Health and Care Bill (First sitting)

Philippa Whitford Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Jo Churchill]

That would be great.

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

I want to declare an interest as a medical practitioner, although not commonly practising, and as a member of the British Medical Association.

[Dr James Davies (Vale of Clwyd) (Con)]

Likewise, I declare an interest as a serving general practitioner in the NHS, a member of the BMA and as a member of the Royal College of General Practitioners.

--- Later in debate ---

[The Chair]

I call Dr Phillipa Whitford, the SNP spokesperson.

[Dr Whitford]

Q Thank you very much, Mrs Murray. Dr Evans, we have talked quite a lot about workforce and highlighted the fact that the workforce move around the UK, and therefore work in the four different nations. Registration of nurses and doctors is UK-wide, although only Scotland has registration for care staff. Do you not think that that needs to be recognised to some extent in clause 33, so that we do not end up having Peter robbing Paul? This year, we have seen a shortage of foundation places. Although all four nations have increased medical student places, a young doctor cannot practise unless they get their two years at foundation level. Do we not need to be consulting specifically with the other health Ministers and looking at the workforce in general? I do not mean transferring control of that workforce, but recognising, for the next five, 10 or 20 years, the needs and the strategies of the different nations so that we do not end up stealing from each other.

Dr Navina Evans: Thank you for the question. It is for Parliament to decide what goes into the Bill. We will, of course, work accordingly with the duties. We already work with the four nations around the foundation year programmes, we share a lot of intelligence and recruitment work and we are continuously looking for ways to strengthen that. It is an important priority for us to share learning and recruitment between countries.

[Dr Whitford]

Q Sorry to interrupt, Dr Evans, but this year the foundation places are managed on a UK basis, and this year, at the beginning of the summer, there were several hundred graduates who did not have a foundation place—I hope they have all got one now. That can mean people literally being sent to a different part of the UK, away from their family and their support mechanisms, and we all know how tough these years are. This is being managed at a UK level, and yet the three devolved nations are also trying to tackle workforce issues. If they are not included in this, or at least consulted, do you not see that as a weakness?

Dr Navina Evans: I see that we are addressing exactly those problems around where people go to do their jobs and where the placements are. Having to travel to get the right training jobs is something that we have been grappling with for a very long time in Health Education England, and I remember that we were grappling with it when I was a trainee. That is something that we focus on anyway, and if it were to be strengthened in the Bill we would, of course, look at the duties that were expected of HEE in terms of working across the four nations to solve this issue. We would be building on what we are already doing to address that.

[Dr Whitford]

Q Thank you. Danny Mortimer, we have talked about the change that is coming, and a lot of it is to enable the innovation that has come through the pandemic. I was back in the NHS in Scotland in the first wave, and I saw that creativity. How do you think it can be done without consuming a lot of the bandwidth of frontline staff? You talked to the shadow Minister about management, but it often takes up frontline staff. Would you see a gradual change? Are you concerned that the footprints of some of the ICSs that have already evolved are apparently going to change? Is that not going to add new upheaval in certain geographical areas?

Danny Mortimer: Thank you, Dr Whitford; there are a couple of things there. On the geographical changes, what ICS leaders wanted was clarity. They have now been given that by the Department and NHS England, and they will move forward and can adapt accordingly.

On the impact on the frontline, throughout the pandemic, and increasingly before it, we saw a much greater sense of teamwork across some of the boundaries that we can create between parts of the health service, and between the health service and other public services. There is an opportunity to accelerate that in lots of our settings. That will be a positive. It will help people care better for their patients. Most importantly, it will help patients and their families to have a much more seamless experience.

This is not a magic thing—you know yourself how complicated the hand-offs and transitions between different teams can sometimes be—but this Bill formalises the recognition that we have had over recent years in England that to start to properly and truly focus on what individuals need, we have to have better co-ordination between our teams. It is not about the institution first; it is about the team first, and obviously most importantly the patient first. The absolute opportunity for us is to do those things better for the patients in between our services.

[Dr Whitford]

Q Yes, I totally recognise that. In Scotland, we reintegrated primary and secondary health back in 2004, and in comparison with the last seven years of trying to integrate health and social care, that was a walk in the park. It is much more challenging, but equally it is where we are all trying to get to. If I can ask you, on a different subject—

[The Chair]

I think we are getting close to the last question.

