My Lords, the noble Lord, Lord Young of Cookham, reminded us last Thursday that we have been talking about the social determinants of health and health inequalities for 40 years. It is now time to act. I want to get practical, and my three amendments are all about the practical detail—the “how” questions—about the transformation of the health culture and about new ways of thinking and working. My focus is on the first small, necessary steps on this journey.
Following my speech at Second Reading, I begin by thanking the noble Lord, Lord Kamall, for agreeing to meet with me and the chairman and CEO of Ashford and St Peter’s Hospitals NHS Foundation Trust in north-west Surrey and allowing us to share with him and his colleagues, in more detail, the work that we have been doing there in recent years. This is set out in Hansard. This work builds on 37 years of work that my colleagues and I have been doing at the Bromley by Bow Centre in east London on the integration and place-making agenda.
The principles of the work in Bromley-by-Bow are now well known and are being shared with communities right across this country, and this work is now starting to have a national reach, through the Well North Enterprises programme, which I lead. I declare my interests. The work in north-west Surrey is one further practical example of what happens when you start to take these principles to scale and apply them to the place and neighbourhood agenda, which I suggest needs to be strengthened in this legislation.
The Minister thought that it might be helpful to the House if I first set out the background to my three amendments, which are focused on the importance of place and the local neighbourhood, before dealing specifically with the first amendment on the Order Paper. What does a modern integrated health service actually look like, and how do we take the first faltering steps towards it? I suggest that the clues are in the micro: in the place and the local neighbourhood.
The NHS is in some difficulty, and much of the narrative that underpins it is from the last century and now well out of date. The chairman of Ashford and St Peter’s hospital describes it as a “financially unsustainable illness service”, not a health service. Science and modern understanding of the integrated nature of life and health have, in recent years, taught us a great deal about the social determinants of health. Ironically, the pandemic has forced all of us—the nation, if not the world—to return to the simple question: what is health? Nowadays, we all know that health is no longer simply a biomedical matter for doctors and hospitals—indeed, it never has been. The Peckham experiment on the social determinants of health was telling us all this early in the last century, but the NHS in 1948 thought that it knew better and chose not to continue with this approach.
Health is everybody’s business. It is not just the domain of health professionals, hospitals and just one government department. If 70% of the determinants of health are social, and if our present business model for the health service is unsustainable, we desperately need to return to the central question: what is health? What changes to the narrative on services and provisions does the state now need to make to respond to this modern understanding of what health is all about? We need to get upstream towards prevention and early intervention. For this modern generation, which takes integration for granted, the siloed approach of the state will no longer cut it.
Over the last 37 years, my colleagues and I have built practical working pathfinder projects in real neighbourhoods with local people. Others may well refer to these in this debate, so I will not waste the Committee’s time now. The Bromley by Bow Centre is in London’s East End and is well known nationally and internationally, but we have been involved in other projects. Today, the Bromley by Bow Centre is responsible for 43,000 patients on four sites in Poplar. Working with local partners, we have built the first independent housing company, which is resident controlled and has connected health, housing, education and jobs and business skills. Today, it brings together people from many nations of the world who live there, around practical place-making, health and social projects. This housing company now owns 10,000 properties, owns 34% of the land in Poplar and has in play a regeneration programme worth many millions of pounds.
Today, the Bromley by Bow centre is visited by over 2,000 people from the public sector and across the world, who we find are desperately asking the same questions as us. These are the practical questions—“how” questions—about how we bring together the health services, local authorities and voluntary and business sectors and generate a 360 degree response to people’s health needs and lives and the opportunities in local communities. This is not a simple matter, but I suggest that the place to start is not in the macro but in the micro: in local communities and neighbourhoods, where lots of talent and opportunity lie that are not being tapped and never will be if you do not join them up and develop a very different approach.
In 2015, Duncan Selbie, who at the time was CEO of Public Health England, asked me to take this place-making work and the working principles of the Bromley by Bow Centre into towns and cities in challenging communities across the country. In partnership with the NHS, local authorities and business and voluntary sector partners, we created 10 innovation platforms in Bradford, Rotherham, Skelmersdale, Doncaster et cetera. We did not write policy papers or research documents, which, in my experience, often few read; we created practical learning-by-doing environments. The clues that we have found are local—in people and relationships—and not necessarily national.
My three amendments seek to use this legislation to tap into this local talent to take the first steps on the road to integration, with a necessary focus on the local, the place, the neighbourhood and the community. Health is a social matter: it is not just about private individuals, and we now desperately need to get upstream on the health agenda in this country and move forward.
This legislation, and the integration White Paper that is soon to follow, can help us all take the first steps in this century in the transformation of the NHS. I suggest that the micro is the way into the macro; it is not the other way around. In local neighbourhoods across the country, at a human level, we now need to create innovation platforms in local places and neighbourhoods, with public sector leaders and local people willing to support and generate new integrated approaches to health, and learn from them. Let a thousand flowers bloom.
As we expand our work across the country through practical engagement, we are finding that lots of people already get all of this. Many of them are in the public sector and the NHS and are desperately frustrated with the present state of affairs. They want to be health creators, but the system is not harnessing their creativity and energy—so, often unintentionally, it is pouring treacle into their projects and disempowering them, creating an ill organisation.
