Examination of Witnesses

Health and Care Bill – in a Public Bill Committee at 2:01 pm on 7th September 2021.

Alert me about debates like this

Saffron Cordery and Matthew Taylor gave evidence.

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak 2:25 pm, 7th September 2021

This panel is mixed. We have Saffron Cordery, the deputy chief executive of NHS Providers, who is joining us remotely via a video link, and Matthew Taylor, the chief executive of the NHS Confederation, who is appearing in person. Can you hear us okay, Saffron?

Saffron Cordery:

indicated assent.

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak

In that case, Saffron first, then Mr Taylor, can you introduce yourselves for the record, please?

Saffron Cordery:

Yes. I am Saffron Cordery and I am deputy chief executive at NHS Providers.

Matthew Taylor:

I am Matthew Taylor and I am chief executive of the NHS Confederation.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Good to see you both. Thank you for coming. I want to talk about accountability. I asked NHS England this morning about how accountability works in the new system and it was clear that local accountability lies with the integrated care board—the chief executive and the finance director, in the first instance. We were then taken through the system up to NHS England and Ms Pritchard then said “through Parliament”, which she corrected to “through the Secretary of State through Parliament”. I asked at what stage the Secretary of State becomes involved in the accountability, a question that she did not answer and which I would like you both to answer for me.

We have also heard that the Bill is something the NHS asked for. I have not met a single person working at any level in the NHS who says that the powers given to the Secretary of State directly, added to the Bill after conversations with the NHS, are a good thing and are clearly workable. That is my pretext.

Perhaps I can give the example of a constituent who came to me about ear wax removal, which was a subject that concerned him greatly. Will I write to the Secretary of State as a Member of Parliament to ask him about the lack of ear wax removal services in my integrated care board area, or will the chief executive be the final arbiter of such decisions? Mr Taylor, do you want to go first on behalf of the confederation?

Matthew Taylor:

Yes. There are two points here. The first is around the structure of accountability at the centre and while that is important, ultimately, it is a less important consideration for health service leaders than the relationship between central accountability and local accountability. That is the focus of the major concern we have about the Bill: the extension of the Secretary of State’s powers in relation to reconfiguration, which we think is a mistake. We think the system, as it is, is not perfect but works pretty well. For the Secretary of State potentially to be embroiled in making decisions not just about major reconfigurations, but really relatively minor reconfigurations runs the risk not only of delaying necessary changes in the system, but of putting less emphasis on the views of local people and of clinical advice.

Representing my members, while the question of the relationship between the Secretary of State, Parliament and NHS England is one that we take an interest in, the issue of the relationship between the centre and local accountability is stronger. Where constituents write to their MPs, the Secretary of State or wherever when they have a problem, they will continue to do so, but I hope in such a system that the first thing to happen to such a letter is that it would be sent back to people locally who could address that issue in a local way. It would be ill-advised for a Secretary of State to try to involve themselves in a question like that.

Saffron Cordery:

I agree with Matthew’s point. It is this central-local relationship that is absolutely critical to those who are working on the frontline—trust leaders from my perspective, and from NHS Providers’ perspective. Coming back to some of your points about the NHS supporting the legislation, I think that is absolutely right. The NHS has come together to support the direction of travel of this legislation, but I think it is worth saying that that agreement was based around an August 2019 set of proposals, when the whole NHS came together on the basis of some recommendations from the Health Committee. It is important to remember that the legislation has changed somewhat since then. We have had a number of elements added to the Bill that sit around the central bit that the NHS agreed with, which probably changed the context somewhat. It is worth remembering that the local reconfigurations issue that Matthew Taylor raised is a very important one.

There are elements as well in the nature of the relationship between the Secretary of State and NHS England in terms of the operating context and its ability to intervene in what goes on nationally, and the knock-on effect locally on trusts. There are some really big issues there, which come together.

The other thing to say is that, often, Secretary of State powers may seem like small elements, but taken together, the cumulative impact can be seen to erode that local accountability. We would hope, whatever happens, that if someone has an issue with ear wax removal, they speak to someone at the most appropriate level to get something done. That is what subsidiarity is about: the delegation of powers to the most appropriate level, and it is really important. It is also important for accountability, because you cannot have a Secretary of State saddled with taking a thousand tiny decisions in an organisation and a system as complex as the NHS. That is one of the challenges of this local reconfiguration issue that is arising.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Chair, can I come back?

