Q We will hear next from Ed Hammond, who is the deputy chief executive at the Centre for Governance and Scrutiny, who is appearing in person, and from Andy Bell, who is the deputy chief executive at the Centre for Mental Health, who is appearing remotely. I will just remind Members: if you are directing your question at Andy, can you make that clear, so that he is aware of it?
Good afternoon, both. Can you both introduce yourself for the record, starting with Ed?
It is a really good question and I think that, on its own, the legislation certainly has some potential to assist with that. Of course, there also need to be a number of other things and I can talk about those if that would be helpful.
The first positive thing to say about this legislation is that the idea of integrated care—the practice of providing care that actually links across between mental and physical health, NHS and social care, and prevention and treatment—undoubtedly is the way to go. I think we have a number of areas within the system where we know that people at the moment get very poor support for their mental and physical health, as a result of the lack of integration in the system.
Examples would be people who have both alcohol and mental health difficulties at the same time; people living with long-term physical illnesses, such as diabetes or kidney disease, who get really inadequate and often very poor emotional support, if indeed they have any emotional support at all; and, indeed, people living with long-term mental health conditions, whose physical health is very often very badly neglected, and they have very little support. Integrating care—actually doing that on the ground—and achieving a real change in the way that services are organised around people’s needs would undoubtedly make quite a significant difference and reduce some of those inequalities.
I think the way that the Bill and the various bits of guidance are written gives us some hope that that may happen; it certainly does not answer all of our questions about it. In and of itself, I think it is potentially a step in the right direction, but we need to give some thought to a number of caveats around that.
Yes, sure. Again, “integrated care”—we like the words; they are good—but the difficulty in a way is, first of all, the fact that this is very much an NHS-dominated set of proposals. It was written by NHS England for NHS England. I think that if we have a genuinely integrated system, where people will get support across the whole range of services, we need this to be an equal partnership between the NHS, local government, and voluntary and community organisations.
If you look at the proposals, in a sense what they are doing is taking decision making and power within the health and social care system further away from local communities into what are effectively sub-regional groupings. There is not anything very local about integrated care systems in many places, and that gives us some pause for thought. It is very much NHS dominated. If we look at the current health and care system, public health and social care are often the less well-funded and less well-resourced parts of the system. From what we see from the spending plans, it looks like that will become even more the case if you have legislation that, in a sense, reinforces the power of the NHS over other partners. I worry we are not going to get that real shift.
In terms of scrutiny generally, it is a challenging picture, as Andy said. There is a challenge around the need for effective local accountability. That scrutiny is best exerted at a local level. Local scrutiny is much more able to assess and make accurate conclusions about what outcomes have been reached. We do a lot of work as an organisation supporting local councils in their formal health scrutiny functions. The past 20 years of that has demonstrated a significant degree of success in local government being able to lead with local healthwatch in, alongside and on behalf of local people, seeking to understand how local health services design and deliver effective outcomes, challenging, where necessary, through the referral power for substantial variations.
My worries echo Andy’s in that the Bill as it stands moves a lot of decision making, commissioning and direction activity up to system level. Depending on the character, relationships and personalities of the key individuals involved, there is a risk that decision making therefore becomes remote from local accountability, making effective scrutiny of outcomes more challenging to achieve.
Q That leads neatly on to my point. We have just heard a great defence of ICSs as the system of accountability, and you have said that system level is where decision making is happening. The chief executive told us very clearly on Tuesday that accountability for decision making was clearly located in the ICB. The ICP—the partnership—is formally a committee of the ICB. I think each of our witnesses—very experienced people—have actually confused those three acronyms. They have also confused the accountability, which NHS England has told us is very clearly in the ICB. The finance director, the accountable officer at the ICB, carries the can. The other person will ultimately be fired, should the accounts not balance and there be some sort of health and safety patient scandal. I think that is clear. First, do you think that is clear? Secondly, how can we encode the good direction of travel in the Bill around local accountability to somebody who could oversee it in a more independent way and better hold that accountability locally?