This Bill and the forthcoming White Paper on integration provide us all with an opportunity to start to lay the foundation stones of a new modern health service which understands that health is no longer a matter for one department called the NHS. If what we eat, how we live, whether we have a job, et cetera, is as important—if not more so—than the doctor, this is a matter for every government department. The place to begin to understand what is now needed is local neighbourhoods across this country, to understand the significance of place, neighbourhood and local people and to use this legislation to help us take the first steps along this road.
The three amendments I have put down, focused on place and neighbourhood, are not perfect. This Bill is not perfect, but it might give us an environment to harness the energy out there in local communities and generate a health-creating society and a learning-by-doing culture. We need to create a solution-focused culture that is entrepreneurial by nature. The modern world is all about facilitating people and relationships in local communities. This is how entrepreneurial solution-focused communities emerge. It is not about central process, strategy and documents any more. It is not topdown or bottom-up; it is about an inside-out approach. As my colleagues and I have got inside local communities through the Well North Enterprises programme, we have spotted real opportunities to strengthen life and health that the present structures are failing to see.
In my Second Reading speech I set out what is happening in one place in north-west Surrey, where the local hospital, four local authorities, the voluntary sector and the business community are starting to build working relationships and do things together. Health is now everybody’s business. The three amendments are not the last word. They are simply an attempt to get this place-based discussion rolling and empower people at the front end in local neighbourhoods and places across the country through this legislation.
I will briefly deal with this first amendment. ICBs must be clear about what a place or neighbourhood is. Neighbourhoods across this country come in different shapes and sizes, be they a place such as Cranleigh village in east Surrey, where my colleagues are working on a new integrated leisure and health campus, with its population of 11,000, or Addlestone, where, with the local authority and health systems in the small town, we are working together on a possible health campus on the street—here, we are looking at 50,000 people. It is not the size that matters, but the local neighbourhood needs to feel real to local people and not an invention of the NHS and the public sector. It must be decided locally.
My professional colleagues in the NHS in north-west Surrey suggest that place-based groups are health and care partnerships at the level of places of a population of about 500,000, encompassing the key providers, which for my colleagues and I means at least NHS-commissioned health providers in that area, including primary care, social care and local government. The neighbourhood is more local and they would work with local partners to agree these. Only those living and working there can possibly know.
The ICS design framework published by NHSEI deals extensively with place-based collaborative partnerships as part of the structure of ICSs, so they are already recognised as part of the structure. For example, on page 23, the framework states that
“as part of the development of ICSs, we now expect that place-based partnerships are consistently recognised as key to the coordination and improvement of service planning and delivery, and as a forum to allow partners to collectively address wider determinants of health.”
Their contribution is acknowledged. My proposal is that they are formally recognised on ICBs as voting members.
We suggest that ICBs need to serve the needs of place and be led by a true understanding of health inequalities at a granular level. This can be done only through strong representation of those who are tasked with leading a place and thus come with an appreciation of those needs. This is about ensuring that an appropriate person, with real practical experience of delivering the necessary innovation in local neighbourhoods, has voting rights on the ICB. ICBs need to avoid intervening where it would be more appropriate to do so at a place-based level. Balanced judgment on this cannot take place without voting place-based members with appropriate skill and local knowledge. If the micro is now the way into the macro, this knowledge on the ICB is crucial.
The restructuring of CCGs into emerging ICBs has led to a high proportion of senior ICB posts being occupied by previous CCG officers. Moving to the new model will require new perspectives and behaviours to be introduced. This will require those who can balance a primary NHS commissioning paradigm and culture with one representing communities, the wider determinants of health and a wider range of sectoral interests. In reality, this will likely need to be quite disruptive for a time to achieve the change in approach that is now needed.
Through my discussions with health and care organisations, it is clear that, in aiming to deliver against the aims of the strategy, the details of implementation, procurement, practicalities, working relationships, understanding of local issues, specifics of local organisations, funding arrangements, et cetera, often get in the way of achieving what was actually intended. In setting strategies aimed at improving public health and decreasing pressure on the health and care services, strategies may particularly fail to specify the practical ways in which bringing together broad collaborations of local organisations to work on the social determinants of health will deliver measurable improvements in public health.
The people who work in these individual organisations and are, or will be, part of the place-based partnerships envisaged by the Bill are well aware of these issues of implementation. If the strategies designed by the ICPs are to succeed rather than be frustrated by implementation issues, it is important that they are set within an understanding of these issues. Mandating inclusion of a voting member on the ICB who is nominated by the place-based partnerships—a person of real local experience and track record—to represent them collectively in bringing these implementation details into the design of the strategy will enable better strategy to be set and better connectivity between strategy and implementation, bringing benefits faster to those whom the strategies intend to help.
I apologise for taking so much of the Committee’s time on this, the first of my amendments, but I thought it important to set out clearly the rationale behind them, based on practical experience on the ground over many years. I beg to move.
My Lords, I support these amendments and I especially support the noble Lord, Lord Mawson. It was typical of him that he started our thinking about what health is; I am sure there are many answers, but I think one of them might be integration—not just integration on the biggest scale but in terms of neighbourhoods, communities and what we now call place. That is so important. Those are the building blocks of all we are trying to do in the hierarchy of the National Health Service.
I am inspired by the noble Lord. He is a man of infinite resource and sagacity, an entrepreneur and, above all, a great achiever, based on solid principles which he believes in and, like a man of the cloth, is anxious to spread to others. He does so with really good effect.
