Health and Care Bill (Twenty Second sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Tuesday 2nd November 2021 Public Bill Committees

[Alex Norris]

I share with the Minister the desire for a shift to prevention. My anxiety, from the Government action we have seen over the last decade, is that that is a rhetorical shift rather than a substantial shift in policy, and definitely not a substantial shift in resourcing. Nevertheless, the Minister’s answer on the documentation that NHS England will be asked to publish is a suitable substitute for a provision being on the face of the Bill. On that basis, I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 63

Young carers’ needs assessments following hospitalisation

“In the Children Act 1989, after section 17ZC, insert—

‘17ZCA Young carers’ needs assessments following hospitalisation

(1) An NHS trust or NHS foundation trust must ascertain during hospitalisation whether a patient when discharged will be cared for primarily by a young carer.

(2) Where an NHS trust or NHS foundation trust ascertains that a patient when discharged will be cared for primarily by a young carer then the NHS trust or NHS foundation trust must give the local authority where the patient lives notice that a young carer will require a needs assessment.

(3) The local authority receiving notice under subsection (2) must carry out a needs assessment, and in doing so must—

(a) ascertain whether it is appropriate for the young carer to provide care, and

(b) identify what support or services need to be in place for safe discharge of the patient.

(4) The needs assessment required by subsection (3) must be conducted before the patient is discharged.’”—(Karin Smyth.)

This new clause would ensure that the needs of young carers are assessed before a patient who they care for can be discharged.

Brought up, and read the First time.

[Karin Smyth (Bristol South) (Lab)]

I beg to move, That the clause be read a Second time.

It is a pleasure to see you in the Chair, Mr McCabe. I will not delay the Committee too long on this new clause, but it is an important one to consider. We had a good discussion last week on the needs of carers, although I am not sure we resolved it satisfactorily. Carers do a huge amount of work on behalf of their families. As my hon. Friend the Member for City of Durham so eloquently said, they want to do that work, but many of them essentially keep our services going. Without them, the demands on our services would be so much greater.

[Mr Peter Bone in the Chair]

All of us who have met or who know young carers recognise the particular stresses and strains on them from caring for their relatives. They do astonishing work. Again, as my hon. Friend said, many feel that they are doing it because these are their loved ones; they do not feel like they are carers in many cases, but they are. Often people then do not come forward, if they are not known to the authorities, to make that clear. That is often because of fear of what that might mean for the family set-up they find themselves in.

The new clause draws attention to the needs of young carers, particularly following hospitalisation. It would require trusts and local authorities to be cognisant of who is caring for a person when they are discharged, particularly where young carers are involved. When the issue was first drawn to my attention—particularly the need to highlight the different needs of young carers—I must confess that I thought that these things were routine in good care settings. Obviously, the situation into which someone is being discharged should be fully known and recognised, and their needs met. We had a good discussion about that and we know that that does not happen, but the pressure on young carers is particularly acute. As part of that discussion last week, I almost intervened on the Minister to ask that when we are considering carers more generally, we highlight young carers separately. A hospital needs to know and understand that the person going back home will be in the charge of a young carer, and the local authority needs to make sure that a needs assessment is conducted.

The new clause suggests that should happen before the patient is discharged. Clearly, the Bill is instigating a new process, which will look at post-discharge. We had a good debate about that. As my hon. Friend the Member for Nottingham North said from the Front Bench, doing that assessment differently may be better in the long run—we do not know. In particular, when it comes to young carers taking up that role, it is even more acute that it is recognised in the new arrangements.

I will not move the new clause to a vote, but I would like the Minister to be cognisant of young carers and assure us that these needs will be highlighted to hospital trusts and local authorities in the discharge planning process.

Health and Care Bill (Twelfth sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Thursday 23rd September 2021 Public Bill Committees

[Karin Smyth]

I will not push my amendment to a vote, but I seek responses from the Minister. I want to highlight the issue that we touched on earlier, and I am grateful for his comments, about how end-of-life and palliative care are the responsibilities of these new bodies.

This particularly relates to coming out of the pandemic, but even before the pandemic we had numerous reports from the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying about how people approaching the end of life do not feel supported to make the decisions they are faced with, are not always given an honest prognosis and do not know what options or choices they have. I think the issue of patient choice is very important in this clause, and I feel very strongly about it. I think this could generally be stronger in the Bill, but I will particularly highlight what is in my own amendment.

Amendment 93 would enable dying people to have conversations about what matters most to them, which is the first step to ensuring that they are at the centre of any decision making about their own care and treatment, and it starts the advance care planning process. I have been fortunate in that I have had three children, and I talked through my birth plans and my choices for the whole experience very carefully. It was presented to me as part of the process of giving birth. It does not always go well, as we know—we had a baby loss event today in Parliament, which many of us could not be part of.

The principle of choice at fundamental points in people’s lives as a patient is one we have embedded in the health service. Co-production of care for most incidents that we face is a fundamental part of clinical practice. Only at the point when people are most vulnerable, at the end of life, is the principle of advance care planning and co-production in their choices and prognosis something we are still not prepared to contemplate in the health service. It really is as basic as that. If I can make those choices about when I am giving birth, we should be able to make those choices when we are on the pathway of the end of our lives.

The evidence on advance care planning in order to support people on where and how they die is well made. This is about promoting earlier access to palliative care, communication, reducing conflict, helping families understand what is ahead and making the person less likely to have to go through rushed accident and emergency and distressing journeys into hospital. There is a need to start supporting advance care planning, and I would welcome the Minister’s comments on where the Government now think they are on that.

A key part of this amendment is proposed new paragraph (c), on authorities and new ICBs having

“regard to the needs and preferences recorded in such conversations in making decisions about the procurement of services.”

The full value of advance care planning can be realised only when individual care preferences are reflected in actual treatment decisions. Again, that is about empowering patients, something that I hope Members from across the House support.

[Alex Norris]

This is an important clause and an important amendment. We have said on many occasions that we want a model that promotes collaboration, rather than competition, but in doing so it is important that we do not create 42 closed shops, where a patient has little agency over their care. That will not feel right for those individuals and it risks weakening a culture of the pursuit of excellence and the best standards of care. Therefore, enshrining choice for citizens actually becomes more important in a collaborative system, so it is right that this is being addressed.

