Health and Care Bill (Fourth sitting)

Philippa Whitford Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

I think we had better move on. Dr Whitford?

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

Q I will start with you, Richard, on tariffs. I have a background in the NHS. I and colleagues south of the border know of people doing outreach work from a hospital trust into a community. They developed services that were successful in reducing admissions, but sometimes the service was shut down precisely because the hospital’s income disappeared. I will come to your colleagues, but are you comfortable that the funding going into the ICB will give that integrated vision of how money is spent, to ensure that people who can be supported or treated by a community project do not end up in hospital just because that is the way the ICB generates money?

Richard Murray: That is a very fair point; it did create that tension within the system, because more activity was what made you successful and gave you your bank balance. The flexibilities that the Bill gives to step away from those more mechanistic tariffs that pay for activity should enable that, with two caveats. First, much of this will come in guidance from NHS England about exactly how this will work; there is clearly not enough detail in the Bill to do that, and why would there be? That still needs to be worked through.

Secondly, it is quite complicated to get right; this is a very difficult thing to do, and one of the pointers we see in some other countries, such as New Zealand, is a focus on everybody working together and not getting too caught up in trying to divide up the pie between competing parties. Again, that is where things such as the triple aim may help to keep people’s minds focused on the purpose, which is good quality care, value for money and a healthy population. There are more flexibilities in this system to do that, so that we do not get the kind of perverse incentives we have seen in the past.

[Dr Whitford]

Q Do you think there will be a friction where, say, a foundation trust has had good financial management and a budget that is not too bad is asked to work with one that has been struggling—particularly in social care, where we are looking for integration?

Richard Murray: I think there will need to be a change in culture here; it is almost inevitable that if you look within different ICSs, you will find extremely financially successful institutions next door to some that are deeply troubled and that are facing problems in community services, general practices and other services. There will be a need for a culture change, but one that does not lose sight of the fact that you want organisations to be well run. You do not want to end up with some of the weaker organisations thinking, “I shall now pass this problem on to my big brother down the road who has very deep pockets.”

You need to try to maintain the right incentives and support for institutions to run themselves well, to keep the value-for-money element of the triple aim, while also being able to move money around the system without getting caught in silos such that the acute trust has all the money and mental health does not. We need to be able to begin to move money across those different boundaries, which the old financial system did not help us to do.

[Dr Whitford]

Q Obviously, the idea is that the ICBs would have that vision and power.

Richard Murray: You would hope that the ICBs would have that power and the ICPs would try to set the direction. For many of the really tricky pieces between community services, general practice and social care, it is probably more at place; the ICBs are often so big that they are unlikely to get directly involved in those decisions. They can set the framework and try to ensure that in some sense it is working as a whole, but many of those decisions will come down at place level.

[Dr Whitford]

Q Nick?

Nick Timmins: I have little to add. This is really an issue of behaviour, culture and financial flows. It is not something that the Bill can lay down or dictate.

[Dr Whitford]

Q But obviously the tariffs created some problems.

Nick Timmins: The tariffs definitely caused some problems. Changing the way the tariff is used is very important, but that does not mean that you should get rid of it entirely.

[Dr Whitford]

Nigel?

Nigel Edwards: I agree with all of that. This gives a vehicle that will allow many of those perverse incentives to be removed. People found ways of working round them previously, but this simplifies things. Richard made the point that it is definitely the case that some trusts, particularly acute trusts, have done very well out of the tariff. They will find it quite painful to make the adjustment, but that is not a reason for not making the change.

[Dr Whitford]

Q Perhaps I can start with you on this question. We obviously hear about the ICB, which appears to be the power base, and the ICP, which is more flexible and will put forward an agenda and an idea. How do you think the power balance or imbalance between those two is going to work?

Nigel Edwards: I have sat with a number of different geographies and tried to work that out, and it is probably going to be different in different places. Some of the ICSs are quite geographically coherent and have a lot to do with each other. For others, such as Cheshire and Merseyside or BOB—Buckinghamshire, Oxfordshire and Berkshire West—there is less in common at the strategic level. It will be quite different in different places, particularly where there are powerful upper-tier local authorities within ICSs. They will want to have a strong voice at the place level.