In answer to your first point, I think it is clear. As we become more familiar with what is a complex system—and health governance is complex—some of this confusion will dissipate. As we start to operate practically within these systems, familiarity will breed a degree of confidence in understanding whose roles relate to what. As with all complex systems, it is vital that everybody understands their individual and collective responsibility for governance within those systems and accountability.
It is great when you have a partnership-led framework, in which everybody in the system is working together, and everybody has some stake in the system and in decision making. It is not a hierarchical, dictatorial system; it is one based, hopefully, on dialogue and, to an extent, consensus. The risk of that is that it necessarily dilutes accountability. Where everybody has a stake in decision making, you need some kind of external source of local accountability. That leads on to a second question. I think there is a need for a distinct and separate form of local accountability within these new arrangements at system, place and neighbourhood level. That role is currently performed at a local level in two main places: through local Healthwatch, from whom you will be hearing later, and through local health overview and scrutiny committees.
For me, the risk of these new arrangements is that, first, the removal of the power of referral to the Secretary of State by health overview and scrutiny committees on matters of concern relating to substantial variation of local health services is a worry for us, as it is for NHS colleagues. Also, the focus on system-level decision making will, by definition, make it more challenging for local health overview and scrutiny committees to co-ordinate to form, where necessary, joint committees to effectively oversee, scrutinise and hold to account ICS, ICB and ICP activity at system level.
Yes. It is a really important question. From the perspective of mental health, we have seen an enormous amount of progress in recent years from local Government really embracing the mental health agenda in many areas and becoming both a partner but also a scrutineer of the NHS through scrutiny committees and through the role of health and wellbeing boards too. The importance of that natural connection through, between the health and wellbeing board with the ICP in particular, the partnership bid, feels like there needs to be a very clear and close relationship and, again, where possible, decisions being made at place level—in the new language—feels really important to allow for that kind of relationship to build and actually become a really positive relationship, because so much of this does come down to relationships. However, clearly, the need for some kind of external scrutiny is incredibly important.
When we think about it from the mental health perspective, where systems or governing bodies—be it the integrated care board or anything else—are allowing mental health to slip through or particular groups of people are being poorly catered for by the system, some kind of external scrutiny and clear accountability is incredibly important. One thing we have said we would like to see in the Bill is an extended and expanded role for the Care Quality Commission to really scrutinise the degree to which integrated care boards and the decisions they are making—and, indeed, partnerships in their strategies—are looking across the board at health inequalities.
At the moment, the Care Quality Commission is very good at inspecting services for whether they are working appropriately with individuals they are seeing, but it has no powers to scrutinise whether the health system as a whole is working fairly and appropriately across all different groups of people. Unfortunately, that means, certainly from what we see in the mental health world, that there are a number of groups of people who get very poor support for their mental health—actually, very little help at all—and there is no current means in the system to address that.
This is for Andy. It is noted that mental health provision has for far too long been seen as the Cinderella service of the health system. Indeed, there is very little in the Bill specifically around mental health. Given the growing number of people suffering with mental ill health and the shortage of services, is there enough in this Bill to satisfy you that mental health will be given parity of esteem alongside physical healthQ ?
It is difficult to tell; the Bill is largely silent on mental health. If we had a system where there was genuinely equal regard for both mental and physical health, we would not have to worry about that, because we would know that the system would treat mental health fairly and equally, and there would be no disparity in the way it was thought about. Unfortunately, all our experience tells us that that is not what happens within many health systems at different levels, from very local to national, so we would like to see some assurances in the Bill.
From our point of view, that could happen in one of two ways. Legislation only gets you so far, but it could place specific duties on both NHS England and integrated care boards—I am being very careful in specifying integrated care boards here—that they must take action to ensure that mental and physical health are given equal regard in their decision making, particularly on resource allocation. We feel strongly that there needs to be a voice for mental health within integrated care boards. That is highly likely to happen within integrated care partnerships, but within integrated care boards we do not have confidence that mental health will be properly represented at the top table where important decisions about resource allocation are made.
