Health and Care Bill (Eighth sitting)

Justin Madders Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Edward Argar]

It is a pleasure once again to serve under your chairmanship, Ms Elliott. Government amendments 12 and 13 are both technical amendments that clarify the commissioning responsibilities of integrated care boards. Clause 15 introduces proposed new section 3 of the National Health Service Act 2006, which places a duty on integrated care boards to commission a range of non-primary health services. The duty to arrange for the provision of primary care is dealt with elsewhere in the Bill.

In the Bill as introduced, there was no specific reference to medical services. Instead, non-primary medical services were considered to be covered by the broad provisions of new section 3(1)(f) and (g), and primary medical services were dealt with elsewhere in the Bill. Similarly, there was no specific reference to ophthalmic services. Instead, non-primary ophthalmic services were considered to be covered by the broad provisions of new section 3(1)(f) and (g), and primary ophthalmic services were dealt with elsewhere in the Bill.

However, the equivalent duties for clinical commissioning groups specifically reference these medical services and ophthalmic services, so the removal of an express reference to non-primary medical services and ophthalmic services generated some concern, which I hope to reassure the Committee is misplaced. There is no change of policy in this area, but to avoid any potential confusion these amendments put beyond doubt the fact that integrated care boards are responsible for these services, and replicate the current language.

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

We will not oppose the amendments or, indeed, clause 15. I think it is important, as the Minister said, to make it very clear that the relevant provision in clause 15, proposed new section 3(1), on ICBs providing services that they consider necessary, does not mean that they can unilaterally withdraw services. That is the concern that has been raised, and I think it is important that it is on the record that that is not what is intended.

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

It is a pleasure to serve under your chairmanship, Ms Elliott. I seek some clarification. With demand for palliative care set to soar because of our ageing population, I would be very grateful for any assurances that my hon. Friend the Minister can give that the reference in clause 15, in line 30 on page 13, to “after-care” includes palliative care and end-of-life care services.

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[The Chair]

We now come to clause 19, to which 15 amendments have been tabled. Although amendments 77 to 79, 4, 56, and 80 to 82 have not been selected for debate as no member of the Committee has signed them, if any Member wants to move those amendments, would they please indicate?

Clause 19

General Functions

[Justin Madders]

I beg to move amendment 45, in clause 19, page 16, line 2, at end insert—

“(c) make arrangements to ensure that patients can access services within maximum waiting times in accordance with their rights in the NHS Constitution.”

This amendment places a duty on each integrated care board, in the exercise of its functions, to meet maximum waiting time standards.

The amendment would insert in clause 19 a new requirement on integrated care boards, in addition to the many requirements set out in the clause, to ensure that patients could access services within the maximum waiting times as set out in the NHS constitution. I expect the Minister will tell us that those requirements are already set out in the constitution and that the amendment is therefore unnecessary, but if the answer is that that is an effective tool for ensuring compliance, by any account it has failed.

In every aspect of performance, the NHS has gone backwards in recent years and there can be no doubting the strength of connection between that going backwards and the decade of austerity that the NHS has endured. It is more than five years since the 18-week standard has been met, and that has led to the record waiting lists we see now. In case there is any doubt about this, let me put it on the record that waiting lists were already at record levels before the pandemic, and despite all the fanfare from the Prime Minister following the national insurance rise, we still do not have a guarantee that they will go down during this Parliament.

Let us not forget why the last Labour Government introduced the standards. Years of underfunding under the 1979 to 1997 Conservative Government led us to a dark place. People were waiting months—sometimes years—to access treatment, and that was rightly identified as a priority to fix by the last Labour Government, who wanted to let record investment into the NHS, but also wanted to ensure that that investment was targeted and effective so that the NHS could be judged on its performance. As a result, the targets were introduced.

Targets and funding combined proved to be effective, which is why, by the time the Labour party left office, the NHS had record satisfaction levels and waiting times that today’s Secretary of State can only dream of. Little wonder the rhetoric in recent months has increasingly been that of scepticism about the benefit of such targets, culminating in the Secretary of State’s words at the weekend that the targets are, in fact, “nonsense”. Well, I think we can see what is going on. Targets have got hopelessly out of reach and there is no real plan for to how to change that, so the Government seek to undermine and ultimately change—or remove altogether—the targets, so that poor performance is disguised or played down.

That does a disservice to the patients who are waiting months—in some cases, sadly, years—for the treatment that they are entitled to. Most of those people will be in significant pain. All will be unable to live their lives to the extent that they would like. Some may be unable to work or undertake other physical activities. We do not need to go through the full list; we can all understand the impact that waiting for treatment can have on individuals. In many cases, their lives are effectively put on hold. They deserve better. The amendment would make it clear that their rights as patients under the constitution meant something and that the ICBs should be expected to focus on delivering those standards.

