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.

Health and Care Bill (Third sitting)

Philippa Whitford Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

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

Chair, I am still a member of the British Medical Association.

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

I remain a member of the BMA.

[Mary Kelly Foy (City of Durham) (Lab)]

I am a member of Unison.

--- Later in debate ---

[The Chair]

Would anybody else like to ask a question from the Back Benches before I move to the Front-Bench spokespeople? Okay, that means that the SNP and Labour spokespeople have around 10 minutes. If they could keep it between nine and 10 minutes, that would be appreciated. I call Dr Philippa Whitford.

[Dr Whitford]

Q Thank you very much, Mrs Murray.

I will ask each of you the same question. Obviously, the aim of the Committee is to improve the Bill and bring in voices. Sara, if you could amend only one part of the Bill, what would it be, and what change do you think would improve it to the greatest degree? I know that you may have three or four—your submissions are here—but what do you want us to do that would have the biggest impact in improving what actually happens to health and social care?

Sara Gorton: I am going to choose something that I think none of the other people you hear from, except staff representative bodies, will pick up on. We would like to see the principle set out in the NHS constitution: to involve staff in decision making about how the service that they work in is set up and run, and in decisions that could affect the way they work. That principle is very clear in the NHS constitution; at the moment, with the system set up the way it is, that is transacted through the relationships that staff have with their employers at a provider level. If the system proposed in the Bill comes in, one of the risks is that that may be undercut by decisions made at ICS level. I think trade unions and staff would feel as though they had a stake and would be reassured that they had involvement in future decisions with workforce implications made by those new bits of the system if that pledge were placed in the legislation and were the underpinning principle.

[Dr Whitford]

Thank you very much. Certainly, for some of the projects in Scotland around quality improvement or patient safety, the involvement of staff has actually made that work. Dr Nagpaul, I am pinning you down to one area and one change that you think will make a big difference.

Dr Chaand Nagpaul: The area would be around collaboration. We would want the section 75 regulations to be amended to make the NHS the preferred provider where it is able to do that. As part of that, there would be legislative changes on the duties of foundation trusts and other NHS providers to collaborate. We believe that at the moment, the changes for section 75 do not tally with any such duty, and we find that providers are focused on their own budgets and balance sheets, so you are talking about collaboration but not enabling it. We would want both those changes.

[Dr Whitford]

Q Obviously, because of the duty of balancing budgets, one of the frictions within the system is going to be where an area that is managing its budget has to collaborate with a service—perhaps in social care—that is not. Clearly, the aim of the Bill is to bring about integration.

Dr Chaand Nagpaul: Can I come back on that? At the moment, we are seeing foundation trusts thinking about their budgets, community providers thinking about theirs, and general practice as well. There is not even collaboration between the community and the hospital. No foundation trust currently has the ability to say, for example, “We will go beyond our budget and invest in the community—it may actually reduce our hospital admissions.” At the moment there is no structure of processes to enable collaboration even within the NHS.

[Dr Whitford]

Q Do you not think that creating the overarching ICB is meant to look at that budget in a more holistic way?

Dr Chaand Nagpaul: It is only looking at it—like sitting around the table. We have had a lot of these arrangements in the past. Until you actually change the duty of a foundation trust to collaborate, so that its board meetings are no longer focused purely on its own balance sheet but actually look at the good of the local community as a statutory change, we do not think this will work. It will just be aspirational.

[Dr Whitford]

Q My second and final question to you both is about the healthcare safety investigations body. I was on the pre-legislative scrutiny Committee for it and I know there will be a lot of support for it across the House. However, on Tuesday we heard Keith Conradi’s concerns about disclosure of safe space material. As a representative of the BMA, what is your view about that part of the Bill—part 4—and the degree to which it protects or weakens safe space, and how do you think it will affect staff engagement with the process?

Dr Chaand Nagpaul: We are supportive of the concept of the HSIB. We know that the NHS is riddled with a fear culture and a targeting of individuals for systemic failures. Based upon the aviation industry, it is absolutely right to have arrangements whereby you can learn from serious incidents, and healthcare staff, doctors and patients have a safe place where they are free, without fear, to contribute and learn from such incidents.

What is important—this is something we learned from a previous episode involving a doctor called Doctor Bawa-Garba, where there were a lot of issues around her information being disclosed—is that safe places should be safe places. They should be legally privileged. That will allow us to make the NHS safer, because I think that openness will allow us to address the systemic issues that actually make up the majority of medical errors in our health service.

[Dr Whitford]

Q And yourself, Sara?

Sara Gorton: The HSSIB is not an area that we have covered and focused on in our response, but like the BMA we are strongly supportive of attempts to drive a just and learning culture across the NHS. We have participated, through the social partnership forum in the NHS, in trying to spread that culture, and we are strongly supportive of the Freedom To Speak Up Guardian programme that is in operation in the NHS in England and its interaction with staff and their representative bodies.

[Dr Whitford]

Q But you would support, as Dr Nagpaul says, the idea that safe space should be protected?

Sara Gorton: Yes, indeed—certainly no opposition to that.

[Dr Whitford]

Thank you very much.

[The Chair]

Thank you very much. I now turn to Justin Madders, the shadow spokesman.

--- Later in debate ---

[The Chair]

Thank you very much. We now turn to the SNP spokesperson, Dr Philippa Whitford. You have about seven minutes.

[Dr Whitford]

Q Thank you very much, Ms Murray. I hope to try to do two questions, so can you focus your answers? If you heard the earlier session, you will know what the first one is. If there is one part of the Bill that you could change, what would it be and what would the change be? Our job over the next couple of months is to improve the Bill, so what would get the biggest bang for our buck?

Pat Cullen: No surprise, it is the accountability for workforce planning sitting and resting with the Secretary of State. I do not think any legislator or politician should have any issue with that. It is not about accountability being forced and pushed to the frontline. Of course, frontline clinical staff will have accountability and responsibility for the delivery of care, but that needs to be enshrined in legislation, and the Secretary of State needs to hold full accountability for workforce assessment and planning, and for ensuring that we have the workforce to deliver the best care for our patients. We owe that to every single nurse in the services today.

[Dr Whitford]

Q Obviously, Wales and Scotland brought in safe staffing legislation, which does not yet exist in England. Of course, workforces move around, so although this is very much a plan for the workforce in England, we do not want to get into robbing Peter to pay Paul. Do you feel that the consultation around that needs to be strengthened—things such as the foundation places for junior doctors might relate more to Helen and Martin—to ensure that the Bill actually takes account of different strategies?