One of the virtues of the legislation as currently formulated is that it allows some flexibility, and it allows people to tailor some of those relationships to fit their local geographies. But I would see the partnership part of this having a very important role in shaping the overall strategy. For quite a lot of people, the risk is having too many meetings and too many partnerships. It is very important that the partnership board sets the agenda and then the places and the ICB get on with it.

[Dr Whitford]

Q So the challenge you see is more about things like footprints and boundaries making it clunky in some areas. It is about trying to get that right.

Nigel Edwards: Yes. The NHS has always had a bit of an obsession with neatness and uniformity. If there is one thing that I have learned from working with these different ICSs, it is that they are very different in terms of their physical, political and psychological geography. Trying to fit a standard model of governance to them would be a mistake. We need to hold them to account for how well they are implementing their plans and how far they are improving outcomes for their population. We need to know whether they are making the best of the money that we are giving them, rather than whether they are conforming to a centrally designed governance model that will work on average, and that will therefore work nowhere.

[The Chair]

I think we had better move on now. I call Justin Madders.

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[Edward Timpson]

Q All the way up to the board?

Louise Patten: From strategy right the way down to grassroots implementation.

[Dr Whitford]

Q In the morning sitting we heard from Professor Marshall, who was talking about your own ICS. I asked about the problem of the power imbalance between the partnership and the board, and he mentioned that you have a primary care sub-group. We have had a lot of discussion about how we gather the voices and ensure everyone is there. What led Gloucestershire to develop that? How do you feel it is working? Do you think that is a good model? How do you ensure the board listen to what the partnership come up with?

Dame Gill Morgan: It is about multi-layering of advice. We will have a primary care sub-committee partly because managing primary care, and all the things that come through GMS and the opportunities, is expert; we do not want it to be subsumed by a generalist groups. We want it to have proper focus, because if our vision of the future is right, we need better and more engaged primary care at local level that can link its services more effectively with support in the hospital and the community. That is the objective, so we will have that.

We will also have an ICB. GPs will have different views. That is one view, which is about me as a jobbing GP. I go in in the morning, and I do my work and all of those things. I need to be supported to do that, but I also need GPs in the system who are engaged in management. We are very proud of our primary care networks, which are beginning to pull together around our localities, because we are smaller and it is not a big place.

There are models where they are working with second tier local government, where they are beginning to think about housing, and they are working with the voluntary sector, so when they are talking about frailty, it is not a GP or a hospital conversation; it is a system conversation in this place. All of a sudden there are things that can be unlocked. If we leave it in any one box, as we have always done in the past—there is a box for acute, for this and for that—we do not get this. Our task is to make those boundaries semi-permeable, with the expectation that we look at the patient flowing through all those boundaries, rather than pretending that patients sit in an individual box, because they do not.

Louise Patten: Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q Thank you both for coming this afternoon. Dame Gill or Ms Patten—it is fairer to ask the question more generally—suppose the integrated care partnership itself put forward plans for the footprint. The integrated care board, under this draft legislation, has to pay due regard to that. If you disagreed with that as a board, how would you manage that? How would that be resolved? How would that manifest locally?

Dame Gill Morgan: The first thing is that you would try to make sure that you have developed a mechanism for engagement and trust, so that you do not get into those sorts of disagreements. If you get into those disagreements while you are sat around the board, you have failed to do the task of integration and partnership. That is what happens in the conversations about how we solve it. If we ever got into that sort of difficulty, it would have to be resolved at the integrated care board, and we will have local government, public health and social care on our board as full and equal partners.

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[The Chair]

Dr Whitford, did you have anything else?

[Dr Whitford]

Q It was really just about other groups. You talked about having a primary care sub-group, and there has been a lot of discussion about how to harvest voices up. Could you expand a little on how your sub-group is working and what other sub-groups you would have? How do you make sure the ICB pays attention to what the partnership comes up with? For me, from outside, it seems like it is the board that has the power in the end. Therefore, how do you ensure that? I understand the need for relationships, but what voices other than primary care are you bringing forward with sub-groups or other ways of working?

Dame Gill Morgan: There are a couple of statutory sub-groups that we are going to require, like accounts, audit and remuneration. More importantly, over the last few years, systems like ours have developed ways of handling finance and quality that have been about a partnership approach, so you do not have a head of quality covering all the organisations, but you have the heads of quality from all the organisations coming together to problem-solve. The heads of finance come together to work out how to allocate the money. That is a very, very effective way of doing it. It teases out the tensions and gets people who are expert in delivery in those conversations. We will have a number of committees like that. The question is: which ones of those become statutory? Which ones do you do through officers? Where do you build people in? All of them will have primary care build-in, because you cannot do service otherwise.