[Edward Argar]

I am grateful to the shadow Minister for tabling the amendment and giving us the opportunity to debate it. Of course we understand the importance of reducing waiting times. The Government are committed to increasing activity, tackling backlogs and ensuring that patients can access timely healthcare, backed up by the record investment announced by the Prime Minister and the Chancellor—indeed, some might agree, to a degree copying what the Labour Government did in putting up national insurance.

For instance, to tackle backlogs and drive up activity, the Government are providing £2 billion of elective recovery funding, which is double our previous commitment, and we are working to encourage innovation to help patients to get the care they need. In his remarks, the shadow Minister highlighted funding. I would point out to him the fact that, despite inheriting a note saying “Sorry, there is no more money,” we have continued to increase spending on the NHS.

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The enabling power under which the standing rules regulations are made is being amended by the Bill to apply to ICBs. Amendments to regulations to confer the relevant duties on ICBs will also be made to coincide with the establishment of ICBs. Furthermore, it would not be appropriate to apply a requirement to ICBs in relation to all the waiting times in the NHS constitution, as some may fall, largely or partly, outside their control—for example, services commissioned nationally by NHS England. For those reasons, we cannot support the amendment, and I will try my luck in encouraging the hon. Gentleman to withdraw it.

[Justin Madders]

I am grateful for the Minister’s vain attempt to persuade me to withdraw the amendment, although he rather missed the central thrust of its purpose, which is, of course, to point out that this is not just about funding; it is about focusing that funding. That is why the targets were introduced in the first place.

We believe it is important that ICBs are also given that focus; we could call it an incentive or a prioritisation. They should be keen to be seen to be delivering that. This is such an important part of the NHS—how are we to judge each ICB’s performance if we do not know how they are performing on waiting lists? This is an important area. We think the general tone and the rhetoric from the Government are that waiting targets are not of significance, so this is an opportunity for them to put right some of the stories that go around in respect of that by supporting the amendment. We will press the amendment to a vote in any case because we believe that this is an important matter, and it should be put on the record.

[Karin Smyth]

I will not repeat my comments of the other day with respect to an amendment that suddenly disappeared from the amendment paper without my noticing. The point I was making was that targets do drive behaviour, and we learnt something in that magnificent drive down from the Conservative Government’s target of 18 months to wait on a list, which seemed acceptable to them at the time. The wait is beyond that now for many services, which seems acceptable to the Government now, although it is completely unacceptable to everyone in my constituency.

We must consider the managerial and clinical effort involved in focusing on those waiting lists, which, as I have said previously, is about making contact with all those patients, assessing their condition and seeing how it has ordinarily deteriorated once on the waiting list. Sadly, many people have died while on those waiting lists. That effort is huge, and it will require focus.

The Government are asking us all to pay a bit more towards the health service, and most of us are conscious of the fact that that is needed. We can debate how it is being done, but we should know what it will get us. We should absolutely be clear to our constituents—given that they have suffered so much, particularly during the pandemic—that the previous standards were not acceptable, and were not being met, and that it is completely unacceptable to ask people to pay more without their having any idea of what that will bring, or indeed of the Government’s intent with regard to how long they think it is acceptable for people to be on a waiting list.

It is also hugely onerous on the clinical managerial staff to manage these waiting lists in the way that they are, which is hugely inefficient. This is a really bad sign of the flow through the system; we have bottlenecks throughout. It will come back to haunt the Government and whoever is speaking on their behalf at this time—I have no doubt about that. I say that with sorrow because it is miserable all round. The Government would be wise to make some kind of assessment of what they think is an acceptable time to wait for various treatments, so that would be clear to people. Supporting our amendment would give some indication of good faith, at the very least.

[Justin Madders]

My hon. Friend has described the amendment very well, and it would be good to know the Government’s intentions in respect of waiting lists, because we consider the rhetoric a distraction and a nuisance. It is politically convenient for them to have such headlines. We want to put the amendment to the vote.

Question put, That the amendment be made.

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[The Chair]

That is absolutely fine. I thank the hon. Member for advising the Committee of that.

[Justin Madders]

I beg to move amendment 58, in clause 19, page 17, line 4, at end insert

“through working with innovation and life sciences ecosystems, facilitated by Academic Health Science Networks, to ensure patients and the public have timely access to transformative innovation.”

This amendment would mandate Trusts to work with AHSNs to promote innovation in health services.

Innovation has allowed us to conquer certain diseases and come up with better and more effective treatments for others. It is integral to societal progress and is a major source of inspiration, new opportunities and, indeed, new financial burdens for the NHS. Most importantly, it means improved outcomes for patients. Innovation needs to reach patients if we are to get the full benefit of the many incredibly talented people who make up our academic and research community.

