Q We will now hear from Dame Gill Morgan, the chair of Gloucestershire integrated care system and the NHS Confederation’s ICS network advisorate, and Louise Patten, the ICS network lead for the NHS Confederation’s ICS network advisorate. Thank you very much for coming. We have until 3.15 for this session. May I ask you both to introduce yourself for the record?
Dame Gill Morgan:
I am Dame Gill Morgan. I am chair-designate of Gloucestershire ICS, but I have been involved there for over two years, so I have seen the development of this movement. I am now the elected chair of the terribly titled NHS Confederation advisorate. What is important about that is that it includes all the ICS chairs that have been and all the ICS people who have been acting in as accountable officers for the work that has developed thus far, so I think I bring a perspective on the reality of what people worry about.
I have been involved with health service Bills for well over 20 years. This one is an exemplar of how people can work with a service to develop a Bill that largely has the support of the system. People have engaged, listened, changed things and taken the frontline views seriously into account. We do not agree with everything, but you asked our think-tank group of people about some of the issues and changes and the permissive approach, and all those things are truly endorsed. For me, it has been the best experience in 25 years of involvement in healthcare. I want to have that noted because people worked really hard to do that.
In contextual terms, you have to realise that this is the first time the NHS has tried to do something fundamentally different. We always legislate for things that look the same—they quack the same, they walk the same, they waddle the same—yet systems and communities are fundamentally different. My ICS, which I am proud to be part of, has a population of about 600,000, and 15 other ICSs have populations of under 1 million. They have our characteristics of closeness of community and long-standing trust. On the other hand, there are some very big ICSs. What the Bill has done well thus far is to create a permissive environment that allows us to see how we can flourish as well as the big places. If you try to define it—
Q I broadly agree with the direction towards permissiveness and the logical direction of the Bill. I am profoundly disturbed, and most of the NHS representatives are making me feel more disturbed, about the lack of local accountability and scrutiny that local people will have of the power that we are giving, with due respect, to people such as you, designated within and by the local health service to police and manage itself. In your drive for permissiveness and power within the system locally, how does a local patient hold you to account for, in my area’s case, the £1.5 billion-worth of decisions that you are going to be making? How do we break the national power and make the local power better?
Dame Gill Morgan:
What is different about this Bill is that it is the first time that local government will be very actively involved in those decisions. It has always been involved in scrutiny and big changes, but it will be heavily represented on our partnership board. We have four local government people, including two elected members on our ICB—integrated care board—so we are bringing in the local government elected people.
We intend our partnership board to meet in public and we are looking at exactly how many of our meetings of the ICB should be in public. Clearly, when talking about quality and clinical stuff, the actual deliberations need a private bit—[Interruption.] When talking about named individuals, yes, they do; but when talking about the quality of the service in general, that is something that needs to be clear and in the public domain. We need to get the balance right between what we need to do publicly and what we need to do privately—as we will, because we will have so much local government involvement, with elected members, as well as Healthwatch and other people like that. They are all intrinsic parts, in a way that they have never been before. It has never felt as engaging to me as it does now, certainly in my patch.
From my point of view, having experienced health overview and scrutiny committees as an accountable officer, the patients and public certainly feel that there is the voice of that local place. It is important to NHS leaders that that continues—that ability to have local scrutiny at local level, which is very much where patients and service users feel is the right place to do it.
At the strategic level, we must not forget that ICSs comprise both the integrated care board and the partnership. This is a real opportunity to tether the NHS to always thinking about the wider determinants of health, social value, public health and, again, patient experience.
Q I am Edward Timpson, the MP for Eddisbury in Cheshire, so coming into the Cheshire and Merseyside ICS, which is a very different proposition from Gloucestershire’s. In that context—it is encouraging to hear how engaged you feel in the process to date, so reflecting on that engagement—what do you think you have discovered already from the preliminary work in Gloucestershire? You have used that example in our evidence sessions. How has that helped to inform the way in which collaboration can best work, bearing in mind that there will be different political, social and economic geographies in each area? In doing so, where do you think clinical representation needs to fit within an ICS, or even within the ICP or the ICB, to ensure that the decisions made are the best for patients and their outcomes?
Dame Gill Morgan:
Our big learning about all of this is that, at the end of the day, many of the structures do not matter; what matters is people being in the same room, having the conversation about common purpose, and getting to know and trust each other. The reflection on that has been why we now have such an emphasis on place. If you have a really large ICS and you are trying to do it all, you are so distant from patients, citizens and clinicians that you will never have the contact. Place, in those bigger systems, has to be where you begin to pull those things together, by getting the right people to engage and developing the right level of trust.