The Minister might not have a reply immediately on this, but he might be able to work with one from his officials about reports overnight in Nottingham, where there is no choice now over someone’s cancer care and such care is being “rationed”—that was the word used—because of workforce shortages. That is exceptionally alarming and will lead to some dreadful outcomes for people in our city. I hope there could be a follow-up letter about what is being done to switch those services back on immediately.

Turning back to the Bill, it is right that NHS England would have the power to investigate cases and direct an ICB as to how to rectify failure. It is good that there is a provision whereby investigations can be averted by an undertaking from an ICB to rectify the failure directly; that feels like the right level to start at. I am keen to understand from the Minister how he expects a person to enter the system and enter into that mechanism. Are they likely to be expected to contact NHS England directly to trigger an investigation or will there be a local process at an ICB level first before escalation? It would seem reasonable that we should exhaust local options before escalating to the regulator. If that is so, what prescription will there be, perhaps in guidance, if not in the Bill, for the form that that takes, so that an ICB that is not engaging positively with an individual cannot act like a blocker to elevating that? Perhaps we could consider bringing in a trusted third party at a local level—for example, Healthwatch would very well placed.

We saw in written evidence concerns that the current plans might not go far enough. The National Community Hearing Association said in its evidence:

“Existing rights to patient choice do not go far enough and typically only apply to primary care and consultant-led services. Giving patients more choice and control over their care for non-consultant-led services, especially for long-term conditions such as adult hearing loss, results in better health outcomes and helps tackle health inequalities. We would ask the Committee to press the case for the regulations to be made under this power to expand a patient’s right to choice. Regulations can do this by enabling patients to choose an NHS community provider for their hearing care where clinically appropriate. Currently only 50% of NHS regions in England offer patients this choice, resulting in inequalities in access to care.”

I wonder whether the Minister has considered that and could perhaps give us his reflection on the matter.

--- Later in debate ---

[Alex Norris]

I beg to move amendment 98, page 68, line 22, at end insert—

“(2A) A social care needs assessment must be carried out by the relevant local authority before a patient is discharged from hospital or within 2 weeks of the date of discharge.

(2B) Each integrated care board must agree with all relevant local authorities the process to apply for social care needs assessment in hospital or after discharge, including reporting on any failures to complete required assessments within the required time and any remedies or penalties that would apply in such cases.

(2C) Each integrated care board must ensure that—

(a) arrangements made for the discharge of any patient without a relevant social care assessment are made with due regard to the care needs and welfare of the patient, and

(b) the additional costs borne by a local authority in caring for a patient whilst carrying out social care needs assessments after a patient has been discharged are met in full.

(2D) The Secretary of State must publish an annual report on the effectiveness of assessment of social care needs after hospital discharge, including a figure of how many patients are readmitted within 28 days.”

Clause 78 is the final clause of part 1, but it is an important one, and we hope that the amendment improves it. I will be interested to hear the Minister’s views. This all relates to discharge to assess, where patients are discharged from hospital into the community setting and have their care needs assessed at home, or wherever they have gone from hospital, rather than waiting to be discharged from hospital and having to stay there longer than they clinically need to before the assessment takes place. Importantly, this is something that has been trialled during the pandemic. There is a lot of vulnerability at that point, and this process will matter to a lot of people. It is right that we give it proper consideration, and I think we ought to tighten it up.

I will confess that I have gone back and forth on the principle of discharge to assess, and I have had this conversation with colleagues in recent months. When the Bill was published, my first instinct on this clause, as former local authority social care lead, was a negative one. I felt—I still have this lingering doubt—that there was a real risk of patients essentially being parked in the community to the detriment of their health, with the obligation and cost put on local authorities. Of course, in many cases, some of that will be borne by continued healthcare funding. However, in the end that will become a local authority responsibility for each individual, and there will be a significant risk of them being readmitted shortly afterwards.

Local authorities are already scandalously underfunded to meet the social care needs of their population. Adding some of the most vulnerable people to that list and to the quantum of need that needs to be met will add greater risk, so I have serious reservations. This is not a conceptual debate, and that makes life easier; we have evidence to work with. Through no one’s planning, we have essentially run a de facto pilot scheme during the pandemic, so we know of what we talk. We have a sense of what is going on on the ground, and clause 78 will put it on a permanent footing.

On matters relating to local government, I always fall back on my former colleagues in local government. Their views on this are very clear, and I have had this conversation with them a lot. It always ends up with me saying, “Are you sure?” However, we should not miss their evidence. They say:

“The repeal of legislation related to delayed discharges is good news. This paves the way for the continuation of discharge arrangements which have worked well during the pandemic. The emerging evidence is that going home straight from hospital is what people want.”

I can certainly understand that. They also want greater clarity on the future of this de facto pilot from next month, in the interregnum between when the Bill becomes law and when the funding runs out next month. That is a very reasonable request, and I hope the Minister can respond. The strength of feeling from local government colleagues—our experts by experience—cannot be ignored, and that is why we are seeking to improve rather than prevent this innovation. It does need improving.

Important concerns were raised in the written evidence from Carers UK, which says:

“Under the CC (Delayed Discharges, etc.) Act 2003 a carer’s assessment can be requested and if so, a decision must be made about what services need to be provided to the carer, whether by social services or a consideration by the NHS, to ensure that the ‘patient is safe to discharge’.”

That will be repealed by clause 78. However, they will still be able to fall back on the Care Act 2014, so the carer will get a carer’s assessment under that if they wish. Presumably, that will now take place post-discharge. That is quite a significant change. A great deal of people will become family carers overnight. They might not be conscious that that will happen, but before anybody has made any assessment of their capability to do so, they will quickly find themselves operating as family carers for very vulnerable people immediately post discharge. By the time they get the carer’s assessment, they may well have been struggling to cope for a significant period of time. That could have some dreadful consequences, which is why amendment 98 states that there must be an assessment within two weeks. Obviously, we would want it much more quickly than that, but two weeks is a bare minimum backstop.