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak

I will come to you if there is time, but I want to move on. Dr Davies.

Photo of James Davies James Davies Conservative, Vale of Clwyd

Thank you. I have a general question about the key feature of the Bill: integration of services. What is the experience of your members with regard to that and have those views changed thanks to the pandemic? Perhaps we can hear from Saffron firstQ .

Saffron Cordery:

The experience of the pandemic, which is a seismic and far-reaching event, really put the frontline of the NHS and other local public services in the frame for delivering for their local communities, and for supporting each other and helping each other out with mutual aid. What we saw there was one very good and important example of how local partnership working, local collaboration and local integration was working in very different ways up and down the country.

We had some common features of all integration, something you would expect at a time of crisis, where there is a lot of command and control and procedures that go on in a state of civil crisis such as this one. We also saw different communities responding in different ways. That is one of the most important points that I want to make about this legislation. In terms of collaboration, we have to see a piece of legislation that is as enabling and permissive as possible. Obviously, legislation has choices. You go down different routes. Really prescriptive legislation will not help in this situation, though. We have to reflect the progress made in some areas and the need for encouragement and support in other areas to get where we want all ICSs to be: that is, really effective and delivering what local populations need. A permissive framework is critical. Going back to your question, it is right that the pandemic has shone a light on both the potential of ICSs and collaboration in particular and the challenges we face right now in implementing any new proposals due to the operational pressures facing the NHS, local government and other public services.

Matthew Taylor:

I agree with Saffron. There have been some very good examples of local collaboration, such as the vaccination programme and reaching out to communities where initial take-up may not have been what we had hoped. There is some really impressive work there. That work presages the wider commitment within the health service to a strategy of population health, which addresses not only those people who express demand but those who do not. We wish that they would, because that is one of the things driving health inequality.

I have been at the confederation only three months, so I look at the legislation from the perspective of a wider interest in public policy over 30 years in government and outside it. This is a very interesting and innovative example of policy making. We have these integrated care systems in large parts of the country, so the policy has already been enacted ahead of the legislation. Though that may raise democratic issues, it enables us to see in practice how people are taking the principles of service integration and focusing them on population health. Despite the challenges of covid, a challenging funding context, and the issues around social care—which are hopefully being addressed in one way or another—we see across the country that there has been a whole array of interesting bits of innovative, collaborative work around issues of population health, prevention and addressing health inequalities.

I want to emphasise a point Saffron made. If you look around the country, you see some systems that are well advanced in their collaboration and other systems that are not. This is for a variety of reasons; in some cases there are issues to do with boundaries and such. Like Saffron, I think it is really important we have a permissive regime that allows these systems to evolve at a pace that is right for them and the places in which they operate. Over time, the systems will move forward, but it is actually a really effective way of working. It would be a mistake to try to impose exactly the same way of working on every part of the country. It would mean those who were ahead will be pulled back and those who are not quite ready to make integration work will be compelled to tick boxes, as it were, rather than work on the development of the relationships that we need.

Photo of Edward Timpson Edward Timpson Conservative, Eddisbury

I want to build on that point about permissiveness and take it a step further in terms of the specification in the Bill around ICBs and ICPs—the boards and partnerships. A lot of us on the Committee have been requested to look carefully at individual parts of the healthcare system. That does have a generality to it, covering mental health, children, palliative care and so on, and their representation is very clear within partnerships and boards. Based on your views around permissiveness and flexibility and the different paces ICSs are currently at, how do you see this? How do we reassure people that their views and the particular parts of the health system they represent will get a fair hearing and that the accountability structures will be in place to make sure they are able to come back if they feel they are not being addressed properlyQ ?

Matthew Taylor:

That is an important point. Let me be completely open about the conversation within the confederation about this issue, for example. We have a mental health network representing mental health providers. Their preference would be to specify the need to have a mental health leader on the board. We as a confederation recognise that view and represented it, but that is not our view overall. Our view is that, partly because configurations differ from place to place—in some places, mental healthcare and community are together, for example—but for a variety of reasons, we would not want to specify further the membership of those boards. Again, that is to maximise local flexibility.

