“(2A) When appointing members to the integrated care partnership, the integrated care partnership must pay particular attention to the range of services used by children and young people aged 0-25.”
This amendment would require integrated care partnerships to consider representation from the full spectrum of services used by babies, children and young people, including education settings.
“(c) include specific consideration of how it will meet the needs of children and young people aged 0-25.”
This amendment would require an integrated care partnership to specifically consider the needs of babies, children and young people when developing its strategy.
I move the amendment on behalf of my hon. Friend the Member for Eddisbury.
These probing amendments would require integrated care partnerships to involve in their joint committee the key partners—including schools and colleges—responsible for meeting the needs of babies, children and young people. The intention is to understand how we can best ensure that children’s needs are given equal priority at ICS level. The Bill provides a genuine opportunity to reduce child health inequalities and improve children’s health outcomes, which is all the more pressing following many children’s severe adverse experiences over the past 18 months.
The Government’s drive towards integrated services and greater collaboration, both within and beyond the health and care system, is very much to be welcomed, but if ICSs are to achieve their aims of improving population health and reducing inequalities, they must give equal weight to the needs of children when they plan and commission services. Why? Because children are a distinct population with their own workforce, infrastructure, developmental needs and legislation. Children’s health is affected by a complex ecosystem of factors, with many interrelated systems encircling the child. Their health is determined not only by primary and secondary health services, but by their nursery or school, children’s social care teams, the local authority SEND workforce, school nursing, health visitors and many other partners.
Building integrated care systems, with babies, children and young people firmly in mind, has the potential to improve health outcomes for children across the country, including those with complex health needs and disabilities. That, in turn, can have a profound impact on population health now and long into the future.
If the key professionals and people involved in children’s lives are missing from the discussions, there is a real risk that the needs of children and young people will not receive the attention that they require. That is why every integrated care partnership should have a plan for involving the full spectrum of services used by children and young people aged zero to 25 and to provide clear leadership for children in an integrated care strategy. To that end, it is clearly also important that ICSs should consider how the voices of children, young people, and parents and carers will be represented in governance structures, including the voices of disabled children and very young children.
On amendment 54, the Bill as drafted will require every integrated care partnership to develop an integrated care strategy. Given that children have distinct health needs and experiences and use a distinct health and care system, it is vital that ICSs are required to consider how they will meet the needs of children when developing this pivotal strategy. When legislation does not explicitly require health systems to consider children, they are often forgotten about in policies and subsequent implementation. Analysis by YoungMinds found that a majority, or 77%, of sustainability and transformation partnerships failed sufficiently to consider children’s needs. We cannot afford for that to be replicated in ICS structures.
If the Government are to deliver on their commendable vision to improve health outcomes and reduce inequalities across the whole population, and not just for adults, ICSs should be required to consider babies, children and young people when developing strategies that will determine the planning, commissioning and delivery of all health services. Some of the things that a strategy might consider include: where local leadership and responsibility for children sit; how the full spectrum of services accessed by children aged zero to 25 are represented in an ICS; the voices of children, young people and their families, including disabled children and very young children; and the capacity and skillset of the local children’s workforce.
It is also important that every partnership recognises that children are not a homogenous group and have distinct needs at different ages. Strategies should also take into account the needs of children across the age range. Above all, it is crucial that there is a clear vision for children’s health in every integrated care partnership to ensure that children are prioritised and not forgotten about during the move to statutory ICSs.
I am grateful to the hon. Member for Eddisbury for tabling the amendments and to the hon. Member for Vale of Clwyd for stepping in to give the Committee a chance to discuss them. I agree completely with what he said about the Bill being a real opportunity on child health in this country and I hope that we can take it.
We should be saddened by what Barnardo’s said in its written evidence:
“Children growing up in England…face some of the worst health outcomes in Europe”— particularly those growing up in poverty. That is really saddening, not least because even prior to the pandemic, according to Action for Children, over 4 million children were living in poverty, including a staggering, breathtakingly sad 46% of children in black and minority ethnic groups. We must seek to do better. These things should stop us in our tracks, given the wealth that we as a country have, the technologies we have, the schooling we have and the assets we have, yet we cannot give our young people, particularly the poorest children, the best start in life. That is really sad.
The only enhancement that I would make to the amendments is that, rather than making them about ages nought to 25, I would extend the range to include the six months prior to birth, because we know how important those services are. I hope, in that spirit, that we may hear some enthusiasm from the Minister and his Government about implementing all the recommendations of the Leadsom review. I know that it will be hard, because it will involve acknowledging some dreadful decisions over the past decade, such as the reduction in Sure Start but, nevertheless, that report has real potential to be the bedrock for a return to something much closer to proper early intervention in this country. We might not have the saddening and completely avoidable outcomes that we have, so I hope that we hear some good news from the Minister on that.