I do not think that this is catastrophising. According to research that Carers UK submitted, 26% of carers had not been consulted about discharge before the discharge of the person they care for, and a third were consulted only at the last minute. I do not think that is setting families up to succeed. If the Minister thinks that that will get better as a result of these innovations, we would welcome that, but I would like to understand why he thinks that might be the case and how the situation will look better. Carers UK recommends putting greater responsibility on the integrated care board to have oversight of how discharge to assess is working for the individuals in their care and across their footprint more generally. That is what we have sought to recommend with amendment 98.

The concerns of Carers UK are echoed by the British Association of Social Workers, and social workers, like family carers, have first-hand experience of the trial. The association worries about there being a move away from the fundamental point that the wellbeing principle is uppermost, and its evidence is concerning:

“A survey of Social Workers conducted in December 2020 involved in hospital discharges highlighted that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers felt that the voice of the individual was lost”.

It is quite significant to say not only that skilled staff would not be able to play their normal role in the process but that the individual’s voice would not be there.

The worst manifestation of the provisions in the clause would be for it to be in the system’s interest to move people out of hospital, because that would then be the priority. We need to make sure that that is not the case. The British Association of Social Workers would rather that the clause was not in the Bill at all, but we have not gone that far and have sought to improve it by putting a maximum two-week wait time in the Bill. That would be prudent. The amendment would also centre the integrated care board in the management and oversight of the process. If the integrated care board is to act as a system leader and integrator, surely such a system process—this is the ultimate system process—that touches on the borders between institutions ought to be within its purview. Otherwise, where will the oversight come from? Who will hold the different parts of the system to account?

I hope that the Minister addresses the concerns I have expressed, because this is an important and, in the plainest-speaking sense, risky decision. There are ways to mitigate that and we have suggested a good one in the amendment. I am keen to hear the Minister reflect on that.

[Karin Smyth]

I echo the comments of my hon. Friend the Member for Nottingham North. We discussed this when the Bill hit the Vote Office, because from a system management point of view I saw this change as a positive move. It was necessary in the system to increase the flow out of hospitals, particularly in the pandemic.

We talk about flows out of hospitals, but we are really talking about individuals—our nearest and dearest. During the summer, my husband and I were both responsible for supporting my mother and my mother-in-law in and out of the system, and my mother-in-law was part of the discharge to assess programme. This is not the place for me to rehearse the traumas of becoming, as my hon. Friend so eloquently put it, a family carer overnight and realising, if I did not know already, how little there is outside hospital. My hon. Friend’s point about families suddenly becoming responsible carers overnight is really important. Thousands and thousands of families are finding themselves in that position. Most people would agree about discharging people out of hospital as soon as possible, particularly given the fear of covid and people not being able to go into hospital to see their loved ones. In my mother’s case, she was discharged very quickly, and we went to get her because there was no ambulance service.

The closure of hospitals to visitors adds to the trauma of an acute episode, and people then have to take on that responsibly. People are assessed for care and told in the same sentence, “You’re assessed for care, but there is no care,” and that care takes several weeks to come into play. Among my own family and my in-laws, we have a clinical person in the team, we are fairly articulate, we are knowledgeable about the system and we perhaps know what we are taking on and have the capacity and capability to manage the situation, but it is deeply worrying that people who have no advocate or no other support—even social workers—are told when they are discharged that they need assessed care but there is none. It will take some time for us to understand what has happened to thousands of people who have found themselves in such a difficult position. I am particularly worried about people who have no advocate.

I suspect that the Minister will not accept the suggestions in the amendment now, but I hope he will take advice so that we can understand better—perhaps through an assessment—what has happened to people who have been discharged in the last few months without having support in place. We need to hear about that.

Health and Care Bill (Tenth sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Tuesday 21st September 2021 Public Bill Committees

[Alex Norris]

And of course the Minister, through appropriate delegation, and we are all the better for it. The Minister can quote me on that—but not on a political leaflet, as that would be very challenging for me.

Covid has shown that the public think that the politicians they elect are accountable for the decisions taken in the interests of their health, however they might manifest in ordinary life, so I think the repeal of the duty to promote autonomy, set out in clause 62, probably follows inevitably from that. We want an expert-run health service that works together and follows the best available evidence and science, not one that is unaccountable and diverges from the interests and expectations of the public at large.

That leads me nicely to clause 37. It is possibly a tautology to say that if someone is held responsible for something, they ought to have responsibility for it, as the clause set outs. To put that bluntly, with more than £100 billion of spending—40% of the Government’s revenue budget—going into that area, people will expect political accountability. If NHS England is not seen to be acting in the public interest at the highest possible levels, there ought to be a mechanism, by exception, to correct that. It is the exceptional part that is really important.

That is defined negatively in the clause by what the Secretary of State may not do—for example, hiring or firing an individual, which I think is right, or directing the healthcare of a specific person. I do not think the Secretary of State would want to be in that position with important cases of individuals who are in the public sphere, or have the ability to act outside NICE guidelines on drugs or treatment, as happens in such cases. I do not think that is a good system, hard though it may be when prominent cases come to our attention.

That gives us a common-sense reading of what these clauses provide for the Secretary of State. Yes, the buck stops with the Secretary of State and his political colleagues as a collective if there are major failings in the health service or major failings of Government and of leadership, but the clause does not give Ministers carte blanche to pick and choose—undoubtedly with political pressures in mind—whether to involve themselves in the detailed running of the service. I think that will be covered in clause 38.

A concern raised by the Nuffield Trust in evidence was that there should be a stronger mechanism by which such decisions can be scrutinised. Will the Minister address that? I heard what he said about publication of information about the Secretary of State’s decisions, but why not provide for a parliamentary mechanism by which decisions could be scrutinised? That would ensure public confidence that there is no Executive overreach or direction at a low level of how our healthcare service operates, which I do not think would be at all desirable. I hope that the Minister will address that in his remarks.

