Integrated Care

Philippa Whitford Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Wollaston]

Coming back to why integrated care does not happen, there are many deeply ingrained structural divides. Since the inception of the NHS 70 years ago, we have had a system that is free at the point of use for the NHS, but means-tested for social care. That presents an extraordinary hurdle when systems are trying to join up. It is not just that; it is different contractual arrangements and working practices. Good integration comes down to individuals and teams being prepared to work together, but it often feels like they are working together to achieve integration despite the systems around them, not because of them.

We need a system where everybody is focused on helping the right kind of integration to take place, and we need to go back and look at that fundamental structural divide between the systems. I ask the Minister to look again at the joint report, “Long-term funding of adult social care”, because that is an important issue that goes to the heart of the barriers to joining up services. It is about contractual differences, different legal accountabilities and payment systems that work against the pooling of budgets, and financial pressures within the NHS.

A certain amount of financial pressure can encourage systems to come together to pool their arrangements and provide a more efficient service, but as the Minister will know, when the elastic is stretched too tight and the financial strain becomes critical, we see the opposite—systems are forced apart. I have seen that happen in my area, where people suddenly feel that they have to retreat to their organisational silos to fulfil their legal obligations. There is no doubt that, for the process to work effectively, we need the right amount of funding—and sufficient funding—and tweaks to the legislative arrangements to allow people to come together, so it does not feel as if they are working together despite the system.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I am grateful to the Chair of the Committee for giving way. Does she agree that when there is an attempt to elicit change through turning off the financial tap, what happens in fact is that people cut what they think is easiest to cut, which is often the most innovative solution, rather than step back with a clear head to consider where they want to get to in the end? Does she also agree that we often find that the result of that kind of cost-cutting is a backward step rather than a forward one?

[Dr Wollaston]

I thank the hon. Member for that intervention and for her own service to the Committee previously—she is very much missed. Her remarks are typical of the constructive input that she has always made to the health debate in emphasising the need to take the long view. Financial pressures so often force us into short-term solutions, not only in the way she set out but through the salami-slicing of services.

One of the points that our Committee feels strongly about and that I was going to make to the Minister is the need to ring-fence transformation funding, because it is so easy for that funding to get lost. I welcome the uplift in funding—a 3.4% increase will be very helpful—alongside a 10-year plan. However, we have to be realistic about what that uplift can achieve, because there are very many demands on that budget, as the Minister will know and as we have seen in the past. We saw it with the sustainability and transformation fund, which tended to get sucked into sustainability and not into transformation. That has been the pattern of recent decades. There is good intention to ring-fence money for transformation, but that money disappears because of other priorities around deficits and, as I have said, the many other calls on the funds available.

That is why we feel that, in order to prevent the continuation of that cycle of past mistakes, it is important that the pattern is recognised and that funding is earmarked for transformation—not only for capital projects but for things such as double-running.

I will give an example from my area. There will be a complete destruction of public trust in new models of care if money is not set aside for double-running. The community was prepared to accept that there would be a new facility—nobody wanted the closure of the local community hospital in Dartmouth, but there was an assurance that there would be a new facility. Unfortunately, despite many of us opposing the closure of the old facility, what happened was that it was closed and then there was a breakdown in the arrangements for the new facility. The community was left with nothing and there has been a huge destruction of public trust in the process, which unfortunately will have ripple effects across other communities. Had we received the money to keep the existing service while the new service was built and got up and running, it would have left us in an entirely different situation. I am afraid that we see that too often across health and social care. There is good intention, but without double-running, which is part of having a ring-fenced transformation fund, I am afraid that the system has broken down too often in the past. I would like the Minister to focus on that when he makes his remarks.

The Committee is also looking forward to the 10-year plan—we look forward to working alongside both NHS England and the Department of Health and Social Care to examine how that plan emerges—but is important to draw attention to legislative changes. Our Committee made a recommendation that legislative proposals should come from the service itself rather top-down from the Department, which would immediately run into difficulties. However, as a Committee we also offered to subject such proposals from the service to pre-legislative scrutiny.

As the hon. Member for Kingston upon Hull North (Diana Johnson) pointed out in her intervention, we need to build cross-party consensus at every point. As it has not been covered in the formal response to the Committee’s report, will the Minister say in his closing marks whether the Government would support the Committee conducting pre-legislative scrutiny?

