Examination of Witnesses

Health and Care Bill – in a Public Bill Committee at 9:29 am on 7th September 2021.

Alert me about debates like this

Amanda Pritchard and Mark Cubbon gave evidence.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall 10:30 am, 7th September 2021

We will now hear from Amanda Pritchard, the chief executive of NHS England, and Mark Cubbon, the chief operating officer of NHS England and NHS Improvement. Both witnesses are appearing via Zoom, and we will run this session until 11.25 am. Could the witnesses please introduce themselves for the record?

Amanda Pritchard:

Good morning. I am Amanda Pritchard, the chief executive of NHS England.

Mark Cubbon:

Good morning. My name is Mark Cubbon, and I am the interim chief operating officer at NHS England and NHS Improvement.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Q Welcome to our witnesses. Ms Pritchard, welcome to your new role.

We have just heard some interesting evidence, and I want us to be very specific about our terminology when we refer to integrated care systems, integrated care partnerships and the integrated care board. In your view, who is accountable for the spending in my local area under the new arrangements? Approximately £1.5 billion is spent in the local area. In the new system, who is accountable for that spend?

Amanda Pritchard:

Thank you. If I start, Mark can come in and add. In the new proposals, the integrated care board carries the statutory responsibility, on behalf of the NHS, for the allocation of spending, performance management and the delivery of NHS services within the system. That, of course, has a delegated set of responsibilities, as per the current commissioning arrangements, down to individual organisations—be they groups of GPs, hospitals or community services— for the spend within those organisations, but the accountable part of the system is the integrated care board. As the proposals set out, it has a very important relationship with the integrated care partnership, but without the line accountability for the funding flowing through that part of the structure.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Q That is really helpful and very clear. The chief executive and the finance director of the integrated care board are clearly accountable. To whom are they accountable?

Amanda Pritchard:

In the current structure, they are accountable through the NHS—sorry, not the current structure, because you are talking about the future structure. In the proposed future structure, they would be accountable to a combined NHS England and NHS Improvement structure. At the moment, we operate that through seven regions, and then through to the national NHSEI executive. We are, in turn, accountable to Parliament.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Q So when I have an issue that I want to bring to my local integrated care board’s finance director and chief executive, I will take it through to NHS England and then back to Parliament, of which I am obviously a Member. At what stage does the Secretary of State get involved with my issue?

Amanda Pritchard:

We have a clear accountability to Parliament through the Secretary of State in the current structure, and the Bill is not proposing that that will change. The other thing that we should say is that CCGs have a clear accountability to involve the public and patients in their decision making. Again, in the current proposals, that responsibility would transfer through to the new integrated care system, and particularly the integrated care board. While we just talked about formal line accountability, that does not detract from the clear expectation that flows through, that the integrated care board would have accountability to involve the public and to consult with them. The transparency that is expected now of the CCGs and NHS organisations is written into the expectations and would flow through to the expectations of the new integrated care boards.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Can I ask about clause 20, which is about externally financed development agreements? In your view, is there a role in that clause to develop primary care and community estate? I am particularly interested in whether that provides the ability to continue the LIFT arrangements that were undertaken by primary care trusts but not by CCGs.Q

Amanda Pritchard:

I do not believe, although I may ask Mark to come in on the detail, that there is any proposed change to those arrangements. Mark, would you like to pick this one up?

Mark Cubbon:

Thank you, Amanda. I am not aware that there is any significant change proposed by the Bill to the arrangements in place at the moment.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

So how do we, in the system, ensure the development of primary and community estate? Are we in the queue with the Treasury, behind the 40 or whatever hospitals? Is there any way in which we can develop primary and community estate within the scope of the Bill? If we cannot do that through the Bill, how do we do it?Q

Amanda Pritchard:

I will give you a headline answer, because I think this is really important. Part of what we would welcome in the Bill is that, by working as a system, one of the things that all partners will want to do is to come round the table together to make some of those important decisions about where the investment goes. In particular, if we are thinking about capital, I know there are examples already of where organisations have chosen to invest in community estate, additional diagnostics facilities or other parts of primary care estate. In fact, Mark and I were on a visit a few weeks ago to an ICS where they were telling us about some of the work they have done on that.