[Karin Smyth (Bristol South) (Lab)]

I would like the Committee to take a moment to mourn the loss of the principle of autonomy as a guiding driver of the health service over some 20-plus years. That principle is part not just of the Lansley reforms, but of previous Labour reforms, and indeed of reforms by the Government before that. The idea was that the system would become more efficient and responsive with more autonomous units, rather than a great mass of health authorities, hospitals and systems that are rarely understood by local people, and that the competition of autonomous units would drive financial and service efficiency, for example. This is quite a moment, and I do not think we should just let it pass.

When I was a member of a primary care trust, which I may have shared earlier, our local region had “earned autonomy.” That meant that if we did certain things particularly well—bringing waiting times and waiting lists down, or fulfilling financial balance requirements, for example—the local team, board and chief executive would earn more autonomy to do more. In modern parlance, things became more permissive, and they were trusted to do something.

Health and Care Bill (Seventh sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

I beg to move amendment 34, in schedule 2, page 120, line 26, at end insert—

“(2C) The constitution must require integrated care boards, and any committee or sub-committee of the board, to meet in public and publish all papers and agendas at least 5 working days before each meeting is held.”

This amendment mandates integrated care boards, and their sub-committees including “place based committees” to meet in public and publish all papers and agendas at least five working days before each meeting is held.

It is a pleasure to resume proceedings with you in the Chair, Mrs Murray. This is a resumption of our discussion on schedule 2, which lays out the rules under which integrated care boards must meet. For all the talk of local flexibility, the reality is that the regulations are quite tight in schedule 2; the amendment seeks to tighten them a little more, but not disproportionately so.

The amendment asks for two things: first, that the boards meet in public, and, secondly, that they publish their papers five days in advance. To start with meeting in public, it has been mentioned on a number of occasions that the 42 different integrated care boards are in different states of development. There will be systems that are well advanced and model good behaviours of transparency and accountability, but we have to set regulations to ensure a minimum floor standard, and this is what the amendment does.

For a struggling system, the worst-case scenario, as we have said before, is that it can become a closed shop of leadership appointed centrally by NHS England and the leaders of the big acute trusts, because it is they who have the power and the resources. We cannot legislate to improve the culture of those systems—that is not what legislation does—but we can ensure proper oversight to try to minimise the risk, and meeting in public is a good way to do that. Sunlight is the best disinfectant, as they say, and this will mean that the public have a good sense of what decisions are being taken in their interests.

A key part of that citizen oversight is to know what decisions are being taken and when. Including a provision in the constitution to publish papers with five working days’ notice seems a good way to do that. I would argue that that represents rather basic good governance, so it is a very low bar to clear. We have spoken before about wanting to allow integrated care boards to be able to vary to fit their local circumstances, but I cannot see under what circumstances it would be desirable or relevant to vary the publication of that information. I do not think there are any local circumstances that would call for that. The requirement would mean that members of the public, elected representatives and those who represent staff or anyone with a general interest would understand what is going to be decided and when, and would give them the opportunity to make representations so that the board members are making decisions in the full knowledge of the facts and the views of the broader system.

In the amendment, that requirement also applies to all committees or sub-committees. This matters, because we heard in the evidence sessions that it is almost inevitable that every system will want to establish sub-committees, both thematic—we heard from the system in Gloucestershire about its primary-care themed one, which I thought was a very desirable way to use a sub-committee—or, inevitably, given what we have said about the size of the footprints of some of the integrated care boards, place-based. It is important that the provision applies to those bodies too.

The question matters even more to the integrated care partnership and its status, and I hope the Minister will be able to address it. My reading of clause 20 and proposed new section 116ZA of the Local Government and Public Involvement in Health Act 2007 states that this is a committee of the integrated care board and the local authority. I would argue that that remains an oddity, because the process was pitched to us on the idea that we have an integrated care board that will be the official NHS fund-holding body, but then we have the integrated care partnership that will provide the broader involvement on an equivalent basis, not as a sub-committee. I hope that point can be addressed, but nevertheless it will be important for that body that the public know what is being discussed and when. We will come back to clause 20, but the commitment from the Government that the meetings and papers should be public is a good thing.

Conceptually, the amendment lands the ICB and any sub-committees at about the level of an executive board of a council. That to me feels about right. The Minister may have reflections about circumstances where, by exception, the boards may need to meet in private for certain decisions, as local authorities would do. There are ways to do that for councils, so I do not think it is beyond our wit to do the same for these bodies, too. As a default, the basic principle of public meetings, with papers published five working days in advance, seems sound.

[Karin Smyth (Bristol South) (Lab)]

I offer my support to my hon. Friend and agree with everything he said. There may be a response from the Minister, although I do not know what he will say, but there is some discussion that perhaps the amendment is not necessary, as this already happens and the Bill refers to publishing—but that is not true. There are exemplar trusts and bodies across the country that have a culture of openness, but NHS boards are secretive and protected.

We have numerous examples of whistleblowing and good journalism uncovering the depths of NHS bureaucracy. Boards with which I have dealings, not just locally in Bristol, do a lot out of the public eye, and a culture of not liking scrutiny has evolved over a couple of decades, even though they should be really proud that people are taking an interest. We need to change that culture, and having a reference in the Bill would help.

Trade union colleagues have often come to me to complain about how they are blocked from getting key information about plans for changes. Changes are announced, and management often want to start TUPE discussions without really understanding what is behind the change. The use of freedom of information requests results in variations across the country in who responds and how they respond. That needs to stop.

The default should be to make things public unless there are reasons not to. I was a non-executive director back in the noughties, and was led by a chair who had come from local authorities—a Labour chair, but I do not think that matters. People who were used to chairing in local authorities found it quite peculiar that the NHS wanted to discuss matters in secret. As a board, we made it the case and culture that managers had to say if there was a really clear reason, and on several occasions we challenged why things were not done properly.

The new NHS is not commercial. The Government tell us that we are not quite getting rid of the purchaser-provider split, but we are moving away from competition as the driver of the health service. The confidentiality argument should be disappearing. I hope that the Minister accepts that the very highest standards now need to be set around openness and transparency and need actually to be enforced. All levels of the NHS and all these committees and sub-committees, however we end up organising them, have to be cognisant of the Nolan principles, which should drive all their work.