We think that would help. There are no 100% safeguards in legislation, but one positive thing we have seen with the 2012 Act is that a clause at the very top of the Act talked about mental and physical health as one of the key purposes of the NHS, and that has been used positively and helpfully to make the case for parity in health systems up and down the country. A few simple words can sometimes make quite a big difference.
Q This is a question for Ed, building on the fact that you have, I think, fairly extensive experience of working with local authorities and supporting them on governance and scrutiny. Having direct involvement in NHS decision making on funding and so on is a fairly new role for local authorities, and different ICSs will have different sizes and geography; for instance, mine is Cheshire and Merseyside, which is one of the largest—I think it is three or four times the size of some other ICSs. Over and above being involved in the board, for local authorities in larger ICSs, where the emphasis on place could be lost if they are not more fused into the system, how do you think the Bill could help to ensure that that is the case, so that we get the right balance between their involvement in the decisions, based on their knowledge of their own population, and the wider regional decisions?
For me it starts with an understanding of what decisions are best made at system level and what decisions are best made at place level. Certainly, I would imagine one of the first things that ICBs and ICPs would need to do, once established, would be to determine how to set up a system-wide framework for ensuring equality and equity in terms of how its health and care service is delivered, and then determine how and where it is most appropriate that more detailed decisions come to be made at place level. Otherwise, the system simply becomes too unwieldy.
There are risks that those partners sitting at that system level will draw decision making into those spaces, rather than pushing it back out to localities, because it is the simplest, in many ways the most efficient and apparently the most co-ordinated way of doing it, but in practice it will not serve the interests of local accountability or better outcomes. That raises the prospect of certain services being delivered in different ways in different localities, depending on the political priorities of different councils, but that is local democracy—that is local government bringing its understanding of the demographics of the populations it serves into the conversation.
I think this can all be made to work if there is sufficient transparency in the system, so that those within and those outside it understand how decisions are being made, on what subjects, and by whom. When you have that clarity, it becomes easier to unpick what is happening at place level. Are decisions being made at system level that would be more appropriately made at a lower level? Is there consistency across the entire system? What does the geography mean for decision making and commissioning, and these kinds of things? It provides assurance, and it provides everybody with more confidence that decisions are being made properly in the interests of local people.
Going back to the point I made before, that is also why some external local accountability is so important, because effective local external accountability can challenge the system on whether the right decisions are being made at the right level, and whether they reflect and are responsive to what the local needs are. Local scrutiny committees are, at the moment, anchored at place level within local authorities. They are well able to publicly draw in the voice and concerns of the public about those kinds of issues, and transmit them to health and care partners so that there is a clear way for those concerns and issues to be responded to.
Q Could I ask you a question, Ed? Obviously, you talked there about better outcomes. Regardless of who is judging it, you need evidence for that, and there are two aspects here to help to know what success looks like. From the perspective of local scrutiny of health improvement—improvement of health and wellbeing at a local population level—how do you see that being done? Obviously, that is what the ICB and ICP are being challenged with. Coming from a breast cancer background, where obviously you have specialist teams that need to be judged, what about the scrutiny of healthcare through quality improvement clinical outcome standards, which require audit and benchmarking against ICSs elsewhere in England, so that you do not have postcode variation in survival, treatment, or anything else? How do you see those two scrutinies working?
That is a challenge, because it brings into focus the role that different accountability partners play in the system. We have already heard a little about the CQC and the work it does in assessing and monitoring clinical outcomes. Of course, within ICBs and ICPs there will come to be—one would hope—robust and effective performance management arrangements. Certainly, looking at the Secretary of State’s expectations around the exercise of new powers, one would expect that, for the Secretary of State to understand where he chooses to intervene and direct services, that would be on the basis of evidence that would need to be collected in a consistent and systematic way across England, but also within individual ICBs. Presumably, we can expect some kind of performance framework to be established nationally to provide evidence to support the Secretary of State in the exercise of their powers.