Pat Cullen: Absolutely, and of course we look with envy at Wales and Scotland, although Scotland is lagging behind our Welsh colleagues in terms of safe staffing legislation. We will certainly push for safe staffing legislation to be brought forward in England as well. Of course, it is no surprise to anyone that our wonderful nurses moved to industrial action in Northern Ireland to push not for pay, but for safe nurse staffing legislation. That is what is important to every single nurse who is trying to care for their patients today.

[Dr Whitford]

Q Thanks very much. Helen, what would you pick as your one place?

Professor Helen Stokes-Lampard: My one place is the same: the workforce issue and clause 33. It is about looking at both the supply of the workforce and the needs of the population—I think it has to be both those things. The responsibility rests with the Secretary of State.

Professor Martin Marshall: I have stated mine already: the strong general practice voice is what will make a difference. That is what will turn a currently fragmented service into an integrated one, and a service that is focused on treating diseases into one focused on preventing them.

[Dr Whitford]

Q This is also, hopefully, a very short, specific one—I will start with you, Martin—on the Healthcare Safety Investigation Body, and the issue of safe space disclosure and discussion after an incident. In the Bill, coroners have access, for example, and others are lobbying for access. What is your view of how tight the safe space should actually be to get staff to really engage with it?

Professor Martin Marshall: Considerably tighter than it is at the moment. I am absolutely in support of safe spaces. A culture change needs to happen here, and legislation seems to be one of the ways of trying to promote that to get us into a much happier space than at the moment.

[Dr Whitford]

Q Do you think there is a misunderstanding of what would be covered by “safe space”, in that it should really apply only to the evidence that HSIB gathers? It does not stop other bodies having access to medical records or doing their own investigations, which they do now.

Professor Martin Marshall: I am not sure I know enough about it to be able to answer that question, I am afraid.

Professor Helen Stokes-Lampard: The academy’s position is that we support the proposals as they are worded—we have not suggested any amendments to them. We certainly believe that putting HSIB on a more formal footing is the right thing to do. On what Martin said about safe spaces being the right thing going forward, there may be detail and finessing in the implementation of that, but no concerns have been raised with us as an organisation representing royal colleges.

[Dr Whitford]

And Pat?

[The Chair]

Pat, before you speak, could I ask you to swivel the microphone to your left towards you a bit? We are still having difficulty hearing you.

Pat Cullen: Can you hear me now? I do not know whether it is my accent or my voice.

It is no surprise to us that the Royal College of Nursing opposes—

[Dr Whitford]

Could you speak a wee bit louder? I am from Northern Ireland as well and we can definitely speak loudly when we want to.

Pat Cullen: We fundamentally oppose the power of the Secretary of State to authorise disclosure, and we will be looking for amendments. We believe that we must protect whistleblowers. They must come forward. That is the only way that we can learn lessons and make sure that our services are fit for purpose, and that we learn from that, so we will be looking for amendments.

[Dr Whitford]

Thank you very much. Thank you, Chair.

[The Chair]

Thank you. I now turn to the shadow Minister, Alex Norris.

Health and Care Bill (Second sitting)

Philippa Whitford Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

I will come to you in a second, Karin. I am just trying to balance it between the respective parties.

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

Q Obviously, a lot of the detail will only be there when the regulations are laid, but there has been a lot of concern in England about the talk of data being provided in a pseudonymised form to commercial companies. Is this not a repeat of the care.data issue, which lost public trust? A lot in these clauses could apply to Scotland. We have real issues in Scotland, where we have a lot of data sharing and analysis, and suddenly this gives NHS Digital to demand data, whether for a registry or for something else. It is about the commercial side; I do not think patients have an issue with Public Health England, universities or whoever learning from their data. The public concern is about the idea of pseudonymised data ending up with commercial companies.

Simon Madden: I completely understand that. We have to be very clear about what we mean by “commercial companies”, because pharmaceutical companies that develop treatments and vaccines are also commercial companies.

[Dr Whitford]

Q But the public are not comfortable with that.

Simon Madden: I get that, but there is no doubt that, in order to improve treatments, we need to contribute to research in some way.

You are absolutely right. It goes back to my trust and transparency point. One of the things that we signalled in the data strategy particularly was a movement towards trusted research environments. That is crucial. In some ways, what we have announced on GP data for planning and research is an acceleration of that work. We have said that data will not be shipped around or disseminated; it will be accessed only within the confines of a secure, trusted research environment, with full transparency about who has access, who runs what queries, and so on. It will be held and will not be shared. That is the general direction of travel that we want to see, and that is why we set that out in the data strategy.

We do not have to make a choice now between enabling access to data, or sharing data, and protecting privacy. Technology has allowed us to create environments where it is perfectly possible for data to be accessed safely and securely, with strict safeguards, without privacy being compromised.

[Dr Whitford]

Q That is the public concern. My concern is that the data in Scotland lives within NHS Scotland. It is not under this Parliament or anything else, and yet there is no mention of Scottish Ministers being able to say, “We will share it in an anonymous form. We will be able to break that code if there is a safety issue on a medicines registry or if a piece of research needs to be traced back to a patient.” You can set filters within your trusted environment without handing over pseudonymised data to a commercial pharmaceutical company.

Simon Madden: Data will not be handed over in a trusted research environment; it is only accessed in one place.

[Dr Whitford]

Q But by whom? That is the public concern. They have no issue with a public body. They are anxious and it goes right back to care.data. The danger is that it will set back your whole digital agenda if you get hundreds of thousands of the public all opting to not take part.

Simon Madden: I completely understand. That is why I mentioned that it is incumbent on us to have not only the right safeguards in place but the right narrative and to engage with the public so that they understand what those safeguards are, how they operate and how they can opt out of the system. One of the things we have been looking at in developing the final version of the data strategy following the engagement is how we can do much more on public trust and transparency. It is not just about a one-off marketing campaign; it is about an ongoing public dialogue and involvement of the public in future policy considerations. Again, it goes back to that resetting point; I think this is a reset moment. Technology now allows us to go that bit further than we have ever been able to go before in terms of protecting privacy, but we have to be in a stronger position to explain that to the public and how it all works.