On the partnership forum, which is a different sort of animal, we had already got into the vehicle whereby the full ICB board took cognisance twice a year, because these outcome measures do not change very rapidly. All we do is talk about those longer-term agendas, so it is not just us saying, “Here’s our plan, over to you.” It is about saying, “What really worries you? How can we help? What is important? How do we do it?” We had a wonderful session on apprenticeships. NHS apprenticeship levy money is being used to support some of the stuff that county councils want to do. That would have never happened in the old days because we were not sat in a room with mutual trust and a single purpose.

At the heart of this, every ICB and every partnership board will have to define, “What’s my purpose? What’s your purpose? What’s our shared purpose?” That managerial trust-developing, partnership-developing work is what will make this a success. I started, and I was rapped across my knuckles by Mr McCabe for saying too much—quite appropriately. At the end of the day, you are not going to get that through legislation. You are going to get it by creating an environment and properly holding us to account for what we are doing in these boxes.

[Dr Whitford]

Q Obviously, we have heard a lot of discussion about voices that are missing or not listened to, so a sub-group approach might actually be a model for other areas to think about harvesting ideas up towards the partnership and the board.

Dame Gill Morgan: Indeed. This is guidance, not legislation, so we have to develop a constitution of what we are doing, and we are committed to reviewing it. If today we think that we know what we will need in three years’ time, we are not asking ourselves the right questions, so we need to be reviewing constantly. That is one of the things that we have historically been very bad at in the NHS. We do something, we enshrine it, and then a few years later we throw it all away and start with a new thing. How do we evaluate it? How do we say, “This has been brill, this has been flaky. Let’s get rid of the flaky, and let’s put more of the brill in”? It is that sort of managerial question with us, rather than the very flat, “How do you hit this today?”

[Dr Whitford]

Q Do you feel that there will be enough evaluation of what works and what has not worked within the structures that are being proposed through audit and formal evaluation?

Dame Gill Morgan: I personally think that we have to be very careful. I do not know if this is a role for legislation. A joke in the NHS is that pilots are phase 1 implementation. That is an old joke. It is not this Government; it is every Government. We have always said that. We have to be really careful that we build in evaluation across the piece and do not pick two or three metrics that look as if they have gone the bad way to prove what we wanted to argue before. That is done both in favour of things and against things, and we end up with this sort of noise in the system. Let us plan now and get a proper, effective academic unit to build in some evaluation at the end of this time, and then let us all take stock in two and a half years and say, “Hasn’t this been brilliant”—in my opinion, it will be brilliant—or, “It won’t do any harm, but it’ll be nothing”. We have got to do better than nothing.

You will gather that I am in favour of ICSs. [Laughter.]

[The Chair]

I think we drew that conclusion from your evidence—absolutely.

May I just thank you both very much for giving evidence today? I am sorry that I had to interrupt you, but I am an obsessive timekeeper. Such is life. Thank you very much.

Examination of Witnesses 

Ed Hammond and Andy Bell gave evidence.

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[The Chair]

Thank you. Dr Whitford.

[Dr Whitford]

Q Could I ask you a question, Ed? Obviously, you talked there about better outcomes. Regardless of who is judging it, you need evidence for that, and there are two aspects here to help to know what success looks like. From the perspective of local scrutiny of health improvement—improvement of health and wellbeing at a local population level—how do you see that being done? Obviously, that is what the ICB and ICP are being challenged with. Coming from a breast cancer background, where obviously you have specialist teams that need to be judged, what about the scrutiny of healthcare through quality improvement clinical outcome standards, which require audit and benchmarking against ICSs elsewhere in England, so that you do not have postcode variation in survival, treatment, or anything else? How do you see those two scrutinies working?

Ed Hammond: That is a challenge, because it brings into focus the role that different accountability partners play in the system. We have already heard a little about the CQC and the work it does in assessing and monitoring clinical outcomes. Of course, within ICBs and ICPs there will come to be—one would hope—robust and effective performance management arrangements. Certainly, looking at the Secretary of State’s expectations around the exercise of new powers, one would expect that, for the Secretary of State to understand where he chooses to intervene and direct services, that would be on the basis of evidence that would need to be collected in a consistent and systematic way across England, but also within individual ICBs. Presumably, we can expect some kind of performance framework to be established nationally to provide evidence to support the Secretary of State in the exercise of their powers.

