Examination of Witnesses

Health and Care Bill – in a Public Bill Committee at 11:32 am on 9th September 2021.

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Professor Martin Marshall, Pat Cullen and Professor Helen Stokes-Lampard gave evidence.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall 12:17 pm, 9th September 2021

We will now hear from Professor Martin Marshall, the chair of the Council of the Royal College of General Practitioners; Pat Cullen, the general secretary and chief executive of the Royal College of Nursing; and Professor Helen Stokes-Lampard, the chair of the Academy of Medical Royal Colleges—all of whom are appearing in person. Starting with Pat Cullen, could I ask you to introduce yourselves for the record?

Pat Cullen:

I am Pat Cullen. Thank you for inviting me along. I am the recently appointed chief executive and general secretary of the Royal College of Nursing. We are a trade union and a professional organisation, and we represent more than 480,000 nurses.

Professor Helen Stokes-Lampard:

Hi! I am Professor Helen Stokes-Lampard, and I am chair of the Academy of Medical Royal Colleges. The Academy is the umbrella body for all the medical royal colleges in the UK and Ireland; we also cover the independent medical faculties.

Professor Martin Marshall:

Good afternoon, everybody. I am Martin Marshall, chair of the Royal College of General Practitioners and a practising GP in Newham in east London.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you. We have until 1 pm for this session, so I propose the same timings as for the last one. I call on Back-Bench Members to indicate if they have any questions.

Photo of James Davies James Davies Conservative, Vale of Clwyd

Q Good afternoon and welcome. I would like to ask all three panellists about the workforce projection elements of the Bill and the adequacy of those, starting with Pat.

Pat Cullen:

We have yet to submit our evidence in relation to the Bill—we are currently doing that. It is very clear to us and our members that the Bill does not go far enough on accountability for the workforce. We are very clear that the workforce shortages in nursing are not addressed properly through the Bill.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Could you speak up a little bit, please? We are finding it quite difficult to hear you.

Pat Cullen:

That is not normal, mind you, for a woman from Northern Ireland! I will try again. Principally, our response to the Bill is that the accountability issues do not go far enough in the Bill. We are asking for the Secretary of State for Health and Social Care to not only clearly have full accountability and responsibility for the assessment of workforce planning, but ensure accountability for the delivery of the workforce. It is not just about the assessment. We are all clear about and know about—it has been played out well—the shortages of nursing staff. We had 40,000 vacancies heading into the pandemic. We make up 26% of the workforce. Everywhere you see a patient, you see a nurse, and we need nurses. That is the only way to provide the best care for our patients. We say that the legislator at the highest level must have that accountability and responsibility for the assessment and the delivery of the workforce shortages in nursing.

Professor Helen Stokes-Lampard:

The Academy of Medical Royal Colleges has worked very closely with the Government on the development of the Bill, and we have been very grateful for the opportunity to collaborate so far. We have been largely supportive of the direction of travel, but the workforce, in clause 33 particularly, is the one area where we probably still have the greatest concern. We feel that it needs to go further. That builds on exactly what Pat has said. Along with other organisations such as the RCN, we have co-signed an amendment that goes further on that.

We feel that workforce planning needs to be very transparent and collaborative across multiple organisations and agencies, but ultimately owned by the Secretary of State for Health and Social Care. It needs to take on board both the projected supply of workforce already in the pipeline and projected demand. We anticipate that the line representing workforce supply going upwards, and the line representing the demand for need and care climbing even more steeply. There is a gap between them that, at the moment, we cannot quantify. It needs to be quantified and made transparent. Even if the state does not feel it can fund for that gap, we should not be afraid of knowledge. Without knowledge, we run into the risk of repeating historical cycles of boom and bust when it comes to workforce planning. That would be our big plea to you: try to strengthen that, and please do not fear knowledge—it will help us in the end.