I am pleased to have had a conversation with Simon Stevens, the chief executive of NHS England, who has confirmed that, as it emerges, the NHS assembly will consider that within its remit—NHS England hopes to produce proposals in draft form before Easter 2019. Nevertheless, as I have said, it would be helpful to receive the Minister’s assurance that proposals will come to our Committee for pre-legislative scrutiny as part of the process of building consensus.

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[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.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, welcome the opening speech of the hon. Member for Totnes (Dr Wollaston), who is a superb Chair of the Committee. The marketisation in NHS England goes back more than 30 years—it has certainly been happening for most of my career. It started with terms such as “resource management”, and in 1990 the internal market—the purchaser-provider split—was introduced. In the early 2000s under Labour, private companies started to introduce independent treatment centres. The Health and Social Care Act 2012 turned it into a massive external market and created the pressure to put all possible contracts out to tender.

The problems are well known. If we base a system on competition and not on collaboration, we inevitably create fragmentation and destroy integration. That has broken up patient pathways and made the system very confusing, to the point that CCGs were looking to employ what they called primary providers, which would have been another layer of cost and health organisation, to try to join things up for patients. Thankfully that has been shelved, because there is a sense of going in a different direction, but up to now there has been a repeated sense that everything can be solved through a healthcare market. That is why, in Scotland, we have grave concerns. One of the 24 powers coming to Scotland is power over public procurement—we do not see the market as the solution to everything.

Just five years on from the actual on-the-ground changes of the Health and Social Care Act, NHS England is facing another big reorganisation. As other Members said, unfortunately the rushed sustainability and transformation plans and the lack of consultation with both the public and staff has created anxiety and fear. As is now recognised, the term “accountable care organisations”, which was copied from the American system, was a PR mistake of the highest order.

In 1999 in Scotland—after devolution—we simply went in a different direction. We merged trusts and then abolished them in 2004. We got rid of primary care trusts in about 2009. We already had an area-based health service for the entire population—not just for people registered with their GP—based on per-capita funding. That meant that we could start to look at how to integrate acute hospitals with community hospitals and even local village hospitals for step up and step down—not everyone who is unwell and cannot be at home needs to be in some big, shiny 10-storey block, and might just need a bit of extra care for a few days, so there is an argument for community hospitals.

In 2014, we started looking at integrating health and social care. Because of the fragmentation in NHS England, it will be necessary to integrate health first, and then integrate social care. Integrating social care is much more challenging because it is made up of different players in the market and is done in a different way. As the hon. Member for Totnes pointed out, the overarching difference between free healthcare and means-tested social care creates major challenges.

[Andrew Selous]

The hon. Lady used the term “village hospital”, as well as the term “community hospital”. “Village hospital” is a new one to me. Could she elaborate on what it means?

[Dr Whitford]

It is not a particularly formal term. I simply mean that there has been a tendency to think that, because community hospitals cannot provide the full range of acute healthcare, they have no place, whereas someone might require only a low-level of in-patient care, such as an elderly person who has a urine infection and lives on their own may need intravenous antibiotics, fluids or extra care. Such hospitals allow us to have much more healthcare—things such as minor injury units—close to the public. The more we take forward to people, the less worried they will be about the fact that we are coalescing specialist services. If they see services coming towards them, they will not have the sense that everything is being taken away. We have utterly failed to impress on the public that healthcare is not about buildings, but very much about people and services. That is what integrated care should be about.

[Diana Johnson]

I am very interested in what the hon. Lady is saying about Scotland. Does she know that areas of England have integrated financial plans involving local government and health to try to bring together that continuity and put patients at the centre?

[Dr Whitford]

That is exactly what we have in Scotland—it was introduced in legislation in 2014, and all areas were up and running by the beginning of 2016. More than 60% of the budget goes to what are called integrated joint boards, which use innovative solutions to deal with all sorts of local groups to try to prevent people who do not need to be in hospital from ending up there, and to try to allow people to come out of hospital when they are ready. It has led approximately to a 9% per year decrease in things such as delayed discharges. Those two measures—acute admissions that could have been avoided and delayed discharges that lead to people being stuck in hospital—are very much looked at. In my early career, if someone was in a bed and ready to go home, they would be told, “Well, it’s your problem. We don’t have room.” There was always friction between secondary and primary care, and between health and social care. That is where we are, but it is not easy—it is not even as easy as integrating within health.