Academic health science networks have an informal role in the NHS, and there is no obligation on any CCG to work with them to ensure that new, innovative medicines are available. There are 15 academic health science networks across England, which were established by NHS England in 2013 to spread innovation at pace and scale, improving health and generating economic growth. Each network has a distinct geography, covering a specific population in each region—it almost sounds like an integrated care system, but there are not quite as many. They are the only bodies that connect to the NHS and the academic organisations, and are catalysts that create the right conditions to facilitate change across health and social care communities with a clear focus, as we believe should be the case, on improving outcomes for patients. We think they are uniquely placed to underline and spread innovation at pace and scale, driving the adoption and spread of innovative ideas and technologies across large populations, but their effectiveness rests on their ability to bring people, resources and organisations together quickly, delivering benefits that could not be achieved if they operated in isolation.

Everything those bodies do is driven by two imperatives: improving health and generating economic growth in our regions. They are the only partnership bodies that bring together all partners across a regional hub economy to improve the health of local communities. They have a remit from NHS England to occupy what is effectively a unique space outside the usual NHS service contracts and performance management structures, enabling them to collaborate to foster important solutions.

Those bodies use local knowledge to harness the influence of partners to drive change and integrate research within health improvements. They are interested in seeing healthcare businesses thrive and grow, creating jobs, bringing investment and seeing the system improve. They have a different focus, but they share the following priorities: promoting economic growth; fostering opportunities for industry to work effectively with the NHS; diffusing innovation; creating the right environment; and supporting collaboration across boundaries to adopt and spread innovation at pace and scale. They improve patient safety by using knowledge, expertise and networks to bring together patients, healthcare staff and partners to determine priorities and to develop and implement solutions. They optimise medicine use—[Interruption.] Perhaps I have predicted what the Minister was about to say?

[Edward Argar]

I am envying the shadow Minister’s breath control as he runs through his list.

[Justin Madders]

I am merely trying to ensure we make good progress today.

Those bodies ensure medication is used to maximum benefit, including safety and making efficient use of NHS resources. They improve quality and reduce variation by spreading best practice—we often talk about the variation among outcomes across different parts of the country. They put research into practice, collaborate on national programmes, and have a unified focus on various initiatives, including the NHS innovation accelerator and patient safety collaborative programme.

The amendment would bake in that good work, some of which I have outlined, by including those bodies within the scope of proposed new section 14Z39 of the National Health Service Act 2006 regarding innovation.

[Karin Smyth]

I rise to support my hon. Friend. We have rightly criticised much of what has happened in the last few years, but we should also remember that some amazing partnerships and networks have developed, including in my area—Bristol, north Somerset and south Gloucestershire—with the universities and others in both primary and secondary care, bringing together clinicians, researchers and so on. They stumbled initially as things were difficult at the beginning, but they have come together very well. They are well regarded—variable but well regarded—and are a useful source of innovation coming together, so I fully echo my hon. Friend’s comments.

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I hope that I have given the Committee some reassurance on the importance and value that we attach to research as a key part our health and care system, and also explained why we think it is right for ICBs to have a duty to promote research on relevant health service matters and to use evidence from such research, without our being over-prescriptive as to how they should do so. I hope that I have offered the shadow Minister, the hon. Member for Ellesmere Port and Neston, some reassurance and words of comfort.

[Justin Madders]

I am grateful for the Minister’s comments. The Opposition would not want to be accused of being over-prescriptive—that is certainly not what we intend. I appreciate what the Minister said about not wanting to limit the role of ICBs and he made a good point about the vaccine roll-out being a pertinent example of how innovation can be of huge benefit. That may be at the forefront of his mind because there is now a vacancy in the Department in the role of Minister for Covid Vaccine Deployment; the Minister may be looking to add to his already extensive portfolio.

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Chris Skidmore (Kingswood) (Con)]

I beg to move amendment 7, in clause 19, page 17, line 7, leave out from beginning to end of line 9 and insert—

“(a) support the conduct of research on matters relevant to the health and care system,

(b) work with universities and other research settings to support the development of the health research workforce and careers, and

(c) promote the use in the health and care system of evidence obtained from research.”

This amendment would require Integrated Care Boards to work with universities to support research in their local health and care systems.

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[Justin Madders]

I am grateful to the Minister for that herculean effort in listing all the powers and responsibilities of ICBs. For a permissive Bill, the fact that it sets out 12 duties suggests that the pendulum has swung a little bit further than the Minister was perhaps prepared to admit on Tuesday. Of course, the number would have been even higher had our amendment been accepted, but there we go; a dozen is still an impressive amount. However, it is really about what that means in practice.

