Health and Care Bill

Philippa Whitford Excerpts

2nd reading
Wednesday 14th July 2021 Commons Chamber

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

The Health and Social Care Act 2012 was what got me involved in politics, as I followed the Lansley proposals in sheer disbelief that anyone could think that breaking the NHS in England into pieces and making them compete with each other would somehow improve patient care. So here we are, less than a decade on, and the Government are having to unpick some of the worst aspects of their legislation, which drove competition instead of collaboration and led to the fragmentation of the NHS in England.

Many will be glad to see the back of section 75, which forced services to be put out to tender to commercial companies, but the Government’s covid response does not exactly suggest that they are any less keen on outsourcing. In the last year, we have seen the establishment of parallel systems of laboratories and contact tracing instead of investment in the expansion of NHS labs and public health teams. Health and care services need collaboration and integration with the patient and their family at the centre. That was key to the NHS requests that led to the Bill.

This is obviously a bit of a kitchen sink Bill, with many disparate components. The main aim is meant to be removing some of the barriers to local collaboration, and to some extent it will do that. Achieving integration, however, will still depend on the establishment of a culture of genuine co-operation within integrated care systems and partnerships. They should be statutory public bodies focused on how to provide the best services to their local population, including working with local government to provide social care and tackle the social determinants of health. Instead, private companies can sit on the integrated care partnership boards, as is the case with Virgin Care in Bath, Somerset, and could influence the commissioning of services for which they are hoping to win contracts. It is hard to see how this is anything other than a blatant conflict of interest and suggests that private providers are moving higher up the ladder and could exert influence on a larger scale.

One issue is transparency, as private companies hide behind commercial confidentiality and do not publish accounts of how they have spent public money. Instead of taking the opportunity to return to a publicly funded and delivered health service, as we are lucky enough to have in Scotland, the purchaser-provider split remains and the principle of commissioning and procurement means that financial competition continues. The administrative costs of such transactional systems waste funding that would be better spent on direct clinical care. Unfortunately, the Government are still wedded to the flawed idea that financial competition drives up quality, yet there is no evidence of that. Indeed, financial competition can mean that, when a service starts to struggle, the loss of funding makes its failure become inevitable. It is actually a relentless focus on safety, clinical audit and peer review that can drive improvement in the quality of patient care.

Thanks to devolution, our NHS was spared this destructive experimentation in marketisation, but we inherited a system of competing hospital and primary care trusts, which were then abolished and replaced with statutory public health boards. These are funded to deliver primary, community and hospital care to the population of their geographical area, and work with local authorities on integrated joint boards to deliver public health and social care to the same population.

The long-term Scottish policy of integration was one of three aspects of our healthcare system that was praised in the Nuffield Trust report, “Learning from Scotland’s NHS” that it considered the NHS in England might want to look at. The other two aspects were quality improvement and patient safety. I was honoured to lead the development of the Scottish breast cancer standards in 2000, and, through our yearly audit and peer review, saw outcomes in all units improve in the following years. We now have regular prospective audits of clinical care in 19 of the most common cancers, as well as standards in a broad range of medical conditions and services as diverse as diabetic retinopathy, bowel screening and forensic medical services.

In contrast, many clinical outcome audits have disappeared in England, and publication of the “Getting it Right First Time” audit into breast cancer services has been held back since December 2019. The whole point of such audits is to identify weaknesses and drive clinical improvement. They should not be delayed for political reasons, because they highlight issues that need to be tackled.

With regard to patient safety, I am very glad to see the proposal for the Health Service Safety Investigations Body make it into the Bill after a four-year delay. The agency will take a similar approach to that used in air accident investigations and share the learning from significant healthcare failures to try to prevent similar episodes in the future. Having been on the pre-legislative Committee, it will be interesting to see how that innovative system evolves.

However, I find it surprising that more has not been taken from Scotland’s national Patient Safety Programme, which promotes a whole-team approach to patient safety to try to prevent incidents from happening in the first place. I remember it being introduced to surgical theatres in 2008 and it reduced post-operative mortality by over a third within two years. It has been extended to almost every division of our health service, leading to a significant reduction in standardised hospital mortality and morbidity, such as sepsis or pressure sores. A key principle at the core of both the patient safety and quality improvement programmes has been the involvement of frontline staff and patients in their design and development. I am sure that the Secretary of State or Health Ministers would be made very welcome by me and my colleagues in the Scottish Government should they wish to visit Scotland to see the programmes in action.

Several clauses of the Bill apply to the devolved nations, but although some relate to traditionally reserved issues such as professional regulation, others are less clear. There is growing concern in Scotland and Wales about how this Government are using the United Kingdom Internal Market Act 2020 to undermine devolution and about how the data-gathering or procurement aspects of the Bill might be widened to apply to our health services.

In 2015, NHS England’s five year forward view highlighted the critical dependence of the NHS on a well-functioning and resilient social care sector. That is still the gaping hole in this legislation. With the funding gap in England now between £8 billion and £10 billion a year, a failure to properly fund social care will undermine the whole integration agenda, as providers are unlikely to be willing to share financial risk with a woefully underfunded service.

Not only has the pandemic highlighted the vulnerability of the social care sector, particularly care homes, but it has brought home the important role played by care staff. The Feeley review for the Scottish Government proposes the development of caring as a profession and proposes taking a human rights approach to social care, valuing it as enabling participation in society rather than looking on care support always as a burden. At the 2019 election, the Prime Minister boasted that he had a fully prepared social care plan, but it has yet to see the light of day. It is hard to see how any integration agenda will succeed without it.

Lord Stevens’s plan stressed the importance of preventive public health to reduce the burden on the NHS, but public health budgets in England have been slashed over the past five years. While policies on tackling obesity are welcome, they are quite narrow and there is little recognition of the role that food poverty plays. Healthy foods are often more expensive. Indeed, poverty is the biggest single driver of ill health. With another decade of Tory austerity due to begin with the cuts to universal credit in September, there is little chance of improving health and wellbeing, particularly among the most disadvantaged.

Wellbeing is not about healthcare, and it is more than just an absence of physical or mental illness. Developing a wellbeing economy would require a total change in philosophy from this Government—and there is little sign that they are interested in taking up the challenge.