There is no escape from legislation. Some legislative change is critical for NHS England to be able to take the barriers out of the way. At the moment, as the hon. Lady mentioned, people are trying to work around those barriers, but when things change in an informally integrated care system, the acute hospital is put into financial difficulties. It is being asked not to admit people, but the existing tariff system rewards the hospital only when it admits people, so when it starts to get into difficulties, we are asking it informally to sacrifice its budget line for the greater good. I am sorry, but tariffs need to be reformed. It is a bizarre system if the aim is not to admit. Hospitals make money on the people who almost do not need to be there and lose money on the sickest, who do need to be there.

[Diana Johnson]

Again, that is very interesting. A good model of that, which is already happening in England, is in my own backyard: Hull. The hospitals have agreed that they will take a sum of money and will not look for additional money from the CCG if they need to treat more people. That is an integration of social care—the local council—and the acute sector, which is important in making this work. It can be done without legislative change, but overall I agree that change is vital.

[Dr Whitford]

That is fine in one place with good leadership and good relationships, but if things got tight it would be very difficult for one chief executive to accept the failure of their budget in order to keep the whole system going. Legislative change is crucial, towards more per-capita funding and away from tariffs, and towards more area organisation of that integrated care partnership.

Reform of section 75 of the Health and Social Care Act 2012 is crucial, because it pressures CCGs to put out to tender all possible contracts. In Surrey, six CCGs were sued by Virgin not for breaking a contract but for not renewing one. We estimate—actual figures are hidden behind commercial confidentiality—that more than £2 million ended up away from the frontline, instead going into Virgin’s pockets, which is not helpful.

In fact, the administration of the bidding and tendering market is estimated to cost between £5 billion and £10 billion, which contributed to the debt that NHS England got itself into by 2015, a mere two years after the changes in the Act came into effect in 2013. Before that, by looking down the back of the sofa and scraping around, and with a little bit of moving money around, the NHS in England usually managed to get to the end of the year in balance.

Moreover, that debt has led to rationing. The problems are not hypothetical ones on a piece of paper. They result in older citizens—we will be having a lot more of them—being held back from hip or knee replacements, cataract surgery and other things that allow them to see or walk, get out and meet friends and keep active, which is crucial.

Finally, it is critical for the accountable care organisations or whatever they are called now to be statutory. The model contract published last August would still allow a private company to bid for and run an entire integrated area. The report states that that is unlikely, but it should be simply ruled out in order to get rid of a huge amount of concern about a threat that might lie around the corner or down the line. Without that statutory basis, a company could hide from freedom of information requests and use its commercial sensitivities even though it is being handed billions of pounds of public money and getting to decide what is delivered to the population in its area. I am sorry, but that cannot be a private company and has to be a statutory body.

There are challenges ahead and we all face similar ones—increased demand, workforce and tight budgets—but we have talked about that before. At the moment, however, the structure for NHS England is hampering the staff on the frontline who are trying to look after people. The challenge of merging a free system with a means-tested system will not go away; it will have to be addressed. In Scotland, we have a slight advantage because we have free personal care, which takes away one of the problems, because it allows us to keep more people at home—in their own home, where they want to be—rather than in hospital.

Even though it is only five years since the last big reorganisation, NHS England is at another major crossroads, so there will be a lot of upheaval. It is important to get that right and to do it in a measured way in the House. Legislation should allow innovation in different parts of the country but get rid of the barriers. We should be radical and, as Members have said, to put the patient or the person right in the middle of the design. That involves more than just the delivery of treatment. Health is not given by the NHS—the NHS catches us when we fall and ought to be called the national illness service, but we would have even worse workforce challenges if we called it that. I echo the call for health in all policies, within the integrated systems and in the House, so that we are actually investing in the health of our population.

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[Stephen Barclay]

The Chair of the Committee is absolutely right. We have always been clear that integration is about improving patient care, and that the NHS will remain free at the point of delivery.

A number of key points arose from the debate. Remarks were made about ensuring that the service is patient-centred, and concerns were expressed about whether transformation funding may be diluted. I will come to pre-legislative scrutiny, to which the Chair of the Committee referred, and primary legislation.