Then at local level, you have, as I mentioned before, local Healthwatch and local health scrutiny communities. Now, local scrutiny committees obviously cannot bring the clinical expertise to bear on issues of concern; the CQC naturally leads on many of those issues. I think what those local partners in local Healthwatch and scrutiny committees can do is understand where there are gaps in the system; where there are concerns about aspects of performance that others have perhaps not picked up on; where there are concerns emerging from conversations within local communities that councillors are hearing about day to day, because they have direct contact with local people; and those concerns that might not otherwise find their way on to a performance scorecard, but might relate to things that are not being monitored, measured or managed particularly well. That local connection is a vital part of what makes health scrutiny work.

[Dr Whitford]

Q But you do think there would be a role for analysing data? My background is breast cancer. You know that what chemo you use and what surgery you did is going to affect the outcome for that woman in 10 years’ time, so in Scotland we have that in clinical standards. Those kinds of metrics would not necessarily go to the Secretary of State initially, but local teams want to improve and clinicians want to drive quality performance. Would that be something that you would be involved in developing; or who would be doing that?

Ed Hammond: Yes. Where ICBs and ICPs are putting those monitoring arrangements in place, I would certainly expect local clinicians to have a role in assessing, evaluating and analysing that data and evidence. As I have said, committees of local councillors would also be able to do that. I think we have a resource challenge in how that local government scrutiny operates, but as a matter of principle local councillors are increasingly adept at that data analysis, despite the fact that they may not be clinical experts. They are able to carry out some form of analysis. Collectively, we can see that, together, those partners can bring to bear a form of local accountability, primarily at system and place level.

[Dr Whitford]

Q A brief question to Andy: there has been discussion over recent years about the need for greater preventative public health. Do you think there is enough discussion or enabling of that approach in mental health? Although we may not do it, we all know what we should do to be physically fitter and healthier—how good we are is up to us. But many of the public have no idea how to protect their mental health. Do you think there is enough population and preventative mental health work? And are there ways of strengthening that in the Bill?

Andy Bell: We have hugely underinvested in it, and indeed very poorly appreciated it. What we have seen in recent years, which we hugely welcome, is huge progress on mental health awareness and understanding. That was not there 10 or 15 years ago. It has not been that long since in a debate in the House of Commons the first Member stood up and spoke about their own experience of mental illness; that was hugely powerful, and began quite a significant social movement. However, we do not yet have literacy around that issue, or indeed a real understanding about what we can do to promote the public’s mental health. With the creation of the new Office for Health Improvement and Disparities—I must remember to get the name right—there is an opportunity to make public mental health as important as public physical health. How we translate that to local areas will be really interesting.

When I talk to people working in local public health departments, I see a huge enthusiasm for and interest in how they can better support mental support in the communities they serve. We have seen incredibly creative work from around the country, such as in Leeds and Bristol, from public health teams that are leading the way who understand that the things that determine our mental health are very much about the society and environments we live in—the families we come from, the schools we go to, the amount of income we have, and the homes and neighbourhoods that we live in. There is a growing understanding of that. However, we have not yet put that into practice on a large scale, and indeed the resources available to public health departments to do that are very threadbare. Many have to be very creative in how they do that.

We very much welcomed the promotion and prevention fund set up recently by the Government, which gave funding to local authorities in the 40 most deprived local areas in England for mental health promotion activities. We are really looking forward to seeing what that money is used for, and we very much hope that it will be the beginning of something much bigger. Our worry, in relation to the Bill in particular, is the understanding of prevention, and indeed the understanding of prevention that I read in yesterday’s Command Paper on the health and social care plan. It is still based on physical health, and the idea that public health is about telling people how to live their lives and how they should behave, rather than what really determines our mental health: how much money we have coming into our home, how safe we feel, and our position in society. It is really clear that very often the way that economic and social inequalities affect our mental health also affects our physical health. Very often it is poor psychological wellbeing that leads to later physical health problems, so we really have to start taking public mental health as seriously as any other part of public health.