Moving to looking at system funding envelopes, particularly around capital, allows much more flexibility about how some of that resource is used in the interests of the whole population and the whole health system, rather than, at the moment, where putting things into slightly more siloed funding arrangements can end up being detrimental to certain parts of the system.

That comes back to some of the guiding principles of why the NHS has welcomed, certainly, the thrust of these proposals where integrated care is concerned, because it is all about building on some of the direction of travel that has been in the NHS for some time about trying to work much more collaboratively together. This helps remove some of the barriers that currently exist, for local systems to do that.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Q Just to be clear, where would this capital come into the system? Presumably it would come to the ICB, as the accountable body. Where would the capital separately come from?

Amanda Pritchard:

Through the existing capital allocation processes. Rather than just going to each individual organisation to then make their own decisions about how they spend it, it would now go through the ICB, so there is a process that allows consideration in the round of how the system spends that money most effectively on behalf of its entire population.

Photo of Jo Gideon Jo Gideon Conservative, Stoke-on-Trent Central

Thank you, Chair. I would like to expand on the previous questions. It is my understanding that the integrated cared boards are the accountable bodies when the funds come in. But is the spending—the actual allocation funds—to be delegated down to integrated care partnerships, or is that at the discretion of individual integrated care boards?Q

Amanda Pritchard:

Again, I will ask Mark to add to this if he would like to. At the moment, the proposal is that funding would go formally through the integrated care board. The expectation is that, in developing the constitution and the detailed ways of working for each integrated care board, they would describe how the decision making is done, at not just the ICB level, but the place level, with the expectation that part of the principle would be subsidiarity.

If you are looking at the most sensible place for making decisions, for big, strategic investment the oversight of the overall allocative decision making may well sit best at ICB level; if you are talking about something that might have more of a borough footprint—thinking about London—you would want a lot of the decisions about local services, community primary care services and capital decision making to support those local initiatives to be made there. There would be a number of layers within the ICB involved in that decision making, but ultimate accountability would sit with the ICB itself.

Mark Cubbon:

The only thing I would add is that this is essentially why we are bringing leaders together to form the ICS body. The key thing will be how the resources allocated to that ICS can be deployed in such a way that strategic objectives can be delivered. The allocation down to place, as you have said, is important so that decision making can be as local as possible to where the service is, so clinicians and frontline staff can make the changes they want in order to deliver improved outcomes for their patients.

Photo of Jo Gideon Jo Gideon Conservative, Stoke-on-Trent Central

Q If I understand you correctly, place sits within the partnership rather than the board? I know the design has been about flexibility for each local board and partnership, to involve as many people as is relevant for local priorities. Do you think there is a tension about who sits on which, and what level of clinical representation do you think should be specified on boards?

Amanda Pritchard:

I will start off, but Mark has led the work for NHS England and NHS Improvement on developing guidance to support local systems exactly in the area you ask about, on how to bring this to life and plan now for what we hope will be legislation coming into effect in April ’22. I do not want to steal his thunder on any of this.

One thing we warmly welcomed in the proposed legislation, and something we have heard about time and time again from our key stakeholders, is the flexibility. There is a minimum mandated legal set of requirements and structures, but, as you say, also an expectation that local systems will develop for themselves the structures and ways of working that make most sense for them. This is an obvious point, but what will work in Devon will by necessity look quite different from what you would want to put in place in somewhere such as Greater Manchester.

On behalf of our stakeholders, we have already welcomed the flexibility around that that has been described, but we have rightly said that, in addition to the suggested roles written into the legislation, there are some roles we would expect to see included on boards—we describe this as “mandatory guidance”. We have used that partly as an opportunity to pick up on exactly the point you make about clinical leadership and clinical representation. As a national health service, it is clearly right that we ensure that we have that strength of clinical voice.

At the moment, the mandatory guidance describes the need for a medical director and a director of nursing in addition to the expectation written into the legislation, which is that there would already be a representative from primary care as part of that ICB. Mark, you have done all the work thinking about how this is going to work in practice; do you want to pick up on that?

Mark Cubbon:

Right at the core of the new working arrangements, we believe that clinical decision making and clinical input and engagement are an essential part of how the new arrangements will be put in place, so that frontline clinicians can shape how services should look and be involved in the planning and delivery of those services. In the guidance that we have put out, we are leaving a lot of flexibility for the ICB to bring in the appropriate number of clinical professionals to support those endeavours, and that is in the shaping of services, the planning and the execution of plans to deliver them.