[Karin Smyth]

Q I hope that this is in scope, Mr McCabe. I have just come from the Chamber, where the Prime Minister is still on his feet. He talked about integrated care records, but I am not quite sure if we are discussing the same thing. This may not be news to you, Mr Madden, but could you clarify whether we are all talking about the same thing? I appreciate that you were not there to hear the Prime Minister, but is it your understanding that what we are hearing today about social care is the same as the conversation we have been having about integrated care records, personal care records and so on?

Simon Madden: Forgive me, but I will take full advantage of the fact that I was not there and have not seen the statement that the Prime Minister made. A feature of our plans set out in the data strategy—not so much in terms of the Bill itself—is for each integrated care system to have a basic shared care record, so that throughout their whole health and care journey a patient or citizen does not have to do simple things like repeat test results or repeat their prescriptions, and so that their care journey between health and social care, with provisions for safeguarding and safeguarding information, is seamless.

--- Later in debate ---

[Karin Smyth]

Q If I may, I will return to the permissiveness and place conversation. I agree with the Bill’s direction of travel around place. I do not like the word “permissiveness”, because we have essentially a local cartel of healthcare providers deciding on resources and their allocation, and that locks out local communities. I am a bit suspicious of the NHS being given permission to do as it sees fit. That is why I put forward the example about ear wax removal—because that matters to local people, as we all know; that is what some of these things come down to.

The Bill falls apart because of the governance arrangements and the accountability, which does not follow the logic of place-based commissioning. My solution for the Government, should they wish to take it, is something around a good governance commission, based on the previous appointments commission-type process. It would bring in skilled people, with clear role descriptions, clear skills and a degree of independence. It would have the trust of local people, and would bring these very powerful chief executives together with local leaders to explain why, in Bristol, you cannot have ear wax removal, or why you are closing certain provision and opening it in Derbyshire or wherever. Have you had an opportunity to look at my proposal for a good governance commission and locally accountable chairs—perhaps elected, or appointed? What do you think of that as a solution that would bring power and accountability closer to local people?

Saffron Cordery: The issue of accountability is absolutely fundamental. One of the things we have not talked about much in this sitting, and which is not talked about that much, is the presence of two bodies in the system. We have the ICB, but also this partnership body that brings together a number of wider partners—particularly local government—with democratic accountability, which I think is really important.

I am wary of adding too much into the structures in the Bill. I understand your perspective on permissiveness, and we need to make sure that there are checks and balances across the whole system, but I would be wary of adding in another structure alongside everything we have. One of the features of this legislation, as I have said throughout the process—we have met the Department of Health and Social Care and talked to their Bill team, who have been very open and helpful—is that it does not really streamline in the way that it thinks it might. It adds to existing structures and processes, rather than starting from a clean sheet of paper and building something that might be deemed to be a good enough model; we will never get to the perfect model.

Right now, what we do not need is a root-and-branch dismantling of NHS structures and something wholly new put in their place, but I think there has been a missed opportunity to look at where we could streamline more. On that basis, I think it is important not to add more in, and it is fundamentally important that we look at the different roles and structures that already exist. From a trust provider perspective, working both at place and within provider collaboratives, and looking at the governance of unitary boards with non-executives and in some places also with governors and members, we see that there is that element of engagement with the community that you perhaps do not see in other places. I do not think it speaks entirely to your cartel point, but it is a step along the way that is well established and well used in many places.

This is a thorny and tricky issue. Using existing structures of accountability will be really important, as well as using the new ones, but I would not want to see anything new added in there.

Matthew Taylor: I largely agree with that, but another point is that if there is a broad policy thrust in this legislation, it is away from a medical model of health towards one that focuses more on social determinants. In the best partnerships—we talk often about West Yorkshire and Harrogate, for example—there is an incredibly strong relationship between health service leaders and local authority leaders. That will be a critical factor in the success of the system. When I look at the best practice emerging in the integrated care systems on issues such as prevention and population health, I see leaders starting to talk about issues such as housing, employment and public space, recognising their importance to health. In one way, that is a progressive move, and one that will probably lead to a louder voice for a variety of local interests, if we understand health much more in these socially determined terms, rather than simply through the medical model.

We had a big announcement today about social care reform, and there is a set of issues that are not in this Bill—issues around health and social care integration, how it will work and how accountability will work. It remains to be seen how the Government address that question.

[Dr Whitford]

Q Matthew, you mentioned that the degree of local integration varies, and that it is impacted by things such as boundaries—particularly the relationship between NHS and local government boundaries in the shift to a wider view of wellbeing. How much of a problem is it that the number and the footprints of the ICSs are different from those of the proposed sustainability and transformation plans? Are people who were growing together suddenly finding that they are no longer working together, and that they will have to start working with someone else? Do you not see that as something that will hold things back?

Matthew Taylor: It is a challenge.

[Dr Whitford]

Q Is it a necessary challenge?

Matthew Taylor: Whenever Government are faced with issues of boundaries, there is no solution that will not upset a lot of people, and this of course has been a vexed issue. I go back to the need for local flexibility. I will not name particular systems, because I do not want to speak for them, but I am thinking of two systems. In one, there have been many years of integration and collaboration, and an enormous amount of collaborative work. There, boundaries are probably much less important than they were in the past. In the other, an ICS is being established that will oversee two places—a city and a county that do not have an enormous amount in common. There, the ICS will have to develop its own proposition about the value that it will add. It would be a mistake for that system to want to draw up an enormous amount of power from two places that are working pretty effectively and would not benefit a great deal from deep integration.

The pattern is different from place to place. That is why we need to allow things to evolve in the light of local circumstances. It is always difficult when boundaries are not coterminous or shift. All I can say is that health services are used to these kinds of challenges, and most who have reached the top have probably worked through at least one of these challenges in the past, and know how to go about it as best they can.

[Dr Whitford]

Q Obviously, the delivery will be different, but the aim will be the same. What mechanism do you see evolving to allow the sharing of good practice? The integration of health and social care has been going ahead for seven years in Scotland, and we know how difficult it is. It is exactly as you say: some areas have made amazing innovations, and others are struggling. In what forum do you see one place being able to learn from another’s experience?

Matthew Taylor: That is a fascinating question. My view, which goes back many years, is that you need the right combination of strategy from the centre and identification of the right thing to do, where there is clearly one best thing to do, although Whitehall has a slight tendency to exaggerate the number of areas in which there is one best thing to do. Then you need peer-to-peer, or horizontal, learning. Providers and the confederation do a lot of work with our members to share best practice. A week will not pass without one of us publishing something around good practice, and bringing our members together to share that. This is another reason why it is important to have local difference. It is in a system of local difference that you will get more innovation. As long as you have innovation coming through, really strong organisations spreading good practice and a centre that focuses on where it can add value, you have the capacity for a self-improving system.