If people feel their voice is not being heard, then that is something they are going to say. We will have to see how this system evolves, but let us start with—going back to a word used earlier—the permissive regime and see how that goes, because after all it is in the interests of everybody in the local health system that they hear the voices they need to hear.

Saffron Cordery:

I agree. This is a thorny issue but I suppose it is one of either, depending on how you look at it, the opportunities or the casualties of creating another level of governance in a local system. When you are thinking about putting collaboration on a statutory footing, you have to surround it with some kind of governance to ensure the effective operation of that body.

It is a tricky issue. You cannot have an integrated care board—the board that will govern how funding flows through and how priorities are agreed, decided and implemented—that is so enormous that it becomes unworkable, but there has to be a clear balance between making sure it is not only the big and the powerful who are represented there, but also all the rights and appropriate interests. There are a number of positions specified in the ICB board arrangements, and it will be interesting and important to see how different ICSs use those roles, particularly the non-executive or wider partnership roles that are specified, in order to have a broad range of voices around the table.

It is worth remembering that many other organisations and structures will be taking part in the ICS arrangements. You will have things like provider collaboratives, which are not in the Bill but feature heavily in the guidance that comes from NHS England and NHS Improvement, which are precisely about organisations working together to deliver on local priorities. Many of those are led by mental health organisations focusing on what they need to deliver.

There are other structures within these arrangements, but no one would say it is ideal. It is not the most ideal solution, but it is very difficult to get to a final configuration that is both workable in terms of numbers and reflects the multiplicity of voices in a locality. It is important to have the right engagement at every single level and the right channels feeding up information and priorities, and to understand what is really important in a system.

Matthew Taylor:

Today the Government have been talking about the importance of integration in the context of its announcement on health and social care. One of the big questions is going to be about the powers that are devolved within systems to places, and I think it will be at the place level that we will see service integration. The evolution of place level forms of accountability is an important part of that, and again a reason why it is really important to allow these structures to evolve locally. I suspect that in some areas more power will be held at the system level and less at the place level. In other places, it will be the reverse, with most of the action taking place at place level. That reflects the nature of places, the legacy of those places and the relationships that have built up.

Photo of Chris Skidmore Chris Skidmore Conservative, Kingswood

I wanted to turn to workforce planning and your views on clause 33. The NHS Confederation, in its written evidence, has suggested that the five-year period for a strategic review on workforce planning is too long. That mirrors my amendment, which has a crack at this. I have suggested an annual review. It was suggested this morning that two years might be the right time length. I see that the NHS Confederation has suggested three years. I want to get your organisations’ views on what a strategic review should look like, but also on the format and how a strategic review should be undertaken so that it actually works as an act of co-creation, rather than being directed centrally by the Secretary of State on to Health Education England.Q

Matthew Taylor:

My area of expertise before coming to the NHS Confederation was work and the future of work, on which I advised the Government, and one of the things I know from that work is how quickly the world of work is changing. It is impacted by a whole variety of things—not least, of course, substantial technological change. In a world where work is evolving very quickly and population needs are evolving, five years is simply far too long. If it were one year, we would be happy. We have fastened on to two years. That would be the minimum that we would want as a gap between assessments of workforce need.

It is also—to emphasise the point that I think you are making—important that this review gathers evidence from a whole variety of bodies, because an enormous amount of extremely good work is taking place around work. Predictions of workforce need are imprecise, so hearing from a variety of voices is important. This should be an independent process, in which independent expertise is brought to bear; there should be wide consultation with those who think about these issues; and a two-year plan would, I think, be an improvement on what is in the Bill.

Saffron Cordery:

We also support this amendment and the work that has been done by the confederation and others on this. There is one other element that I would add to this that supports this perspective. It has been really hard, across NHS workforce planning, to light upon one version of the truth, in terms of workforce numbers. Anything that starts to move towards a collective perspective on workforce needs and workforce planning will be absolutely critical.

Getting an agreed perspective on how we create that figure will be fundamental. In my time working across the health service, there have been many different perspectives on workforce—on the gaps, the numbers who are in roles, and what those roles need to be. It is important to have lots of views, but I think this is also important. Although, as Matthew says, it is not a precise science, we need to light upon a version that is independently agreed, but that we all sign up to as the numbers we are working to.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

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

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

Saffron Cordery:

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

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

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

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

Matthew Taylor:

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

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

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

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

Matthew Taylor:

It is a challenge.