While we talk a lot about doctors and nurses, there are 14 other allied health professions, and it is quite difficult to allow everyone to have a seat around the top table. We are strongly encouraging all ICBs to ensure that they have the right level of engagement and the right forum in place to ensure that the voices of all those professionals can be incorporated in the development of plans to deliver better services for patients and improve outcomes for members of the community. That is what we are asking all the organisations to do, and it has all been built on evidence that we have gathered from the clinical community over quite an extensive period of engagement. In fact, we published the guidance that Amanda referenced only last week, and it refers to the importance of clinical leadership at all levels: where the services are delivered at place; where services are planned for more local arrangements in the way that we have described; and then sitting more strategically at the ICS board as well.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you. I call Dr James Davies.

Photo of James Davies James Davies Conservative, Vale of Clwyd

Q Thank you, Mrs Murray. To follow on from the discussion about special interest groups and particular clinicians on the ICS boards, are you saying, therefore, that you do not think the legislation should specify, for instance, that there is a representative for mental health in relation to children, or in relation to social care? How do we explain to the representatives of those very important subject areas that it is down to local flexibility? What happens if local flexibility results in a lack of attention to those issues?

Amanda Pritchard:

On a positive, it is great that so many people want a seat on the boards, because I think that actually shows the level of engagement in ICSs. In practice, this is a very organic development from where the NHS has been since 2016, when we first started talking about STPs, as they were known then. This has been very pragmatic, bottom-up and testing as we go, and it now feels as though it is very much with the grain of where the NHS is.

I am not surprised, but I am really pleased, that so many different groups want to be involved. The balance that Mark has just described, which I think the legislation gets right at the moment, is in recognising that to be functional, we have to have the right number of people around the table. At one point we added up how many there would be if you allowed everybody who wanted one a formal seat at the table, and I think Cheshire and Merseyside ended up with 63 people who would be formal members of the board. That is completely unworkable.

It is about trying to find a balance that says, “Let’s be clear what you must have. Let’s use the opportunity that we have through NHSEI to introduce both mandatory guidance—things that people have to do—and guidance that sets out what we would consider to be best practice.” We have been very clear about, for example, the need to have arrangements in place to hear from all those terribly important stakeholders, and indeed for some of the duties, as I have mentioned already, that CCGs continue to carry around engagement with patients and the public, which is the other critical voice that we do not want to lose in any of this. That is the right balance, because it allows us to use some of those tools to keep some safeguards in place to give some clear direction, but it does not try to end up with either a one-size-fits-all solution for ICBs or something that is just unworkable because of the scale.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you. I believe Mr Edward Timpson indicated that he wanted to ask a question.

Photo of Edward Timpson Edward Timpson Conservative, Eddisbury

Q I did; thank you, Mrs Murray. I want to ask a brief question, if I may, about the proposed merger of NHS England and NHS Improvement. I assume, although I do not know, that this is part of the long-term plan that was set out by NHS England, but I hope it is a direction of travel that you are both comfortable with. Could you explain what you see as the practical benefits of the merger, in terms of both the working behind the scenes to ensure that we keep quality high in the health service and the experience of patients, who will be on the receiving end of those services?

Amanda Pritchard:

This absolutely, again, falls into the category of formalising, in large parts, the way NHSEI already works, but removing some of the slightly more bureaucratic and legal barriers that we have in place at the moment. I came in two years ago as the chief executive of NHS Improvement and into Mark’s role as the chief operating officer of NHS England at the same time. Certainly, my experience over the last two years has been that, in practice, NHSE and NHSI really do work, to all intents and purposes, as a single organisation—but, as I say, with some of the bureaucracy that is still around that—and that has been absolutely essential over the last 18 months, particularly through the pandemic.

NHS leadership absolutely has to speak with one voice and has to be able to have consistent decision making. We have to have a way of managing, where this comes up, the tensions that sometimes arise between different parts of the system, but also leading in practice that integrated working and joined-up approach, right from the top. It was really only, I think, the 2012 Act that brought in the separation formally, legally, so in a sense what we are doing is stepping back to something that was always the way the NHS worked prior to that. As I say, we are really now just formalising the way things currently work, and have needed to work over the last 18 months or two years.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you. Now we will hear from Mr Chris Skidmore.