[Dr Whitford]

But how do you—

[The Chair]

I am wondering if we should hear from our other witness.

[Dr Whitford]

I was going to ask Matthew all my questions, and then go to Saffron with them all.

[The Chair]

Well, you only have about two minutes.

Matthew Taylor: By the way, I think it is important for us to learn from Scotland. We have been having a conversation in the confederation about the importance of recognising that we have different health systems now across the UK, and that there is an opportunity here for good learning.

[Dr Whitford]

Saffron?

Saffron Cordery: In the interests of time, I will say that I do not have a huge amount to add. Peer learning, peer challenge and peer support are absolutely critical. Variation, in its broadest sense, is important, and you can call that innovation or whatever you want. How you respond to local circumstances is critical. That is why cookie-cutter mode does not really work. Going back to your point on boundaries, they are, of course, a vexed issue. I know from my time in local government how vexed an issue it is there. Any kind of local government reorganisation can tie you up for years and years. It is worth remembering that boundaries were challenging at the start of this process. A number of STPs, which were the forerunners to ICSs, had boundaries imposed on them, rather than choosing those boundaries.

There have been a few policy developments that perhaps have not been as widely discussed as they might have been, including the fact that coterminosity with local government, although not necessarily the wrong step, was brought in relatively late in the day and did lead to some of the later boundary changes, as we have seen. I am not saying that that is wrong, but it demonstrates the need for wider discussion, consultation and engagement with the NHS and local government system as a whole before the decisions are made to help understand how best to do it. Sometimes just saying that it must happen and decreeing that is not the best way of making something a smooth operation that gets the best out of local systems. On occasions, there is something in the process of policy-making that could be looked at.

[The Chair]

We had better move on.

--- Later in debate ---

[Dr Davies]

Q Mr Trenholm, you referred to the fact that the CQC will be assessing ICSs in future, which was a recommendation of the Health and Social Care Committee. You also referred to oversight of social care provision. Can you clarify whether that is by virtue of your assessment of the ICSs as a whole, or is it through a local authority-targeted assessment that the Health and Social Care Committee has also called for in an Ofsted-style rating?

Ian Trenholm: Can we not call it a CQC-style rating? There are two separate things. The Bill currently contains an explicit provision about providing assurance on how a local authority is discharging its responsibilities in relation to the Care Act. That is important because the way in which care is commissioned is as important for outcomes as the way in which it is delivered. That is one part and that is a discrete piece of work. There is a broader piece of work that we are expecting Government to ask us to bring forward on assurance on ICSs. It will look at the ICS partnership board, how that works, the ICS strategy and so forth. They are two complementary pieces of work, but they are separate, as you describe.

[Dr Whitford]

Q Mr Conradi, you have talked about this coming from Air Accidents Investigation Branch, where the safe space is very tightly protected. That is very much as has been put forward. The key concern is the fact that coroners are listed in the Bill. The ombudsman is already lobbying and many of us are being lobbied to get access to safe space testimony. The Campaign for Freedom of Information is also lobbying for that. Will that not just kill it dead, in that you can compel people to come and give you testimony, but you cannot compel them to talk about all the soft weaknesses within a system that contributed to that tragedy or failure? Should it not be that maybe we need to define more tightly what is protected? All these bodies should be able to investigate as they do now. They are not losing anything because you would have safe space.

Keith Conradi: I totally agree with you. I think it will have a major impact on people’s wish to speak to us. It is not just me that thinks that; the medical unions have said that their members are concerned. The whole idea is that you want people to talk about, as you say, the “soft” things. They tend to be things like the culture of an organisation and the pressures that are brought upon them to do various pieces of work. In the past that has been a bit of an Achilles heel in terms of safety in the NHS. People have often been blamed for these things. They have been disciplined for speaking out—we talked about whistleblowers earlier.

Anything that we can do to bring that information up to an investigation body, which is not about blame and liability, is going to help patient safety in the long run. They will find their way into our final reports—that is the whole idea of getting this information. We want to encourage that as much as possible. I do not think this helps. I think a previous Joint Committee looked at a similar piece of legislation, and that came to exactly the same conclusion. As you say, what is the problem with other bodies such as coroners conducting their own interviews to get the same piece of information or any information they require?

[Dr Whitford]

Q I was on the pre-legislative scrutiny Committee and we spent a lot of our time debating this. It can be very easy as MPs to say, “Everything should be available to everyone.” In actual fact, we need to learn rather than blame. Obviously you do not want it to be with coroners, but do you think there needs to be redefinition within the Bill to make it clear that it is only the testimony and documents that you are holding? You are not stopping anyone else getting medical records, calling witnesses and doing what they should be doing now. The Bill almost gives the impression that you will squash other investigations.

Keith Conradi: Yes. In a way, the powers are so sweeping that they go well beyond what we think we would need, and well beyond what is used in other sectors—the transport sectors. We know that parallel investigations will take place into many of the things that we look at, and that is fine. The problem is that if we have these sweeping powers, which pretty much say that anything we touch or come across we then have to protect, and that we can then unwind and release some of them with a fairly bureaucratic process, that will be difficult in terms of transparency and our ability to share the information with others who have a legitimate need. The key things that we absolutely want to protect are statements given to us by witnesses and any draft notes, opinions and reports that we generate from doing the investigation. It is the final report that is our piece of work that we want to produce at the end of the day, and that is it.

[Dr Whitford]

Thank you. In the interests of time, I am happy with that.

Ian Trenholm: If I could make just one point, I think you are absolutely right: the broader responsibilities of an individual provider, particularly around such things as duty of candour, would still stand. Therefore, at an institutional level, people will still need to do the things that they always needed to do, but there is a very specific set of circumstances that Keith was describing where safe space may apply.

[Justin Madders]

Q I have a couple of questions for Mr Trenholm. You mentioned the importance of co-operation with other agencies. At the moment, are there barriers that the Bill could help with in terms of identifying people who may provide inadequate care under the guise of a company and then dissolve it, move on and create another? Is there anything in the Bill that will help you to track those people?

