Health and Care Bill (Fourth sitting)

Justin Madders Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

I think we had better move on now. I call Justin Madders.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

Q Good afternoon, and thank you for coming today. You will have heard the Prime Minister’s statement on Tuesday. He referred to a White Paper on integration. As the Bill is primarily concerned with integration, perhaps you could save him some time by pointing out the deficiencies in the Bill—in terms of integration—that need to be included.

Nigel Edwards: This took us all somewhat by surprise, I think it is fair to say. Richard may have had a different briefing from the Department of Health and Social Care on yesterday’s announcement. I picked it up on reading the document; it was not pointed out to me. I think I read it slightly differently. It seemed to me that the plan was likely to be a formalisation of all the activities that are currently going on, rather than a new direction of policy, but I am probably the wrong person to be asking about that. If it is not that, it would not be very helpful.

Richard Murray: One of the things the documentation speaks about is the planning of the health and social care workforce. You asked where I think the Bill is deficient. One example is its inability to help with the very poor track record, over quite a long time, in planning the health and social care workforce—hence all the problems that we have with the workforce right now. There is a nod in the White Paper to that. It may only be that the crossover between those two workforces is not the fundamentals of the numbers that go through them.

Otherwise, I really hope that the White Paper is not about further legislative change. It might be about setting out, for example, the outcome measures that would really work for an ICS, meaning that it will cover both critical issues for the NHS and critical issues for health, public health and social care, to make sure that you have that rounded and meaningful measure so you know who is doing well. If it is another round of legislation, I must admit that I would pause before saying whether that is a good idea, with the exception of the workforce issue, which remains the critical factor here.

[Justin Madders]

Anything to add, Nick?

Nick Timmins: The workforce does need to be tackled—it is just a glaring hole in all this. The NHS has plenty of policy at the moment; it has had an eight-year drive towards better integrated care—that is what the Bill is focused on—and a lot of that will not come through legislation, beyond what is in the Bill.

[Justin Madders]

Q Nigel, can I ask you a specific question about tracking where the money is distributed within an ICS, which you referred to earlier? You have already mentioned the Cheshire and Merseyside ICS, which my constituency falls within—what was 12 CCGs moved not so long ago into one massive beast, for want of a better description. If I wanted to hold someone to account on whether the money was distributed on a fair and equal basis consistent with historical distributions, who would I speak to and who would be responsible for that?

Nigel Edwards: Each ICS is supposed to have a chief finance officer—a director of finance—and an accountable officer. That is the starting point. I think the question to ask them would be to what extent they are spending money in a way that reduces health inequalities and improves outcomes in an equitable fashion—I think they would want to do that. One of the things that has very much struck me in my conversations with ICSs—this is very much influenced by local government, which will be a powerful advocate for this, as will primary care networks—is that quite a lot of people will be scrutinising this. The person to ask who is clearly accountable for answering that question is the accountable officer of the ICS.

Of course, ICSs do not have a legal obligation to distribute money below place level. You might not want to do that, because there is a need to be flexible, and sometimes you might want to spend more in a particular area if there is a sudden strategic priority, but over the long term, the expectation is that those accountable officers should be able to demonstrate that they are spending money in ways that relate to the objectively assessed needs of their populations.

[Justin Madders]

Q Thank you. I have a question for all three of you. The Secretary of State is seeking some quite broad powers of direction. What problem do you think he is trying to fix by giving himself those powers?

Nick Timmins: I think that is exactly the right question to ask. What have Ministers not been able to get the NHS to do without the powers of direction that he is seeking? When they were presented, it was as though the NHS was somehow unaccountable when, as I am sure you all know, Ministers can tell the NHS what to do through the mandate. The difference in the current system is that NHS England has to agree that what it is being asked to do is reasonable. If NHS England does not think it is reasonable, resourceful or doable, it can object, and the Minister then has to come to Parliament and explain why he is, in effect, instructing the NHS to do something. A measure comes before you and is subject to a negative resolution. If someone rejects it, it can be debated, so there is a perfectly good mechanism there right now. I think the really, really important question is: what are Ministers not able to get the NHS to do that means that they now feel the need for new powers of direction?

[Justin Madders]

Does anyone wish to add to that?

Nigel Edwards: I have no answer to that question.

Richard Murray: If the reason is not made clear, you end up starting to get worried and suspicious: “Are they trying to direct money towards one part of the country rather than another and overturning the allocation mechanism? Do they want powers to intervene in procurements?” Those are all the things that you would not want them to do which, to be honest, health Ministers generally have not done anyway. Even when they had the powers, they tried desperately not to get involved, because it is extremely poor governance and extremely poor value for money. However, without that explanation of why they want it, the temptation is to start worrying about what they want the power for.

