Integrated Care

Luciana Berger Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Wollaston]

I thank the hon. Lady, my fellow Committee member, for her input. We on the Committee heard that there is a complex spaghetti of acronyms—STPs, ICPs, ACOs—and nobody knows what they mean. Even those working in the system struggle to keep pace with them and with the changes. We have to keep bringing it back to plain English and why it matters to people and hold our attention there.

The integration of health and social care has been a long-term goal for successive Governments for decades, so we might ask why it is not happening everywhere if we have been striving for it for so long. We saw and heard about many fantastic examples of good integrated care, but they sometimes felt like oases in a desert of inactivity. It is also possible to have an area that does some things very well but others not so well.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I commend the hon. Lady for the way she is making her remarks on our report, which I welcome. I looked closely at the Government’s response, in which they said that they

“remain keen to consider how to build political consensus on the case for reform and funding as part of the development of the NHS”

10-year plan, but we have heard no reference to exactly how any mechanism for reaching such a consensus might be pursued. We have heard a lot of talk about integrated care for many years, but we now find ourselves at a critical moment. The Government are about to launch their 10-year plan, and it must be front and centre of what they put forward.

[Dr Wollaston]

I will respond further to the hon. Lady’s remarks when I comment on legislative change and how we can get legislative change through a hung Parliament. I will also comment on the importance of engaging with the service and why that needs to come bottom-up from the service, and the importance of politicians from across the House listening to the service and being focusing on its message and the message from patients and patient representative groups. I thank her for her constructive input. The Committee has been successful in building consensus about how this should go forward. I hope the Minister has heard that intervention and that he will respond specifically to that point in his closing remarks.

--- Later in debate ---

[Dr Wollaston]

Hon. Members know that a lack of proper pre-legislative scrutiny that responded to concerns expressed led to many of the barriers. We have to go back and address them when they could have been addressed in a more collaborative process during the passage of the Health and Social Care Act 2012. I am thinking of the need to reconsider the legal basis for merging NHS England and NHS Improvement, and how we establish a better statutory basis for the process so that provider partnerships do not always have to go back to separate boards to gain their approval. It is about considering how we address issues such as geographical arrangements so that they make more sense to local communities. The Committee could play a constructive role in a host of areas but—I say this to the Minister—unless proposals are subjected to pre-legislative scrutiny and unless a cross-party consensus is established, proposals are likely to fail.

My final point—other Committee colleagues will probably want to develop it further—is this: what will happen around establishing a legal basis for integrated care providers? For two reasons, the Committee welcomes the change of name from “accountable care organisations” to “integrated care partnerships”. First, the original name confused the debate about Americanisation. The “accountable care organisations” proposed were not the same as those organisations in the States, and the original name caused a great deal of unnecessary anxiety. We do not see the process as Americanisation.

A concern raised with the Committee was that the process will be a vehicle for privatisation. We did not agree. In fact, we thought the opposite: we agreed with the witnesses who told us that the process provided an opportunity to row back from the internal market and away from endless contracting rounds, and move towards much more collaborative working. We would like that change to be properly reinforced within the legal status of health bodies, and are disappointed that the Government have not agreed to say categorically that these bodies would be classed as NHS bodies. When the Minister sums up the debate, I would like him to reflect on whether any form of wording can put the matter beyond doubt and ensure that these health bodies will not be taken over by large, too-big-to-fail private sector organisations.

It is not a concern that groups of GPs might want a leading role in the bodies. The Minister will know that the public concern is more about them being taken over by very large too-big-to-fail private sector organisations. It should be possible to come up with a solution. The Committee heard—the Minister knows this—that those working in the service have the view that the bodies are not likely in practice to be taken over by private sector providers. However, that public concern exists and is a barrier to change. If we can put this matter beyond doubt, we should try to do so.

[Luciana Berger]

I would add a bit of clarification on that point about the size of private organisations that might become involved. My concern is that, irrespective of size—whether private organisations are big or small—the threat of a takeover happening within our NHS has distracted the debate. Anything that would categorically rule it out would be very helpful.

--- Later in debate ---

[Dr Williams]

I thank the hon. Lady for emphasising that point.

My second point is on what the broader health goals of an integrated system should be. The NHS is focused on reducing unplanned hospital admissions. Although that is important—it is especially important because of the financial costs to the service of unplanned hospital admissions—I want to see integrated care providers trying to achieve broader health goals. Success should not be measured by a reduction in secondary care activity alone, although I agree that in many cases the use of unplanned secondary care is a failure of prevention. ICPs will provide healthcare for a population of people. They need to take a population needs-based approach to healthcare, and they need to be prepared to invest outside the traditional medical model of care, including investing in the voluntary and community sector. We know that loneliness, social isolation and bereavement can have a huge impact on health, and we need integrated care not to be integrated medical care, but integrated holistic healthcare. I consider that integrated care providers will have succeeded if resources are focused on improving the health of the members of our population who have the greatest health needs.

Health needs are often not expressed. The inverse care law tells us that those with the greatest needs often have the least access to healthcare. A clever healthcare system does not just react to the people who turn up; it works with communities to identify and address needs within communities. For example, many people with mental health problems simply do not access healthcare, and it is not only their mental health that suffers as a result; their physical and social health suffer, too. On average, people with learning disabilities die 15 years younger than those without. They do not die because of those learning disabilities; they die because they are not accessing healthcare, both preventive and curative. We know about the health issues suffered by people living in poverty and other vulnerable people, including those with substance misuse problems, homeless people, veterans and vulnerable migrants.

Overall, I will consider integrated care to be a success if the share of healthcare expenditure that goes to preventive care, community care and mental health care increases year on year. Also, prevention must be prioritised, and I am pleased it is one of the three named priorities of the new Secretary of State for Health and Social Care. We need prevention at all its levels: better early detection, better immunisation and screening coverage, better prevention of falls, and better prevention of mental health problems, including investment in prevention right at the beginning of life—the first 1,000 days—where it has the greatest impact.

My third test for success is that performance, quality and safety are all maintained within a system that is taking out competition. There is a genuine risk that taking away some of those internal market forces might take away some of the incentives to keep waiting lists and waiting times down and to improve quality. As we integrate care, we need to ensure that we maintain those things.

[Luciana Berger]

I am listening closely to my hon. Friend’s remarkably informed remarks. Taking him back to his second priority, prevention, does he agree that the Minister should be thinking about what he should be doing beyond his own Department? The Minister and his colleagues in the Department of Health will not on their own be able to do what is needed on prevention as well as tackle this country’s mental health crisis and increasing lifestyle-related disease. If we are to address those challenges seriously, it will also be about what happens in our communities, our schools and our workplaces. That comes from local government and is what will ultimately make the difference.

[Dame Cheryl Gillan (in the Chair)]

I remind colleagues that interventions are meant to be short. I hope Members will be able to keep them a little briefer.