It is no accident that I entitled my first report to the Government, many years ago when I was Mrs Cumberlege, Neighbourhood Nursing: A Focus for Care, as I believe the neighbourhood—or, in today’s parlance, the place—is all-important. This is what colours how people think, behave, succeed and, sometimes, fail. The noble Lord, Lord Mawson, has shown how even the most deprived areas can be rejuvenated and thrive with strong leadership, purpose and commitment. The noble Lord’s deep unshakeable philosophy is that patients, people and the local community should be the movers and shakers and be in control.
I want to mention Bromley by Bow, because it was a really innovative and new way of thinking about things. I remember visiting it years ago, not quite when it first started but when it was beginning to really thrive. Bromley by Bow was the first health centre in the country to be owned by the patients. Founded in 1984, it began with just 12 elderly patients, a rundown church, and just £400 in the bank. Today, by applying entrepreneurial principles to challenge social and health issues, it now has more than 250 staff. It is responsible for 43,000 patients, as the noble Lord said, and four health centre sites across Poplar. It operates on 30 sites even more widely across east London. It has supported local entrepreneurs. What is really interesting is that it has built 93 small and medium-sized enterprises. This is people helping themselves and ensuring that there is employment through a charitable structure, a housing company, which is controlled by the residents and now owns 10,000 properties and 34% of the land in Poplar.
This is a remarkable achievement in a very poor part of London. It is effective because it recognises that health and wealth are profoundly connected—not in huge municipal buildings and ivory towers remote from their populations but by the people who live and work in that area. The schemes are intertwined with the population. They are neighbourhood schemes and recognised as such. They are valued by being part of the destiny of a place in which local people live and work.
I visited Bromley by Bow in the early days, as I said, and I am really disappointed by my GP practice in the village in which I live and grew up. My father, one of two GPs, knew his patients literally inside and out. He knew who was getting off with whom. As his children, the first thing we learned was confidentiality and how to respect it, because we heard all sorts of things. He managed to get a health centre built. It is called that: above the entrance to the building it says, “The Health Centre”, but today it has been renamed the medical centre. It is a service that is not about health but about transacting to patients what the doctors think they need. The practice even shuns social prescribing, which is prevalent in many areas. It is also very careful not to involve the community. The friends of the health service have become disillusioned. They were established about 20 years ago and they are fed up with what is going on. Two weeks ago, they closed that organisation.
The noble Lord, Lord Mawson, in his Amendment 41A seeks to use the new world of integrated care boards to ensure that local representation is guaranteed. We have had a lot of debate in this Committee about who should be on what board and so on, but in listening to those debates—there was a big one last Tuesday—I was very struck by people talking about the big battalions. I could see that people were trying to ensure places on the integrated care boards that were represented by the big battalions. That is understandable. They are the component parts of the NHS. There are parliamentarians who see this as the only way forward.
The noble Lord, Lord Mawson, has shown us other ways, but it is a struggle. Today, the Bromley by Bow Centre has to deal with far too many sources of funding from the public sector. The money from the Treasury is disbursed to the silos: education, local government and other agencies. The centre spends too much time trying to put it back together again to deliver integrated projects. The centre runs hand to mouth, even after all these years, because mainstream funders in government do not recognise what the centre actually does. Schools, treatment centres, tertiary colleges, hospitals and traditional health centres are well understood, but Bromley by Bow does not fit any of these traditional silos.
I welcome the amendment and the others that follow it. The noble Lord is trying to free up the claustrophobic, traditional ways of not only working but, equally importantly, thinking. But the dilemma we face is this: warm words are given that we must not stifle innovation, but innovation is challenging. It is uncomfortable. When Henry Ford was describing his new invention, the motor car, he asked the public what they thought of it and what they would like. The reply he got was, “Just give us faster horses.”
We have a serious dilemma, as big government departments, especially the Department of Health, are about providing the same standard of health and the same provision across our nation. Again, we have a debate on that concerning Scotland, Wales and Northern Ireland. But even the nation grumbles as soon as it perceives a postcode lottery appearing.
Trying to square this circle is really difficult. The department seeks change through laborious systems. Those are the tools it has. Big departments deliver to the nation through their own power lines. This amendment threatens a short circuit that might set the structure alight or give the department an electric shock. That is no reason not to try. People of stature and proven trustworthiness who are competent and prepared to take responsibility for their innovations and to report to the department, say, every two or three years an audited evaluation of the scheme’s progress and outcomes, should be supported. It might help to square the circle, because if the funders of public money have to be accountable, this is one way of doing it.
I support not only innovation but these amendments. I urge both Ministers to risk their all: to let new ideas for places in need, through special workable collaboration, have their head. If we want to level up, then let us be brave and let sparks fly, because it is time to get behind people with a proven track record who are entrepreneurial, not people who talk and write reports about it.
The noble Lord, Lord Mawson, has taught us that the future is about creating a learning-by-doing culture, as he mentioned in his introduction. That is the culture that we want in the NHS, where the whole system learns through best practice on the ground, in real places with real people. Where things are not working, let people such as the noble Lord intervene and turn problems into opportunities. He has spent his life doing just that.
Seeing is believing. I encourage my noble friend on the Front Bench to visit Bromley-by-Bow, as a past Minister, Sir Brian Mawhinney, did. He ensured the future of this enterprise for a few more years and enabled it to flourish. I know that ministerial diaries are a real challenge, having had one, but I assure my noble friend that a visit to Bromley-by-Bow will never be forgotten and will make a deep impression.