Ian Trenholm: I do not think that there is at an individual provider level. What you have just described is our normal registration regulation process at an individual provider level. As we start to look across individual places and ICSs, we might be able to talk to individual partnership boards about people who are operating locally, but I do not think the Bill explicitly gives us more powers to look at individual providers in any more detail than we already would as part of our normal registration process.

--- Later in debate ---

[Dr Whitford]

Q Obviously the pandemic has highlighted the impact of health inequalities and social and economic inequalities across the UK. Tackling them would be critical to improving population health, but how do you think the local systems will manage to balance need versus demand? Often we have the loudest voices expressing demand and the people with the greatest need are either silent or simply not listened to, so how will these changes help to get their voices listened to?

Professor Maggie Rae: That is right at the heart of health inequalities. If we did not know that before covid, we certainly know it now. An area where we could strengthen the legislation is in having that responsibility for all the people in your population. I led on health inequalities in the only time we have narrowed the gap, so health inequalities are not something that are just there and that we cannot do anything about except talk and say how sympathetic we are to them. We can deliver these changes. If we get the legislation and the organisational functionality, we will not change this unless we engage with communities. That is absolutely right, and we must engage with the local authorities.

Unless we target every intervention that we apply to the most disadvantaged and ensure that they have a good opportunity for uptake, we are widening health inequalities. I could take you to any health intervention, whether it is the covid vaccine, the flu vaccine, any uptake on health programmes or cancer screenings. They are all skewed to the most affluent population. In our country we want general population services, because we need everyone to be healthier, but we have to try to ensure that these organisations understand population need and know where the deprived populations are.

I have never met an MP or councillor who did not know where their deprived populations were, so we need those organisations to know that, but just knowing it is not enough. You have to then see the pattern of services and service delivery change to give a better chance to the people who need to take up these services. We have all understood that it is not that those people are hard to reach; it is just that we do not run the services to suit them and get a better uptake. I would like to see us concentrate on that. We probably cannot mention every single intervention, but for me it would not be enough to concentrate on obesity and fluoridation and think that the job is done on health. We have higher drug deaths than the rest of Europe—Scotland, as you know, is probably one of the worst in the world, if not the worst—and alcohol and all the other issues there, but I believe we can make a difference, and it will not take us 25 years if we focus on the right things, having the right interventions and making them readily available for people, and have a nice balance with what the NHS can do.

The NHS is the greatest service in the world and it can really help with health inequalities, but it cannot do it all. I am not an either/or person; we need the wider determinants and everything we can do that is place based through the local authorities, but we need the NHS to do that too.

[Dr Whitford]

Q Councillor Jamieson, this talks about a shift, which we have seen some of the devolved nations also following, from treating illness to trying to promote wellbeing in a holistic sense. A lot of that, as we have already touched on in this session, falls under local government. There is no budgetary discussion in this, but how much will that be impacted by the ability of local government to tackle the poverty and deprivation that are among the biggest drivers of ill health? As you say, housing, active travel, pollution and so on are your brief, but we know that local governments have been on a very tight financial leash for quite a long time.

Cllr James Jamieson: This is where the legislation is helpful, because it is enabling. The more we can move away from the NHS pound, the local government pound, the health pound or the DEFRA pound, and towards, “This is the pound for Newcastle or Cornwall; how can we achieve the best outcome for it?”, the better. I know that is difficult and, as you say, things such as housing, getting someone into a job or promoting active travel can make a massive difference to people’s health. They can make big differences, and having that forum and the opportunity to have those discussions is very helpful. A forum where we can start moving from investment in, as you rightly say, curing someone to preventing them from getting ill or, as Maggie said earlier, getting early cancer diagnoses is critical.

This Bill does provide a framework, but the important stuff will be the statutory and non-statutory guidelines and where the money is spent. That is very important, and we hope to see more spending on preventing and less on fixing a problem that need not happen.

[Dr Whitford]

You mentioned there—

[The Chair]

I am really sorry, but we had better move on to Alex Norris.

--- Later in debate ---

[The Chair]

Thank you. Do either of you wish to add anything to that?

Eluned Morgan: Lyn or Mari, do you have anything to add?

Mari Williams: No, thank you.

[Dr Whitford]

Q Obviously, as a Scottish MP, I echo the same concerns from the Scottish Government about these areas. Although it is largely billed as legislation for England, quite a lot of clauses extend further, yet there is often no mention even of consultation, let alone of consent. Certainly, one matter than concerns me is medical information, so what consultation did the Welsh Government have? Unlike Scotland, Wales is mentioned in the extent of the Bill, so how early were the Welsh Government consulted when it was being put together before its launch at the end of July, which is pretty much when the Scottish Government got to see it?

Eluned Morgan: To be fair, my officials have had regular meetings with the Bill and policy teams, and I have met once with Minister Argar to discuss the Bill. However, I am afraid that that did not lead to our key concerns being addressed before the Bill’s introduction.

I concur with you that we were really disappointed at the lateness of the notification of this Bill, and the absence of engagement with the Welsh Government in terms of the practicalities of the outcomes of discussions. For example, we received sight of the White Paper statement on the Bill only on the afternoon before it was published. We had sight of all the Bill’s clauses only the day before introduction. With the best will in the world, we have some brilliant officials in the Welsh Government, but even they cannot work at that supersonic speed. We did not have the opportunity to look at all the final clauses and to respond to them before the Bill was introduced.

The point is that if the UK Government are serious about saying that we will be consulted, this is not a good model for them to show us that we have been consulted. Their stated aim was, “In your areas, where the power is rightly yours, you will be consulted.” If this is the model that they are going to use, we are in for a really tough time. That is why I would concur with you that the real issue is that we want consent on areas that are rightfully and constitutionally ours.

[Dr Whitford]

Q We obviously heard in the Prime Minister’s statement today talk about spending directly in health and social care despite its being devolved.

May I ask you a short, specific question? The healthcare services safety investigation body is England-only at the moment, but it is described that investigations could be requested in Welsh cases due to people coming over the border. Is that something that the Welsh Government are considering? At what level would such a decision be made? Would that be a local request, or would it go up through your central structures?

Eluned Morgan: Lyn or Mari may want to come in here. The key thing to remember—Dr James Davies will be aware of this—is that a huge amount of cross-border working happens between Wales and England, so it is important that we understand each system. I do not think that we would have an objection in principle to working in the way that you suggest, but where, for example, there is a body that is “England and Wales”, it is rightly written in our legislation that we cannot be told what to do. It is not about the policy itself. For example, if there is an auditing issue, we will not go to war or have a fight about how something is audited; it is the process that we are concerned with. It is not that we would object, but it is rightfully in our power to determine whether we want to do something.