Then at local level, you have, as I mentioned before, local Healthwatch and local health scrutiny communities. Now, local scrutiny committees obviously cannot bring the clinical expertise to bear on issues of concern; the CQC naturally leads on many of those issues. I think what those local partners in local Healthwatch and scrutiny committees can do is understand where there are gaps in the system; where there are concerns about aspects of performance that others have perhaps not picked up on; where there are concerns emerging from conversations within local communities that councillors are hearing about day to day, because they have direct contact with local people; and those concerns that might not otherwise find their way on to a performance scorecard, but might relate to things that are not being monitored, measured or managed particularly well. That local connection is a vital part of what makes health scrutiny work.
Q But you do think there would be a role for analysing data? My background is breast cancer. You know that what chemo you use and what surgery you did is going to affect the outcome for that woman in 10 years’ time, so in Scotland we have that in clinical standards. Those kinds of metrics would not necessarily go to the Secretary of State initially, but local teams want to improve and clinicians want to drive quality performance. Would that be something that you would be involved in developing; or who would be doing that?
Yes. Where ICBs and ICPs are putting those monitoring arrangements in place, I would certainly expect local clinicians to have a role in assessing, evaluating and analysing that data and evidence. As I have said, committees of local councillors would also be able to do that. I think we have a resource challenge in how that local government scrutiny operates, but as a matter of principle local councillors are increasingly adept at that data analysis, despite the fact that they may not be clinical experts. They are able to carry out some form of analysis. Collectively, we can see that, together, those partners can bring to bear a form of local accountability, primarily at system and place level.
Q A brief question to Andy: there has been discussion over recent years about the need for greater preventative public health. Do you think there is enough discussion or enabling of that approach in mental health? Although we may not do it, we all know what we should do to be physically fitter and healthier—how good we are is up to us. But many of the public have no idea how to protect their mental health. Do you think there is enough population and preventative mental health work? And are there ways of strengthening that in the Bill?
We have hugely underinvested in it, and indeed very poorly appreciated it. What we have seen in recent years, which we hugely welcome, is huge progress on mental health awareness and understanding. That was not there 10 or 15 years ago. It has not been that long since in a debate in the House of Commons the first Member stood up and spoke about their own experience of mental illness; that was hugely powerful, and began quite a significant social movement. However, we do not yet have literacy around that issue, or indeed a real understanding about what we can do to promote the public’s mental health. With the creation of the new Office for Health Improvement and Disparities—I must remember to get the name right—there is an opportunity to make public mental health as important as public physical health. How we translate that to local areas will be really interesting.
When I talk to people working in local public health departments, I see a huge enthusiasm for and interest in how they can better support mental support in the communities they serve. We have seen incredibly creative work from around the country, such as in Leeds and Bristol, from public health teams that are leading the way who understand that the things that determine our mental health are very much about the society and environments we live in—the families we come from, the schools we go to, the amount of income we have, and the homes and neighbourhoods that we live in. There is a growing understanding of that. However, we have not yet put that into practice on a large scale, and indeed the resources available to public health departments to do that are very threadbare. Many have to be very creative in how they do that.
We very much welcomed the promotion and prevention fund set up recently by the Government, which gave funding to local authorities in the 40 most deprived local areas in England for mental health promotion activities. We are really looking forward to seeing what that money is used for, and we very much hope that it will be the beginning of something much bigger. Our worry, in relation to the Bill in particular, is the understanding of prevention, and indeed the understanding of prevention that I read in yesterday’s Command Paper on the health and social care plan. It is still based on physical health, and the idea that public health is about telling people how to live their lives and how they should behave, rather than what really determines our mental health: how much money we have coming into our home, how safe we feel, and our position in society. It is really clear that very often the way that economic and social inequalities affect our mental health also affects our physical health. Very often it is poor psychological wellbeing that leads to later physical health problems, so we really have to start taking public mental health as seriously as any other part of public health.
Q I have just one question for you, Mr Hammond. You obviously have the ICB decisions being made. What, in your understanding of the Bill, would happen if—hopefully this will not happen, but we have to look at every possibility—the chief executive of the ICB was making decisions that the ICP and other partners were not in agreement with, and they effectively lost confidence in him? Is there any mechanism that would be able to deal with that situation?