Might I have some clarification from the noble Lord, Lord Mawson? He and the noble Baroness, Lady Cumberlege, have referred to three amendments and I can see only one. I would be grateful if he could enlighten me on which the other two amendments are that we might be addressing in this debate.
My Lords, it is a huge pleasure to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Cumberlege. I have signed and strongly support all the amendments tabled by the noble Lord to ensure that integrated care boards are closely connected to local communities. We have riches yet to come: the noble Lord’s later amendments ensure that local solutions are prioritised, and that procurement is firmly rooted in local communities, but I will speak only to Amendment 41A.
I will give an example of when the noble Lord and I have been involved in another project, beyond the very important Bromley-by-Bow project that the noble Baroness, Lady Cumberlege, talked about; namely, the St Paul’s Way Transformation Project, the health, education, jobs and skills, and community campus which started in 2006. It is a great example of a response to the local challenges faced in an east London neighbourhood very close to Bromley-by-Bow, with failing health and education services and community relationships. This transformation project was focused on integration from day one and has been a huge success.
The noble Baroness, Lady Cumberlege, talked about the extraordinary track record of the noble Lord, Lord Mawson, as a social entrepreneur. He launched this project in partnership with the NHS and Tower Hamlets Council, and brought together the local authority, the local school, the GP network, the local housing association, Poplar Housing and Regeneration Community Association, and the diocese of London, to bring about transformational change in and around St Paul’s Way, a main street running through Poplar. Together they built a new secondary school, new primary school, new health centre, new mosque, new community centre and restaurant, new park, new street scene and 595 new homes. In parallel with this, the quality of the local leadership, and hence of local service provision, was transformed. The failing secondary school moved to Ofsted outstanding, the failed GP practice was replaced and its successor became CQC outstanding, and the independently monitored residents’ satisfaction level is currently 85%.
The St Paul’s Way project has been a great success story of local partnership with other local actors. For example, near neighbour Queen Mary University of London, the governing body of which I chair, with two campuses in Tower Hamlets, and which is intimately involved in the governance of St Paul’s Way Trust School, helped design and develop the school’s new science labs. They are in the health building, which the school uses and where we have taken space for our school of dentistry and DNA research.
Partners in the local schools, the GP practice and the housing association have played an important role in recent years, as they have shared their work and experience with communities in towns and cities across the north of England and now beyond. However, the project faces major challenges, as outdated NHS procurement systems are now in danger of undermining the good work that it has been doing for over a decade. Amid this project being put together, the PCT procured a primary healthcare provider with no London experience, let alone any local experience. After two years, it surrendered the contract because it had not understood that primary healthcare is very different and costs a lot more to deliver in Poplar than in affluent suburbs. This experience is an illustration of the importance of there being a neighbourhood voice in the making of decisions by the NHS, which, if they are got wrong, can damage the ability of local integrated partnerships to function and develop effectively at the neighbourhood level. There is an opportunity to address this in legislation.
In this light, how can the Government make integration a reality? This is a clear example of disconnects that will be replicated on other streets across the country, and a demonstration of what happens when the NHS procurement systems and policy do not take place and neighbourhood seriously. Health is about bringing people and communities together, not undermining them. The solutions are often local and not in large outdated systems and processes. This local approach must be embraced. It is at the 50,000-person neighbourhood level, not an enormous eight-borough ICS where integration aimed at innovation in prevention and recovery can be most effective. Neighbourhood must be understood, valued, and given leverage in the system and flexible use of budgets. It is at this level that the actual practical interventions can happen. It is here that schools, housing, job opportunities and community action can happen. Neighbourhoods can act with speed and agility.
The noble Baroness, Lady Cumberlege, suggested that the Ministers visit Bromley-by-Bow; equally, I suggest a visit to the St Paul’s Way transformation project. This amendment is as much about creating the right culture as the right representative structure. I hope that the Government accept this important amendment and the other amendments tabled by the noble Lord, Lord Mawson, on this subject.
My Lords, I too was very happy to sign this amendment. I will speak only to it. I congratulate the noble Baroness, Lady Cumberlege, on her very moving speech, and the noble Lord, Lord Mawson, on a very comprehensive speech. I will be brief. In view of the logic of everything that I have heard in debates on previous amendments this afternoon, this amendment is even more important than I thought. When the Committee is discussing how to make the ICBs as effective, powerful, salient and comprehensive as possible for the people that they are bound to serve, all these factors must be taken into consideration, but the power of place itself and the opportunity that the ICB creates to make this manifest, just as the noble Lord, Lord Mawson, has made manifest in Bow, is a unique and highly innovative opportunity, and one which may not come again.
What the noble Lord proposes is extremely modest. It is to give just one person from the partnership voting power. However, it is essential, and it is in the spirit and the logic of what place-based partnerships are intended to do. It means that on the ICB there will be people who can bring nearsight, access and reach into the community to the decisions of the ICBs. They can help to inform those decisions, to bring that knowledge and sensitivity of the lives that people live, what they are faced with, and their specific choices. They are one of the most optimistic partnerships and ideas that we have had in this House for some years.