Photo of Chris Skidmore Chris Skidmore Conservative, Kingswood

Q I know we have spoken about the need for flexibility in the composition of ICBs and also their related duties. I wanted to ask, though, whether it would be helpful if there were greater clarity in the Bill on the role of universities when it comes to training and education. I would think I am the only person in Parliament who has been both a Health Minister and Universities Minister, and it was very clear to me, when dealing with healthcare education, that there was not the integration around higher education and health in the way ideally we should have set it out. The Bill provides an opportunity to perhaps rectify this.

Also, I wanted to ask for your views on the duties for the ICBs, particularly around research and innovation. It may be a terminology issue, but the duty to promote innovation and to promote research, through the ICBs, is only

“on matters relevant to the health service” or

“in the provision of health services”.

It does not cover the care system. I would have thought that when we look at the very definition of an integrated care board, it should actually be promoting research and also innovation when it comes to the care system, as well as health services. I would greatly appreciate your thoughts on that.

Amanda Pritchard:

It is a very good reflection on the importance of education as one of the key partners that would absolutely come round the table. I think that is where the ICS structure really helps us as well, because it allows that broader partnership construct, including education and local authorities. I would say—again, from some of the visits I have done recently—that people are really clear about the importance of things such as housing as part of the partnership, as colleagues would expect. Lots of people with different perspectives and different important roles in the system absolutely need to come together around that broader ICS structure, I think, to really give us the maximum benefit from the legislation that is proposed.

To pick up specifically on education, you are right to say that there are two parts to it. Clearly, there is a role for education providers, whether that is schools, universities or other providers. Part of what we have written into the expectation of ICSs in this core role, which is about contributing to the broader economic and social inequalities agenda within their own area, speaks directly to that. That is as much about education, training and employment within health and care as it is, of course, about the wider economy. The NHS, as an anchor institution in many parts of the country, can be an important player in that as well; so it is very clearly our expectation that education will be a key partner in all those different ways.

On research and innovation, as you have rightly noted, there is again a carry-over from the CCG responsibilities, which carry over into integrated care. We have made it clear in guidance that we see this as a really critical opportunity. Certainly, that is not and should not be limited to health. However, again, we have seen during the pandemic in the last 18 months that the power of bench-to-bedside translational research could not have been clearer, as well as the opportunities now to write in, right from the start—certainly through what we have been doing on guidance—the expectation that that research would be strongly supported and encouraged by integrated care systems as they go forward. Again, that is absolutely with the grain of what the health service wants to do and intends to do. Mark, did you want to add to that?

Mark Cubbon:

Just two key points. With universities, we would expect them to be heavily engaged at place level. We have recently published some guidance with the LGA, which considered how we get place-based activities and partnerships so that we have places thriving—the guidance is called “Thriving places”. We also talk about the benefits of the university sector being involved with place-based arrangements, to do all the things that Amanda just set out.

Therefore, we certainly expect that local arrangements and local dialogue, co-ordination and planning around education for local communities can help with recruitment and the workforce contribution that it can make, but also for the betterment of the local community itself.

We would also expect, probably at partnership level, some university input, whether from an academic health science network or indeed colleagues at NIHR. We have recently been doing sessions with NIHR to talk about how to ensure that our clear ambition for this translational research and this health and care research can really be brought to the fore. It is a key pillar of activity that has seen us through some really difficult times during the pandemic and one that will also be essential as part of our recovery.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you. We now move to the shadow Minister, Mr Justin Madders, and Mr Alex Norris.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q Good morning and congratulations on your appointment, Ms Pritchard. Obviously, the NHS has got lots of challenges. Covid is still very much in play, and there are the waiting lists and the workforce crisis. To your mind, which is the biggest challenge that the NHS faces and how will it be addressed by this Bill?

Amanda Pritchard:

One of the really important things in all of this, of course, is that we do not over-claim for what the Bill will achieve. If I look at what has happened in the NHS over the last 18 months to two years, it is absolutely clear to me that the ability to work together has been critical to the ability of the country to respond to covid, and the opportunity now to strengthen those arrangements, write them into legislation and remove some of the barriers that exist will be an important factor in helping the health service now, in partnership with local government, education and others that we have talked about, absolutely to recover from the challenges of the last year and to continue to build on those really strong local arrangements that have been such a hallmark of the way that things have worked over the last couple of years.