As far as clinical engagement is concerned, the ICS is about three things—the triple aim, which is, basically, how do we get better health services today, which are responsive, high-quality and all those things we want; how in the long term do we create populations that are healthier than they are today, which means thinking about employment and all those bigger things; and, in the middle, how do we take services that we deliver today and transform them to be more community-orientated, better for citizens and delivered where people want them? In each of those three boxes, clinicians are absolutely fundamental.
A lot of our effort—in particular around covid and some of the successes—has been in getting that synergy, with clinicians in the transformation box feeling that they can not only write on what the hospital does, but define what the community does and what the GPs do, because they are all working collectively. That has been transformational. Certainly, we would not have managed covid as effectively as we have without those sorts of relationships running all the way through the system as a thread.
The clinical leadership has to be multi-layered, right the way through from the strategic level to place. We have to have clinical advice and we must heed it when we are talking about planning clinical services. That is fundamental. I think it will involve different groups of people. If it is a care pathway about cardio-vascular disease or a professional pathway about social care, we must heed clinical and professional advice when we are planning these services, so it is multi-layered.
Q In the morning sitting we heard from Professor Marshall, who was talking about your own ICS. I asked about the problem of the power imbalance between the partnership and the board, and he mentioned that you have a primary care sub-group. We have had a lot of discussion about how we gather the voices and ensure everyone is there. What led Gloucestershire to develop that? How do you feel it is working? Do you think that is a good model? How do you ensure the board listen to what the partnership come up with?
Dame Gill Morgan:
It is about multi-layering of advice. We will have a primary care sub-committee partly because managing primary care, and all the things that come through GMS and the opportunities, is expert; we do not want it to be subsumed by a generalist groups. We want it to have proper focus, because if our vision of the future is right, we need better and more engaged primary care at local level that can link its services more effectively with support in the hospital and the community. That is the objective, so we will have that.
We will also have an ICB. GPs will have different views. That is one view, which is about me as a jobbing GP. I go in in the morning, and I do my work and all of those things. I need to be supported to do that, but I also need GPs in the system who are engaged in management. We are very proud of our primary care networks, which are beginning to pull together around our localities, because we are smaller and it is not a big place.
There are models where they are working with second tier local government, where they are beginning to think about housing, and they are working with the voluntary sector, so when they are talking about frailty, it is not a GP or a hospital conversation; it is a system conversation in this place. All of a sudden there are things that can be unlocked. If we leave it in any one box, as we have always done in the past—there is a box for acute, for this and for that—we do not get this. Our task is to make those boundaries semi-permeable, with the expectation that we look at the patient flowing through all those boundaries, rather than pretending that patients sit in an individual box, because they do not.
Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.
Thank you both for coming this afternoon. Dame Gill or Ms Patten—it is fairer to ask the question more generally—suppose the integrated care partnership itself put forward plans for the footprint. The integrated care board, under this draft legislation, has to pay due regard to that. If you disagreed with that as a board, how would you manage that? How would that be resolved? How would that manifest locallyQ ?
Dame Gill Morgan:
The first thing is that you would try to make sure that you have developed a mechanism for engagement and trust, so that you do not get into those sorts of disagreements. If you get into those disagreements while you are sat around the board, you have failed to do the task of integration and partnership. That is what happens in the conversations about how we solve it. If we ever got into that sort of difficulty, it would have to be resolved at the integrated care board, and we will have local government, public health and social care on our board as full and equal partners.
Q That is a very helpful answer, thank you. Obviously there would be old informal mechanism. From my time as chair of health and wellbeing in Nottingham, I remember that the best thing you could ever do was just phone someone up and talk about it. Beyond that, for systems that may not be advanced or relationships that may not yet be embedded, is there a good formal mechanism that we could be writing in to ensure that that existed?
Dame Gill Morgan:
The more you try to write in legislation, the more it becomes the lowest common denominator and the less you unleash the innovation that you want. I would do something quite different. I would probably write something that requires the different models of ICSs to be formally evaluated over a period of time, so for the first time we could look to structural change and say, “This is what it has demonstrated, not just against the outcome measures measured by the Department of Health and suchlike, but this has been a structural change that has added benefit, or not.” If you are going to do that, it must be done from day one. I think that is more important than trying to put something about solving problems in the Bill. You will never hit the particular strange circumstances of a locality that has problems, because they are always serendipitous.
Q Louise, with your broader advisorate hat on, what do you feel about the selection of chairs and how we could get local voices into both the selection and—hopefully never needed—removal of chairs?