I have spoken many times in this House on the power of place, what it can achieve and how it affects people’s lives, particularly their health. The noble Lord, Lord Clement-Jones, and I published quite a useful report on building better places when we were on the same committee a few years ago. We diagnosed the relationship between good design, good buildings, good environments and good health. Maybe it is time to get that back off the shelf.
What is also useful is that the partnership principle is alive and well and is generating good practice. There is increasing evidence that it works and that there is an increasing exchange of ideas and skills, and we are learning all the time about what is possible. There is nothing to be said against this.
The expertise that the partnership can offer to the ICB may come from different partners. I am particularly interested, for example, in the role that housing providers could have, and I am sure the noble Lord, Lord Best, will speak to this in his amendment. They will bring a perspective from the point of view of the tenant, and the diseases of poverty in poor housing, which the board will need to hear, and act on.
Equally, there could be a role for mental health providers who know why young people cannot access mental health support. They know where the bottlenecks are, and what is needed. The partnership will choose for itself who will represent it, who has the most effective voice and who knows the place, as has been said this afternoon. But the essential criterion is that they know what will be delivered best.
I hope noble Lords will indulge me for a moment as I share a bit of history, because this has a very long history. In 1889, Charles Booth in his maps in Life and Labour of the People in London literally mapped disease against places and housing conditions—the stews of London—in a graphic illustration of where the worst concentrations of poverty were. In so doing, he redefined both health and poverty. Significantly, the first evidence came from the school boards and the local policemen: real partners in place. He certainly understood that you could not reduce inequalities or promote good health unless you had decent housing, fresh air and a decent wage. The geography of poverty has not changed that much—it is still the geography of disease and premature death—and the prescription has not changed at all. This amendment is an opportunity to put that into immediate and direct practice.
I hope that the Minister does not need much persuasion on this. It is a very simple and a very necessary amendment, and he would certainly have the support of the Committee in entertaining it.
My Lords, I declare my interest as an adviser to Well North Enterprises, which was mentioned by the noble Lord, Lord Mawson. I congratulate him, and other noble Lords from different parts of the House who have spoken on this amendment, on making the whole issue extremely clear.
I will make a few very specific points. First, we have heard about great big projects making a massive different. Everyone in your Lordships’ House, I am sure, knows of smaller examples that are making a real difference, as well as the larger examples, and how the small examples are important and add up.
Secondly, this is about change happening locally, but it is also about what is happening globally. I have previously quoted, in this House, a saying by a friend of mine, who used to run the Ugandan health service, that “Health is made at home, hospitals are for repairs”. It is a powerful expression, and one might say that health is made at home and in the community, and in the workplace and in the school. It also contains the notion that health can be created; it is not just about preventing disease.
Noble Lords may like to know that, more recently, globally, the WHO published the Geneva Charter for Well-being at the end of December, which explicitly talks about the creation of a “well-being society”. So this is a global movement we are talking about, not just a local one—although, as the noble Lord, Lord Mawson, has continually emphasised, this is about the importance of practical changes at the local level.
I will make two final points. The big one is that when we think about the membership of the ICBs, it is important we have the insiders there—the clinicians and the people who know how the systems work—but we also need some outsiders there. Referring to the debate on the last group, this is not just about different skill sets; it is about different behaviours and doing different things in different ways. Those of us who have worked within the system are bound by the system and think in terms of the system and its regularities.
The sort of people the noble Lord, Lord Mawson, is talking about do not start by thinking about the system; they start by basing things on relationships and learning by doing—a point that he emphasised. So there are different ways of doing things, and it is important that, as these boards are constructed, they bring in people with that different approach, alongside the great knowledge and skill that NHS and other clinicians bring to this. I know that we will really achieve success by bringing together insiders and outsiders, and getting people working together and understanding how to do things.
My final point is that this amendment proposes having a person representing or drawn from these groups on the ICB. I recognise the debate that has been going on about tying the hands of local people about what is happening on these ICBs. I understand that as these things get larger not only are you including more voices but also, implicitly, you are including more vetoes. The health service has, over the years, suffered from having too many people with too many vetoes in terms of making change happen.
I understand the complexity and difficulty here, but the final part of my point is to ask the Minister a question. I asked him a question earlier, because—I do not know whether I am alone here—I am not sure that I understand how, in reality, all these bits will fit together and work together in this new structure. I know he committed, in an earlier part of the debate on the Bill, to providing us with a diagram and perhaps more of an explanation of how it will all work. I can see how the complexities of everything we are talking about here can be difficult.
The single point I want to reinforce is the importance of not just having insiders in the decision-making process, but also having more disruptive influences. It is not just about skill sets; it is about different ways of thinking and behaving, and a focus on relationships, not just on systems.
I support the Bill precisely because integration will be key to delivering the health outcomes that we all seek. But I worry that, if the Bill is just rearranging the organisational deckchairs, with exactly the same people in different organisations with different three-letter acronyms, we will not change anything at all.
I think that, over the course of the nearly three days we have spent in Committee and on Second Reading, there is cross-party agreement on the nature of the problem we are trying to solve. In each debate we have had over the last two and a half days, whether on health inequalities, mental health, the social determinants of health, or person-centred digitally enabled care, there has been extraordinary cross-party agreement on the nature of the problem. As the noble Lord, Lord Clement-Jones, said, we are debating and disagreeing more on the means to the ends than anything else.