[Dr Whitford]

This is the last question.

On the health services safety investigations body, I was on the pre-legislative Committee, where there was an aim of protecting the safe space disclosures quite thoroughly to ensure staff had the confidence to discuss very sensitive issues. In the version that is in this Bill, much more is covered by safe space protection, but then there are exemptions such as the coroner. Although staff can be summoned and made to give evidence, if they feel that that will end up being shared through a lot of disclosure exemptions, do you think they will really believe that that space is protected, in the way it is in the airline sector?

Danny Mortimer: There is a very difficult balance that health service leaders know they need to strike. The requirements around transparency to the public are much higher for the health services and for people such as you and Dr Evans, as health service practitioners. The coroner’s ability to review what happened is a really important step for families, and we are very respectful of that.

What the Bill does—this is how it describes the investigations branch—is to build on work that the NHS and the Government have been taking forward since Robert Francis’s inquiry into whistleblowing to ensure that we have cultures, practices and processes that enable people to be candid and open without fear of consequence, in terms of what has happened. We realise that that is how we learn and improve. We also realise that have a lot of work to do to help all parts of our workforce—clinical and non-clinical—feel much more comfortable and supported to raise concerns, give feedback and be honest about what happened. As you will know, there is an enormous amount of work going on across the four countries to create those kinds of cultures, but at the same time, we also recognise that we have that responsibility in terms of transparency to the public, and to patients and their families.

[Dr Whitford]

Thank you.

[The Chair]

Thank you. I call the Minister.

--- Later in debate ---

[Justin Madders]

Thank you.

[Dr Whitford]

Q Following on from Dr Davies’s comments about the structure of the ICS board and the representation of some of the sectors, such as mental health, we have not talked much about the partnerships this morning, so could you explain what you think their role is? I know there are concerns about who will be represented on them, potential conflicts of interest—obviously, particularly around the lack of financial transparency if private providers are used—and some of the sectors, such as dentistry, community pharmacy, end of life and palliative care. People on the ground, at the frontline, are not sure who will represent them in either of those structures to ensure that that service is available for every community and that we do not end up with postcode prescribing. Will there be some guidance? How do you think that will work? I will start with Mark and then go to Amanda, because this is nuts and bolts.

Mark Cubbon: The ICB is essentially how the NHS leaders come together specifically to oversee how resources are allocated and how the NHS delivers its side of the bargain, in terms of how the rest of the ICS works and is able to support integration. The ICP—the partnership—is where we bring together other partners who will have a view, an input and a role to play in that integration agenda. That is essentially, at a very high level, the separation of the partnership and the ICB itself.

On how we get representative views from the whole breadth of the clinical community, again this was published in our guidance—we have further guidance that was published last week—which talks about the clinical community, based on all the engagement that has been done so far. The kind of arrangements that we are very likely to see are where we have clinical reference groups and clinical boards that start to shape all the representative views that give a holistic perspective on how services should be planned and how we should be delivering services for our patients and communities.

Although not every individual will have a seat around the board or partnership table, we are advising the boards and clinicians across the whole footprint to ensure there is deep-rooted engagement. We are trying to galvanise the clinical community and get consensus on the direction of travel in terms of how services should be delivered for patients to deliver better outcomes. That is what we are encouraging our local ICSs to do. We are giving as much guidance as possible, but it will be down to this local flexibility so that our clinicians locally can start to work out how they best come together to do all the things I just set out.

[Dr Whitford]

Q Obviously, there is quite a different balance, in both power and accountability, between the two organisations. Do you think there is an advantage in there being a split, or had you expected there to be a single body for each area making the decisions? That surprised some people when the Bill was published. Could you give just a brief answer on what you think about whether having one board or these two boards is an advantage or disadvantage? Amanda, you look like you want to come in on that.

Amanda Pritchard: I am happy to, and Mark may well want to add. You are absolutely right that when the NHS went out to consult as part of the exercise that we undertook back in February, we were describing a single board structure at that moment. It is a change that we proposed to Government on the back of the stakeholder feedback that we had, particularly from the LGA, which suggested the dual board structure, partly because it gives the real clarity, as we talked about earlier, about where the money flows and where the accountability for NHS service delivery sits. It therefore allows a wider partnership to play in, with a particular view to all the other aspects of population health and the wider agenda. That is not where we started, but it is where we now feel very comfortable, in response to the strong stakeholder feedback.