Professor Martin Marshall:

The Royal College of General Practitioners, as members of the Academy, are completely in line with Helen’s position. There is a marked workforce crisis relating to general practitioners and other health professionals who work in general practice. Without an adequate workforce, it will be very difficult to deliver any of the ambitions of the Bill, so we are absolutely in favour of a much stronger emphasis on workforce. I think workforce planning is an oxymoron and has been for many years in the NHS. This is an opportunity to do something about it.

Photo of Chris Skidmore Chris Skidmore Conservative, Kingswood

I have two questions. On clause 33, which we have just spoken about, what would be the best compromise when it comes to planning for a workforce strategy? The Bill suggests five years, and that the Secretary of State should direct Health Education England and NHS England to produce this report. Would you suggest a more frequent process? If so, how frequent should it be? What organisations should be involved with workforce planning, and how would you see that operatingQ ?

Professor Helen Stokes-Lampard:

We have thought about this seriously—what would be a sensible interval? Having discussed this extensively with colleagues right across the health and care landscape, we have come to the conclusion that two-yearly feels about right. Annually just feels too intense, and it would be too labour-intensive to get meaningful data out in that period; you would run the risk of fatigue in the system. If we go much longer than two years, we run the risk of fundamental change coming into the system—another pandemic or some other national thing happening that needs to be factored in, and of which we need to be made aware. We have come down on two years, and that is the proposal that we put forward.

Every time, the work needs to look five, 10 and 20 years ahead. We need that longer-term projection. It takes so long to train doctors—that is the agency that I represent—from their entry to medical school to consultant independent practice that you need to have that time lag built into the system. That way, you can look at the totality of the workforce and ensure that you have the right interim solutions for the needs of the population.

Photo of Chris Skidmore Chris Skidmore Conservative, Kingswood

Q Do the other organisations agree with that assessment?

Pat Cullen:

Yes, we would certainly agree. We believe that annual plans are too short-term for the reasons that Helen has laid out—training nurses takes three years, and when you think about the added training for clinical specialist nurses and other advanced nurses in practice, it absolutely needs to be at least two years.

Professor Martin Marshall:

We agree that two years is the right interval. I think the request of HEE to produce a high-level framework is a good start—that is correct—but it is just a start, and a high-level framework does not help workforce planning on the ground. It is right that most workforce planning should happen at a local level, but some elements need to be managed nationally. Basically, this is such an important issue for the NHS that it needs to be absolutely top priority in the Bill.

Professor Helen Stokes-Lampard:

I am conscious that I did not answer the second part of your question about who should be involved. We propose that this be led by Health Education England, but it has to be done in collaboration with NHS England. We cannot look at the needs of the population without involving them. There are other bodies, too. For doctors in particular, we would argue that the Medical Schools Council and the GMC have to be involved. I am sure Pat will have similar views.

In terms of population needs, we need to look at the Office for Budget Responsibility and use the resources of the Office for National Statistics. We need to go widely on this; it is not about saying, “That is one person’s problem to sort, and then the Secretary of State signs it off.” This is a truly collaborative effort, and we need to legislate for and enable collaboration in the greatest possible sense.

Photo of Chris Skidmore Chris Skidmore Conservative, Kingswood

Q On clause 19 and the duties on the ICBs and ICSs, particularly, in your case, around education, training and research, do you have any thoughts about who might be able to help those ICCs with their duties, and about the role of universities, which are not mentioned in the Bill? How can we integrate not just health and social care, which are the focus of the Bill, but education and training, and what needs to take place for that integration to happen?

Professor Martin Marshall:

Universities have an enormous amount to offer. If we look at the way that universities have operated in academic health science networks in the current structures, in many parts they have played a really significant role. I absolutely think that ICSs give us an opportunity to bring universities into the debate.

Education is particularly important here. If the Bill is to achieve its potential of better population health, there are some massive training leads for all the workforce, and universities clearly need to be involved in that process.