One of the means to the ends is local—genuine local ownership and leadership. Like many in your Lordships’ House, I have made the pilgrimage to Bromley by Bow and I have also been to St Paul’s Way. When I first joined the NHS, about five years ago, I was told to go to Bromley by Bow, and I was told by a number of NHS insiders how brilliant it was, but how impossible it was to replicate anywhere else. “Go and have a look at it, Dido,” they said, “because you’ll be amazed and impressed, but no one’s worked out how to spread it”.
What I have actually discovered, as we have heard today from people with far more experience of place-based leadership than I have, is that brilliant though Bromley by Bow is, it is not alone. There are fantastic place-based leaders in communities across the country. It is those local groups and leaders who we owe the exit from Covid to more than anyone else, I suspect.
I have had the privilege of working alongside them. I have been to north-west Surrey with the noble Lord, Lord Mawson, but also to Wolverhampton, to the Guru Nanak Sikh gurdwara, one of the first local testing sites for NHS Test and Trace. I have been to Gloucester and spent time with Gloucester FM, a local community radio station that for the first time in its existence got funding to run an advertising campaign to encourage people to come and get vaccinated in the local community. That was the first time it had succeeded in working collaboratively with the local NHS.
I have been across the country in the last two years talking to people from groups who feel excluded. Whether it is the Roma Gypsy community, Travellers, refugees, taxi drivers or faith leaders from a whole host of communities, all have told me—in both my previous role as chair of NHS Improvement and as executive chair of NHS Test and Trace—how in different ways they felt excluded not just from the NHS but from society in general. They also said, generally to a man and a woman, how hard the NHS is to work with when you are from a small, outside local group, as those of us who have worked in the NHS know.
It is with that knowledge base that I wholeheartedly endorse the spirit of the amendment of the noble Lord, Lord Mawson—but with a “but”. I have been consistent in the last two and a half days of Committee in being nervous about adding specific roles and experiences to what is now a growing list of characteristics and past experience we would all like to see in this new three-letter acronym NHS entity, the integrated care board.
I would like to post a question to the Minister. It is clear that we need these local voices—the grit in the oyster, as my noble friend Lady Cumberlege described it; the difference that the noble Lord, Lord Crisp, is referencing; people from outside the system—if this new reorganisation is going to be anything more than a rearranging of the deck chairs. How will we ensure that those local voices are genuinely heard in an integrated care board?
My Lords, I rise to support the amendment in the name of my noble friend Mawson and others, and in so doing congratulate him on his thoughtful introduction. It is clear that one of the most important aspects, and the purpose, of this Bill is to ensure integration at a local level. But the purpose of that integration must surely be—as has been confirmed by the Minister—to improve health outcomes for the entire population. It is well recognised that that can happen only if the social determinants of health in local communities are addressed appropriately and effectively, in a way that our health system has not been able to do to date.
If we accept that to be the purpose, then local integration—that focus on and understanding of the social determinants of health—and responding to local needs must be secured in the organisation of the integrated care systems and their boards. As we have heard from the noble Lord, Lord Mawson, and others, to achieve that, one must not only understand, appreciate and hear the local voice, but be clear that the culture that is established in these systems is responsive to those voices and is determined to act on them and the understanding of the local situation—particularly those social determinants that extend far beyond what has been and can be delivered through healthcare alone—and focus on other issues such as housing, education and employment. It would be most helpful if the Minister, in answering this debate, could explain how that is going to be achieved in the proposed construction of the integrated care boards.
Of course, one recognises that Her Majesty’s Government are deeply committed to this agenda. But it is clear that if these boards are not constructed in such a way that they can change the culture and drive, in an effective and determined fashion, a recognition of those social determinants and create opportunities at a local level to address them, much of the purpose of this well meant and well accepted proposal for greater integrated care at a local level will fail.
My Lords, I did not originally intend to contribute to this debate. However, I would like to thank the noble Lord, Lord Mawson, for his Amendment 41A, which, although modest in scope, has initiated an extremely useful debate and raised a lot of important issues. I do not want to add a lot of material to the debate, but I want to focus on the questions that have emerged from it.
It will not surprise noble Lords to know that I have been to Bromley by Bow, as shadow Secretary of State, and as Secretary of State in the company of Sam Everington, now Sir Sam, who was and is an advocate for clinical commissioning. I put on the record that we must not lose sight of the value of clinically-led commissioning in delivering best-quality outcomes in healthcare. I do not think it is the Government’s intention to lose that, but we need to make sure it is not lost sight of.
Taking the example of Bromley by Bow, where did it get to? It had the Tower Hamlets clinical commissioning group, which was once CCG of the year, an exemplar in this field. That CCG and others eventually came together in a large conglomerate operation—I think the noble Lord, Lord Kakkar, will know it very well—the seven CCGs in north-east London. A population of about 2 million eventually came together in one large organisation.
We started out with clinical commissioning groups whose understanding was that they need to work with local authorities through the health and well-being boards. They needed additional powers for the integration, which is absolutely fine. But as I said on Second Reading, we have ended up with the NHS and its management getting themselves in a terrible twist in terms of organisational structures and geography. The noble Lord, Lord Mawson, talked about place-based partnerships with a population of half a million. The noble Baroness, Lady Cumberlege, talked about place and localities with a 50,000 population. My point is that the 2012 legislation, even if it did not achieve what was intended, at least said that clinical commissioning groups could determine whatever population they like—they could set it at whatever level made sense. They ended up with about 300,000, on average, but the range goes from 30,000 to 800,000.