[Justin Madders]

Q I have just one question for you, Mr Hammond. You obviously have the ICB decisions being made. What, in your understanding of the Bill, would happen if—hopefully this will not happen, but we have to look at every possibility—the chief executive of the ICB was making decisions that the ICP and other partners were not in agreement with, and they effectively lost confidence in him? Is there any mechanism that would be able to deal with that situation?

Ed Hammond: The obvious mechanism is the Secretary of State’s power of intervention. It is all about that referral upwards really to the Secretary of State to act. Ideally, these kinds of things can and should be resolved through dialogue, because the Secretary of State can intervene only so much. One of my worries about the focus in certain elements of the Bill on the new and enhanced powers of the Secretary of State is that it sort of assumes that the Secretary of State will need to have fingers in lots of pies to be aware of where these issues are occurring across England, and be prepared to step in where they are happening, which requires the exercise of a significant watching brief across a wide range of areas in a way that does not currently happen.

Ideally, these kinds of things can and should be thrashed out by the people involved at local level. The Secretary of State can intervene but does that intervention persist if relationships have effectively broken down? What do you do then? You cannot run everything from Whitehall; there has to be some kind of mechanism to rebuild relationships and trust. One would hope that it would not get that bad, but I know of past tensions. There are divergent priorities between local authorities, NHS partners and other partners in respect of health and care issues. The logic of ICPs is that you are aligning those priorities better, but that is not guaranteed.

That is one of the reasons we consider that there should be a role sitting with local health scrutiny committees to escalate matters of particular concern to the Secretary of State, so there is not this assumption that the Secretary of State is exercising a continual watching brief over everything that is going on. There is that formal power of escalation from an external body holding the system to account that can, before that escalation, exert some kind of influence at local level to try to knock heads together and bring some form of agreement in place, so that you are not in a situation where you have a persistent assumption that Whitehall will need to step in in every case where these kinds of issues occur.

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[Karin Smyth]

Q May I take you back to the ideal person or Healthwatch person on the ICB? In my early days in management, in the 1990s, the community health council secretary and chair—I realise the situation was varied across the country—were important people locally. They had access culturally, and any changes to the system were expected to work with them. They had much access, regardless of their position on bodies. In my view, what has come since healthwatches were abolished—I will not say by who—has never really replicated that cultural relationship. You might wish to comment on that. Were you saying that having a person on the ICB would help with this situation, or is there another way in which we can embed a culture that recognises the importance of some sort of patient voice outwith the system?

Sir Robert Francis: First, there is no ideal person to do the job. I think that past iterations of what is now Healthwatch may have been slightly too full of people who were more interested in constitutional matters than the actual provision of health services. That was the impression I formed during the Stafford inquiry, but I think that is not true of Healthwatch. The presence of a Healthwatch person—by the way, this requires a new level of Healthwatch collaboration and function, but that is not difficult to provide in the Bill—will not produce, in itself, the culture that you talk of. The health service is still an organisation that, in the jargon, is top-down and is delivering things to people, rather than getting their ideas and responding to them. But the presence of the Healthwatch person, or some independent person, is at least a symbol of the need to have such a culture and to develop it. It will be someone whose principal task may be to question whether that culture is being led and developed.

If you have that person, you can back it up if you need to—in regulatory terms—with whatever form of systemic review the Care Quality Commission is tasked with doing. Its reports could certainly be a very valuable tool in relation to this, but you need a channel of communication between the ICB, if that is to be the centre of all this, and the wider world within its constituency. Unless there is someone whose independent role is to oversee whether that is happening, I am not sure it will. All organisations currently in the NHS have directors of engagement and communication. I suspect that, with the best will in the world, most of them see it as their job to defend the organisation. This is not about defending an organisation; it is about welcoming constructive comment from the public and responding to the needs that people communicate to them.

[Dr Whitford]

Q I want to look at the Health Services Safety Investigations Body, which is discussed in part 4 of the Bill. Obviously, you have been involved in the past with whistleblowers, Mid Staffs and so forth. We have talked a lot in recent years about learning, not blaming. What is your view on that part of the Bill? How do we protect what is given within the safe space, paralleling Air Accidents Investigation Branch, but give the public the confidence through Healthwatch that this is not stopping any other investigation happening now, and that taking that approach can get under the bonnet of real issues that have led to tragedy?