[Dr Whitford]

Q And that would apply also to things like sharing patient information of a certain type, and whether it was anonymised or pseudo-anonymised and so on? That would be a concern for you?

Eluned Morgan: Absolutely, and we are developing our own systems in relation to those things, of course. It is our patient information, and we should be deciding who has access to it and when.

[Alex Norris]

Q I thank you, Minister, and your officials for your time this afternoon. You mentioned correspondence with Ministers in the UK Government. Is that correspondence publicly available, or is it something you are willing to make publicly available?

Eluned Morgan: I am more than happy to send the correspondence that I have sent to Minister Argar to the Committee, so you can see it. It sets out all the issues that we are concerned with in relation to the Bill.

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.

Covid-19 Update

Philippa Whitford Excerpts

Thursday 22nd July 2021 Commons Chamber

[Nadhim Zahawi]

I will take those questions in reverse order. I thank the Chairman of the Select Committee, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), for his always diligent and thoughtful questions. As he will know, we gave the NHS in England an historic settlement in 2018 that will see its budget rise by £33.9 billion by 2023-24. We have provided over £27 billion to support the NHS in England since the start of the pandemic, including £9.7 billion so far for 2021-22. We will continue to make sure the NHS has everything it needs to continue supporting its staff and providing excellent care to the public, throughout the pandemic and beyond.

My right hon. Friend specifically asked about social care, and I know the Secretary of State and the Prime Minister are committed to making sure we deliver on our social care promise by the end of this year.

Public compliance is incredibly important, and I thank each and every person who has come forward and got themselves protected. Over the past few days, we have seen an almost doubling of the number of people going on to the NHS website to book appointments. There has almost been a doubling of appointments, too, which is incredible, considering where we are at the moment—we are almost touching 90% of all adults. These are the hard yards, and people are still coming forward. There are no easy decisions on this, as I said in answer to the shadow Health Secretary. We know that our most effective tool is the vaccination, but the second most effective is self-isolation. We are attempting to transition this virus from pandemic to endemic status. If we allow all these things to happen too rapidly and people then decide not to self-isolate, we run the risk of infection rates running away with us and challenging the strategy of our being the first major economy to transition. So we are working with business, and we are working flat out with the frontline critical infrastructure and key workers to get that guidance out. I am sure that colleagues in this House will be the first to receive it—I will make sure of that, even during recess.

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

I wish you, colleagues and all the House staff a safe and happy summer recess, Mr Speaker. Clearly, vaccination is critical to fighting this pandemic. We all need to encourage uptake among younger adults, but is the Minister in a position to guarantee sufficient supplies of Pfizer or Moderna vaccines to vaccinate them before the end of September? Whether this is done legally, as in the case of care homes staff, or through excluding people from social activities, does he recognise that making vaccination mandatory can increase distrust among those who are hesitant and drive them to become outright vaccine refusers? Despite the talk about caution, covid cases in England were already surging when the Government ploughed ahead with lifting all legal restrictions on Monday. Although vaccination has reduced the hospitalisation rate to between 2% and 3%, the Secretary of State suggested that covid cases could soar to 100,000 a day, which would result in 2,000 to 3,000 admissions, which is similar to what happened in the first wave. Does the Minister really not recognise that that would put health services under enormous pressure and cause the patient backlog to grow further? Are the Government even considering the impact of uncontrolled virus spread on vulnerable people, the incidence of long covid or the risk of generating yet another variant, with even greater vaccine resistance than delta? Finally, what contingencies are being put in place in case during recess the Government need to reintroduce covid restrictions, as has happened in Israel and the Netherlands?

[Nadhim Zahawi]

The hon. Lady makes a number of important points, especially the final one, where she reminded the House, as I did in my statement, that a number of countries have opened up and then had to reverse some of their decisions, which is why we are being very careful to ensure that this transition is successful and then that transitioning the virus from pandemic to endemic status is as successful as possible. She asked about children’s vaccination. She will know that the Scottish Health Minister, Humza Yousaf, has accepted, as the Welsh, Northern Irish and ourselves in England have done, the JCVI guidelines on vaccinating vulnerable children, children living with vulnerable adults and those approaching their 18th birthday. If the JCVI goes further, as it is reviewing more data on vaccinating all children, I assure her that we have available the supply of Pfizer and Moderna to undertake that, while we also continue to deliver on the double vaccinations of all adults by the end of September. She asked about the immunosuppressed and of course the guidelines have gone out on the precautionary measures that immunosuppressed people would take; similar to the rest of the country, they should be careful and wear masks in crowded indoor spaces—there is advice on ventilation as well. The JCVI has gone further in its interim advice for our booster campaign, where it has placed the immunosuppressed at the top of the priority list. That campaign will begin in early September—that is the operational target we are working to for beginning boosting and of course co-administering, wherever possible, the flu vaccination.

Cervical Screening

Philippa Whitford Excerpts

Monday 19th July 2021 Westminster Hall

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

It is an honour to serve under your chairmanship, Mr Pritchard. First, I want to extend my sympathy to Fiona’s family and friends, who were moved by her loss to set up the petition in her name. I have seen at first hand the impact of cervical cancer, as one of my friends lost her beautiful and vibrant daughter at the age of just 28 to this horrible disease. As a breast cancer surgeon for more than 30 years, I know the devastation caused by the death of any young woman.

Before we go further, I want to emphasise that any woman with symptoms of vaginal discharge or bleeding should not wait for a screening appointment, but should go and see her GP. There is usually a simple cause, but it is always important to get checked out.

Although the petition specifically calls for annual cervical smear tests, what we are all actually trying to achieve is the prevention and eventual elimination of cervical cancer, as called for by the World Health Organisation last August. For that we have to understand the cause of cervical cancer, and that is where our knowledge has developed considerably. We know that 99.7% of cervical cancers are caused by high risk strains of human papillomavirus, or HPV, and that is therefore the target of our efforts. This is through a two-pronged strategy, providing protection to the younger generation through vaccination against HPV and using more sensitive polymerase chain reaction testing to detect HPV on cervical smear samples to identify those at increased risk.