The hon. Member for Central Ayrshire (Dr Whitford) raised concerns about private firms and the role of GP-led organisations. The hon. Member for Stockton South (Dr Williams) and my hon. Friend the Member for South West Bedfordshire (Andrew Selous) referred to focusing on prevention and taking a wider needs-based approach. A number of Members referred to information sharing, leadership and the lessons from Liverpool Community Health NHS Trust—the hon. Member for West Lancashire (Rosie Cooper) performed a great service by highlighting that. That is reflected in the work I have commissioned from Tom Kark on the fit-and-proper test.

[Ms Karen Buck in the Chair]

Members focused on the need for a patient-centred approach, which the hon. Member for Kingston upon Hull North (Diana Johnson) emphasised in her intervention. In our approach to integrated care, we seek to build a healthcare solution around what is best for the patient and, in the words of the Chair of the Committee, why it matters to patients. That is very much the Government’s intention.

As the Committee Chair said, financial pressure can both incentivise and impede integration. She will be aware that the up to £20 billion a year that will go into the NHS as part of the Prime Minister’s commitment to funding the service will be front-loaded—there is more in the first two years in recognition of the importance of the double-running to which the Chair of the Committee referred. According to past National Audit Office reports, there have been a number of cross-party initiatives under successive Governments. As she and other Committee members set out, sustainability trumps transformation, which is one of the key challenges for the NHS family as it brings forward its 10-year plan. For the first two years, an extra £4.1 billion will go in, with front-loading of 3.6% compared with the average over the five years of 3.4%, which very much reflects the concerns she articulated.

The tone of the debate was one of broad consensus, and we will realise that first by asking the NHS itself to lead on the legislative changes required. The NHS will bring forward its proposals through the 10-year plan. We will not mandate, but let local areas decide what fits their locality best. That will be informed, for example, by health and wellbeing boards. I met the chair of the Lancashire health and wellbeing board yesterday—that speaks to the concern raised about the need for Health Ministers to take a wider approach rather than, as the hon. Member for Stockton South said, looking purely at the NHS element. We are looking much more widely and bringing in local authorities. Indeed, the Department’s name has changed, and the work of the Care Minister reflects the wider integration in our approach.

Although we welcome the Committee’s work on testing the NHS proposals as part of the long-term plan, we will wait for the NHS proposals before confirming the specific pre-legislative scrutiny arrangements. I hope the approach I have taken in discussions with members of the Committee underscores the importance I place on working in a cross-party way. The approach we have set out very much reflects that.

[Dr Whitford]

Can the Minister commit to looking at legislative change? It is fine for designs to come from the NHS, but if those designs are based on existing barriers, they will not reach their full potential.

[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.

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[Stephen Barclay]

Indeed I will, Ms Buck.

I draw the hon. Gentleman’s attention to the Committee report, which states:

“There is also little appetite from within the private sector itself to be the sole provider of…contracts…There are several reasons why the prospect of a private provider holding an ACO contract is unlikely…Integrated care partnerships between NHS bodies looking to use the contract to form a large integrated care provider would have an advantage over non-statutory providers that are less likely to have experience of managing the same scope of services”.

The hon. Gentleman himself referred to the desire not to rule out GP-led organisations, which are independent. He also mentioned GP-led organisations becoming NHS bodies. I am happy to meet him to explore exactly what he means. It is not the Government’s intention for private firms to run ICP contracts.

[Dr Whitford]

The Minister says that that is unlikely and that private firms do not want to run such contracts, but we are talking about a 10-year plan. Does he therefore recognise that it should be ruled out to give surety? We do not want another Hinchingbrooke, where a private company takes a contract on and an entire area faces a private provider walking away from an integrated care partnership.

[Stephen Barclay]

These arguments were explored at the Committee, which addressed that question. The fear of privatisation has been overplayed.

We are taking a people-centred approach and letting the NHS lead on shaping it. We have said we will respond to the points the NHS raises and act on them, but integration will enable services holistically to deliver better care for patients—as the hon. Member for Strangford (Jim Shannon) said, that includes better data sharing—and put the needs of patients front and centre. That is reflected in the report and in the cross-party consensus on how we want to take integration forward.