The obvious mechanism is the Secretary of State’s power of intervention. It is all about that referral upwards really to the Secretary of State to act. Ideally, these kinds of things can and should be resolved through dialogue, because the Secretary of State can intervene only so much. One of my worries about the focus in certain elements of the Bill on the new and enhanced powers of the Secretary of State is that it sort of assumes that the Secretary of State will need to have fingers in lots of pies to be aware of where these issues are occurring across England, and be prepared to step in where they are happening, which requires the exercise of a significant watching brief across a wide range of areas in a way that does not currently happen.
Ideally, these kinds of things can and should be thrashed out by the people involved at local level. The Secretary of State can intervene but does that intervention persist if relationships have effectively broken down? What do you do then? You cannot run everything from Whitehall; there has to be some kind of mechanism to rebuild relationships and trust. One would hope that it would not get that bad, but I know of past tensions. There are divergent priorities between local authorities, NHS partners and other partners in respect of health and care issues. The logic of ICPs is that you are aligning those priorities better, but that is not guaranteed.
That is one of the reasons we consider that there should be a role sitting with local health scrutiny committees to escalate matters of particular concern to the Secretary of State, so there is not this assumption that the Secretary of State is exercising a continual watching brief over everything that is going on. There is that formal power of escalation from an external body holding the system to account that can, before that escalation, exert some kind of influence at local level to try to knock heads together and bring some form of agreement in place, so that you are not in a situation where you have a persistent assumption that Whitehall will need to step in in every case where these kinds of issues occur.
At the moment, it is really impossible to say. I would like to see the Bill achieving parity of esteem for mental health. As I say, the principles of integrated care could certainly enable that to happen, if combined with a lot of other very significant and important activity to shift the culture in the health service, apart from anything else. The lack of specific provisions in the Bill to ensure that parity is taken seriously is a real worry. I think there are still gaps in the Bill that could be very simply addressed and would help to ensure that system leaders, wherever they are—whether they are on integrated care boards or any other three-letter acronym that gets created—realise that their personal responsibility is to bring about parity for mental health.
I think we are at a point now where there is some recognition in most parts of the system that mental health is important, but very often, outside specific mental health services, there is still an assumption that mental health is something other people and other organisations do, and there is not that shared responsibility for it in quite the way that we think would help to move us forward.
Q I have one more question, Mr McCabe. One of the consistent points we have heard from witnesses is that they are not convinced that the provisions in the Bill on workforce are sufficient to deal with the workforce challenges that the NHS faces. Would that be something that you feel is also the case for mental health professionals?
This is incredibly difficult. We have some very ambitious plans now—the NHS long-term plan ambitions for mental health. There is, quite rightly, an awful lot of money going into that, because we have a very big gap in our ability to meet people’s needs. The only way that is going to succeed is if we have a very significant expansion in the mental health workforce.
We need to remember that that workforce is not just what people think it is. It is obviously nursing and obviously psychiatry, but it is also social work—a lot of really important mental health provision is in local government under social care. We need to think about the importance of advocacy and the importance of peer support, the importance of employment and housing rights workers, who we know make a big difference to people’s lives. There is also the key role of the voluntary sector in providing forms of support that may not come under traditional clinical headings, but none the less make a huge impact in people’s lives. We need to build the workforce.
The Bill gives some steps forward and summary assurances. In some ways, it is not quite the right place to be dealing with this. This is about whether the various parts of the system—the health education system, the NHS itself and its partners in local government—have the resources and the right ways to encourage people to come and work in mental health. It would be great to see the kind of recruitment campaigns we have had for the NHS as a whole to really help bridge that very big gap in the mental health workforce. At the moment, I think the Bill is probably neutral on it. It would be good to see some stronger assurances, at the very least holding the Secretary of State to account for how they are achieving the workforce ambitions set out in the long-term plan and future policies that will have to come.
Q Good afternoon, Ed and Andy. Andy, in my first question, can I pick up on something you said there, before I broaden out to a question to you both? You talked there, quite rightly, about the importance of parity of esteem for mental health. As a local councillor years ago, I saw how important local councils and the NHS working hand in glove on mental health provision is, because if we get one half right but not the other half, it just does not work.