But of course, that is only one part of what it will take for the NHS to respond to the challenges that we have at the moment. It is absolutely right that the NHS staff, who have worked so tirelessly over the past two years and of course beyond to look after what we now know are over 400,000 covid in-patients, get the backing and the funding they need, not just to deal with what is very much still with us, with covid in our hospitals and communities right now, but absolutely to make sure that we are as front-foot as possible in tackling the inevitable backlogs that have built up over the past couple of years.

There is a complex set of things. Workforce is critical: the support we give to the people who have already done so much for us—we continue to invest in them and support them, so that we have the right pipeline for new staff joining, the right skills and the right support. Then there is the funding that we need to do the work that we have, and the capital funding to invest in some of the transformation that has already begun and needs to continue. But also, I think the Bill provides us with the framework to continue to support that really powerful local joint working that we have seen over the last two years, and which we are already seeing really at the heart of the covid recovery within the NHS and more broadly.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q You touched on funding. You will obviously be aware of what NHS Providers and the NHS Confederation said last week about what might be required to address the operation backlog. Do you think that figure is about right?

Amanda Pritchard:

It is worth saying that there are some big unknowns in the position at the moment. We just do not know, really, how covid is going to play out over the next few months and years. One of the things that colleagues have talked about, and are very aware of, is that a lot of people did not come forward for care over the past two years. One of the messages that I would like to give again is that, for anyone who is concerned about symptoms, the NHS is absolutely open for business. Please do come forward and seek diagnosis, treatment and support.

We do not know, as we sit here today with two big variables, quite how things are going to play out. What we can say for certain is that today we have over 6,000 people with covid in hospitals. It is costing the NHS more both to care for those patients safely, with all of the infection control arrangements that need to be in place—

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you for that, but I just remind the shadow Minister to keep within the scope of the Bill.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q Of course. I was merely responding to the answer that was given. In terms of how the Bill is implemented, what would you say success will look like in five years’ time?

Amanda Pritchard:

Actually, in some ways that does link to what I was just saying, because—you would expect me to say this—just to reflect the reality of where we are now, covid is still with us, but we also have a real commitment and opportunity to lean in now to that recovery of routine services. I think success looks clearly like we now have the platform right to be able to continue to evidence that local partnership working is really making a difference. What does that mean? It means partnership in practice, both to deal with the current challenges that the NHS is facing and will continue to face, and to start to show that we can really eat into the backlog of routine care that we know is with us and make the commitment, which I know is felt so deeply across the NHS, to tackling inequalities and really trying to think about some of those long-term planning commitments that talked about prevention and outcomes.

We want to see progress against all those things, but we also want to continue to support local systems, as they have been all the way through, to partner together to continue to deliver things such as the vaccine programme in really innovative ways. For me, this is all about putting the NHS on a firmer statutory footing, whereby partnership becomes the way that we do things, building on what has happened over the last few years and removing any remaining barriers that we know exist and which stop us progressing with the really important job now of improving care for the population and for our patients.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q Could you just turn that around to the patient’s experience? I know that there are so many different variables in this, but from a patient’s perspective, how will the Bill improve their experience?

Amanda Pritchard:

Thank you for that, because from the NHS perspective, the reason we have been supportive, particularly of the integration parts of the Bill, is that it is all about what it enables us to do for patients. Mark and I have done a lot over the last few weeks and months. We have seen so many examples in practice of where it is about the ability to work in partnership, whether that is about mental health crisis lines that are partly delivered through the voluntary sector, with a bit of funding from the NHS, but with support from specialists and mental health trusts as well as primary care. It is about coming together to create those sorts of innovative services, whether it is children’s and young people’s services, such as in south-east London, or whether it is in schools, picking up where children and families have medical and health problems. It is about linking them to the right support within local government, housing and so forth.

That is the sort of thing that we have seen develop over the last few years. As I say, it has been turbocharged through covid, but what we now want to do—this is the critical part of the legislation—is to make that easier. We want to make it the norm and allow people the right opportunities to come together and think about what their population needs and what will make services. It is back to the triple aim of improving the health of the population, the quality of care for patients and the sustainability of services. But ultimately, it is about being able to work together to set up those sorts of innovative arrangements, to see them embedded in practice and to see the NHS working in an integrated way around individuals as the norm. Let me bring in Mark, because this is absolutely his operational space.