If a trust is finally forced by a tribunal to disclose information, it should have been provided earlier. There should be consequences. Where there is a bad culture, we need to change it. To reference my hobby-horse, there should be a business case to support every major decision. Later we will discuss my new clause 7, which comes from the pain I have experienced trying to unearth business cases, particularly in wholly owned companies and subsidiaries, to deliver facilities management. I have asked for business cases only to be told, “No, it is confidential.” There should be no need for it to be confidential at all. I do not understand how a business case can be confidential—at best, a few lines might be sensitive, but not a full business case.

That shows that NHS bodies who fear a change think they have something to hide. It is wholly wrong. If a change is proposed, the case for change should be published. We need to know why it is necessary. I would go further; I would publish all details of the tender process and the contract management. If anyone wants to do business with the NHS, which we welcome, they need to be open and transparent. It really is a test of the intention to change course and move to an integrated, collaborative model, because as we exit the market, we need to be make sure that the wellbeing of the public and the patient really comes first in commissioning. As I say, that culture needs to be changed.

To come back to my theme, ICBs need to be the bodies that the public recognise and understand as being where some sort of accountability resides. That means that nothing should be secret. Let us go further: the public has the right to question. That is what we come back to. There has to be a figurehead—ideally an elected figurehead —or non-executive directors who can be truly independent and challenge that secretive culture. I hope the Minister will look favourably on the amendment.

--- Later in debate ---

[Karin Smyth]

I agree, and we will probably all have examples through the primary care networks of practices that were not in old houses but that had perhaps had a LIFT scheme or another new development. In my constituency, the Bridge View Medical practice was able to have a flow through the building and move patients downstairs because it had a large, fairly new building. The pandemic has shown that in an emergency we need to make sure that the community-based estate is brought together in some way. Actually, that applies not just to the health service, but to ex-local authority or even Ministry of Defence or other Government Department estates. The place-based aspect of the Bill should be encouraging people to do that locally. Because estates are not part of it, they will struggle to deliver on the service intent of the Bill.

[Alex Norris]

I am grateful for the opportunity to comment on amendment 17 and the insight that my hon. Friend the Member for Bristol South brings from her long period of working in the NHS. What is at the crux of this point is quite important. We have spoken quite a lot about integrated care and revenue, but the capital component is as important, so I am glad we have the opportunity to discuss it.

I have great affection for the Bulwell Riverside facility in my community, which co-locates two GP surgeries, community services and pharmacy services with local authority neighbourhood services, the local library and youth services. Pre-covid, I and the local councillors would be there every week for an event. Every year, my annual jobs fair is there—it is today, but we are not inside because of covid, so it is out in the marketplace. If any of my constituents are watching, we are there until 2.30 pm.

That joint service centre has driven a culture of integration and collaboration, exactly in the spirit of everything we have been discussing on the Bill. It is a very practical example of integration in practice. It was funded on the LIFT model because, at that point, more than a decade ago, that was the way to get money into the system. The logical consequences on the ground of the legislative direction that we are told is intended here will be more need for this sort of joint service centre model. We need to give that proper consideration.

As my hon. Friend the Member for Bristol South said, this element is one of the few bits of the 2012 Act that is not being removed to take us back to pre-2012 status. Then, primary care trusts could enter into these arrangements locally, whereas their successors, clinical commissioning groups, could not and, at the moment, the successor ICBs cannot either. The amendment would remedy that.

Why is that provision not being added back in? It looks a bit like a wheeze. Originally, PCTs would have had a 40% stake in the arrangements and would have benefited exactly as my hon. Friend said. Now, that stake is owned by community health partnerships. Who owns 100% of community health partnerships? That is the Department of Health and Social Care. It is not that nobody benefits from these arrangements—it is that the Department does, rather than local communities. We are told this Bill is about localisation and devolving resources and powers to local communities, so why on earth is this bit not going back in? It is definitely a point of interest, particularly with existing LIFT models.

On LIFT models, it may be that the Government do not think that they are in vogue now or that they are the right model. I would be interested to hear what other methods the Minister might prefer.

How to get capital back into the system is a significant point. The NHS backlog is now £17 billion, as the bill for austerity becomes due, so we will have to address it by one means or another. If that is not to be done through this system, I am keen to hear from the Minister how it is to be addressed.

Health and Care Bill (Eighth sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to serve with you in the Chair, Ms Elliott. I wish to speak to amendments 28 and 29, and will also briefly address a couple of brief points relating to the clause.

I am grateful for the Minister’s response—it is handy to know in advance the likely arguments against the amendments. I referred to the amendments late on Tuesday afternoon, with regard to private company involvement in integrated care boards. We are heartened to hear what the Minister said about that and look forward to having those conversations. My original notes said that the amendments go a little further and might be a little rich for the Committee’s blood, and that may well be the case, but they are nevertheless important.

As I said the other day, the vast majority—around 70% —of GP services are provided on the general medical services contracting model, between local and national commissioners and a GP or GPs and their practice. A little more than a quarter of services are on the personal medical services terms, which allow greater local flexibility, although I understand that the intention is to phase them out. There is a small but growing number of APMSs, which we are debating. APMSs allow bespoke contracting with private companies, with no obligation for a GP behind them. The Minister mentioned their being time-limited as an asset; I am not sure that that is necessarily true. Of course, there has to be flexibility for commissioners to meet need, but my argument is that this is being misused and is operating as a loophole for private companies to enter the market and cream off profits in a way that I do not think is generally the direction that service users in the NHS want. Colleagues should not think that, because the model currently provides just over 2.5% of contracts, this is in some way small beer. The largest provider of GP services in this country is wholly owned by a US megacorporation and has 500,000 patients on its books. I do not think that is what our constituents want from their national health service in England, and I do not think that is what they expect it to look like either.

Therefore, it is reasonable to use the Bill to try to do something about it, because this will be the model. It will grow at pace unless it is checked, and there are many reasons to tackle the issue. It is not just because I find the model distasteful, which I do. First, such contracts are poor value for money. For a registered patient, the mean payment to an APMS provider is 11% greater than that to a GMS provider. Of course, the Minister made the argument on Tuesday that such practices often serve the hardest cohorts, so perhaps that could account for the difference, but that is not the case either. When patients are weighted according to need, the mean payment is actually 16% greater on APMS contracts—it gets worse. If we read that across the entire patient list across the country, it would be the equivalent of £1.5 billion. That is the risk, if this grows to be the dominant model. Such contracts also provide less satisfactory care, with a 2017 survey of nearly 1 million patients finding that APMS services generated lower levels of satisfaction.