Professor Helen Stokes-Lampard:

To supplement what Martin has said, we have not criticised what the Bill says at the moment. For us, this is where the Bill is an enabler, and we hope it is a greater enabler that what we have currently. In that sense, the logical thing to do next is greater collaboration. The challenge with legislation is that although it can remove barriers and enable, it does not actually change culture. We need to engage with the individuals who are establishing this and ensure that the frontline educators and clinicians are on board with it to make it a reality.

Clearly, I support what Martin said about the vital need for education right across the piece. I think you will find that the universities are very much up for that and keen. It has been difficult to expand training places across nursing and medicine in short order, but it is something the universities are really stepping up to do. I think we would all argue that we want to go further and faster to deliver the best possible care for the public.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you very much. We have about 10 minutes, and three people have indicated that they want to ask questions, so if we could direct our questions to one person and keep questions and answers brief, that would be very helpful, because I would like to include everybody.

Photo of Hywel Williams Hywel Williams Chair, Speaker's Advisory Committee on Works of Art, Shadow PC Spokesperson (International Development), Shadow PC Spokesperson (Work and Pensions), Shadow PC Spokesperson (Defence), Shadow PC Spokesperson (Cabinet Office), Shadow PC Spokesperson (International Trade), Shadow PC Spokesperson (Foreign Affairs), Shadow PC Chief Whip

Q I have a question for Pat. You have indicated some concern about the new powers regarding professional regulators and the fact that there may be changes, including the dismissal of regulators and that sort of thing, through secondary legislation. Given that those bodies are UK-wide, do you think that the Senedd, the Welsh Government in Cardiff, and the other Governments should have some input into those sorts of decisions about professional regulators?

Pat Cullen:

We have had some thoughts about this across the countries—and we can learn from all of the countries, really. Of course, you will know from my accent that I come from Northern Ireland, and our regulator is a four-country regulator. In relation to the standards that are referred to within the Bill, I think our royal college will play an important role in terms of working with our regulator to look at some of the devolved responsibilities and the role that we can play in setting standards for our profession, and assisting and supporting our regulator in the setting of those standards right across the country, and obviously the other countries as well.

More recently, we have just brought out our nursing workforce standards, which apply across the four countries, and we had significant engagement in those right across the four countries. If you look at those standards being aligned in the new Bill and reading across to the new Bill, working across with our regulator and having more powers devolved to a royal college will enhance the regulator’s response to standards and the applicability of those standards, and their implementation across the countries.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you very much, Mr Williams. I now turn to Edward Timpson.

Photo of Edward Timpson Edward Timpson Conservative, Eddisbury

Q Thank you very much, Mrs Murray. This is directed to Martin. Perhaps unsurprisingly, there is a lot of demand on representation or membership of the integrated care boards, and I think we heard evidence earlier that in my own area of Cheshire and Merseyside, if everyone who wanted to sit around the table was sitting around the table, there would have to be 63 seats, which is clearly unwieldy and unworkable. Specifically thinking about the organisations that you represent, when it comes to clinical representation, moving from the CCGs to the ICS, what do you think should be specified about clinical representation on these new ICBs?

Professor Martin Marshall:

We have pushed very hard for clinical representation on the board, and I think that the acknowledgement that a primary care representative is required is absolutely right. Of course, one representative is not going to change the world, but there is something symbolic about it, and there is something about having a primary care voice that is really important. The nature of that primary care voice is interesting, because of course, general practice is a multi-disciplinary specialty, and we work very closely with our nursing colleagues, our pharmacy colleagues and a whole range of different clinical disciplines. I think that in most localities, it is likely that a GP will be the representative of primary care, most obviously because general practice has a long track record of being involved in the management of the NHS, and the onus will then be on that general practitioner to represent all of the primary care voices. As a college, just last week we had a very productive workshop involving all the different specialties in primary care, and a strong sense of consensus that we must and will work together to drive this forward.