[Dr Whitford]

Q The ICS board is very NHS, so how do we ensure that attention is paid to the strategy or the findings of the partnership, so that we do not end up with a very health model, when you are trying to get to a wellbeing model?

Amanda Pritchard: Again, you are absolutely right, and that is a risk, which is why we started where we did. What is now described—the requirement to have regard to and respond to that overarching strategy—is the safeguard that means you cannot have the NHS in any way separated from that broader ICS structure, and from that wider strategy for which the partnership will be responsible. As we have discussed, I am not expecting that that will necessarily be the only way in which wider partners are brought into the ICB, but the fact that there will be a local government seat on the ICB is another important way that stops the NHS just working on its own.

[Dr Whitford]

Q And you think “with regard to” is sufficiently strong to ensure that that happens?

Amanda Pritchard: It has quite a specific, technical meaning, so from our point of view we would understand that to be a very clear direction.

[Dr Whitford]

Q Okay. That’s fine. In one of your earlier answers, you talked about improving clinical quality, which obviously goes along with patient safety, both of which were my background when I was in the NHS. But that is still going to involve procurement and a degree of financial competition. Something that has disappeared in England over the past decade is peer-reviewed audit of clinical quality outcomes, which is the outcome for patients. With the title NHS Improvement—and it did surprise me when I came to this place that that is not what it is about—how do you think that will come back, because it should not just be about money; it has to be about achieving better clinical outcomes? I understand that the report on breast cancer, “Getting it Right First Time”, has still not been published, even though it was ready in December 2019. Having led on this kind of thing in Scotland, how are you going to drive clinical quality for patients? I will start with you, Amanda, and then go to Mark quickly.

Amanda Pritchard: I might let Mark come in on this, because it is something that we have thought a lot about. You are absolutely right that the purpose of all of this is to make sure that we are improving care and services to patients, but with regard to that triple A, it is also of course about the sustainability of services and the broader population health challenge. Part of the structure that the Bill will allow us to put in place on things such as the provider collaboratives absolutely begins to put back firmly at the core of how we do our business procedures such as the clinical peer review.

We have now got the data through things such as GIRFT, which means that we can incorporate it formally in a structure that brings together the providers and also crosses pathways, so that we are not dealing with acute on its own, or with mental health or primary care on its own. We can then look at each against best practice and see how different parts of the system are performing, assess some of the challenges and collectively think about how to come together to secure improvement. That is already happening, but the Bill will allow us to make that much more at the core of how the systems approach local improvement. Mark, would you like to add to that?

[Dr Whitford]

Q Just before we go to Mark, would you see a re-emergence of national quality audits such as for certain cancers, which have been largely lost in England over the past 10 years? Would you hope that they would return?

Amanda Pritchard: Yes. There is still a huge amount of national audit work that does take place. Thank you for mentioning GIRFT, because we do have some other really important improvement programmes that are very data driven, which have an important place in this conversation. We certainly see the proposed legislative changes as a real opportunity to bake that way of working in, not just nationally but through systems coming together to do it as part of their local activity as well.

[Dr Whitford]

Mark, do you have anything to add very briefly?

Mark Cubbon: One of the major changes is a move away from competition to much more collaboration, and that is one of the things that the Bill sets out. That is what we believe in and what people are looking for, from what we hear from the service. With that collaboration what we start to see is much more accessible input from people and organisations, so that we can share and learn from each other and start to instil the best practice that we see in one part of an ICS, and have the opportunity to discuss that and see how it can benefit other parts of the ICS, and so reduce variation and deliver much more consistent care to patients.

Before I started my job at NHSEI, I was chief executive of an acute hospital on the south coast. While there have always been opportunities for colleagues to come together and discuss how best to approach a challenge, and to ensure opportunities for sharing good practice and learning from each other, the Bill starts to take down barriers and is much more enabling than what came before. Yes, of course clinicians have informal ways of coming together to look at how changes can benefit patients, but these structures are intended to allow a much greater exchange of ideas, which will be of great benefit to patients; hopefully we can start to implement those ideas at greater speed.

[The Chair]

Before I call the Minister, I remind Members that there will be a hard stop at 11.25 am. If witnesses could keep their answers as brief as possible, it would be much appreciated.