Finally, the contracts are easier to walk away from. Within the NHS, we already know that when it stops working for private providers corporately, they are willing to just walk away from contracts and hand them straight back. I strongly say to the Minister that such arrangements are a distortion of the health service’s founding principles. They are costly, they are of lesser quality and they are less reliable.

Amendment 28 is designed to stop integrated care boards entering or renewing such contacts, and amendment 29 would do the same for NHS England. I fear that the Minister may have slightly catastrophised the impact of that, because if this was accepted today, there would be GP services that could no longer operate tomorrow. For a start, the Bill has an awful long way to go, and I gently say that if there is anxiety about health organisations working in advance and presupposing that this will become law at some point and will be operational in April, I am afraid that the Government started that a very long time ago and have already started to fill places in shadow. I do not think there should be any anxiety about getting prepared in this way, so that there would not be a cliff edge.

I am willing to take the argument that perhaps there is a better and more elegant way of drafting this, and I would happily accept an amendment in lieu, but what I cannot accept is nothing at all. Again, the Minister’s point on Tuesday was very good, because sometimes there will need to be a way to provide flexibility for very bespoke services. I think the example he used was services for street homeless people. Of course, that might be a very different model from that of the GPs on my estate. I would accept that as a principle, but the corporation that has the biggest patient list, at 500,000, is a bricks-and-mortar primary care service in my community. That is not a use of flexibility; it is using that as a loophole.

I do not think that can be right, and I do not think the answer can be that the provision needs to exist and therefore we must open this space for that sort of distortion. We are either saying, “There needs to be flexibility, and here is the best way of having a flexible system. Don’t worry—we’ll make sure it is not misused,” or we are saying that we are happy with such organisations entering the market. The Government need to say which one is their preference.

I will make a point about primary care networks before I move on to clause stand part. Obviously, primary care networks are not in the Bill, but I put quite a lot of stock in them. I think that, locally, they will be a very important unit of organisation of care services in our community. I want them to work, and I am playing an active role in the primary care network in my constituency. I think they have real potential. However, who will lead them if we lose our GP practices to those who do not have an interest in our community? The model will become much more distant and uninterested, based on finances rather than the local population. I believe that would be a very, very bad thing indeed. As I say, the amendments may not offer the best way to close that loophole, but I have not heard a better one, or indeed a desire to close it, so I wish to press the amendments to a Division.

Finally, a couple of quick points on schedule 3, which we do not intend to press to a Division. We have had quite a lot of discussion—the Minister touched on this in the previous stand part debate—about the arrangement of integrated care systems, such as they exist. At the moment, we know that NHS England holds certain responsibilities, the regional teams hold certain responsibilities and CCGs hold certain responsibilities at a local level. It is possible, after these reforms, that CCGs will be replaced by ICBs and the previous arrangements and responsibilities will remain unchanged, with NHS England nationally doing the same things, the regional teams doing the same things and ICBs picking up the responsibilities of their predecessors. I suspect, however, that that is not the intention, so I want to press the Minister a little bit on that.

The explanatory notes, on page 59, paragraph 286, state that the functions relating to medical, dental and ophthalmic primary care sit with NHS England, but that

“The intention is that Integrated Care Boards will hold the majority of these functions…in the future.”

Will the Minister expand on that? Does a “majority” mean two out of the three in a different area? Does he intend—again, we touched on this the other day—that this should all be devolved to the 42 ICBs at the same time, or will there be a sense of when each system is ready to pick up those important services? If so, what criteria will that be based on?

Finally, in case we do not come back to this topic—I do not expect the Minister to have an exhaustive list to hand—what is the thinking on other NHS England national and regional functions? Are they likely to be devolved to ICBs? Can he give an example of what sorts of things might be retained? He mentioned that we would want to retain specialist commissioning at a national level. The final question is this: is it ICB by default unless there is a very good reason why it cannot and therefore it has to be done at a national level, or is it at a national level unless it is proven that ICBs are competent to take it on? The answer may be a bit of a mixed economy, but if that is the case, I am keen to know what criteria he will use, or the Secretary of State will use, to make those decisions.

[Karin Smyth]

I rise to support my hon. Friend the Member for Nottingham North, who made an excellent case for amendments 28 and 29. While on a primary care trust board, I commissioned APMS contracts under a previous magnificent Government—I am not saying this one’s not magnificent, but—because they offered flexibility. Then, as now, they were a sign of a failure of the system and the model of primary care contracting to deliver, particularly in areas of high deprivation. To provide flexibility in Bristol, for example, we had an 8 am to 8 pm service in the city centre to allow better access for people in the city centre, partly to drive down demand on emergency care services, which is a circle that we just keep on going round. Whether they worked or not is a bit of moot point, but it is a model and it is clear that something is needed—I would certainly concede that—so I understand the Government’s difficulty here with having something that is flexible.

I was slightly concerned when the Minister said that the APMS model would be developed further. I wonder if he wants to come back on that. We have to accept that they are problematic at the moment and we would like to see them go because of that. They are now being used as a back door, a very unfortunate one, for large private companies to start hoovering up general practices, which is, yet again, a sign of failure as to why they cannot survive in their environment. If they are going to be developed further, that is something we would like to hear more about. If not now, perhaps the Minister responsible could come back to us on that. Patients are always surprised when they find out that their GP is a private contractor. I accept that this is a difficult area to be completely black and white on. We are certainly in favour of flexibility in developing services in areas of high demand where, for reasons around capital or the type of contract, a GP might enter into partnerships. We know that the workforce is changing rapidly and the model of partnerships is not as attractive and is not recruiting people into the service. It is—not to overuse the word—a crisis.

I am sure we have all been contacted by various bodies representing GPs in our own constituencies. They are fearful not just about the current pressures, but the future attractiveness of primary care. We are not going to get into the future model of the contract today, but I always pity the poor Minister who has to negotiate the contract.