I do not think we should get obsessed with geography. We should still, even at this late stage, be letting the ICS achieve what it needs to by being a relatively large organisation with the capacity to do population health management and to manage commissioning at a higher level. Going back to what my noble friend Lord Hunt of Wirral said, it should be bigger—this is the key to why size matters—in the jungle than the big provider trusts, making sure that conflicts of interest do not arise and the providers do not run the commissioning. But then, if you have a big ICS, there is a big gap. How is place and local leadership going to be incorporated? The noble Lord, Lord Mawson, rightly talks about it being represented on the integrated care board. But where is it in the Bill? I know that NHS England, NHS Improvement and the Local Government Association have produced guidance and referred to place-based partnerships being an integral factor in the Bill. But I do not see it in the Bill. It is not there. How are we going to put it in the Bill? How are we are going to make sure it happens? How are we going to achieve the objective that the integrated care boards genuinely integrate health, social care and the whole range of those services, which in my view is what they should do, in order to deliver health?
The integrated care partnership, incorporating health and well-being boards, should be about achieving the social determinants of health. I depart from the noble Lord, Lord Kakkar, in that I do not think it is the job of the health system to deliver the social determinants of health. It is the job of government to deliver the improvement in well-being and health that is implied by moving in the right direction on the social determinants. The integrated care partnership is where that should happen.
I see no reason why the clinical commissioning groups cannot be a place-based, clinically led basis for creating place—they are going to be abolished, but in that sense, why are we doing that, since they already exist? Secondly—to repeat a point—health and well-being boards to my mind are the basis for creating an integrated care partnership that is the essence of well-being. That seems to me a much simpler structure. I was accused a decade ago of making it all too complicated; it is now at risk of becoming even more complicated. Let us at least start with what we have, which is exactly what they did in north-east London. They came together and said, “Look, for the three boroughs of Newham, Tower Hamlets and Waltham Forest we can create something that is large enough to work, and inside it we have the borough-based relationships which are the method that we ourselves apply locally to deliver the health and well-being that we hope to achieve”.
So I ask my noble friend, at this stage—as we are just starting out on this—whether he would be kind enough to show us where in the Bill the essential element of place is to be inserted. Then we can debate it further and put it into the Bill in its right form.
I thank noble Lords for what has been a very interesting and important debate. I thank the noble Lord, Lord Mawson, for his amendment, and I look forward to further development of the thought process that he has put before the Committee. Of course, it is not new. I started my working life working for Michael Young, the great sociologist in Bethnal Green, and we talked about ethnographic research in our neighbourhoods and places. It was about giving people who lived in those places power and developing their own leadership of what they wanted to happen. Of course, in those days, when he started doing his work, it was about regenerating inner London—the bomb-strewn East End. I had the great privilege of running the Young Foundation: a few years ago, I took a couple of years off from this job here to go and run it, and we were doing exactly the place-based work that the noble Lord, Lord Mawson, talked about.
The noble Baroness, Lady Harding, is completely right: there are many Bromley by Bow-type programmes across the country—and thank goodness for that. If the Minister decides to go on trips to places, Bromley by Bow is of course important. I went there when it started out, when I was the founding chair of Social Enterprise UK, and the noble Lord, Lord Lansley, is quite right: it is brilliant, it is wonderful, it does great work —but why has it not been replicated? That is a question I have discussed with the noble Lord, Lord Mawson, on and off over many years. But there are many other types, and I suggest that the Minister might go to Manchester, Bradford or Nottingham, where there are some brilliant programmes where this place-based delivery of healthcare and other care is thriving.
The consensus breaking out between myself and the noble Lord, Lord Lansley, is of course that this Bill is an opportunity: how and where in the Bill can that place-based initiative be expressed? Where is it and how can it be encouraged? The King’s Fund did a piece of work developing place-based partnerships as part of the process leading up to the Bill, which was published last year. It has some interesting and useful things which express the sorts of sentiments—but in NHS-speak—that the noble Lord, Lord Mawson, talked about today: the importance of connecting communities, jointly planning and co-ordinating services, making the best of financial resources, supporting the local workforce, and driving improvements through local oversight and quality provision. There are certain elements of this which need to be there and need somehow to be built into the Bill, possibly in enabling form, because they mean building multiagency partnerships which involve local government, NHS organisations, voluntary service organisations, social enterprises and the communities themselves.
The noble Lord, Lord Mawson, rightly asks in his amendment for one voting ICB board member to be nominated by place-based partnerships. That may or may not be a good way forward, but we are trying to do systems change and, whether or not putting one person on a board is the way to do that, it is a very good place to start. So we on these Benches are very interested in how this develops and want to be part of the discussions across the House about how we do that.
My Lords, no one is better placed, whether inside or outside your Lordships’ House, to advocate place-based partnerships than the noble Lord, Lord Mawson. I know he will remember that one of my first visits as a Health Minister in 2010, at his invitation, was to Bromley by Bow. What I learned that day made a deep impression on me, so I, like many noble Lords, need no convincing of the case that he and other speakers have made today.