The Minister referred to the duty whereby ICBs are required to promote awareness of the NHS constitution. In the context of the debate that we have just had on NHS waiting lists, it strikes me as similar to the scene—it might be familiar to many Members—at the end of each “Bullseye” episode, when the speedboat that the unlucky contestant had not succeeded in getting was brought out, so as to say, “Look what you could have won!” In this case, it is, “Look what the NHS constitution says about waiting times. By the way, we are not delivering on that for you.” That is the nub of some of the duties—how will they be enforced in practice? The Minister referred to mechanisms for NHS England intervention, although we would have liked that to be further strengthened with specific reference to waiting lists.

I note that in proposed new section 14Z59(4), NHS England has retained the ability to terminate the appointment of an ICB chief executive, but also to direct the chair of the board as to which individual to appoint as their replacement and on what terms. That is quite a strong power. The way I read that, if NHS England decides to get rid of someone, it, and it alone, will decide who will replace them. That really goes against the spirit of what we have been discussing for the last couple of days. Would the Minister be able to allay my fears in that respect, or at least put into context the circumstances in which that clause might operate?

I was interested to hear what the Minister said about proposed new section 14Z47 and ICBs’ ability to offer grants and loans on whatever terms they see fit. It now seems that the “B” in ICB stands for bank, or possibly building society. Obviously, at the moment these bodies do not exist in law and so have no capital resources to draw on to create such grants or loans, but of course that will change in due course. Again, will the Minister advise the Committee in what kind of situations that might be a possibility?

Finally, I draw the Committee’s attention to the powers and responsibilities in proposed new section 14Z52, on health and wellbeing boards’ comments about forward plans. Like much of this, it is a process-driven, tick-box exercise where people have to “take regard” and explain why they are not doing something that everyone else has asked them to do. A whole lot of this raises the question: in a disagreement, what are the levers to get proper accountability and change that the whole of the system, apart from the ICB, wants to see?

[Chris Skidmore]

Although I entirely support clause 19 as an essential ingredient of the Bill that will provide certainty and legal confidence to ICBs, I wish to draw the Minister’s attention again to the duty to promote research. The past year has demonstrated the increased engagement, across all healthcare settings, in research and those activities relating to the pandemic.

Research demonstrates the enormous benefits not only to patients, but to organisations that see improved outcomes, lower mortality rates and increased confidence in care as a result of being research-led organisations. It also shows the staggering gross value added that is produced within the NHS—£2.7 billion in 2018-19, through the National Institute for Health Research clinical research network that supports clinical research activities. For every patient recruited on to a commercial trial between 2016 and 2018, the NHS in England received more than £9,000. When a drug is replaced by a new one—a trial drug—there is another saving of nearly £6,000.

Research not only improves lives; we know it saves lives. I am a passionate advocate for expanding our research and development capacity across society if we are to succeed as global Britain. That is one reason we have that cross-Government target of raising the amount spent on R&D, both public and private, to 2.4% of GDP by 2027.

I want to come back to this idea of the duty to promote research. I recall serving on the Bill Committee for what became the Health and Social Care Act 2012, when the duty to promote research was first written into legislation, with the duty on CCGs. That has now been transferred across in the text for ICBs, in proposed new sections 14Z39 and 14Z40 to the National Health Service Act 2006.

As my hon. Friend the Member for Vale of Clwyd mentioned, the duty to promote may not be strong enough. I do not have an amendment to hand, but I wanted to raise this point more generally so that the Minister and his Bill team might give it some consideration. Given that ICSs are established as the strategic system leaders for the NHS and partner organisations to deliver integrated care and take that whole-systems approach, research will have to be a core element of ICSs’ regional plans if we are to maximise the strengths of the NHS, our world-leading science capability and the opportunities I have spoken about.

I therefore urge the Government to consider whether there might be an opportunity to change the duty to promote into a duty to conduct and resource clinical research during the passage of the Bill. It is important to stress that a duty to promote has to be accompanied by the necessary infrastructure: staffing levels, research capability, digital resources, access to services, efficient trial approval processes, the ability to reliably recruit patients, guidance and dedicated staff time for research. The whole idea of “promotion” is doing a lot of heavy lifting. There might be an opportunity for us to be more detailed in creating a duty to conduct and resource clinical research.

Such a duty—this has been raised with me—would present the opportunity that research brings to highlight clinical inequalities within the NHS. We need to be able to measure research activity; we cannot manage or even promote research activity unless we are able to measure it effectively. With that comes the whole question of clinical auditing—making sure that there is an effective auditing process in place to ensure that research-led activities are able to be effectively measured and therefore effectively managed. I am sure that that will be raised in the other place during the passage of the Bill. I act as a canary in the coalmine to provide the Minister with due warning that I am sure these debates will come up during the passage of the Bill in the other place.

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[Edward Argar]

I am grateful, as ever, to my right hon. Friend the Member for Kingswood for his comments. I hope I can reassure him that the issues he raised, and the issues that he has aired in the Committee today, will continue to be reflected on carefully by officials and Ministers during the passage of the Bill.