Matthew Taylor:

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

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

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

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

Matthew Taylor:

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

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak

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

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

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

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak

Well, you only have about two minutes.

Matthew Taylor:

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

Saffron Cordery:

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

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

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

Good afternoon. Obviously, you have the ICB and the ICP both within an ICS. If there is a disagreement between them about the direction of travel on a particular policy issue, who arbitrates? In your opinion, who is likely to be sided with in such a dispute?Q

Matthew Taylor:

I defer to Saffron on that one.

Saffron Cordery:

I think this is one of those elements that we have seen quite a lot of throughout the legislation in terms of where is the recourse—that is not the right word, but I cannot think of another one right now—if things go wrong. Collaboration by its very nature is a positive process where willing parties come together to reach agreement. Everyone’s hope and aspiration is that that is how ICSs will work overall, and that is how the ICB and ICP will work together. It is not currently clear how there will be recourse to arbitration or dispute resolution, if you like, in the process of this legislation. We have seen an optimistic approach to how this legislation has been brought together—rightly in some senses—and of course we do not want a situation where we are anticipating that the evolution of a new way of working will not be functional. At the same time, the role of legislation is to anticipate what can go wrong, as well as to support what needs to be done. It is not yet clear how some of this will shake out in terms of where ICBs and ICPs need to turn to should there be challenges, issues and disagreements. We have to remember that those bodies, once they have their independent chairs and accountable officers and chief executives, sit within the NHS system, so they sit within the regional NHS England system and within the overall NHS system. Routes will be pursued, but at the moment it is not clear to me how disputes, for want of a better word, will be resolved.

Matthew Taylor:

The only thing I would want to add is that during covid, we have understood the scale of health inequalities. The evidence has been that those inequalities are growing. That has demonstrated that we need a conversation between the health service in relation to how it deals with the demand that is presented to it and the wider question about how we address population health. In some cases, that might mean that you have some creative tension between those two levels. As Saffron said, it will come down to the quality of relationships, and if those relationships break down, I am sure that the centre will need to intervene to address that because the system cannot work if it breaks down. But the fact that those two bodies might have a slightly different emphasis and focus is probably a good thing because this debate about how we best use our health resources to address population health and health inequalities is an important debate for us to be having nationally and locally. Let us face it, we have not got this right up till now.

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

Q On the Secretary of State’s powers of intervention on reconfigurations, is it your understanding that a local system could agree across the board that particular changes were necessary and actually that it was important for reasons of patient safety that those changes were made but that the Secretary of State could intervene at any time to stop them?

Matthew Taylor:

Yes, unfortunately that is our understanding, and we think that it would be a retrograde step. It is not a power that I would want if I were a Secretary of State and I wanted to focus on strategic policy questions. I would not have advised the Secretary of State to want those powers.

Our view would be that we should remove the extension of the Secretary of State’s power entirely, but, failing that, we should put some guard rails on in relation to hearing the views of local health overview and scrutiny committees, getting local clinical advice on what is best and having a public interest test that should be passed. If those guard rails were in place, we could cope with this.

What we do not want is a chilling effect on the capacity of local leaders to make the decisions that they need to make to use their resources effectively. The third element of the triple mandate is the effective use of resources, and that involves making decisions at a whole variety of levels around how you configure services. If you feel you are going to go through that process and potentially engage local populations in difficult conversations, and then at the end of the day a local MP, for whatever reason, is going to kibosh that by appealing to the Secretary of State, why would you embark on the process in the first place? That is why, while we are very supportive of the Bill, as you have heard from both Saffron and me, we do think that the powers of reconfiguration are the Achilles heel. I appeal to you to recognise that that is unnecessary and goes against the spirit of the Bill.

Saffron Cordery:

I wholeheartedly support what Matthew says, and it speaks to a point I made earlier about adding to existing structures in a way that really is not necessary. I notice that you have representatives from the Local Government Association as witnesses later on. I am pretty sure that they will have some strong views about what these measures do for the powers of local health overview and scrutiny committees, because they already have the power to refer to the Secretary of State should they need that to happen. The powers that are currently in place are a really effective way of doing it. People getting something past a local health overview and scrutiny committee is a really important hurdle for any service change. It is already well respected, well used and very effective. This is one of those elements that at best is redundant and at worst is going to create a lot of work and a lot of unnecessary tension and friction where we already have challenge.