Some of the behaviours could be governed through the framework agreement, or they should be able to be. You have the mandate that sets direction over the short to medium term, but the framework agreement also sets out the way NHS England should work with other parts of the system, so there are other things that you can use within this system. As it stands, and if it stays as it is now, to provide comfort to people, the temptation is to start listing the things that Secretaries of State should not direct—they should not direct allocations to individual parts of the country; they should not interfere in procurement decisions. You end up with quite a long negative list, but I would probably rather have a negative list than no list.

Nigel Edwards: The problem with negative lists, of course, is that you will forget something.

[The Chair]

I had better move on at this stage. I am really sorry, Nigel. Minister?

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[The Chair]

We have time to squeeze in one very quick one, if anyone has something else to ask.

[Justin Madders]

Q Thank you, Chair. Do you see any risks attached to the flexibility the Secretary of State has given himself with the mandates?

Richard Murray: I think a longer-term mandate is a better thing. The idea that each year, sometime between December and March, you can set a different expectation on the NHS is operationally unreal for the system. They cannot do it, so I think we want to get back to something where you set out a clearer medium-term objective for the things you want the NHS to achieve, whether that is reduced waiting times or better health, and allow them to try and work towards it.

Budgets on that basis would also be incredibly helpful—if you are working in the service not knowing what capital you might have two years down the line and what revenue you might have. I think there is a real chance to do that in the spending review. That is a move in the right direction; we just have to make sure that if the budgets are still set on an annual basis, you do not get a diversion between what it is you have been asked and the budget then being suddenly moved on that annual basis. I would strongly encourage the Government to also try and set multi-year settlements for the NHS, as used to be done, so that people can plan at local level.

Nick Timmins: If memory serves me right, the original idea of the mandate was a rolling three-year mandate. You set the objectives of the NHS and what you want it to achieve, and you can have a little review of it each year, but it is clear. I probably should have said that if the money was also planned on the same basis, that would help no end.

[The Chair]

That brings us to the end of our time. I thank our witnesses very much.

Examination of Witnesses

Dame Gill Morgan and Louise Patten gave evidence.

--- Later in debate ---

[Dr Whitford]

Q A brief question to Andy: there has been discussion over recent years about the need for greater preventative public health. Do you think there is enough discussion or enabling of that approach in mental health? Although we may not do it, we all know what we should do to be physically fitter and healthier—how good we are is up to us. But many of the public have no idea how to protect their mental health. Do you think there is enough population and preventative mental health work? And are there ways of strengthening that in the Bill?

Andy Bell: We have hugely underinvested in it, and indeed very poorly appreciated it. What we have seen in recent years, which we hugely welcome, is huge progress on mental health awareness and understanding. That was not there 10 or 15 years ago. It has not been that long since in a debate in the House of Commons the first Member stood up and spoke about their own experience of mental illness; that was hugely powerful, and began quite a significant social movement. However, we do not yet have literacy around that issue, or indeed a real understanding about what we can do to promote the public’s mental health. With the creation of the new Office for Health Improvement and Disparities—I must remember to get the name right—there is an opportunity to make public mental health as important as public physical health. How we translate that to local areas will be really interesting.

When I talk to people working in local public health departments, I see a huge enthusiasm for and interest in how they can better support mental support in the communities they serve. We have seen incredibly creative work from around the country, such as in Leeds and Bristol, from public health teams that are leading the way who understand that the things that determine our mental health are very much about the society and environments we live in—the families we come from, the schools we go to, the amount of income we have, and the homes and neighbourhoods that we live in. There is a growing understanding of that. However, we have not yet put that into practice on a large scale, and indeed the resources available to public health departments to do that are very threadbare. Many have to be very creative in how they do that.

We very much welcomed the promotion and prevention fund set up recently by the Government, which gave funding to local authorities in the 40 most deprived local areas in England for mental health promotion activities. We are really looking forward to seeing what that money is used for, and we very much hope that it will be the beginning of something much bigger. Our worry, in relation to the Bill in particular, is the understanding of prevention, and indeed the understanding of prevention that I read in yesterday’s Command Paper on the health and social care plan. It is still based on physical health, and the idea that public health is about telling people how to live their lives and how they should behave, rather than what really determines our mental health: how much money we have coming into our home, how safe we feel, and our position in society. It is really clear that very often the way that economic and social inequalities affect our mental health also affects our physical health. Very often it is poor psychological wellbeing that leads to later physical health problems, so we really have to start taking public mental health as seriously as any other part of public health.