I am grateful to my hon. Friend the Member—I cannot pronounce that—and to my hon. Friend the Member for Eddisbury, on whose behalf my hon. Friend for Vale of Clwyd spoke. I also wish to put on the record my gratitude to Lord Farmer and his team for the work that they have been doing in this space. I have had the pleasure of meeting them, and—to reassure the shadow Minister—I have already met once, or possibly twice, with my right hon. Friend Dame Andrea Leadsom to discuss her review. I know that my hon. Friend the Member for Bury St Edmunds has also worked with her on it, and we continue to work together to try to find ways to move that forward.
I hope that all Members agree that the creation of integrated care boards and ICPs represents a significant opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people. We acknowledge that these amendments understandably intend to ensure that the needs of children and young people aged 0 to 25 are represented on the ICP and are considered by the ICP when developing its strategy. While we entirely agree with the intentions behind the amendments, we come back to the point that we wish to provide local areas with the flexibility to determine what will work best for their systems, their priorities and how they develop their plans and membership. Overly prescriptive approaches in the Bill would risk making it harder for systems to design the approaches that will work best in their area.
Turning to amendment 54, we would not want ICPs to create plans for children disconnected from the wider healthcare system. We know that the very best systems consider how their health systems are meeting everyone’s need, including where there are transitions between different stages of life. However, I do hope that I can provide some further comfort for my hon. Friend the Member for Vale of Clwyd. We are working on bespoke guidance for babies, children and young people, which will set out clearly how ICBs and ICPs are obliged to deliver for them. This will cover the importance of the ICB forward plan and the ICP strategy and how they can set clear objectives for babies, children and young people. The Department is working closely on the drafting of this guidance with NHS England, the Department for Education and, indeed the relevant Minister, my hon. Friend Vicky Ford—I presume that she is still the relevant Minister as we speak. We will also be working with all stakeholders, including the National Children’s Bureau, in the coming months. I suspect that this is a theme and an issue that we will return to at various points both in Committee and indeed in the further passage of this legislation.
I hope that I can reassure my hon. Friend the Member for Vale of Clwyd on this matter. I entirely understand where he is coming from, but ask that, on this occasion, he does not press his amendment—or the amendment of my hon. Friend the Member for Eddisbury—to a vote.
“(3) The Secretary of State must make regulations which set out the procedure to be followed should an integrated care partnership believe that an integrated care board has failed in its duty under this section.”
This amendment would require the Secretary of State to establish a procedure for the resolution of any dispute between an integrated care partnership and an integrated care board concerning the implementation of a strategy produced by the integrated care partnership.
(a) in exercising its functions a responsible local authority or integrated care board diverges from an assessment or strategy mentioned in subsection (1), or
(b) in exercising any functions in arranging for the provision of health services in relation to the area of a responsible local authority NHS England diverges from an assessment or strategy mentioned in subsection (2), that local authority, that integrated care board or (as the case may be) NHS England must—
(a) (i) within 30 days, make a public statement of its divergence from the assessment or strategy, and
(ii) within 60 days, publish its reasons for the divergence, together with any supporting evidence.”
I will talk briefly about amendment 83 which has been grouped with amendment 47.
Amendment 47 focuses on the whole discussion that we have had, and that we will continue to have, around integrated partnerships and what they will be able to do to deliver for their communities. I do not know if “Marmotisation” is a word; if it is, this could be seen as the first step towards that, but we will see how it works in practice. We must be clear, however, that this is a first step. The names of the partners being bandied about shows that this Bill is about the integration of not just health and social care but the whole wider public sector and other partners, and shows, too, that health issues permeate almost every walk of life. This certainly does not, as evidenced by the Prime Minister’s comments last week, constitute a solution to the integration of health and social care.
Putting that aside, there is an opportunity here to do something different. However, for all the froth and grand statements about partnership working we fear we may be looking at giant CCGs with less GP involvement—we have made this point a number of times so I will not labour it. What we are presented with is a reorganisation of the NHS, not a panacea for integration. We have tried a couple of times already to elicit from the Minister what is missing from the Bill in terms of the integration that the Prime Minister believes necessitates a White Paper. I think the Minister might struggle sometimes to understand what exactly is going on in the Prime Minister’s head in relation to this—or indeed anything else that is going on in his head—but we await his response on that with interest.
I would like to make some general points on the relationship between the NHS and local authorities, because that is important. The Bill acknowledges that greater interaction is needed, but the big question is whether it actually delivers that solution. If there is to be a genuine generational shift from thinking of the NHS as dealing with sickness to contributing to overall wellbeing, that will be welcome, although if our amendment on patient outcomes had been accepted that would have been a better start. There have been some discussions around SDPs and ICSs in the Bill, and that gives us hope that there might be something here we can work with.
The need to bring services together and integrate is blindingly obvious, but it is also very hard to do as the following example demonstrates. A patient with a long-term condition such as chronic obstructive pulmonary disease, and with both healthcare and social care needs, has an acute episode and is admitted to hospital and is then discharged back into their home, which unfortunately suffers from a chronic damp problem—something many Members will know about from their constituency casework. The housing provider—a local authority, perhaps, or an arm’s length management organisation or registered social landlord—is doing its best, but it does not have enough resources to get to the root of the problem, so there is a liaison meeting where this case is discussed between the NHS and local councillors. The councillor for the area where the individual is located asks the chief executive of the trust whether it would be a good idea for some of the health budget to be invested in social housing so that people such as this individual would not be readmitted for a problem that is essentially caused by the property they are living in. The chief executive responds by asking why they would throw money away on something like that, even though a more holistic view shows that would be of benefit for everyone in the long run.