--- Later in debate ---

[Alex Norris]

Amendment 83 builds on my hon. Friend’s argument about creating some balance between the integrated care partnership and the integrated care board, so I will not repeat it. I simply underscore the fact that the ICPs have the money, power and accountability at the moment, but there is a risk that they become a closed shop and not bodies about integration at all.

We are told that integrated care partnerships will be the way in which the broader health and care family and the community will come together as they lead and play a pivotal role. We need a safeguard in the Bill to ensure what we would do if the relationship breaks down. The amendment is a version of what Sir Robert Francis from Healthwatch said about one possible way in an evidence session. I am not prescriptive about this, but I am keen to hear what the Minister might suggest to give us comfort on this. If the ICPs are to function as promised, their plans ought to have some sort of status, so that if the integrated care board chooses to diverge, it must make a public statement that it is going to within 30 days and then publish its reasons with evidence within 60 days.

There is an equivalent provision in NHS England for responsibilities held at a national level. If nothing else, this is basic accountability. It does not restrict any activity, so there is no risk in it. Even if a partnership does not like the decision made or value the reasons given, it cannot remove the chair of the board. Although the constitution has already prevented that, at least we will know what has happened, so the safeguard is quite modest. There is a blizzard of different ways to do it, but I hope that we can have some comfort on ensuring a balance between the partnership and the board, if not at this stage, then by the time we come back on Report.

[Karin Smyth]

Will the Minister share with us what he thinks the difference is between ICPs and health and wellbeing boards?

Health and Care Bill (Sixth sitting)

Debate between Karin Smyth and Alex Norris

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Karin Smyth (Bristol South) (Lab)]

Further to those points about clarity around the exercising of powers, the move to give NHS England that power is entirely sensible. The medical, dental, ophthalmic and pharmaceutical services have had a lower profile in our constituencies over the last few years, as I think we would all agree. It is important to give them the profile they need to be integrated into the system, because they have certainly not been so far.

The evolution of delegating that power to CCGs came late in the day, and remains muddled around the commissioning of primary care services. Therefore, while allowing the delegation of function is entirely sensible, it is not clear, as my hon. Friend the Member for Ellesmere Port and Neston has said, when or how that delegation will be sought. I think the Minister was referring to the involvement of the Secretary of State, but I am not sure in what circumstances the Secretary of State would be doing that, and why this would not be when NHS England, or NHS England regions, decides that the ICB is of a maturity to accept commissioning responsibilities.

One assumes that NHS England believes that at the moment some of those putative organisations are mature enough already; will some of them start doing that on day one, six months in or a year in? How will we know and how will they be resourced to do it? Is it a transfer of power? How NHS England and the local ICB, without representatives of medical, dental, ophthalmic and pharmaceutical bodies, will be taking that on board is all very opaque.

[Alex Norris (Nottingham North) (Lab/Co-op)]

My hon. Friend has a local Mayor, but my community does not. If someone lives in Greater Manchester there is a Mayor, but in other places there may not be. We have a very asymmetric model of local devolution. Does she agree that an asymmetric model of devolution, where some ICBs had certain powers and others did not, would be undesirable and may create more confusion than it solves?

Covid-19

Debate between Karin Smyth and Alex Norris

Wednesday 18th November 2020 Commons Chamber

[Alex Norris]

The hon. Gentleman gives a concerning example that shows how the system is struggling in general. I hope that the Minister will address that issue when she winds up the debate, and I will refer more directly to local authority public health shortly.

I do not want to carp on about what is not working without providing any solutions, so I come armed with three things that Ministers could do at a stroke of their collective pens that would radically improve test and trace in short order. First, we must better use NHS lab capacity to turn tests around. I very much welcome what the Minister said about megalabs, which we have eagerly anticipated for some months. However, there has been a large gap in which we have not had that lab capacity, and we will not have it for some time yet. In the meantime, let us put our NHS lab capacity to use in getting tests turned around.

Secondly, we should give control and resources to local authorities to run the tracing operation. They know our communities and already have a local presence. They are a trusted voice and, crucially, they do this routinely. They do this already. Admittedly, that is on a smaller scale—perhaps related to an outbreak of food poisoning linked to a takeaway—but they do it effectively. Let us support them to do it fully. Thirdly, we must develop a proper package of support for those who need to isolate—that is self-evident. Those three things could be done immediately, and we would all be better off if they were.

We have seen the consequence of failure and of a test and trace system that is struggling, and that is another lockdown. This time last year we were banging on doors in the cold and the rain, and none of us supported the lockdown because we want to keep family members away from each other, or to shut businesses in our community or anybody else’s. However, the failure to break the transmission rate of the virus leads us there.

There are two important things that I wish the Government would communicate more. This is not a choice between lockdown and the economy; it is not a choice between lockdown and non-covid healthcare treatment in the NHS. We must have the lockdown for those purposes, and the longer we delay putting restrictions in place, the worse are the long-term impacts on our economy. If we do not introduce regulations to reduce the transmission of the virus, the greater are the pressures on our hospitals, and the less likely they are to be able do other treatments. Those things are not in tension; they are very much complementary.

The failures of test and trace may have led us to a lockdown, but that lockdown buys us time to sort out problems in the system. We must see progress. Lockdowns alone will not tackle or eradicate the virus, but they buy us time to put in place the things that do. We have now had two weeks of lockdown, but we have not heard about what is improving in the test and trace system, or what will be better, including in the next two weeks. Ministers really need to say this today, so we can be sure and confident that the time is being used wisely. Otherwise, when we leave lockdown, this will all recur again, something that none of us wants.

We are all very wary of Christmas. Depending on which newspaper Members read, they may have woken up yet again to see that the Government’s plans, this time regarding yuletide festivities, had been briefed out to national newspapers. Putting aside the discourtesy to the Speaker and Deputy Speakers, to all of us and to this place in general, that is all well and good, but those plans are only going to be feasible if the right efforts are put in place now and this time is used wisely.