Building on what you have already said about the legislation, what would you identify as the opportunities of the legislation, if properly implemented or interpreted in the right way, for furthering that linkage and that joined-up mental health provision? Obviously, that goes beyond local council services and the NHS. There are a whole wraparound series of services that impact on someone’s mental health. What do you see as the opportunities in the legislation that we either need to draw out further or at least not lose sight of?
This is about building real, sustainable, long-term partnerships. One of the things I know colleagues in the NHS and local government find very frustrating is that they just find a way of working with each other and then the legislation changes again and they have to start all over, so it is about having a system that actually works and stays working, that builds on the best of what is there already. I think there is some frustration in places where they spent a long time building relationships between clinical commissioning groups and local authority colleagues, sometimes with jointly employed staff, and now they have to start all over again because we are moving to a different thing. That will be immensely frustrating for many folk.
If we take the principle that this is about integrating care and equal partnerships between different players, including the voluntary and community sector, and if we give that time to work, we will enable partnerships to form with a clear voice for people—for example, in the case of mental health, for people living with mental health difficulties—so that decisions are being made with and in partnership with the people who use them rather than remotely by professional experts on their own.
Collaboration is incredibly important too. One thing we really welcome about the Bill is that it is moving us away from a system of competing providers to providers working collaboratively—literally, in providing collaboratives. There is a slight risk that all the power will be vested in one organisation and there will not be that check and balance between commissioner and provider. But some of the early provider collaboratives working in children’s mental health services that we have looked at have made really huge strides really quickly to reduce, for example, the number of children forced to go to hospital outside their local area in a mental health crisis. They have come together, looked at what support is needed for children in a crisis and put community services, in particular, in place to achieve that.
One further thing that will be important is that there is some positive provision in the Bill to ensure that ICBs—I think it is ICBs, yes, it is—have to take into account inequalities in access and outcomes. That is great, but there is not that requirement to pay attention to inequalities in health and to go out and identify which groups of people are experiencing health inequalities and what the system can do to deal with that upstream rather than waiting for people to need formal healthcare. That would be the other part that would really help in the Bill—to build on some of the positive noises and moves in the right direction in collaborating at the level of prevention and on the things that determine our health as well as in the provision of services when things have reached a point where people need care.
Q In the two and a bit minutes I have, in order not to get cut off by Mr McCabe, I will direct my question to Ed and will bring you in, Andy, if I have time. We have heard about how what is proposed in many ways enhances local accountability and local authority involvement in decision making, but to go back to your earlier comments, would it be fair—you are entirely entitled to say that it would be unfair, and that I am misinterpreting—to say that alongside that your request was a request that in enhancing that we should not lose the local accountability mechanisms and processes that have already grown up over the years in local authorities, be that health and wellbeing boards, joint overview and scrutiny committees, or whatever? Is that a fair characterisation? Feel free to correct it.
Broadly speaking, yes, that is fair. My central point would be that those structures and the opportunity that local government has through this Bill for more direct and active involvement in health and care decision making are good, but there still needs to be that separate independent source of accountability that we feel sits properly at a local level with democratically elected local councillors who have powers through health scrutiny committees to talk to local people about their needs. That needs to be there and needs to be strengthened. In respect of the Secretary of State powers I was talking about, my worry would be that we would see ICBs and ICPs looking over their shoulder at what the Secretary of State might want to do rather than looking down to local communities to understand where local need lies, with decision making being led somewhat by what people think national priorities should be.
Part of the solution to that problem is the things we have proposed around, for example, requiring the Secretary of State to consult with local scrutiny committees before exercising those powers, having the powers for local scrutiny committees formally to escalate things to the Secretary of State to act on, and what we have suggested for more effective joint scrutiny by multiple councils of the ICB at system level as well. Those are all part of that strength and accountability framework. It is about saying, “Okay, we have involved local government in decision making through the ICPs and through continuing the health and wellbeing process, but in doing so we also have to enhance and build on our existing health scrutiny arrangements.” As things stand, the Bill removes elements of those by removing the power of referral. It is about having a balance of accountability arrangements and ensuring that that strong external accountability continues.