I have a particular focus on the primary care voice—I guess that is my job; Helen might refer to other clinical voices—but it is particularly important for primary care, for the simple reason that in primary care, we deal with about 90% of the presentations that come to the NHS every day. We live in, and are closest to, the communities that we serve. We are trained to address the broader determinants of health. We are trained as doctors, as GPs, for example, but we are trained to understand the social determinants of health and health inequalities. Everything that is important about this Bill is stuff that general practice is expert in, so we feel the general practice voice is really important.

One of our biggest concerns—not so much with the legislation, but the way that this is likely to play out on the ground—is that the general practice voice threatens to be diminished as a consequence of the change in legislation around CCGs. If you look at what the boards will look like, we know that the acute trusts will still have their governance arrangements and their budgets. CCGs are going to disappear. We are not necessarily saying that that is the wrong thing, but it means that a lot of the experienced clinical leaders in CCGs risk getting lost, and we know that that is not happening in some of the ICSs around the country, but it is happening in others. The CCG staff are just being transferred into the ICSs, but there is a real risk that the leaders who have been around for a decade or two decades, who understand the nature of organisational change and understand what the Bill is trying to achieve, will get lost. We know from the evidence that the most successful integrated care organisations around the world are the ones that are primary care led, so if primary care does not have a dominant voice, the ICSs are much less likely to achieve their potential.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

It is as though we have rehearsed, because that was my question. I was a GP manager leader in my area before coming to Parliament, and GPs have been at the forefront of developing CCGs, as you said, which followed on from the great desire of Governments to move the gatekeeper up the food chain, shall we say, in order to provide clinical leadership and—to be crude—control costs.Q

I would like to ask this to everybody. Personally, I think this issue of clinical representation is a backwards step in this Bill. You may or may not want to say whether you think that is true, but given that you have said that successful organisations are primary care-led, and none of these organisations will be clinically-led, let alone primary care-led, that is not rectifiable in the Bill through an amendment, I suspect. How will we ensure that these organisations are successful from a clinical leadership perspective, given the current state of the legislation, or would you be putting forward suggestions for amendments? I am sorry, but I do not think I have time to ask all three of you. Currently, CCGs are GP-led, so—

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

We have about three minutes, so could you keep your answers to one minute each?

Professor Martin Marshall:

I speak very rapidly.

“How?” is an interesting question. Can it be done in legislation? I think there have to be some legislative levers to ensure that this happens properly on the ground. There are some examples—one in Surrey and one in Gloucestershire—where there is already a very strong commitment to a robust primary care voice, so there is something about shining a light on those examples, which others can learn from. That is not a legislative responsibility, but it is a really important one. There is certainly something about holding localities to account and understanding what is happening on the ground at regular intervals, in terms of whether those voices are present and whether they are being heard.

Professor Helen Stokes-Lampard:

I would strongly advocate that everyone takes a look at the very excellent document that NHS England put out just a few days ago, which is about implementation guidance for ICSs on clinical leadership. I have to say that whoever put it together absolutely nailed it, in terms of what to do and how. There is a how-to guide there. I had no input into it, so I feel I can shamelessly give you that, because there are a lot of answers in there.

The legislation as it stands on clinical leadership does not prevent any of those things, as I understand it. That goes back to my other point about ensuring that the legislation removes barriers and is a facilitative enabler of these things. Clearly, my colleagues have more specific things about it. I just want to draw to your attention to the fact that it says that clinicians who get involved in leadership need to be supported, protected and resourced to do so, because unfortunately clinician time is expensive. That comes back to the original conversation about workforce, but we have to factor it in. The evidence is quite clear that better clinical input in all disciplines helps systems run better and be safer. It is more cost-effective, but that needs support factored in from the outside.