Sir Robert Francis: What I am about to say in answer to your question is my personal view. Healthwatch England, for reasons you will understand, does not have a view on that—apart from welcoming the existence of this body and the fact it has a statutory function. I confess to some concern about the safe place provisions, and I said this in part to a parliamentary Committee before. On the one hand, I fully endorse the need to protect people who come forward to give information—sometimes potentially damaging to themselves—so we can learn the relevant lessons of safety. Therefore, I absolutely support the idea that anything said in these circumstances cannot of itself be used to prosecute or discipline them, or indeed be used in civil proceedings.

On that point, as a lawyer, I would be very hesitant on the advice I would give to someone on the basis of the Bill as it stands, because there is no certainty that what goes into the safe space stays there. It is all a matter of discretion, albeit a High Court judge’s discretion or sometimes a coroner’s discretion. That would have to be worked out. It is probably difficult to reinforce more, but if it could be it should be.

However, I think that is different from denying bereaved families and victims of an incident, if they are still alive, knowledge of what has been said to the investigation board. At the very minimum, I would like to see there be discretion to share that information with families. I can see there may be circumstances in which that is not possible, and I can see that it might be necessary for there to be quite stringent conditions around what they personally can do with the information they are given. What worries me about the position at the moment is that it starts from a presumption of dividing the staff from the patient from the families, and you get straight into, I presume, an adversarial situation. That is not necessary the case, and if we work the system and the learning culture properly, everyone will be trying to contribute to learning rather than blaming each other. You are not going to get that if you are denying one half of the incident the information that the other half has.

[Dr Whitford]

Q When we took evidence from Keith Conradi, he said that obviously the learning from the safe space is in the reports, so there is discussion. Obviously there is no naming of people. Are you talking about the family or the patient having access to the raw data?

Sir Robert Francis: Yes, or something closer to it. After all, it is rather artificial. The family will often know the people involved in the treatment of their loved one. Where there is already likely to have been a breakdown of trust and confidence, this would be perpetuated and possibly increased if they are not given access to information that it is possible to share responsibly with them. I can see circumstances in which that would not be the case—that is why it would have to be discretionary—but I think many concerns of people I know who would have possibly been settled if only they had seen something more than they get in the report.

[Dr Whitford]

Q HSSIB does not remove the duty of candour or the need for a local trust or hospital to investigate. It should not remove the need for significant adverse event inquiries and discussion—the families not having been involved as an external on those. Often the family simply want to know what happened and that it will not happen again. However, we often talk about failures as system failure and that can be down to personality. It is not necessarily the case that staff are giving evidence that conflicts with the patient, but often it is quite sensitive things about poor personal relationships within a hospital or team that have had an impact, or a lack of something.

Sir Robert Francis: Often, if I may say so, things that patients and their relatives have seen for themselves. If I were a relative of someone who died in hospital and I was being told, “This is due to a systematic fault. It was not down to the nurse or the doctor,” I would want to know a bit more about that. I would want, if I could, to talk to those individuals so that they could perhaps learn a little more from the impact of all this on people. I am not saying that it should happen in all circumstances, but in order for the family to have a true understanding of it. It does not necessarily mean they need to know the names in that sort of case that you mentioned, but I do not think it should be automatically assumed that they will be excluded from that information.

[Dr Whitford]

But in what way—

[The Chair]

I know it is fascinating, but we had better go to Mr Norris.

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[The Chair]

Do you want to add anything, Ms Nosowska?

Gerry Nosowska: Yes, please. The issue with getting out of hospital is not about getting out of hospital; it is about getting your life back and getting back to your normal life. We know that reablement can be a really important part of that. The persistence, co-ordination and attention to the impact of a transition from hospital to home is something that social workers can really help with, and I do not think we should underestimate how potentially complex that can be. It is not just a question of somebody going back home and picking up where they left off.

Having really good support rapidly following up is absolutely essential. We have concerns about evidence of either inappropriate support or lack of support, support that has not been there or follow-up that has not happened. I would want us to be careful about checks and balances here.

[Dr Whitford]

Q May I start with you, Gerry? Do you think the provisions in the Bill will bring about genuine integration of health and social care, which is something that has been talked about through quite a lot of my lifetime in the NHS? If you could only change one thing in the Bill to get the best outcome from it, what would it be?