It also ought to be stated that this lockdown is longer and more painful than it needed to be because, once again, the Government acted too slowly. The scientists told them they needed to lock down, as did we, but for two weeks the Prime Minister disregarded reality, which meant that the situation worsened. That has meant that the lockdown will be longer and harder, and also meant that we lost the benefits of the school holidays. These are mistakes that cannot be repeated in the future.

As we exit lockdown, the Government need to be honest with the British people—not in off-the-record briefings to mates in the media, but to the British people—about what will come next, both at Christmas and in the return to a tiered system. I know from our experience in Nottingham that trying to negotiate restrictions was painful, even when we wanted them at the beginning of October as our infection rates increased precipitously. We could not get the initial restrictions we wanted, because the Government were moving to the tiered system and it did not fit their timeline. We then managed to get into the tiered system at tier 2; the next day, the Government said that they wanted us to move into tier 3 and were going to call us, which they did not for a further week. Eventually, we had the painful negotiations about what that actually meant for Nottingham: we brought those restrictions in on the Friday, and by the Saturday, the national lockdown had leaked out. The system has not worked for Nottingham, so we need to know that in any return to a tiered system, the Government are going to work much more quickly and in a more agile manner. Every day wasted is a day when the virus thrives, so we need to be better upon exit.

Turning to the vaccine, we strongly welcome the Government’s efforts in this area: they were right to pre-order doses across a wide portfolio, and they were also right to back British. With our excellent research and our proud record in this area, we should be in the vanguard of it, and patriotic about our efforts to tackle this global issue. Last week, I responded on behalf of the Opposition in an excellent Westminster Hall debate on the covid-19 vaccine, secured by the hon. Member for North Herefordshire (Bill Wiggin), the day after the news broke that the Pfizer-BioNTech vaccine had achieved success in a phase 3 study. Since then, we have heard similarly positive news about the NIH-Moderna vaccine candidate, which is likely to be followed by other candidates, whether that of the University of Oxford and AstraZeneca, the candidate referenced by the Minister, or candidates developed elsewhere. I understand that overnight, there have been further promising developments for a Chinese candidate.

During that debate, colleagues and I raised the challenges and considerations that need to be addressed to make sure that this is handled and executed well. I will not repeat those contributions in the level of detail we went into then—they are on the record in Hansard for people to read. However, the theme was that we cannot repeat the slowness or logistical challenges that we saw early in the pandemic with regard to the procurement of personal protective equipment and testing: no Nottingham people being sent to Llandudno or Inverness for their healthcare this time, please, Minister.

As we have done throughout the pandemic, we on the Opposition Benches will work constructively with the Government to support viable vaccines being secured, ensure the right groups are being prioritised, develop an effective delivery programme, counter vaccine hesitancy—that is critical—and continue to support these efforts globally. A failure on any of those points will undermine the whole process, so it is absolutely crucial that we come together, and I am sure that Ministers will welcome that.

However, I want to briefly reference a point that my hon. Friend the Member for Bristol South (Karin Smyth) made regarding the NAO report. Again, we understand—as that report did—that the Government were having to do things that would normally take 18 months’ worth of planning in hours and days, and that comes with some efficiency trade-offs. However, we did not hear clearly enough in the Minister’s opening statement a sense that that has been reflected upon, and we did not hear what will be different in future to make sure those mistakes are not repeated.

[Karin Smyth]

I appreciate my hon. Friend having picked up on the point I made. The Minister very carefully read out a statement in reply to my question about the Government’s response to the NAO report. I am concerned that she was saying that the Government stand by what they did in that period, and do not think that the way in which those contracts and large procurement processes were handled was a problem. It may be that the Minister wants to correct the record, but if that is the case, does my hon. Friend agree that that is deeply worrying?

[Alex Norris]

I heard the point that the test had been clear that nothing wrong had been done, which, frankly, is a very low bar. I do not think anybody would say that there was nothing that happened in the early procurement phases that we would not perhaps want to change or do better later. I hope that the Paymaster General in winding up might reflect on that.

Perhaps this is the best place to say that the announcement on long covid will be very much welcomed by a lot of people, including my good friend Jo Platt who has been campaigning on this for many months, as well as living with her long covid. This is a story for lots of people up and down the country, across all our constituencies, who are living with the after-effects of this horrible virus over and over again. The act of knowing that they are being heard, as well as the 40 clinics, will be a real tonic to a great number of people, so we very much welcome that.

I turn to inequalities. At the beginning of the pandemic, we talked about the virus being a great leveller, not distinguishing between us depending on our lives, our jobs and our postcodes, but nine months on we know that to be patently untrue. Sixty per cent. of those who died were living with disabilities. Those of Bangladeshi heritage are twice as likely to die as those who are white British. Those of Chinese, Indian, Pakistani and black Caribbean ethnicities are 10% to 15% more likely to die than I am. Mortality rates in the most deprived communities are more than twice those of the least deprived communities. This pandemic has shone a light on our inequalities, whether that means the inequality in work, in housing or in income, and these inequalities have had tragic consequences for some and, in the aggregate, are catastrophic for all of us.

When we beat this virus, which together we will, what comes out of it must be a fair settlement that recognises these inequalities as bad and tackles them head-on. That is why it is already concerning to see again—of course, leaked to national newspapers—that the overseas aid budget is the first on the chopping block. In 2010, the Government chose to target those who had the least to pay for a crisis that they did not cause, and these reports are a sign that maybe this is the plan again. We will not let them repeat this in 2020. It simply would be hugely unjust.

Before I finish, I would like to take this opportunity to thank our incredible NHS and social care staff for all they have done for us. They are truly the best of Britain. Similarly, the pandemic has revealed the key workers all over our communities and all over our economy, so this week, during Respect for Shopworkers Week, I would like to say a special thank you to those working in our shops, keeping us fed, but still facing rising violence and abuse every day. The Government should take better action to protect you—the Government could, of course, adopt my private Member’s Bill and I encourage them to do so—but whether it is that or through another mechanism, we will fight for you until they do.

In conclusion, now more than ever we must stand together as a country, as families and as communities, and show once again that at a moment of national crisis, the British people always rise to the challenge, support those who need it and pull together. That involves not only recognising successes, but assertively tackling the failures that have held us back during the pandemic. If we address these, we will beat this virus.