[Justin Madders]

Q I have just one question for you, Mr Hammond. You obviously have the ICB decisions being made. What, in your understanding of the Bill, would happen if—hopefully this will not happen, but we have to look at every possibility—the chief executive of the ICB was making decisions that the ICP and other partners were not in agreement with, and they effectively lost confidence in him? Is there any mechanism that would be able to deal with that situation?

Ed Hammond: The obvious mechanism is the Secretary of State’s power of intervention. It is all about that referral upwards really to the Secretary of State to act. Ideally, these kinds of things can and should be resolved through dialogue, because the Secretary of State can intervene only so much. One of my worries about the focus in certain elements of the Bill on the new and enhanced powers of the Secretary of State is that it sort of assumes that the Secretary of State will need to have fingers in lots of pies to be aware of where these issues are occurring across England, and be prepared to step in where they are happening, which requires the exercise of a significant watching brief across a wide range of areas in a way that does not currently happen.

Ideally, these kinds of things can and should be thrashed out by the people involved at local level. The Secretary of State can intervene but does that intervention persist if relationships have effectively broken down? What do you do then? You cannot run everything from Whitehall; there has to be some kind of mechanism to rebuild relationships and trust. One would hope that it would not get that bad, but I know of past tensions. There are divergent priorities between local authorities, NHS partners and other partners in respect of health and care issues. The logic of ICPs is that you are aligning those priorities better, but that is not guaranteed.

That is one of the reasons we consider that there should be a role sitting with local health scrutiny committees to escalate matters of particular concern to the Secretary of State, so there is not this assumption that the Secretary of State is exercising a continual watching brief over everything that is going on. There is that formal power of escalation from an external body holding the system to account that can, before that escalation, exert some kind of influence at local level to try to knock heads together and bring some form of agreement in place, so that you are not in a situation where you have a persistent assumption that Whitehall will need to step in in every case where these kinds of issues occur.

[Justin Madders]

Q Thank you. Mr Bell, do you see this Bill helping to achieve parity of esteem for mental health?

Andy Bell: At the moment, it is really impossible to say. I would like to see the Bill achieving parity of esteem for mental health. As I say, the principles of integrated care could certainly enable that to happen, if combined with a lot of other very significant and important activity to shift the culture in the health service, apart from anything else. The lack of specific provisions in the Bill to ensure that parity is taken seriously is a real worry. I think there are still gaps in the Bill that could be very simply addressed and would help to ensure that system leaders, wherever they are—whether they are on integrated care boards or any other three-letter acronym that gets created—realise that their personal responsibility is to bring about parity for mental health.

I think we are at a point now where there is some recognition in most parts of the system that mental health is important, but very often, outside specific mental health services, there is still an assumption that mental health is something other people and other organisations do, and there is not that shared responsibility for it in quite the way that we think would help to move us forward.

[Justin Madders]

Q I have one more question, Mr McCabe. One of the consistent points we have heard from witnesses is that they are not convinced that the provisions in the Bill on workforce are sufficient to deal with the workforce challenges that the NHS faces. Would that be something that you feel is also the case for mental health professionals?

Andy Bell: This is incredibly difficult. We have some very ambitious plans now—the NHS long-term plan ambitions for mental health. There is, quite rightly, an awful lot of money going into that, because we have a very big gap in our ability to meet people’s needs. The only way that is going to succeed is if we have a very significant expansion in the mental health workforce.

We need to remember that that workforce is not just what people think it is. It is obviously nursing and obviously psychiatry, but it is also social work—a lot of really important mental health provision is in local government under social care. We need to think about the importance of advocacy and the importance of peer support, the importance of employment and housing rights workers, who we know make a big difference to people’s lives. There is also the key role of the voluntary sector in providing forms of support that may not come under traditional clinical headings, but none the less make a huge impact in people’s lives. We need to build the workforce.

The Bill gives some steps forward and summary assurances. In some ways, it is not quite the right place to be dealing with this. This is about whether the various parts of the system—the health education system, the NHS itself and its partners in local government—have the resources and the right ways to encourage people to come and work in mental health. It would be great to see the kind of recruitment campaigns we have had for the NHS as a whole to really help bridge that very big gap in the mental health workforce. At the moment, I think the Bill is probably neutral on it. It would be good to see some stronger assurances, at the very least holding the Secretary of State to account for how they are achieving the workforce ambitions set out in the long-term plan and future policies that will have to come.