I will try to address the specific points raised by the hon. Members for Ellesmere Port and Neston and for Arfon. The hon. Member for Ellesmere Port and Neston touched on the appointment of chief executives and the termination of appointments. That power is broadly akin to the current power that CCGs have, and we are simply moving across the power that NHS England has over CCGs to reflect the new environment of integrated care boards.

[Justin Madders]

I am grateful for the clarification from the Minister, but does that not expose our fear that, really, ICBs are just bigger CCGs?

[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

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[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.

[The Chair]

With this it will be convenient to discuss amendment 83, in clause 20, page 31, line 31, at end insert—

“(3) Where—

(a) in exercising its functions a responsible local authority or integrated care board diverges from an assessment or strategy mentioned in subsection (1), or

(b) in exercising any functions in arranging for the provision of health services in relation to the area of a responsible local authority NHS England diverges from an assessment or strategy mentioned in subsection (2),

that local authority, that integrated care board or (as the case may be) NHS England must—

(a) (i) within 30 days, make a public statement of its divergence from the assessment or strategy, and

(ii) within 60 days, publish its reasons for the divergence, together with any supporting evidence.”

[Justin Madders]

I will talk briefly about amendment 83 which has been grouped with amendment 47.

Amendment 47 focuses on the whole discussion that we have had, and that we will continue to have, around integrated partnerships and what they will be able to do to deliver for their communities. I do not know if “Marmotisation” is a word; if it is, this could be seen as the first step towards that, but we will see how it works in practice. We must be clear, however, that this is a first step. The names of the partners being bandied about shows that this Bill is about the integration of not just health and social care but the whole wider public sector and other partners, and shows, too, that health issues permeate almost every walk of life. This certainly does not, as evidenced by the Prime Minister’s comments last week, constitute a solution to the integration of health and social care.

Putting that aside, there is an opportunity here to do something different. However, for all the froth and grand statements about partnership working we fear we may be looking at giant CCGs with less GP involvement—we have made this point a number of times so I will not labour it. What we are presented with is a reorganisation of the NHS, not a panacea for integration. We have tried a couple of times already to elicit from the Minister what is missing from the Bill in terms of the integration that the Prime Minister believes necessitates a White Paper. I think the Minister might struggle sometimes to understand what exactly is going on in the Prime Minister’s head in relation to this—or indeed anything else that is going on in his head—but we await his response on that with interest.

I would like to make some general points on the relationship between the NHS and local authorities, because that is important. The Bill acknowledges that greater interaction is needed, but the big question is whether it actually delivers that solution. If there is to be a genuine generational shift from thinking of the NHS as dealing with sickness to contributing to overall wellbeing, that will be welcome, although if our amendment on patient outcomes had been accepted that would have been a better start. There have been some discussions around SDPs and ICSs in the Bill, and that gives us hope that there might be something here we can work with.

The need to bring services together and integrate is blindingly obvious, but it is also very hard to do as the following example demonstrates. A patient with a long-term condition such as chronic obstructive pulmonary disease, and with both healthcare and social care needs, has an acute episode and is admitted to hospital and is then discharged back into their home, which unfortunately suffers from a chronic damp problem—something many Members will know about from their constituency casework. The housing provider—a local authority, perhaps, or an arm’s length management organisation or registered social landlord—is doing its best, but it does not have enough resources to get to the root of the problem, so there is a liaison meeting where this case is discussed between the NHS and local councillors. The councillor for the area where the individual is located asks the chief executive of the trust whether it would be a good idea for some of the health budget to be invested in social housing so that people such as this individual would not be readmitted for a problem that is essentially caused by the property they are living in. The chief executive responds by asking why they would throw money away on something like that, even though a more holistic view shows that would be of benefit for everyone in the long run.

That illustrates why we need to work harder on integration, and it is not an isolated incident. As any councillor who has been in post for any number of years will know—if the Minister and I totted up between us how many years we have served, it would probably be quite a lot—sometimes it is difficult to have the level of interaction with the NHS that we would like. As an aside, I might add that children in care meetings or care around the child meetings are incredibly important, but often the GP does not attend because they have many other priorities.

We have talked about this many times, but the vaccine roll-out has been an exemplar of how local government and the NHS can work together. That was a specific task at the time of the national crisis. It is clearly more difficult to repeat that kind of synergy on a day-to-day basis, but it does show what can be done.

In Wales, the Government have a far-reaching strategy around the wellbeing of future generations. They have made a big leap, moving the NHS away from market thinking and focusing on the way it delivers its service to the public. Both Scotland and Wales have accepted the need for that approach, and their integrated joint boards, joint integration boards, health boards and local authorities have all been talking about integration for some time. Of course, they have the sense to make their health boards coterminous with local authority areas. That would have been a very wise move. We have already had some chat about devolved involvement and I am sure that we will return to that.