Pat Cullen:

You will not be surprised to hear me say that the Bill does not go far enough, and we will be looking for an amendment. There absolutely needs to be a director of nursing at the top table if you are to prevent what has happened and what has gone before, where the financial balancing of books significantly impacts the decisions of that table. The only way to ensure patient safety and quality of care, and that the workforce that we deserve and need for our patients are paramount and the centre of those discussions, is to have our clinical leaders at the top table. That must be a director of nursing, not only to bring evidence on the clinical care that needs to be delivered to the table to shape each strategic decision, but to hold that person to account for our workforce and ensure that the workforce is available to provide care for our patients.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

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

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

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

Pat Cullen:

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

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

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

Pat Cullen:

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

Professor Helen Stokes-Lampard:

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

Professor Martin Marshall:

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

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

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

Professor Martin Marshall:

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

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

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

Professor Martin Marshall:

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

Professor Helen Stokes-Lampard:

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

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

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

Pat Cullen:

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

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

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

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

Pat Cullen:

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

Photo of Alex Norris Alex Norris Shadow Minister (Health and Social Care)

Thank you, Chair. Thank you to all three of you for joining us this afternoon, and thank you for everything Q your members have done for us in such difficult times in recent months. Collectively, you speak for tens of thousands of NHS staff and allied professionals, so a simple first question from me. Pat, you might go first: how do staff feel at the moment?

Pat Cullen:

Where do I start? They feel exhausted, demoralised; they are tired to say the least, and they are very concerned about the future. Why is that? Because they do not have the workforce to deliver.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Could I just remind the shadow Minister to stick within the scope of the Bill, please?

Photo of Alex Norris Alex Norris Shadow Minister (Health and Social Care)

On a point of order, Mrs Murray. How our staff are at the moment is within the scope of a Bill about the NHS, I would have thought.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Okay, but can we just make sure that we stay within the scope of the Bill?

Pat Cullen:

I will try and answer in relation to the Bill. All the issues that I have just spoken about in relation to that exhaustion, the tiredness and the fact that they are not able to provide the care for their patients—there are opportunities in the Bill to correct some of those things. Again, going back—I hate to harp back to it in my Northern Ireland words—but the fact is that if we ensure that accountability sits with the legislator and with the Secretary of State, to ensure that we do not find ourselves back in this place again, with 40,000 vacancies going into a pandemic or at any other emergency situation we find our nurses in, that will absolutely assist and support. However, there are opportunities for the workforce in the Bill that we do not believe are being grasped at the minute, and that is further adding to the demoralisation that they are feeling.

Professor Helen Stokes-Lampard:

I will keep it succinct. I completely agree that the clinical workforce—doctors—are demoralised, and I think anxiety would be the greatest feedback that we get: anxiety and fear of the amount of risk that is being held in the system at the moment. We are in the grip of a third wave of this pandemic, which many in the media seem to have completely forgotten about. People are dying by their hundreds on a daily basis still. This is a huge challenge. It goes back to exactly the point in the Bill about workforce planning for the future, so that we never find ourselves in a similar situation again. While we cannot predict when the next pandemic will hit, we can certainly be assured that another pandemic will come. The challenges around the climate and the global problems are going to impact on our health and wellbeing hugely, and we can plan for them now if we choose to. So, fearful and anxious, but we can do something about it. We have a unique moment in time to grasp this, and this legislation is one part of that unique moment in time.

Professor Martin Marshall:

You will not be surprised to hear that morale in general practice is at rock bottom. We read about it in the newspapers every day. Surveys that we have conducted of our members suggest that 60% of GPs say that their mental health has deteriorated significantly over the last year. Anxiety, depression, suicide, ideation—33% of GPs say that at least once a week they find it almost impossible—

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Order. Could we keep to referring to what is in the Bill, please?

Professor Martin Marshall:

Yes, and I am going to do so. The issue here is that if you speak to GPs, because of the stats that I have just described to you, nobody is talking about the Bill.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

But we are here to talk about the Bill.

Professor Martin Marshall:

And almost nobody is talking about the implications of the Bill, because I guess our job is to engage clinicians with the potential of the Bill.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

I am just saying from the Chair that we are here to talk about what is in the Bill and to take evidence on the Bill, so we should stay within the confines of what is in the Bill.