[Edward Argar]

Q Good afternoon, Ed and Andy. Andy, in my first question, can I pick up on something you said there, before I broaden out to a question to you both? You talked there, quite rightly, about the importance of parity of esteem for mental health. As a local councillor years ago, I saw how important local councils and the NHS working hand in glove on mental health provision is, because if we get one half right but not the other half, it just does not work.

Building on what you have already said about the legislation, what would you identify as the opportunities of the legislation, if properly implemented or interpreted in the right way, for furthering that linkage and that joined-up mental health provision? Obviously, that goes beyond local council services and the NHS. There are a whole wraparound series of services that impact on someone’s mental health. What do you see as the opportunities in the legislation that we either need to draw out further or at least not lose sight of?

Andy Bell: This is about building real, sustainable, long-term partnerships. One of the things I know colleagues in the NHS and local government find very frustrating is that they just find a way of working with each other and then the legislation changes again and they have to start all over, so it is about having a system that actually works and stays working, that builds on the best of what is there already. I think there is some frustration in places where they spent a long time building relationships between clinical commissioning groups and local authority colleagues, sometimes with jointly employed staff, and now they have to start all over again because we are moving to a different thing. That will be immensely frustrating for many folk.

If we take the principle that this is about integrating care and equal partnerships between different players, including the voluntary and community sector, and if we give that time to work, we will enable partnerships to form with a clear voice for people—for example, in the case of mental health, for people living with mental health difficulties—so that decisions are being made with and in partnership with the people who use them rather than remotely by professional experts on their own.

Collaboration is incredibly important too. One thing we really welcome about the Bill is that it is moving us away from a system of competing providers to providers working collaboratively—literally, in providing collaboratives. There is a slight risk that all the power will be vested in one organisation and there will not be that check and balance between commissioner and provider. But some of the early provider collaboratives working in children’s mental health services that we have looked at have made really huge strides really quickly to reduce, for example, the number of children forced to go to hospital outside their local area in a mental health crisis. They have come together, looked at what support is needed for children in a crisis and put community services, in particular, in place to achieve that.

One further thing that will be important is that there is some positive provision in the Bill to ensure that ICBs—I think it is ICBs, yes, it is—have to take into account inequalities in access and outcomes. That is great, but there is not that requirement to pay attention to inequalities in health and to go out and identify which groups of people are experiencing health inequalities and what the system can do to deal with that upstream rather than waiting for people to need formal healthcare. That would be the other part that would really help in the Bill—to build on some of the positive noises and moves in the right direction in collaborating at the level of prevention and on the things that determine our health as well as in the provision of services when things have reached a point where people need care.

--- Later in debate ---

[Dr Whitford]

Q So is there a bit of the Bill you would want to change? If we let you write an amendment, what would you write?

Stephen Chandler: I will come back to you on that. I cannot immediately think of a part.

[Justin Madders]

Q I have a couple of questions for Gerry. Your briefing made it clear that your members had a concern about discharge to assess; a clear majority said they did not support it, although the numbers are quite small. Would you say that is an accurate reflection of your overall membership?

Gerry Nosowska: It is a genuine concern, yes—partly because, as Stephen was saying, it was rolled out very rapidly, at scale, during an unusual and very pressured time. Social workers have often been involved in those transitions, and very well, to advocate and to ensure that the person’s voice is heard and that people do not get lost somewhere in the system or forgotten, but the concerns are around the potential weakening of that social work role.

Not everybody will need that, but I advocate for a social worker being available to anybody who might need that kind of co-ordination, therapeutic support and advocacy at the point of such a major life transition. We want a review of the model, but we also have concerns about just taking out wholesale all the elements around notification of social care and everything that was in the care Act. A lot will hinge on what the statutory guidance says about this. We must make sure we do not lose people in the system, because there is always an incentive to free up a valuable resource in hospital, but our statutory job is to promote wellbeing.

[Justin Madders]

Q You mentioned the review; your briefing said that you had expected one to be undertaken back in March, and it has not been done yet. Do you know why that has happened?

Gerry Nosowska: My understanding was that the discharge to assess was due to be reviewed, but I do not know why there has been a delay on that.

[Justin Madders]

Q Okay. But as far as you are aware, there has not been a review up to now?

Gerry Nosowska: I am not aware of a large-scale, formal review of it, no.

[Justin Madders]

Thank you. That is all I have, Chair.

Stephen Chandler: If I could help, I am aware that the Department of Health and Social Care has undertaken a review of some discharge to assess arrangements. It is not a national review, but I think about eight separate systems have been subject to a review. I have not seen the outcome of it, but a review of a limited capacity has taken place.

[The Chair]

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