Health and Care Bill (Fourth sitting)

Debate between Mary Kelly Foy and Edward Timpson

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Mary Kelly Foy (City of Durham) (Lab)]

Q This is for Andy. It is noted that mental health provision has for far too long been seen as the Cinderella service of the health system. Indeed, there is very little in the Bill specifically around mental health. Given the growing number of people suffering with mental ill health and the shortage of services, is there enough in this Bill to satisfy you that mental health will be given parity of esteem alongside physical health?

Andy Bell: It is difficult to tell; the Bill is largely silent on mental health. If we had a system where there was genuinely equal regard for both mental and physical health, we would not have to worry about that, because we would know that the system would treat mental health fairly and equally, and there would be no disparity in the way it was thought about. Unfortunately, all our experience tells us that that is not what happens within many health systems at different levels, from very local to national, so we would like to see some assurances in the Bill.

From our point of view, that could happen in one of two ways. Legislation only gets you so far, but it could place specific duties on both NHS England and integrated care boards—I am being very careful in specifying integrated care boards here—that they must take action to ensure that mental and physical health are given equal regard in their decision making, particularly on resource allocation. We feel strongly that there needs to be a voice for mental health within integrated care boards. That is highly likely to happen within integrated care partnerships, but within integrated care boards we do not have confidence that mental health will be properly represented at the top table where important decisions about resource allocation are made.

We think that would help. There are no 100% safeguards in legislation, but one positive thing we have seen with the 2012 Act is that a clause at the very top of the Act talked about mental and physical health as one of the key purposes of the NHS, and that has been used positively and helpfully to make the case for parity in health systems up and down the country. A few simple words can sometimes make quite a big difference.

[Edward Timpson]

Q This is a question for Ed, building on the fact that you have, I think, fairly extensive experience of working with local authorities and supporting them on governance and scrutiny. Having direct involvement in NHS decision making on funding and so on is a fairly new role for local authorities, and different ICSs will have different sizes and geography; for instance, mine is Cheshire and Merseyside, which is one of the largest—I think it is three or four times the size of some other ICSs. Over and above being involved in the board, for local authorities in larger ICSs, where the emphasis on place could be lost if they are not more fused into the system, how do you think the Bill could help to ensure that that is the case, so that we get the right balance between their involvement in the decisions, based on their knowledge of their own population, and the wider regional decisions?

Ed Hammond: For me it starts with an understanding of what decisions are best made at system level and what decisions are best made at place level. Certainly, I would imagine one of the first things that ICBs and ICPs would need to do, once established, would be to determine how to set up a system-wide framework for ensuring equality and equity in terms of how its health and care service is delivered, and then determine how and where it is most appropriate that more detailed decisions come to be made at place level. Otherwise, the system simply becomes too unwieldy.

There are risks that those partners sitting at that system level will draw decision making into those spaces, rather than pushing it back out to localities, because it is the simplest, in many ways the most efficient and apparently the most co-ordinated way of doing it, but in practice it will not serve the interests of local accountability or better outcomes. That raises the prospect of certain services being delivered in different ways in different localities, depending on the political priorities of different councils, but that is local democracy—that is local government bringing its understanding of the demographics of the populations it serves into the conversation.

I think this can all be made to work if there is sufficient transparency in the system, so that those within and those outside it understand how decisions are being made, on what subjects, and by whom. When you have that clarity, it becomes easier to unpick what is happening at place level. Are decisions being made at system level that would be more appropriately made at a lower level? Is there consistency across the entire system? What does the geography mean for decision making and commissioning, and these kinds of things? It provides assurance, and it provides everybody with more confidence that decisions are being made properly in the interests of local people.

Going back to the point I made before, that is also why some external local accountability is so important, because effective local external accountability can challenge the system on whether the right decisions are being made at the right level, and whether they reflect and are responsive to what the local needs are. Local scrutiny committees are, at the moment, anchored at place level within local authorities. They are well able to publicly draw in the voice and concerns of the public about those kinds of issues, and transmit them to health and care partners so that there is a clear way for those concerns and issues to be responded to.