Mark Cubbon:

Thank you, Amanda. Going back to what patients can expect to see, I think they can expect our local integrated care systems to continue all the efforts to engage with our communities and talk about how we are planning to provide more joined-up care for our communities, because that is one of the key benefits that we will get from the new arrangements. There will be fewer hand-offs in care and fewer organisational boundaries for patients to bump into occasionally, so that we can have joined-up conversations and talk about how things are going to be better. Our local systems, leaders and clinicians will be better placed, so that we really face into and talk about how we will reduce the inequalities and deliver better outcomes. That engagement will be really important, and I think we will build on what works well at the moment and continue to make sure that the patient point is front and centre of all that we are trying to do. We have clinicians leading the charge, in terms of the delivery of those services.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q In terms of the reorganisation, we know that they always come with a price tag. Do you have a figure for how much the reorganisation that will follow, which is being undertaken as a result of the Bill, will cost the NHS?

Amanda Pritchard:

Mark, do you want to pick this one up? I know you have been leading on this issue for us.

Mark Cubbon:

I will indeed. This is definitely a different change from 2012, and probably different from any other changes that have been put in place in previous times as well. We are very much approaching this in the way that we have done. From the outset, we have given a clear message and reassurance to staff who are working in CCGs on job security, so that they know that almost all posts, and the individuals holding those posts, will transfer over to the new organisations. There are not big redundancy bills attached to these changes. We very much want to make sure that the job security is there and that the roles are transferred—

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

Q Sorry to cut across you, Mark, but I am running up against time and do not want to upset the Chair. I was just looking for a figure. Do you have a figure for how much this is all costing?

Mark Cubbon:

We do not have a figure for all the changes, but we know that the CCG cost envelope, which is attributed to every CCG as it stands at the moment, is the cost envelope that will be allocated to each of the ICSs as well. We are not expecting the running costs to be significantly different from those that we have for CCGs.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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?

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

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.

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.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

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.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

Q Thank you, Mrs Murray. I will try to rattle through three quick questions. I think this is my first public opportunity to put on record, as the shadow Minister did, my congratulations to you, Amanda, on your appointment.

If I recall correctly, your predecessor, now Lord Stevens, says that about 85% of provisions in the Bill were things that the NHS asked for in its 2019 consultation. Do you recognise that figure, and how would you characterise the approach that has been adopted to the development of the Bill?

Amanda Pritchard:

Thank you. I would struggle to give an exact percentage, but the Bill certainly contains widely supported proposals for integrated care. We have been working very closely with our stakeholders, colleagues across the system, you and others to ensure, as far as possible, the same approach to consultation, listening and hearing. You cannot please everybody all the time, but we want to reflect what feels genuinely like a consensus view about what will best help the NHS deliver on all the challenges we have discussed. That is reflected in the Bill, so thank you for that. As it goes through Parliament, we very much want to continue to see that spirit of joint working, consensus building and engagement, so that when it hopefully becomes legislation in April ’22, it lands with all the support that I think it currently has.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

Q I will confine myself to one more question, Mrs Murray, to make sure that we do not run up against the time limit. This question has been asked of other witnesses, and I suspect it will be asked of others. To what extent is this the right time to make these changes?

Amanda Pritchard:

As I said, I genuinely think that our experience across covid has strengthened the argument for moving to legislation now, because our way of working in the past two years has been characterised by integration and partnership, and that is how the NHS and partners need and want to work—now and as we head into next year, facing that set of challenges that people are so very committed to continuing to tackle together. Yes, Minister, I think this is an important Bill. The integration agenda is not the whole answer, but it is an important component of it, and the sooner it comes, the better.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

Q Mark, in the minute or so before Mrs Murray closes the proceedings, is there anything you want to add on those two questions?

Mark Cubbon:

All I would say is that collaboration and partnership work is a key feature of our response to covid. It is ever more critical, in the light of the question of how we will approach our recovery. Fantastic working has been enabled locally through necessity; now, we hear from the whole service that we want to build on that. We look forward to the future with that in mind; the Bill allows us to do that.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

As there are no further questions, I thank the witnesses for their evidence. That brings us to the end of our morning sitting. The Committee will meet again at 2 pm in this room to take further evidence.

Ordered,

That further consideration be now adjourned.—(Maggie Throup.)

Adjourned till this day at Two o’clock.