Integrated Care

Paul Williams Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I thank the hon. Member for Totnes (Dr Wollaston) for securing this debate and for her outstanding leadership of the Health and Social Care Committee. As a GP and a public health doctor, I have a lot of experience of care that has not been adequately integrated. Too many times, I have seen patients repeat their story again and again to different health and care professionals. Too many times, I have seen doctors, nurses, managers and secretaries waste time searching for information that has not been passed from one part of the system to another. Too many times, I have seen dedicated community nurses, social workers, GPs and therapists all providing care that either overlaps with or contradicts care provided by other health workers.

Integrated care, as the Committee has acknowledged, is a very laudable aim, and the Government have some credible plans on delivering more integrated care. I will use my speech to focus on where those plans need to be strengthened. I will talk about resource, about what success should look like, a little bit about legislation and governance, about keeping the NHS as a public sector organisation, and about leadership.

First, integrated care needs to be properly resourced. The new care models pilots have had significant resource to facilitate change, as the hon. Lady indicated, and that may be a key factor in any reported success. Greater Manchester has also had significant investment of extra funding. Can the Minster assure us that, as other areas move towards integration, we will not see what usually happens: the pilots get extra resources and then the roll-out fails because of a lack of extra resource?

[Dr Whitford]

I am glad that the hon. Gentleman has highlighted that problem, which we have been seeing for literally decades. Early adopters are well resourced and well supported and have the ear of the health board or the Government, but during roll-out, all the people who did not have that experience are told to do it out of existing budgets, and it fails.

[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.

[Dr Williams]

I thank my hon. Friend for her informed comments. I agree with her. We need a cross-governmental approach, particularly for children. There is a glaring absence of a cross-governmental strategy that would enable us to focus on all the things that have an impact on children.

The third area I want to mention is legislation. Under current rules, clinical commissioning groups will remain the statutory accountable bodies, even as the relationship between commissioners and providers starts to evaporate. At the moment, STPs, where the providers and commissioners are getting together, are making decisions—often behind closed doors—which are then rubber-stamped by the accountable bodies, which are the CCGs. That does not feel to me like particularly good governance. Legislation needs to follow the new provision arrangements.

We might also need to consider legislation to improve information sharing. The duty to share information—the eighth Caldicott principle—is often forgotten. In my experience the biggest barrier to integration is the fear that NHS providers have about sharing information with other parts of the system, and their resistance to do so. We are not necessarily doing enough in legislation to protect that duty to share information in the interests of providing good-quality clinical care.

The current situation on procurement is very difficult for CCGs. The law says that many services have to be procured if they are over a certain value. CCGs, as small organisations with accountability for their local pot of NHS funds, genuinely fear legal challenge. When they ask lawyers they are, unsurprisingly, advised that they have to follow the law, but the political and NHS England leadership strategy is to integrate care, which often cannot be achieved when care is fragmented by putting services out to tender, and provided by numerous different organisations. Many CCG governing bodies want and need to be cautious. They are just not going to take the risk given the current legislative framework.

Quite simply, if we, as elected politicians, want the NHS to collaborate, we should legislate for collaboration. In my view, the Health and Social Care Committee should be an enabler of that process. We would like to provide pre-legislative scrutiny, but we would like first to ask the health and care community what changes in the law would enable them to achieve their goal of providing integrated care to patients. I would like to know whether the Minister agrees with that proposition.

My fourth point is that integrated care providers should be NHS organisations—a recommendation the Committee made in its report. There is a well-founded concern in the health and care community that, under current legislation, private companies might bid to win contracts to provide significant chunks of our health services. That concern could be alleviated if it were made clear that integrated care partnerships need to be NHS bodies. In their response to our report, the Government did not accept that recommendation, arguing that ICP contracts could be held by GP-led organisations. It would be a very good thing to have GP-led organisations running primary and community care and other parts of the health service, but I see no reason why those GP-led organisations cannot be NHS organisations.

It is a barrier to progress in the NHS that there are not community-based NHS organisations that GPs can lead and work for. I urge the Government to look seriously at the recommendations in the Institute for Public Policy Research report “Better health and care for all”, published in June, which suggests the creation of integrated care trusts in communities and a right to NHS employment within such organisations, which would provide all non-hospital care in an area.

My final point is about leadership. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is a member of the Health and Social Care Committee but cannot be here today, has done significant work shining a light on leadership failures within the NHS. Integrated care is possible only if we have the best and most talented managers in the NHS. As was evident in the failure of management in Liverpool Community Health NHS Trust highlighted by Dr Bill Kirkup, we are far from achieving excellence and need to be certain we have the right mechanisms in place to ensure that we have only the best and the brightest. Will the Minister assure us that the Kark review will be expansive in its remit and that those NHS leaders charged with fixing the mess in Liverpool have been consulted for their expert views?

To conclude, the purchaser-provider split has not always achieved the best NHS care for patients. I welcome the step towards integrated care, but I do not think it will succeed when the legislation promotes, and sometimes mandates, competition. There is political will—certainly from the cross-party Committee—to work with the NHS and care system, including the NHS assembly, on proposals to change legislation, keep integrated care providers within the NHS, improve governance and remove mandatory competition. I hope the Minister will respond positively to those concerns. Integrated care has the potential to transform the lives of millions of patients in our health service. I commend the Committee’s report, and I thank the Government for the changes they are making.

--- Later in debate ---

[Stephen Barclay]

The Prime Minister has set out that it will be for the NHS itself to come forward, rather than for the Government to specify legislative change in a top-down way. As part of the long-term plan, the NHS will determine what can be done within the existing framework and whether change is needed. That will flow from the work that comes forward later in the autumn from Simon Stevens, Ian Dalton and others in the NHS, who are best placed to lead.

[Dr Paul Williams]

In the short time the Minister has left, will he will address the invitation he was given categorically to rule out integrated care providers being private sector organisations? Does he accept that the language he has used—he said the NHS will continue to be free at the point of use—increases concerns about private sector provision?

[Ms Karen Buck (in the Chair)]

Order. Minister, in responding, will you be mindful of the time and the need to leave the Chair of the Select Committee a couple of minutes to respond?