The HPV vaccine was introduced for young teenage girls in 2008 and initially included those up to 18 years, so that they would be vaccinated before leaving school. Research from the Scottish cervical screening programme in 2017 reported a reduction in the presence of HPV in the smears of vaccinated women from 30% to 4.5%, and by 2019 demonstrated an 89% fall in grade 3 cervical intraepithelial neoplasia—the cell changes that can evolve into cervical cancer if left untreated. That dramatic reduction in CIN 3 among the first cohort of vaccinated girls gives great hope that we will see a fall in cervical cancer in that age group in the coming years.

The vaccine is now also provided to boys, both to protect them from other HPV-related cancers and to provide additional protection to women by reducing how many men carry HPV in the first place. It is vaccination against HPV that really offers the chance to eliminate this terrible disease by the end of the decade. To achieve that, we need to vaccinate 90% of all teenagers, and our uptake rates have drifted below that level over the past five years. Some of that is likely due to fears that the vaccine was associated with health issues such as chronic fatigue or regional pain syndromes. However, a review by the European Medicines Agency found that those conditions were very common among teenagers generally, and there was no increase among those who had been vaccinated.

To reduce the risk of cervical cancer, we need to get rid of the stigma of HPV and ensure that all women and young people understand its importance in the development of cancer. It is a very common virus, which, in the vast majority of cases, causes no harm and is cleared by the body’s own defences, but some strains pose a higher risk of causing malignant change. After vaccination, the other critical approach to preventing cervical cancer is, of course, screening itself, but here too the focus is now on detecting HPV as the driver of cervical changes that can eventually lead to cancer. Classical cytology, which looks for abnormal cells within cervical smears, does not pick up every case, while PCR, about which we have heard so much during the pandemic, is more sensitive in detecting HPV and identifying the women at higher risk.

The UK National Screening Committee has therefore recommended changing to a two-step testing procedure, with the cervical sample tested for HPV first and then cytology performed on those samples that contain virus. Currently, that is carried out on one sample, which is collected in the traditional way—a clinician having to visualise the cervix directly. If the sample contains HPV, cytology is carried out on the cervical cells. If any changes are found, the patient is referred to a gynaecologist for a colposcopy, where the cervix is examined and biopsied to assess the grade of cell changes.

If the woman is HPV-positive but has no cell changes and therefore would never have been highlighted under the old system, she will undergo repeat screening the following year; if the virus persists after two years, even without cell changes, she will be referred for colposcopy. By focusing on the presence of the virus, women carrying HPV and at higher risk are provided with more intensive follow-up. It is the UK National Screening Committee that has recommended that women who are HPV-negative and therefore at very low risk are offered routine repeat screening every five years, from the ages of 25 to 65. That system has been fully rolled out in Scotland since March last year, but I highlight that the same approach is planned across all four UK nations once the PCR testing and data systems are in place.

Screening remains vital in detecting cervical cancer and its precursors in women who did not have the opportunity to be vaccinated against HPV. But uptake is at a 20-year low, with just over 70% of women attending overall. Attendance is even lower among younger women and those from minority ethnic groups or more deprived communities, as well as among lesbian or transgender people, who make mistakenly think that they are less at risk of HPV infections. The challenge is there for how to engage more women to take part in cervical screening. Changing to annual cervical examination might actually cause more women to withdraw from the programme.

HPV is found in only about 10% of cervical smear tests, so carrying out a simple vaginal swab to test for HPV could reduce the number of women who have to undergo a formal cervical smear with direct visualisation of the cervix. That would avoid the need to use a speculum and reduce the discomfort, which puts some women off taking up future appointments. It would also greatly reduce the difficulties experienced by those with physical or learning disabilities. Indeed, disabled women have been campaigning for years about the fact that those with the greatest physical difficulties often struggle to take part in screening at all.

A team at Dumfries and Galloway health board in Scotland established a trial in 2012 in which over 5,000 women took vaginal swabs themselves as well as getting a formal cervical smear done in the traditional way. That demonstrated both the accuracy and acceptability of this approach and the team is working with the Scottish Government to consider making that part of our routine screening programme. The UK National Screening Committee is still evaluating that approach, but research by Jo’s Cervical Cancer Trust suggests that this simpler method of sampling could get more women to engage and take up HPV testing as the first step of screening.

The issue is particularly important among groups that currently have a much higher risk of cancer but a lower engagement with a screening programme. NHS England has now begun a trial offering self-administered HPV swabs to 31,000 women in parts of London who have failed to attend their routine appointments. My one gripe with that excellent project was that the publicity and social media around its launch described the tests as self-administered smear tests instead of explaining that they were simple vaginal swabs, which a woman should easily be able to carry out at home. That caused a lot of consternation among women, who wondered how on earth they were meant to ensure that they visualised, or took a sample from, their own cervixes. It could put some off from trying to take the sample in the first place. Describing them as smear tests could also lead someone who is HPV-positive to fail to attend their GP practice for formal assessment, if they are under the mistaken impression that they have already had a cervical smear.

The NHS project in London is designed to engage those who have not taken up their routine invitations, but I hope that simple vaginal swabs to test for HPV will eventually become a routine step available to all women—whether self-administered in the privacy of their own home, or by a clinician in their local GP practice. HPV vaccination holds the potential to drastically reduce the number of young women who are even at risk of cervical cancer, but screening will always be important in order to detect cell changes or early cancer, and all of us need to encourage high uptake of both vaccination and screening. Although I recognise the anguish that led Fiona’s family to start the petition, I hope they can see that our understanding of this terrible disease and its cause opens up new and better approaches to eliminating cervical cancer in this coming decade, so that other families do not suffer the loss that they are going through.

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.

National Health Service

Philippa Whitford Excerpts

Tuesday 13th July 2021 Commons Chamber

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

I do not usually speak in the debates about statutory instruments on covid regulations as they apply only in England, but I feel I have to make a couple of points on the plan to make covid vaccination mandatory for all care home staff—the first mandatory vaccination legislation in the UK for well over a century.

As chair of the all-party parliamentary group on vaccinations for all, I totally support vaccination and I draw attention to our recent report, published in May, on how to improve the uptake of all vaccines. Virtually all our expert contributors highlighted the dangers of making vaccination legally mandatory because while it may force uptake among some, it tends to increase distrust and suspicion of vaccines and drive those who are hesitant to become vaccine refusers.