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I hope my comments give hon. Members a degree of reassurance and, as I have frequently done this afternoon, I will try to tempt Opposition Members not to press their amendments to a Division.

[Justin Madders]

The Minister has made some interesting points. I will have to come back on the reference to “weasel words”. I was a lawyer for a number of years, and when it comes to their use, I think that lawyers are probably second only to Members of Parliament in being able to use them.

There were many occasions when we were negotiating and drafting documents. Once, I wanted something to happen and another person said, “Well, we don’t want to actually make that an absolute commitment, but we intend to do it.” We always ended up with the compromise of reasonable endeavours. Best endeavours was another one. Often that led to one side being slightly disappointed, but that was usually the point of compromise. But that, I would suggest, is actually going further than what is in the current legislation, which is to “have regard”. That really is the nub of this, because we do not think that is enough to give the ICPs the teeth that they need and the strength and leverage that they might need if they are to be truly effective.

The Minister said that if there was a divergence, he would expect an ICB to put forward reasonable explanations as to why it was not going to follow a particular strategy. But that would then lead to the conclusion that if it was not able to do that, it was acting unreasonably, which of course could give rise to judicial review. That, I am sure, is a road that the Minister does not want ICBs and ICPs to go down. I do not think that would be in anyone’s interest, so we are actually, once again, trying to help the Minister out by coming up with a solution that avoids litigation and dispute and gives us confidence that we will not see a repeat of the lack of genuine engagement that we have seen in some areas in the past, but will see a real force, in legislation, to encourage the wider public sector to have real influence on the modelling of health policies and strategies in the future. Therefore we will—with your permission, Ms Elliott —press amendment 47 to a vote.

Question put, That the amendment be made.

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[Edward Argar]

The clause introduces the integrated care partnership known as an ICP, as a joint committee of the integrated care board and local authorities in its geography. It gives the partnership its core function of preparing the integrated care strategy. The ICP was developed with the Local Government Association and NHS partners in recognition of the fact that the system has been calling for two different and important types of integration: integration within and across the NHS to deliver healthcare services within a defined locality, and integration between the NHS and local government and wider partners.

The ICP is intended to bring together health, social care and public health to develop a strategy to address the needs of the area also covered by the integrated care board. If the ICP wants to go further, it can also involve representatives from the wider system where appropriate, such as voluntary and community groups, and social care or housing providers. That will be up to the ICP, and we will welcome locally driven innovation to reflect local circumstances.

When preparing the strategy, the integrated care partnership must take into account the NHS mandate, any guidance from the Secretary of State and any relevant local joint strategic needs assessment. The ICP must also involve the local Healthwatch, as well people who live and work in the area. The strategy will need to look at how local authorities and NHS bodies can work together using arrangements under section 75 of the National Health Service Act 2006.

Local authorities, integrated care boards and NHS England, when providing services in the area, must have regard to the relevant integrated care strategy when exercising their functions, as well as, more locally, any joint strategic needs assessment or joint local health and wellbeing strategies. This will enable more joined-up planning and provision, both within the NHS and in local authorities. As a result, we would expect to see more integration of the services people receive, more efficient and effective commissioning, and closer working between local authorities and the local NHS.

The clause makes it a legal requirement for all ICBs and local authorities to establish an ICP for their area. These partnerships will promote and facilitate integration across health and care throughout England, thereby contributing to delivering on the ambitious aims put forward in the Bill to further integrate health and care systems.

[Justin Madders]

I will not detain the Committee as I have already said most of what I wanted to say. The Minister just talked about the ambitious aims to achieve integration. Obviously, they were not that ambitious; if they had been, we would not need another White Paper.

[Edward Argar]

Even more ambitious!

[Justin Madders]

We can never be too ambitious, can we? I will be interested to see those working practices. As hon. Members can probably gather, we are somewhat sceptical that the ICPs will really be the transformative and influential bodies that we want them to be. I will keep a close eye on what kind of partners end up on them. If we started involving every potential body in the Cheshire and Merseyside one, we would probably need to hire out Anfield to fit everyone in. It might be more entertaining than the football fare on there—we could have a Division on that. We will probably revisit this in future days, weeks and months. We will not oppose the clause but we wish to put on the record where we think its shortcomings are.

Question put and agreed to.

Clause 20 accordingly ordered to stand part of the Bill.

Clause 21

NHS England’s financial responsibilities

Question proposed, That the clause stand part of the Bill.

[The Chair]

With this it will be convenient to discuss clause 22 stand part.

[Edward Argar]

The clause provides for a number of financial responsibilities of NHS England and provides powers for the Secretary of State to direct NHS England in relation to those responsibilities. Clause 22 provides the ability to amend the provision in clause 21 that imposes a duty on NHS England to ensure that its expenditure, together with that of integrated care boards, does not exceed the sums received in a year.

