appreciative of that. One of the things we discussed was interoperability —the fact that the health service in a lot of Wales interacts with that in neighbouring parts of England. We have talked today about data sharing in general, and I wonder what your thoughts are about the importance of comparable and interoperable data between England and Wales.

Eluned Morgan: There is clearly merit in having a system where data can be shared. We do not have a fundamental objection in principle to that and we would be very keen to set up systems that can speak to each other. I guess our objection would be where we are forced to share information that we do not necessarily feel should be shared. Why is that information needed and for what purposes? We would have to be very clear on that. It is not an objection in principle. In our discussion, I was very clear that I think it makes perfect sense for us to get those systems to be able to speak to each other. Again, it is more about the constitutional issues that have been thrown up and the UK Government’s ability to work in our NHS system and to gain information that is not theirs to have. If we want to give it, we are more than willing to do that.

[Dr Davies]

Thank you.

[The Chair]

Before I move on, do Ms Williams or Ms Summers want to add anything to the questions that have been asked so far?

Eluned Morgan: I do not think they have got anything to add.

Health and Care Bill

James Davies Excerpts

2nd reading
Wednesday 14th July 2021 Commons Chamber

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

I welcome the Bill, particularly its intention to better integrate health and social care in England. As vice-chair of the all-party parliamentary group on obesity, I am pleased to see the introduction of restrictions on the advertising of high fat, salt and sugar products online, and on television before 9 pm. I would, however, emphasise the need for a level playing field between the two. As a member of the Health and Social Care Committee, I endorse the findings of our inquiry into the preceding White Paper, especially its comments on social care provision and workforce planning. I hope that these matters can be addressed as the Bill, and indeed the year, progresses.

The Bill also provides the opportunity to address some of the disparities in healthcare provision across the United Kingdom. Further to my constructive engagement with colleagues at the Department, I hope that the Minister for Health, my hon. Friend the Member for Charnwood (Edward Argar), will consider four key proposals.

First, we should mandate the collection of an agreed set of UK-wide directly comparable data on NHS performance and outcomes, for clinical and research purposes. I am already engaging with the Office for National Statistics on how that could work in practice, and believe that the Bill could have an important enabling role to play. Secondly, data interoperability must be improved. It is unacceptable that the health service in Wales often cannot communicate in a fit-for-purpose way with services in England, and vice versa. Thirdly, my direct experience of working in the NHS leads me to feel strongly that inspection, safety and audit mechanisms should be introduced at a national level to ensure a minimum standard of care for all British citizens. Those who are managing inferior services must be able to learn lessons from more effectively run areas and, ultimately, be held to account.

Finally, I hope that the Bill can be used to provide people with equal access to and choice of secondary and tertiary healthcare services across the country, regardless of where in Britain they live. My constituent Ian Kightley was diagnosed with cancer in 2015. As a result of his treatment, he developed problems with his vision and required cataract surgery in both eyes. Like so many in north Wales, when he was advised of a two-year waiting list he was forced to pay for private healthcare, which he was able to do only through fundraising. Only in the last week, while working as a GP, I saw patients who had been advised of two-year waits solely for their first out-patient clinic appointments at Glan Clwyd Hospital.

This Bill provides a vital opportunity for us to level up healthcare and ensure that all our constituents can access the best treatment as soon as possible.

Dementia Action Week

James Davies Excerpts

Thursday 27th May 2021 Commons Chamber

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

It is a pleasure to speak in this important debate, which comes at an important time. Last month, dementia overtook covid-19 to reassume its grim title of the leading cause of death in England and Wales. We also know that a quarter of covid deaths have been among those living with dementia. Dementia affects an ever-increasing number of people in the UK, which is presently estimated at 850,000, and it costs our economy £26 billion a year, more than any other disease. Like so many in this Chamber, I have personal family experience of it.

Finding a cure to Alzheimer’s and the other less common types of dementia must be our aim. A cure would be a game-changer for so many. With 88% of people with dementia facing comorbidities, finding a cure would ultimately help to simplify care for hundreds of thousands of older people. To find a cure, clinical trials must be supported. While the 216 dementia trials since 2004 provide valuable information, that number appears insignificant when compared to the 2,900 studies for cancer over the same period. The UK Dementia Research Institute reports that effective treatments and preventions for dementia are within reach. Further progress on existing research provision is therefore essential.

Investment in dementia research comprises just 0.3% of the current costs we face as a result of dementia. In our 2019 manifesto, we pledged to launch a dementia moonshot to find a cure for dementia, doubling research funding and speeding up trials for new treatments. I very much look forward to its implementation as soon as possible. As a former clinical champion for dementia, I recognise that providing a diagnosis to individuals is pivotal to helping to ensure that they receive the necessary support. Early diagnosis is also critical when it comes to ensuring a sufficient cohort for clinical trials.

As part of the ongoing work on social care, will the Minister acknowledge that her Department is considering how to improve diagnosis rates further in all parts of the UK? Will she also comment on the value of technological advances in diagnosis, including the use of apps? Will she confirm that her Department recognises the value of a healthy diet and exercise when it comes to preventing or delaying dementia onset, something very relevant to the debate later today on obesity? As we look beyond the pandemic, which has had such a knock-on effect for those with dementia, I hope Ministers will work to re-energise the fight against dementia in our best efforts to support the estimated 1.6 million people who will live with the disease by 2040.

Covid-19

James Davies Excerpts

Tuesday 25th May 2021 Commons Chamber

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

When does my hon. Friend anticipate that the NHS smartphone app will be enabled to allow those in Wales to demonstrate their covid vaccination status? Further to that, does he expect that other features of the app, such as the ability to book GP appointments, to order prescriptions and to view notes will also be enabled in Wales?

[Nadhim Zahawi]

We are working closely with the Welsh Government to enable the integration of Welsh citizens’ data with the NHS app, NHS.uk, for the purpose of covid status certification, including undertaking the required scoping and impact assessment that will enable us to set out a detailed timeline for the delivery of that integration.