Photo of Alex Norris Alex Norris Shadow Minister (Health and Social Care)

With that in mind, given the quite challenging picture that all three of you describe there, do you have any anxieties that this is not the right time to have the Bill and that, with staff anxious, demoralised and tired, a reorganisation might add to those anxieties and concerns for the future?Q

Professor Martin Marshall:

There could not be a worse time for general practice to introduce the Bill, but I do not think that means it should not happen. It has to happen now. The NHS is ready for it, so it has to happen. The fact that general practice does not have the capacity or capability to engage fully with the implications of the Bill will mean that the Bill will not realise its full potential.

Professor Helen Stokes-Lampard:

From my point of view, there is never an ideal time to introduce legislation and, certainly, in the midst of a global pandemic is on nobody’s agenda as a good time to do anything legislatively. However, the consequences of not doing it are that the integrated care systems, which are in a really vital part of their evolution and formation, will stall and therefore are far more likely to fail. So my view and the view of the Academy of Medical Royal Colleges is that we absolutely must go ahead with this legislation in the timeframe. There is never a good time to have a baby or move house, but you still need to crack on and do these things at bad times.

Pat Cullen:

Same here: never a right time. If you were to ask nurses on the ground today, carrying out patient care in frontline services, they would say that anything that might improve where things are at the minute will be a bonus. But the issue is how it plays out and whether we are listened to. The professional royal colleges do represent nurses. I am here representing 480,000 nurses today. It is really important that we get this right. There is never a right time, but it is actually a great time if we do get it right.

Photo of Alex Norris Alex Norris Shadow Minister (Health and Social Care)

Q I will just ask a final question in my last couple of minutes. Martin, notwithstanding what you said about a greater GP voice on boards, and similarly Pat regarding directors of nursing on integrated care boards, what else could we do to get the voice of the staff really heard in the plans generated by the integrated care partnerships and then executed by the boards? What mechanisms do you think are effective ways of hearing from the frontline what is happening day in, day out? Perhaps, Martin, you could go first.

Professor Martin Marshall:

I cited earlier the example in Gloucestershire. It has very purposefully built a primary care subgroup of the board in order to provide that clinical expertise and that clinical sounding board to everything that goes on at board level. That seems to me to be a really good way of moving on from a single GP on the board—which will be helpful but will have limited impact—to actually making a real difference on the ground. The real change, of course, will not happen at ICS level anyway. It will happen at local level; it will happen at the place level. That is where real change in integrated care, from the patient perspective, will be enacted and will be felt.

Professor Helen Stokes-Lampard:

To build on what Martin has said, there are great examples of clinical panels, which is essentially what we will be talking about. That is a model that works extremely well and which can be broadly based and covering a huge range: primary and secondary care—the whole range of specialities. But in the same way, citizen panels have become something that can be hugely helpful as well. I am very anxious that we also hear the patient voice in the decision making at community level.

There has been a covid culture of creativity. When there was less top-down insistence on following direct process at the start of the pandemic, a lot of creativity was allowed to flourish. I feel we need to capitalise on that culture of creativity. These kinds of panels are exactly the sort of output that has come and they have been hugely beneficial. And, of course, the move to greater digital working has meant that we have been able to reach people that we have not otherwise been able to get. Clinicians leaving the clinical environment to participate has become easier when they can do so remotely. There is a dividend that we should build on.

Pat Cullen:

To add to that, I fundamentally believe that the patient voice must be heard in those structures beneath the board. That is how we will really influence and move forward in terms of what is required, and those voices will feed into the population needs assessment at local level. But there needs to be a nurse involved in each one of those structures that feeds right in through to the director of nursing that sits on the board, and that is how you will hold the accountability line up and down.

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

Q Thank you, Mrs Murray. I will endeavour to be relatively brief, as I am conscious of time.