I am aware that the noble Lord, Lord Hunt of Kings Heath, has tabled Amendment 165 on place-based arrangements, to be debated by this Committee later in our proceedings, so no doubt we will cover the issues in more detail then. For now, I say that the Government absolutely agree with the importance of having strong place-based elements in ICBs. Place-based structures will play an important role in delivering healthcare services for their population groups and we expect there to be open and clear lines of communication between the board of the ICB and place-based structures.
How is a sense of place given—as it were—tangible substance and meaning? I would argue that we do not necessarily need the Bill to articulate the reality. At a very basic level, an ICB will cover a geographic area. We would expect ICBs to be closely linked to their places via bodies such as health and well-being boards, where they will sit as the successor bodies to CCGs, and local authorities. ICBs will sit on the integrated care partnership as well as the health and well-being boards. Both bodies are vital in bringing together health, social care, public health and, potentially, wider views as well. That will be part and parcel of delivering their duty to involve patients, carers and the public when discharging their functions.
We expect ICBs to have place-based structures in place, but we do not want to prescribe what those structures are. As the noble Lord, Lord Mawson, said himself, we do not want ICBs to think that place-based partnerships are achievable via a central blueprint, or that a set of instructions from above is likely to be a substitute for learning by doing and local relationships. What we shall insist on is that an ICB sets out the arrangements for the exercise of its functions clearly in its constitution. Different areas have different needs, and I hope it is a point of agreement across the Committee that a one-size-fits-all model would not be appropriate.
I heard what the noble Lord, Lord Mawson, said about the need to join up strategy with implementation and having an individual whose job it is to oversee this. That may often be the way that ICBs choose to go, but we feel that requiring voting rights for place-based partnerships is simply not necessary and would come at a bureaucratic cost. Our view is that we should not attempt to overlegislate for the composition of ICBs. Instead, we should let them evolve as effective local entities to reflect their local needs. I hope the noble Lord, Lord Mawson, will forgive me for not wanting to pepper the Bill with requirements and duties for ICBs. If we want to make a thousand flowers bloom, I do not think this is the way to achieve that. I fear that the amendment would risk making the boards less nimble, undermining their ability to make important decisions efficiently.
Having said that, I am not at all suggesting that the centre should wash its hands of this agenda. In answer, in particular, to my noble friend Lady Harding, NHS England will be keeping a close eye on the constitutions of ICBs, and we expect the assessment that NHS England makes will include whether there are suitable place-based structures and whether there is clarity about the expectations and roles of those structures, including what they are responsible for commissioning, what powers have been delegated to them and what resources they are responsible for.
With those points in mind and looking forward, as I say, to our further debates on the subject, I hope that this assures noble Lords that the Government have this agenda very firmly in their sights and that NHS England has equally. Therefore, I hope that the noble Lord will be able to withdraw his amendment, in the knowledge that I am sure we shall have further things to say on this important subject.
My Lords, I thank the Minister for those thoughts and comments. I also thank noble Lords who have supported this amendment and this very encouraging debate. The purpose of today was to open up a discussion about these issues. They have been very well aired and I think the discussion needs to go further. Certainly, I would like to take further with the Minister and his colleague the discussion around the implications. My concern is to ensure that the significance of place and neighbourhood and that the role of the micro is absolutely clear at an ICB level. Senior colleagues in the NHS where I am working warn me to be very careful about this. The danger is that fine words will be used, but as others have said, this is not about words; this is about understanding the actions that now need to take place to really transform the health service. The micro and the macro need to learn to dance together, and that will not happen unless there is greater clarity on it. It has been a helpful conversation and one that I hope will be taken further.
I have a few final thoughts. It has been good to have colleagues from different parties and very different backgrounds in this discussion, which I have found very helpful. This is not a party-political matter; this is about the next 20 or 30 years of the National Health Service. There are likely to be different Governments and different parties with responsibility, but laying the foundation stones correctly and getting the detail right—it is all about the devil in the detail, in my view—is really important.
It was very interesting to hear bits of the history. It was Lord Michael Young who came to see me, many years ago, in Bromley by Bow, precisely because he got very interested in what we were doing. It was not just that he joined us as a community and became our patron—we have had patrons from different parties; Lord Peyton from the Conservative Party was a patron for many years, as was Lord Ennals from the Labour Party. Lord Young ended up asking me to marry him and his new wife. I had to do the marriage, and eventually the baptism of his child, so there is a long history. Allison Trimble, my former chief executive, was called to work in the King’s Fund precisely to help it understand the devil in the detail of what we were discovering, so this debate brought back many memories for me.
One of the last few things to say is that it is important in this journey that we create a learning-by-doing culture. This culture is very well known to science. In part of my life, I work with Professor Brian Cox, who knows a thing or two about science. I think the reason we get on is that we both understand that science and entrepreneurship are profoundly connected. It is not just the health service, in my view, but the whole public sector that needs now to embrace a learning-by-doing culture that moves beyond strategy and process into learning from the practical things it does and does not do.
Finally, I thank Suzanne Rankin, the chief executive of Ashford and St Peter’s Hospitals, and the chairman, Andy Field—Suzanne is a brilliant chief exec and Andy is a rather excellent chairman—for joining in this conversation with the Minister. I also thank colleagues from the hospital, who I think we would agree have been very brave, and who have now, with four local authorities, set out on a journey to lead the way in Surrey on what this might mean when you start to move it to scale. Having said that, I beg leave to withdraw the amendment.
Amendment 41A withdrawn.
Amendment 41B not moved.