The selection process for chairs and the executive team has got to be about what this integrated care system requires, what sort of leadership, and what are the partners that we have got. No two ICSs are the same. In order to achieve that, it needs to be a local discussion about what it is that this system needs to make sure it has the best leadership to take it forward. That will involve discussion with local people, local stakeholders and potentially the public to sort that, because the leadership will be different in different ICSs.
The two will have a very good idea collectively about what leadership is required: one from experience of leaders and the other very much from the grassroots level of, “If this is our system, this is what we need.” It is a combination of the two.
Q I only have a couple of questions, Mr McCabe. I welcome the witnesses and thank them for their evidence so far. One question will be one that I have asked witnesses in previous sessions. We are seeking with this legislation to recognise the existing evolution of the system and the limitations of legislation in driving implementation and behaviours on the ground, as opposed to people finding their own ways of working within a framework. We have therefore focused on a permissive as opposed to a prescriptive approach. Do you believe that we have got the balance right in seeking a permissive framework rather than a prescriptive one? Are there any examples that you would add to what you have already said to illustrate your perspective on that?
Dame Gill Morgan:
Yes, I think you have got the balance, and that is the joy of working with a Bill team. I think the balance is right. You have tried not to be prescriptive and tie our hands, but you have been clear in the sense of setting a direction and focus that we will all take into account, so you do not have to tell us things to make the NHS do it. We do it because we pick up the runes.
On the issues that we would be more concerned about, I personally am concerned about the ability of the Secretary of State to call in changes. In part that is because the one thing I think the NHS has learnt in the time that I was out and came back is how to do relatively good consultations. We have just finished a massive consultation. Patients have gone with us. The local communities have gone with us, mostly. We have had citizens juries and all sorts of things to reach a consensus about the direction of travel. The worst thing in the world would be that people say, “There is no point in engaging in those mechanisms locally because, at the end of the day, we will just complain to the Secretary of State and it will not happen.” If that becomes the way people manage that part of the Bill, it will take us backwards, not forwards, in terms of proper citizen engagement.
On balance, it is about the Secretary of State’s powers of reconfiguration, and NHS leaders in general are concerned about that. It is not so much about the Secretary of State having an early understanding of the reconfigurations or the intent, but about the fact that that decision could be taken at a point where all the evidence is not ready to be properly considered.
Building on Gill’s point, patients and the public would be very frustrated if they felt that they had not had an opportunity to be answered, so we are asking, if not for the clause to be removed, for at least the clinical case for change to be considered from the ICB. Coming back to clinical decisions about clinical services, we want that accountability to local communities, not just up to Whitehall, and some transparency about why the decision was made, and on what basis and information it was taken.
Q Thank you. My next question follows on from that, acknowledging that point about reconfiguration powers, and builds on your clear answer to Karin that you think that what is framed here strengthens local accountability and engagement, and relates to something that you may have mentioned earlier, Gill, in some of your answers. Do you think that it is the right approach, in terms of ICB membership and others, to set a de minimis core membership and then allow that local flexibility to reflect local needs, local accountability and local engagement, to expand it as the local system and local people feel appropriate? Do you think that strikes the right balance?
Dame Gill Morgan:
I think you are absolutely right: de minimis. What I have argued throughout is that if the centre, if you and then NHS England, which issues guidance, are clear about the principle that we have a proper engagement mechanism with our local authorities and citizens, they need to ask us how we are doing that, and to ensure that our constitution meets that. There are plenty of checks to ensure that it happens without you telling us that we have to have this, this and this.
In our case, we will have mental health and social care around the table, not because we are told to but because we could not imagine how we could do our work at a local level without having those people feeling that they are full partners and sitting around the table. There is a set of concerns about having local government involved in making decisions about the expenditure of large amounts of NHS money. I do not care; they are the local people who need to be involved in the decision making. Actually, if they see the deliberations and challenge first hand we will get better-aligned budgets. At the end of the day, that is to everybody’s benefit.
There are already five mandated board positions in the legislation. A further five will be in the mandated guidance from NHS England. We are up to 10 already. I think the most important thing here is: where do you stop? There is a risk that there is a perception of two tiers—that those who have a mandated position on the board are of more importance than others. That flies in the face of partnership working.
Q A final question, if time allows. I entirely take on board your point about the aim, the underlying point about implementation being key here—almost more so than the legislative framework—and the point about a single pot and sense of ownership. I remember the old section 75 of the National Health Service Act 2006, rather than the Health and Social Care Act 2012, being the mechanism that I used when I was a councillor to work with the primary care trust. It worked, but it was a bit clunky at times. My question is one that I have asked other witnesses, so I suspect that it will not come as a surprise to you. Do you think that this is the right time to be introducing these changes and legislation and, if not, when would be?