Welcome and thank you very much for your evidence this morning and your frank answers to the questions posed. I want to ask a question in the context of what a number of you have raised about the different voices and the extent to which they need to be represented at the different decision-making levels of the new structure. We heard from previous witnesses, for example in the context of public health voices also, about the value that they add. The principle behind this legislation is that it is permissive rather than prescriptive. Therefore it is possible to have a lot more voices; there is only a de minimis level specified as prescribed. What is your view as to whether the appropriate balance between permissive and prescriptive has been struck in the Bill? If you think it has not been, where do you think the balance between permissive and prescriptive has been missed? Shall we start with Pat and then work our way along?

Pat Cullen:

I have said very clearly that I believe the nurse needs to be represented at the board, and that needs to be an executive director of nursing. That needs to be prescriptive; it is not good enough to have it placed within mandatory guidance, it needs to be within the Bill. That is a red line for our nurses, and it will remain a red line, and we will be putting it forward as a red line.

Professor Helen Stokes-Lampard:

I am going to be slightly subtler with what I say about this. I think the legislation, as drafted at the moment, is very enabling, and the implementation of it is where the great improvement in how we deliver care will come. I do think it is permissive, and I do think that it is enabling, and I completely understand my colleague’s desire to include specific words relating to nurses, GPs and whoever. What is vital for me is that the clinical voice is loud, clear, and can be influential. That is about implementation, culture and behaviour at a local level. Once we have the words for the final legislation, it is a question of how on earth we deliver it and support people to do it well, and how we learn from the best practice that is out there. That would be my—and our—view.

Professor Martin Marshall:

In my 30 years as a GP, I cannot think of a single piece of legislation that has directly changed my practice on the ground. What I can see is the extent that legislation sets a tone and a culture within which clinical care is provided. I think this Bill is appropriately permissive, but, given the variation in all the challenges that we have identified, it needs to be permissive with really good oversight to ensure that the consequences of implementation do not lead to dramatic variation across the country.

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

Q Thank you. I have three minutes left, so I may try a follow up. That is really helpful, and thank you again for the candour of your answers. Much as it may sometimes pain us in this place, we do recognise that legislation can be an enabler, but we cannot sit here and solve problems on the ground simply by legislation. I sat on a PCT board many years ago, and the culture and the working relationships were almost more valuable than the framework that sat around them.

Going back to Pat’s evidence, but also to all of you: we have heard in our evidence today, and we heard it on Tuesday, a lot of different, vital parts of the system arguing the case for why they should be represented in a prescriptive way. Equally, we will have others arguing that a committee beyond a certain size becomes less effective. In terms of numbers, we have set a minimum. You are entirely entitled to say that you do not have a view on this, but how would you see the balance being struck between different groups making the case for representation, but, equally, having an effectively sized decision-making body? We will start with Martin, and then work backwards.

Professor Martin Marshall:

I am glad to say that I do not have a view, but I do think that the boards should be small in order to be effective. They need to listen to advisory groups and sub-boards below them; it is the structures below the board level that will really make the difference.

Professor Helen Stokes-Lampard:

Formally, the Academy of Medical Royal Colleges does not have a view. Personally, I have chaired boards from as few as five people, through to boards of 70 people, all of which can be hugely effective if managed well. However, the larger the board gets, the tighter the management has to be, because it is harder to get voices heard and for everyone to feel represented. Essentially, I am saying the same as Martin: smaller boards are generally more effective at getting through the agenda, but there has to be a high degree of trust in those that are actually on the board, and strong lines to sub-groups, for them to function with maximum effectiveness.

Pat Cullen:

The board needs to comprise the right people. It is not about numbers; it needs to have the right people with clinical focus and patient care driving the outcomes for patients, and it needs to make sure that it does not develop a financially focused agenda. As director of nursing I have been there too many times: the table loses focus on the patient’s voice and needs. There needs to be a clinical focus and the right people at the table.

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

Thank you all very much, I have no more questions.

Photo of Sheryll Murray Sheryll Murray Conservative, South East Cornwall

Thank you very much. As there are no further questions, I thank our witnesses for their evidence. That brings us to the end of our morning session. The Committee will meet again at 2 o’clock this afternoon to take further evidence.

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

Adjourned till this day at Two o'clock.