Integrated Care

Steve Barclay Excerpts

Thursday 6th September 2018 Westminster Hall

[The Minister for Health (Stephen Barclay)]

indicated assent.

[Dr Wollaston]

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

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

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

--- Later in debate ---

[The Minister for Health (Stephen Barclay)]

Thank you, Dame Cheryl, it is a pleasure once again to serve under your chairmanship. I join the hon. Member for Ellesmere Port and Neston (Justin Madders) in paying tribute to my hon. Friend the Member for Totnes (Dr Wollaston) as Chair of the Health and Social Care Committee, and to all the members of the Committee, for a very good report and for raising important issues regularly on behalf of the NHS and the wider health fraternity.

As a country, we are living longer, which clearly is to be celebrated. However, it means that people live with multiple long-term and more complex conditions. For the NHS to continue to deliver high-quality care as it has done for the last 70 years, it is increasingly important for NHS services to work closely with social care. We got a flavour of that from a number of the remarks made in the debate.

I very much welcome the Committee’s conclusion that fears that integration might lead to privatisation are unfounded. Indeed, the Chair of the Committee said,

“The evidence to our inquiry was that ACOs,”—

now referred to as integrated care partnerships—

“and other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”

That relates to some of the points I will make on pre-legislative scrutiny and points to the value of the work done by the Health and Social Care Committee to provide a cross-party view of proposals, which has allowed us to address some of the myths built up in the past. The Committee has done the House a service by slaying some of those misconceptions.

[Dr Wollaston]

I thank the Minister for referring to my remarks, but does he accept that the Committee went on to say that we felt the issue of privatisation should be put beyond doubt in legislation?

--- Later in debate ---

[Stephen Barclay]

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

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

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

[Ms Karen Buck in the Chair]

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

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

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

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

[Dr Whitford]

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

[Stephen Barclay]

The Prime Minister has set out that it will be for the NHS itself to come forward, rather than for the Government to specify legislative change in a top-down way. As part of the long-term plan, the NHS will determine what can be done within the existing framework and whether change is needed. That will flow from the work that comes forward later in the autumn from Simon Stevens, Ian Dalton and others in the NHS, who are best placed to lead.

[Dr Paul Williams]

In the short time the Minister has left, will he will address the invitation he was given categorically to rule out integrated care providers being private sector organisations? Does he accept that the language he has used—he said the NHS will continue to be free at the point of use—increases concerns about private sector provision?

[Ms Karen Buck (in the Chair)]

Order. Minister, in responding, will you be mindful of the time and the need to leave the Chair of the Select Committee a couple of minutes to respond?

[Stephen Barclay]

Indeed I will, Ms Buck.

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

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

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

[Dr Whitford]

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

[Stephen Barclay]

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

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