Health and Care Bill (Fourth sitting)

Jo Churchill Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

Right. We have two Ministers now. Jo, did you want to ask something?

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

No, my question was covered earlier. I had assumed that I would be called as a Back Bencher, if you see what I mean, as I am not the lead Minister on this Committee.

[The Chair]

I apologise for that, but I understood that we had decided to share the time between Back Benchers and Front Benchers, and I counted you among the Front Benchers. There we go. Never mind.

[Jo Churchill]

Q I will ask a supplementary. We have spoken about discharge. I have a particular interest in how we develop the system by the use of ICBs and ICPs in order to highlight prevention. Very often, admission is the result of issues before, and as Stephen highlighted and Gerry alluded to, carers and families all take the weight of the stress when somebody is admitted, and when somebody is discharged and needs reablement. What does the Bill do, or what would you like to see in it, to help prevent people falling ill?

Stephen Chandler: The Bill reaffirms and formalises the requirement to plan very carefully for the population at a place level first, and then at a system level. In doing so, it sets up an integrated care partnership with a clear set of objectives, based on the population. Of course, it emphasises the importance of prevention as a way of helping people remain healthy and well for longer.

In Oxfordshire, we have set up our shadow partnership, and one of the areas we are looking at is our out-of-hospital support—particularly how we can avoid the need for hospital admissions. Again—this goes back to a point I made earlier—in doing so, we are looking at how we as a system can contribute individually, and therefore collectively, to reducing crisis and therefore the need for hospital admission. It has changed the tone of the discussion from, “Isn’t that an NHS responsibility, whether primary care or secondary care?” to, “How can we do better for our population?”.

You might say, “Well, hold on. That sounds like a very subtle change.” Let me be clear: some of these subtle changes really do make an impact. Coming back to an earlier question about resources, this also enables us to have the conversation around the prioritisation and impact of those resources. Instead of saying, “Here is the county council’s budget plan and here is the NHS’s”, we can ask how we make best use of that collective resource. The Bill helps by formalising that and providing some additional structures and focus on that.

The Bill is helpful, but it will be interesting to see how it works where, perhaps, systems have not had positive relationships or have had a more adversarial approach. I was really lucky in Somerset, because the emerging ICS there was coterminous with the local authority. It was a single provider. It was perfect in a way. I am in an ICS now where there are three different population groups. We know some ICSs have significantly more.

The opportunity is there to be grasped. This provides a fantastic focus if it can be ensured. In fairness to colleagues, the focus seems to be “start at place and work upwards”, rather than “start at system and work downwards”, in order to make really good differences to people, particularly around hospital admission avoidance. It also gives me, from a local authority point of view, greater leverage to challenge my NHS colleagues around their investment in secondary care and community care resources, because that area has, unfortunately, seen significant reductions over the years.

[Jo Churchill]

Q So you might see a positive outflow, in terms of more investment in community, in order to keep people well?

Stephen Chandler: Absolutely.

[Jo Churchill]

Q Thank you. Gerry?

Gerry Nosowska: Prevention is always undermined by the resources moving into urgent and acute needs. In practice, social workers are not able to do therapeutic, restorative support work that they would be able to if they had the time to spend with people who need that. There is a fundamental resource issue that the Bill does not address directly, but it may help with the potential for pooling resources. Again, people in the community do not care whether it is a health or social care resource. If there is a need emerging that can be responded to, and preventive work can be done, it should happen without health and social care arguing about exactly whose purse it comes out of.

There are some really successful examples of reablement and preventing avoidable hospital admissions. We know it is possible. Scarcity does breed competition rather than collaboration, so that is something to think about. As for what the Bill might also do, the partnership strategy ought to have a very strong preventive element to it, and that needs to be dug down into locally—into particular communities, neighbourhoods and streets. That is where you really need lived experiences. I have a question about the regard that the integrated care board would have to that, and the potential for a wonderful, collaborative partnership strategy around prevention to be disregarded because of an acute need. I was listening to Robert Francis, and I think his suggestion that there be a written explanation to a local community if that happens is very good.

[Edward Argar]

Q Just one question to both of you, if I may. First, thank you for all that you and your members have done and continue to do. I say that as a former council cabinet member for adult social care and health and public health. I know the shadow Minister will share that sentiment. When I was doing that job some years ago and I was not quite so grey, the director of adult social services with whom I worked was a lady called Marian Harrington, who had been working in adult social care for a long time. A key point that she always emphasised to me was the importance of a close working relationship between the NHS locally, social care and the local council, particularly on discharge, but also on the ongoing care of people with multiple needs who were receiving social care. She would always say to me that although the framework was important, equally important were the culture, the behaviours, and trusting relationships between organisations in the framework.

I will turn to Stephen first and then to Gerry. We have sought to be permissive rather than prescriptive in this Bill. Have we struck broadly the right balance, or are there areas where it might need to be tweaked, either in legislation or in guidance?

Stephen Chandler: Your director colleague was absolutely right. I think that you have got the balance right in relation to permissiveness. I worry that the guidance does not prescribe directly how we should develop that culture, but having worked as long as I have, I realise that you cannot prescribe how relationships are formed and how cultures work. You have to create the conditions for success. Some of those conditions are in the Bill. I have talked about some of them in relation to the pooling, the boards and the assurance methodology. What has to be absolutely clear—and I am hearing it clearly, so it is not that I have not heard it—is the importance of seeing this as a vehicle for meaningful change to people’s lives, not a restructuring of health and social care. Rather, this is a vehicle for improving the lives of people in communities and systems, and for allowing health and social care professionals to maximise their individual abilities for that collective good. In a way, there is a duty on me as a leader in the system to create that culture and environment.

You have not gone into the area of assurance, but for me it is really important that when assurance looks at a system, it looks at the leadership and how that leadership translates the freedom, the permissiveness, but also the accountability, clearly. The feedback I am hearing from our members is, “We favour the permissive approach that is taken in this.” We would not say that the tolerance should be changed one way or the other.