Gerry Nosowska: I think that this can achieve some strengthening of integration if it is not just a reorganisation that sucks in energy and resource, but a change that is absolutely about relationship, trust and understanding of local services, and it leads to a flow of resources and attention to that idea of home and community. There is potential, absolutely, but we have seen efforts to build integration before. What makes them work, certainly from a frontline point of view, is parity of esteem, trust, understanding and recognition of expertise, and relational time together.

One question I have is about how the integrated care partnership and the board have the appropriate input, the right people in there and the right people engaged, so that those relationships can really build, bearing in mind that we might be talking about quite a large area. We also have to make sure that from the point of view of the person who needs help or care, it is about their local community and neighbourhood. If I were going to change something, I would want to make sure that there was lived experience and social work expertise at the heart of those integrated structures.

[Dr Whitford]

Q A common theme that we have heard throughout both days of discussion is about how to capture the voices and the understanding from such a broad landscape within health and social care. In Scotland, we have been working on integration since about 2013. It is clear that in some areas it is massively successful and in other areas it is struggling. A lot of it comes down to relationships, understanding and willingness to step forward together.

May I ask you the same questions, Stephen? Do you think it will improve integration? What is the one thing you would change?

Stephen Chandler: I do believe that it will improve integration. As I said earlier, anything that helps those people who have yet to be convinced that integration is a good thing or provides them with some of the roadmaps for putting integration into place is great. From a local government point of view, strengthening the role that local government has in relation to the health and wellbeing of its citizens in the way that this does is good. I look forward to the refined guidance around the roles that health and wellbeing boards will have, because when I talk to my leader, I emphasise to her the importance that that gives her, as an elected member who chairs that board.

On whether I would change anything, we risk focusing a lot on either people who are acutely unwell or the elderly. From a local government and social care point of view, we work with people across their life course, including working-age adults, many of whom often have very complex underlying health and care needs. Recognising the need to ensure that health and care systems work well for a 25-year-old with learning disabilities who is trying to achieve his potential, or to help somebody with a severe and enduring mental illness to maintain their employment and therefore their accommodation, is really important.

Unfortunately, those voices are not always as obvious in what we are doing, but they are so important. I have been quoting this a lot of late, but each and every one of us is just one accident or life-changing illness away from needing that. We all recognise that we may need healthcare to deal with it, but very few of us think that we may then need and want the support of social care. In my case, if I had an accident or a significant stroke on the way home, I would need help maintaining my family. All the things we take for granted are only possible for a lot of people through the help that local government and social care provide, but doing that together with our health colleagues offers even greater opportunities.

[Dr Whitford]

Q As you say, we often think of the frail elderly when we think of social care, but is it not the case that the need for social care among working-age and younger people—you talked about learning difficulties and disability—is a growing and under-serviced area?

Stephen Chandler: It absolutely is. If you think of a young person with a complex health need associated with a learning disability, we need to work together to ensure that we are allowing them to maximise their potential while managing the risk associated with their health needs. For somebody who is coming out of the criminal justice system, maximising their potential to reintegrate into society, get a job and get a house is only possible if we work together. That is why integration must be much more than just a focus on the frail elderly.

[Dr Whitford]

Q So is there a bit of the Bill you would want to change? If we let you write an amendment, what would you write?

Stephen Chandler: I will come back to you on that. I cannot immediately think of a part.

[Justin Madders]

Q I have a couple of questions for Gerry. Your briefing made it clear that your members had a concern about discharge to assess; a clear majority said they did not support it, although the numbers are quite small. Would you say that is an accurate reflection of your overall membership?

Gerry Nosowska: It is a genuine concern, yes—partly because, as Stephen was saying, it was rolled out very rapidly, at scale, during an unusual and very pressured time. Social workers have often been involved in those transitions, and very well, to advocate and to ensure that the person’s voice is heard and that people do not get lost somewhere in the system or forgotten, but the concerns are around the potential weakening of that social work role.

Not everybody will need that, but I advocate for a social worker being available to anybody who might need that kind of co-ordination, therapeutic support and advocacy at the point of such a major life transition. We want a review of the model, but we also have concerns about just taking out wholesale all the elements around notification of social care and everything that was in the care Act. A lot will hinge on what the statutory guidance says about this. We must make sure we do not lose people in the system, because there is always an incentive to free up a valuable resource in hospital, but our statutory job is to promote wellbeing.