In Scotland, virtually 100% of care home staff are fully vaccinated with both doses, without mandating it. That has been achieved through three key policy approaches. First, as part of developing caring as a profession, care home staff in Scotland are now registered, which means we have information on who we are trying to reach. Secondly, when the Scottish Government became aware that care home staff were being deliberately targeted with disinformation on covid vaccines, they arranged expert webinars for staff with our chief medical officers and NHS director. Thirdly, as soon as the Pfizer vaccine became available in December, care home staff were vaccinated at the same visit as residents. That not only improved convenience, but created a strong sense of solidarity between colleagues and with the vulnerable people they care for.

The Scottish Government faced considerable criticism at the start of the year for spending so much time and effort on care homes rather than pushing ahead with mass vaccination centres, but it has paid off. We hear that in England, 86% of care home staff have received a first dose and 75% are fully vaccinated, although I understand that that hides a wide variation in uptake. While repeat visits have now been provided to care homes in England, that was not national policy at the start of the programme when many providers reported difficulty in accessing vaccine appointments for their staff.

The UK Government have never taken forward the principle of care staff registration and professionalisation in the care sector. As has been highlighted, staff in England are not even paid the real living wage. Care home staff have faced a very difficult time in the last 18 months and we all owe them a great debt of thanks. I still believe that locally targeted support, information and persuasion would be more successful in convincing care home staff than heavy-handed legislation, which threatens their jobs.

We all agree about the need to get the highest rate of vaccination possible to protect care home residents. The difference is in how to get there. Our APPG report makes it clear that the most important approach when dealing with communities with hesitancy is not to make assumptions about the cause but to listen to them and then act on what they are seeking.

Apart from my concerns about the principle of mandating vaccination, I call on the Minister to clarify that the legislation applies to England only. The Scottish Government do not accept the principle of making vaccines mandatory, nor do they see the need for such an approach after the fantastic uptake by our care home staff.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 13th July 2021 Commons Chamber

[Mr Speaker]

Mr Zeichner has withdrawn, so let us go to the SNP spokesperson.

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

The Government’s plan to give pharmaceutical firms access to pseudo-anonymised data from GP practices in England is creating public concern and distrust, just like the failed care.data project of 2013. Most patients would be happy to see better communication and information sharing within the NHS, as well as for public health and academic research, but are concerned about commercial access to their data. Will the Minister halt the process to allow time for genuine debate and public consultation?

[Jo Churchill]

The hon. Member and I are both passionate about the use of data to enhance patient care, as she outlined. That is the prize here. We are listening. We are taking our time. The data will only be used for health and care planning and research purposes by organisations that have a legal basis and a legitimate need to use the data. NHS Digital will publish all the details of the data we have shared on our data release register. We want to build confidence. We want to build trust. We are listening, but this is an important agenda that we need to get right to deliver better care for patients.

[Dr Whitford]

The problem is that the plan to allow commercial access is going to undermine the public trust in improving digitisation within the NHS, and the Minister will be aware of that. The current plans apply only to the NHS in England, but can she guarantee that the United Kingdom Internal Market Act 2020 will not be used to force commercial access to patient data from Scotland’s NHS? If so, can she explain why the Department for International Trade is advertising access to the health data of 65 million people, which is the population of the whole UK?

[Jo Churchill]

I go back to the answer I gave: we do not allow data to be used for commercial purposes. NHS Digital will not approve requests for data where the purpose is for marketing and so on and so forth. The hon. Member would not expect me to respond on behalf of another Department, but I reiterate that we are communicating and building trust. There will be a public information campaign. We will be working across the professions and across research to make sure that access is appropriate and proportionate. In the Health and Care Bill, we will be redoubling our efforts to make sure people have that confidence.

Covid-19 Update

Philippa Whitford Excerpts

Monday 12th July 2021 Commons Chamber

[Sajid Javid]

I am very happy to give my right hon. Friend that assurance. He made some excellent points. I thank him for his support for the Government’s action, but he is right to point out that there is still uncertainty for us and countries across the world in dealing with this pandemic. I am very pleased to assure him that if that risk matrix changes, for example with variants of concern, we will not hesitate to take the appropriate action.

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

I would first like to associate myself and my colleagues with the Health Secretary’s condemnation of the racism sadly faced by members of the England football team after their impressive performance throughout the Euros.

Turning to covid, the Secretary of State himself has suggested that covid cases could soar to 100,000 a day once all restrictions are removed next Monday. While research shows that hospitalisation rates have, thankfully, dropped to 3% of cases because of vaccination, that would still mean up to 3,000 admissions, the same as during the first wave. Can he explain how he will avoid such a surge putting pressure on health services, which would further delay clearance of the backlog of patients waiting with other conditions?

With the likelihood of such high transmission rates, how does the Secretary of State hope to prevent the generation in the UK of yet more new variants, perhaps with significant vaccine resistance? Evidence is growing of the debilitating impact of post-covid morbidity, and the Office for National Statistics estimates that it could affect 10% of those who have had the virus, so how does he plan to avoid an unacceptably high risk of long covid in young adults and children, who are not fully vaccinated?

Finally, why is the Secretary of State ending the mandatory wearing of masks in indoor spaces and on public transport, given that they reduce viral spread and cause no economic detriment? Does he not recognise that, as vulnerable people cannot count on others wearing masks, for them 19 July will not be freedom day but the exact opposite?

[Sajid Javid]

I thank the hon. Lady for what she said about the English football team, but I noticed that she did not say who she supported. I hope it was England.

The hon. Lady is right to raise hospitalisations, as other colleagues have. Of course, as cases rise, which sadly they will for the reasons I have set out, hospitalisations will rise too. However, again for reasons I have set out—No. 1 being the vaccine—the rate of hospitalisation will be far, far lower than anything we have seen before. She will also know, given her experience, that the treatments available are a lot better and more effective than what we had at the start of the pandemic and during the last wave. That is also helping should people, sadly, find themselves in hospital. That is part of the three tests, test number three, that we have looked at very carefully. We have looked at the data and we of course work very closely with our colleagues in the NHS on an almost minute-by-minute basis to ensure that the increased pressure—I accept there will be increased pressure; I have been very open about that—can be met in a sustained way.

The hon. Lady mentioned the backlog. It is important to understand that the backlog built up over the pandemic because people stayed away from the NHS for perfectly understandable reasons, but we need to start to get back to normal as quickly as we reasonably can so that we can start to see more and more people in the longer term and improve the backlog more quickly.

As for masks, I believe I have answered that question. The most important thing is that our guidelines will be very clear. They will be published later today, too.