On clause 21, proposed new section 223C of the National Health Service Act 2006 places a duty on NHS England to ensure that in each financial year, the expenditure of NHS England and integrated care boards does not exceed the aggregate amount received by them. It should be noted that that is in the context of the historic settlement for the NHS reached in 2018, which will see its budget rise by £33.9 billion by 2023-24. Proposed new section 223CA simply replicates a provision in the 2006 Act, which enables the Secretary of State to specify the banking facilities that NHS England may use.

Proposed new section 233D of the 2006 Act enables the Secretary of State to give directions to NHS England concerning resource use. Any directions given by the Secretary of State under that proposed new section must be published and laid before Parliament. Proposed new section 223E empowers the Secretary of State to direct that the capital and revenue resource used by NHS England and ICBs for specified matters does not exceed a limit set.

Clause 22 could be commenced at a later date than clause 21. It would expand the duty on NHS England to ensure its own expenditure, as well as that of ICBs and English NHS trusts and foundation trusts, did not exceed the sums received by those bodies in a year. The clause is essential to ensure that achieving financial balance is inclusive of the finance of NHS trusts and foundation trusts. It recognises that NHS England must be mindful of the need to ensure that public money is spent as effectively as possible and in the best interests of the public we serve. However, we recognise that the NHS is moving out of an unprecedented period, so we will not commence the clause until it is ready. The provisions will help to ensure that there is clear accountability for public spending and that the NHS lives within its means.

[Justin Madders]

I will talk briefly about clauses 21 and 22, although with your indulgence, Ms Elliott, I will step over into clauses 23 and 24, because we cannot really look at these points without having some regard to those clauses. I promise I will not repeat the same points when we get to them.

We know that ICBs and NHS trusts will have spending limits, and that in theory they cannot go into deficit in any year, but the combined deficits of trusts before the pandemic was several billion pounds. Foundation trusts are in a slightly different position. Monitor is going—clause 26, which I suspect we will not get to today, goes into that, and it reads quite brutally in isolation—so it needs to be clear in the Bill how performance management and financial oversight will work in its absence. We still have questions about that, particularly how accountability will work with those new systems.

We see in these clauses a basic tension that NHS England will apply totals to systems, but individuals within the systems all have their own duties and responsibilities. We might think it is the ICB plus all the providers that deliver the services required, which are paid for by the ICB, but I am not sure that is how it will work in practice.

If I am correct, an integrated system is not defined in the Bill, so how do we control something that does not exist in law? Where accountability lies is very vague. The terminology used in proposed new section 233M, which is where the Bill tries to constrain aggregate financial spending each year, is:

“Each integrated care board and its partner NHS trusts and NHS foundation trusts”.

That suggests some kind of joint responsibility, but where community health services are provided by Virgin Care, that does not appear within that wording. GPs and their spend are considered outside, even though they are commissioned by the ICBs, so how do their costs fit into this system? There have to be some answers on that.

--- Later in debate ---

[Edward Argar]

I will be relatively brief because I am conscious of the fact that we have agreed to get through quite a few more clauses today, although I will try to address the points that hon. Members have made. One of the key issues at the heart of what I think the shadow Minister, the hon. Member for Ellesmere Port and Neston, was saying is around what happens if an ICB or a foundation trust spends beyond its limit. How does that work? What is the process? I am pleased that this brings some welcome clarity, rather than the fragmentation we sometimes see in accounting cashflow, following the cash processes at the moment.

First and foremost, local systems will be informed of their resource envelope at the start of the year and will be required to agree a plan that matches, or is within, that envelope. Therefore, all will start the year with a plan that sets out what is being delivered and how much funding they will receive to deliver those services. However, if overspends emerge within year, that should initially be resolved within the system by the individual organisation either finding offsetting savings or securing savings elsewhere within that system envelope. Through the financial duties imposed by the Bill, the system is encouraged to be collectively responsible for managing its funding envelope, moving away from what we often see at the moment, which is fragmentation in understanding how the money flows, and each organisation considering itself to a degree in isolation.

If the overspend cannot be managed within the system, NHS England and NHS Improvement can use the powers in the Bill to hold the system to account through mechanisms such as the system oversight framework and providing support via the recovery support programme, as well as more informal support from the local region. Additionally, individual trusts or FTs that are not working collaboratively within the system can be held to account using the provider licence and enforcement options available for breaches. Finally, of course, in extremis the Department of Health and Social Care can provide cash support to NHS trusts and FTs to ensure that services continue to be delivered.

The second concomitant part of the shadow Minister’s question was what action NHS England or the ICB can take in response to financial difficulties. Financial performance will be monitored by both of them, and in the first instance any difficulties will be resolved locally. However, as I have set out, tougher mechanisms or sanctions can be imposed on trusts that are not meeting their reporting and financial accounting obligations under the clauses.