Dame Gill Morgan:
My view is that we are where we are and we need to progress. Going backwards would be a problem, but actually I am a bit more positive than that. Covid has demonstrated to people that if they think innovatively, out of the box and in partnership ways they can get solutions that are quicker than they would have been before, so in the system as a whole there is a recognition that partnership has offered more. We will all retrench as the world moves on from where we are, but there is real learning from covid on which we can capitalise. Many systems have done reviews of what worked and why, looking for the silver linings in that learning. I think the Bill goes with the analyses that have come out.
At the NHS Confederation, we have that sort of umbrella view. We must not forget that, on collaboration and integration, people have been working to this for some time. There are some great examples of it, and this legislation moves that opportunity to really accelerate it. People recognise that it is a tight timescale, but they are absolutely committed to doing it.
Q It was really just about other groups. You talked about having a primary care sub-group, and there has been a lot of discussion about how to harvest voices up. Could you expand a little on how your sub-group is working and what other sub-groups you would have? How do you make sure the ICB pays attention to what the partnership comes up with? For me, from outside, it seems like it is the board that has the power in the end. Therefore, how do you ensure that? I understand the need for relationships, but what voices other than primary care are you bringing forward with sub-groups or other ways of working?
Dame Gill Morgan:
There are a couple of statutory sub-groups that we are going to require, like accounts, audit and remuneration. More importantly, over the last few years, systems like ours have developed ways of handling finance and quality that have been about a partnership approach, so you do not have a head of quality covering all the organisations, but you have the heads of quality from all the organisations coming together to problem-solve. The heads of finance come together to work out how to allocate the money. That is a very, very effective way of doing it. It teases out the tensions and gets people who are expert in delivery in those conversations. We will have a number of committees like that. The question is: which ones of those become statutory? Which ones do you do through officers? Where do you build people in? All of them will have primary care build-in, because you cannot do service otherwise.
On the partnership forum, which is a different sort of animal, we had already got into the vehicle whereby the full ICB board took cognisance twice a year, because these outcome measures do not change very rapidly. All we do is talk about those longer-term agendas, so it is not just us saying, “Here’s our plan, over to you.” It is about saying, “What really worries you? How can we help? What is important? How do we do it?” We had a wonderful session on apprenticeships. NHS apprenticeship levy money is being used to support some of the stuff that county councils want to do. That would have never happened in the old days because we were not sat in a room with mutual trust and a single purpose.
At the heart of this, every ICB and every partnership board will have to define, “What’s my purpose? What’s your purpose? What’s our shared purpose?” That managerial trust-developing, partnership-developing work is what will make this a success. I started, and I was rapped across my knuckles by Mr McCabe for saying too much—quite appropriately. At the end of the day, you are not going to get that through legislation. You are going to get it by creating an environment and properly holding us to account for what we are doing in these boxes.
Q Obviously, we have heard a lot of discussion about voices that are missing or not listened to, so a sub-group approach might actually be a model for other areas to think about harvesting ideas up towards the partnership and the board.
Dame Gill Morgan:
Indeed. This is guidance, not legislation, so we have to develop a constitution of what we are doing, and we are committed to reviewing it. If today we think that we know what we will need in three years’ time, we are not asking ourselves the right questions, so we need to be reviewing constantly. That is one of the things that we have historically been very bad at in the NHS. We do something, we enshrine it, and then a few years later we throw it all away and start with a new thing. How do we evaluate it? How do we say, “This has been brill, this has been flaky. Let’s get rid of the flaky, and let’s put more of the brill in”? It is that sort of managerial question with us, rather than the very flat, “How do you hit this today?”
Q Do you feel that there will be enough evaluation of what works and what has not worked within the structures that are being proposed through audit and formal evaluation?
Dame Gill Morgan:
I personally think that we have to be very careful. I do not know if this is a role for legislation. A joke in the NHS is that pilots are phase 1 implementation. That is an old joke. It is not this Government; it is every Government. We have always said that. We have to be really careful that we build in evaluation across the piece and do not pick two or three metrics that look as if they have gone the bad way to prove what we wanted to argue before. That is done both in favour of things and against things, and we end up with this sort of noise in the system. Let us plan now and get a proper, effective academic unit to build in some evaluation at the end of this time, and then let us all take stock in two and a half years and say, “Hasn’t this been brilliant”—in my opinion, it will be brilliant—or, “It won’t do any harm, but it’ll be nothing”. We have got to do better than nothing.
I think we drew that conclusion from your evidence—absolutely.
May I just thank you both very much for giving evidence today? I am sorry that I had to interrupt you, but I am an obsessive timekeeper. Such is life. Thank you very much.