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

Q I have just a couple of questions, because a lot of the issues have been explored. My first one is something that we have not touched on yet in our questioning of witnesses. I welcome both your thoughts on the proposals in the Bill to delete and replace section 75 of the 2012 legislation, around procurement, and your reflections on the opportunities or challenges that that presents.

Saffron Cordery:

As we see a change in the system, obviously the nature of how we have procured services in the past does have to change. It is obviously a complex area, but one of the things that we really need to look at is the effectiveness of the current contracting regime, which for certain parts of the provider sector in particular is incredibly burdensome. If you sit in a mental health or a community trust, you are subject to a whole host of retendering, which can have a potentially far-reaching impact on your trust’s sustainability or the future operation of key services. For many bits of the system, that will be very important.

The procurement regime is fundamental. It underpins how this will operate. We need to make sure that the elements of fairness are upheld and that it does not disproportionately put a burden on any one part of the system in particular.

Matthew Taylor:

I agree with that. It is important to remember that one of the goals of the Bill is to reduce the weight of bureaucracy in the system. If we can reduce the weight of bureaucracy as it applies to procurement, that is only a good thing.

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

Q My second question—I think this has come through in what both of you have said, but feel free to challenge it when you answer if I have misrepresented what you have said—involves one of the key things I have detected, which is that we must be careful not to forget that no one size fits all in this context. Back in the dim and distant past when I was a councillor, I sat on a primary care trust board as a local authority representative, and I found that joint working could be highly effective, so what is the right balance? You have touched on this in some of your previous answers. Recognising that it is sometimes as much about relationships as about formal structures, what do you think is the right balance between permissive and prescriptive in what we are trying to do here? How do we strike that balance appropriately, and have we struck it appropriately?

Matthew Taylor:

Of course, one of the most challenging questions in all parts of central Government is to get that balance right. The one point that I want to make is about the nature of system leadership. If you lead an organisation—I lead an organisation—the parameters of what you do are reasonably well defined and you lead that organisation as best you can, and you can be regulated as an organisation in relation to its objectives. The thing about system leadership is that it involves developing a concrete and specific account of how you want to add value in a particular local circumstance—how is it that, working as a system, you will make a difference?

By looking towards population health and engaging local people, that proposition will vary from place to place. It is important that, when we look at how systems work, we allow them to develop a value proposition that is specific to their local circumstances and their local needs. That is why, for example, we would be very resistant to any kind of Ofsted inspection regime for systems, because systems are not the same as hospitals or as schools; they are very different and their aspirations will be very different.

When you look at the Bill, the reality of central-local relations is that rules are set out in legislation, but then there is the custom and practice of how Departments and other bodies actually work. Sadly and inevitably, the drift of custom and practice tends to be towards centralisation. That is why it is important to avoid things in the Bill that create an opening—this is why we can have our concerns about reconfiguration—which can get ever wider and thus undermine the key principles that lie at the heart of the Bill. So we are happy with the intentions of the Bill, but we are worried that there are certain elements of it and certain elements that might be involved in the operationalising of it that could undermine its intentions.

Saffron Cordery:

I go back to a point that I made earlier in this session, which is that this balance between permissiveness and prescriptiveness is critical. The August 2019 agreement, when all the stakeholders came together to look at how we might legislate for an integrated care system that got that balance right, I think is there. You have to remember that what sits around a set of proposals will have a massive impact on it, so the Secretary of State’s powers as we have seen them, and the operating environment overall, will have an impact on how these proposals will be implemented, and how effectively they will be implemented.

We cannot forget covid in this. We cannot forget the extreme financial pressures that we are seeing. We cannot forget demand. We cannot forget an incredibly tired workforce. That is not going to change any time soon; that is going to be for the next few years, so we are implementing something against that backdrop. But if we go back to the slightly lighter touch of the August 2019 proposals, we will probably get to a place that would hit the spot, as it were. I reiterate that we support collaboration in systems and the direction of travel.

Photo of Steve McCabe Steve McCabe Labour, Birmingham, Selly Oak

Given the time, we will leave it there. I thank our witnesses, Saffron Cordery and Matthew Taylor.