Question put and agreed to.

Clause 21 accordingly ordered to stand part of the Bill.

Clause 22 ordered to stand part of the Bill.

Clause 23

Financial responsibilities of integrated care boards and their partners

[Justin Madders]

I beg to move amendment 53, in clause 23, page 35, line 14, at end insert—

“(5) NHS England must publish guidance on the means by which an integrated care board, NHS trust or NHS foundation trust which believes its capital resource limit or revenue resource limit risks compromising patient safety may object to the limit set.”

This amendment would introduce an objection mechanism when an Integrated Care Board, Trust or Foundation Trust believes its capital resource limit or revenue resource limit risks compromising patient safety.

[The Chair]

With this it will be convenient to discuss the following:

Clause stand part.

Clause 24 stand part.

[Justin Madders]

With this amendment, we are probably having another bash at the debate we have just had to some extent, but we are also making an important point about patient safety.

--- Later in debate ---

[Edward Argar]

Clause 23 provides for NHS England to set overall system financial objectives for ICBs, NHS trusts and NHS foundation trusts, which must operate with a view to achieving these objectives. This includes the ability to set limits on local capital resource use and local revenue resource use for ICBs, NHS trusts and NHS foundation trusts.

Clause 23 removes the sections in the National Health Service Act 2006 relating to financial duties of CCGs and replaces them with new sections setting out the financial responsibilities of ICBs and their partners. Improving population health requires the breaking down of silos. Traditional financial control focused on individual providers and organisations artificially creates barriers and fragmentation that get in the way of high-quality care.

The new approach will help to break down those barriers by enabling NHS England to set joint system financial objectives for ICBs and partner NHS trusts and NHS foundation trusts, which must operate with a view to achieving these objectives. This includes the ability to set limits on local capital resource use and local revenue resource use for ICBs, and for partner NHS trusts and NHS foundation trusts. NHS England can also give directions to ICBs, NHS trusts and NHS foundation trusts on resource apportionment.

I turn to amendment 53, tabled by the hon. Member for Ellesmere Port and Neston. I am grateful to him for tabling it as it gives us an opportunity to air a number of issues. It would require NHS England to produce guidance to set out a process whereby ICBs, NHS trusts or NHS foundation trusts could object to their capital and revenue resource limits. Although I understand the motivation behind the amendment, which is about ensuring that the NHS has sufficient funds to deliver services safely, I do not believe that it is needed. The ability for NHS England to set system limits is important to enable systems to effectively plan their services and it enables NHS England to meet its obligation on delivering system balance and its broader obligation to taxpayers.

The decision to allocate revenue funding to systems is based on a weighted capitation formula, which produces a target allocation or “fair share” for each area, based on a complex assessment of factors such as demography, morbidity, deprivation and the unavoidable cost of providing services in different areas, meaning that systems will get funding linked to their individual needs. NHS trusts and foundation trusts will be represented on ICBs, so they will play a role in deciding how resources will be allocated within the system. They can raise concerns about proposals, including with regard to patient safety, as part of the decision-making process, although we do not consider that these clauses would put patient safety at risk. Capital allocations already include a funding element to address emergency or patient safety needs, based on planning information from systems. The funding element is intended to be used to address any issues that could arise, including in the context of patient safety.

Furthermore, clause 24 futureproofs the ICB financial duties provisions. It provides for some of the provisions in clause 23 to be replaced and is designed to be commenced at a later date. Once ICBs and their partner trusts are deemed ready to take on greater financial accountability, clause 24 can be used to replace clause 23 with a new joint expenditure limit duty on the ICB and its partner trusts. At a time when it is considered appropriate, the clause will require ICBs and their partner NHS trusts and foundation trusts to exercise their functions in a way that ensures their expenditure when taken together does not exceed their income. The intended effect is that each local area is mutually invested in achieving financial control at a system level, meaning that public funds can be spent in a more sustainable, joined-up and effective way. This should enable a nimbler approach to expenditure where needs across the system can be addressed more flexibly and holistically.

Should unexpected needs for funding arise, there is another safeguard in place to allow NHS services to continue operating safely, as the Department can issue cash to NHS trusts and foundation trusts. For example, if emergency support is needed to address patient safety issues, trusts can apply for additional cash funding to safeguard delivery of care. It is for those reasons that I invite the hon. Member for Ellesmere Port and Neston to withdraw his amendment. I commend clauses 23 and 24 to the Committee.

[Justin Madders]

I do not know whether it is too late on a Thursday afternoon, but I did feel like I had wandered into an episode of “Yes Minister” there. I will not press the amendment to a vote, but I will read the transcript of what the Minister has said with some care over the next few days. I am not entirely clear that he has addressed the central points that were made, but we will no doubt return to this at some point anyway. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 23 ordered to stand part of the Bill.

Clause 24 ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Jo Churchill.)