Health and Care Bill (Fourth sitting)

Jo Gideon Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

I am really sorry, Karin, but I think we have to move on, because we have about seven minutes left for Back Benchers, and three indicating. Jo Gideon.

[Jo Gideon (Stoke-on-Trent Central) (Con)]

Q We have had a pretty large consensus across a large number of organisations that the Bill is welcome as an enabler. Also, earlier this morning, we had a comment that no Bill has ever changed people’s behaviour. To what extent do you think the Bill will enable people’s behaviour to change, in terms of how partners work together at a local level?

Richard Murray: It will certainly make it easier. You remove some of the unnecessary impediments that have got in people’s way and pushed them into complex workarounds. It creates a structure through ICBs and integrated care providers to bring people together, so in that sense, it enables these things and makes them easier. However, if I am honest, you could still have NHS England and the Department deciding to run everything through ICBs and making them behave an awful lot like NHS bodies of the past. It enables those things, but the legislation by itself cannot prevent some of the older behaviours from living on. That is why implementation and what happens afterwards is critical, to try to ensure that it delivers on the things that I genuinely think it is trying to do. There is a heavy weight from the past of very centralised control that focuses very much on the independent republic of the NHS. That is the cultural issue that the people who will have to implement this will have to work against.

[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.

--- Later in debate ---

[The Chair]

I think I am going to move on. Jo Gideon.

[Jo Gideon]

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

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

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

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

[Edward Timpson]

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

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

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