That illustrates why we need to work harder on integration, and it is not an isolated incident. As any councillor who has been in post for any number of years will know—if the Minister and I totted up between us how many years we have served, it would probably be quite a lot—sometimes it is difficult to have the level of interaction with the NHS that we would like. As an aside, I might add that children in care meetings or care around the child meetings are incredibly important, but often the GP does not attend because they have many other priorities.
We have talked about this many times, but the vaccine roll-out has been an exemplar of how local government and the NHS can work together. That was a specific task at the time of the national crisis. It is clearly more difficult to repeat that kind of synergy on a day-to-day basis, but it does show what can be done.
In Wales, the Government have a far-reaching strategy around the wellbeing of future generations. They have made a big leap, moving the NHS away from market thinking and focusing on the way it delivers its service to the public. Both Scotland and Wales have accepted the need for that approach, and their integrated joint boards, joint integration boards, health boards and local authorities have all been talking about integration for some time. Of course, they have the sense to make their health boards coterminous with local authority areas. That would have been a very wise move. We have already had some chat about devolved involvement and I am sure that we will return to that.
The Bill at least makes a start on how we move away from the market and talk more about collaboration, but it fails to challenge the dominance of the big acute trusts, which have their own priorities and often take the lion’s share of resources. Thirty years of experience with commissioning with CCGs and primary care trusts shows that it is difficult to challenge and influence these larger provider trusts, so how will the combination of ICBs and ICPs be any different?
I have described things in this way, because at the heart of the issue that we are trying to address with the amendment is how the money is spent: who sets the priorities and allocates funding, down to the place or the particular service? If it is just the NHS, the same problems will still apply; it is not going to change anything in reality. Somehow we have to broaden decision making and accountability to ensure that all voices are heard. As we said earlier this week, that has to include the public and patients. If our amendments in that regard had been accepted, we might have made a start on that. We have heard many times that the ICB is an NHS body that it is accountable for NHS money and that the ICP has no role in resource allocation, and we know that money often dictates influence and power.
We have had health and wellbeing boards for years. They have had a similar role to the ICBs, setting out a wider strategy. However, it is fair to say that they do not always have the influence they would like. They were, in effect, an afterthought to the machinations of the Health and Social Care Act 2012. I wonder whether the Minister is aware of any assessments or studies on the effectiveness of health and wellbeing boards, particularly on whether they have produced a shift in policy at a system level.
It is worth reminding the Committee—we touched on this on Tuesday—that the National Health Service Act 1946 was set up with local authorities very much at its heart. The NHS and local authorities worked together closely, but as time has gone on that divide has grown. We need to think about devolution and the direction of travel more generally. There is more that we can do in that respect. We support the prospect of more devolution, but that has to be more than a simple passporting of funds down through a body to another provider. Our amendment is about giving real power and influence to local communities, making devolution mean something and taking back control, not the passing of powers from one set of unelected people to another.
I have dealt with some of the philosophy, so let me now turn to the practicalities. Many have said in response to the Bill that they want minimal prescription. We understand that, which is why we are trying to do this with one single clause. Much is left to local bodies to try to sort this all out together, and many will be able to do that, but we know that that will not be the case everywhere. What should happen is that we have a provision that ensures that ICPs have some focus not just on wider wellbeing but on the need to reduce inequalities and leverage the maximum social value for their area. There are huge amounts of money here and we must not underestimate—I am a firm believer in this—the power of procurement to be used positively for a community.
Has the Minister given any thought to what key values an ICP could champion when it is in operation? The amendment does not suggest the imposition of a chair or any particular arrangements as to how that is decided. That is why we have accepted for the purposes of ICPs the value of local solutions. Amendments 47 and 83 set out the minimum position that we think is necessary for ICPs to have real influence and not be just another talking shop. There has to be a process for disagreement to be flagged up and properly considered in a robust way that can actually change direction if required.
I hope the Minister takes away the point that I am trying to make and reflects on it, because it is not enough to just use the weasel words “regard to”. That is just a given in my opinion. That just tries to pretend that something will happen when there is nothing to compel change.
There are wider questions about ICPs, which are set out in clause 20. How are they performance-managed? How do they run? Will there be funding for them to ensure that they can discharge their functions effectively? Presumably, they cannot provide other services, but will the Minister confirm that? Will they be able to form their own bodies themselves? There is plenty more where we need some meat on the bones. I hope the Minister will be able to provide that when he responds to our amendment.
Amendment 83 builds on my hon. Friend’s argument about creating some balance between the integrated care partnership and the integrated care board, so I will not repeat it. I simply underscore the fact that the ICPs have the money, power and accountability at the moment, but there is a risk that they become a closed shop and not bodies about integration at all.
We are told that integrated care partnerships will be the way in which the broader health and care family and the community will come together as they lead and play a pivotal role. We need a safeguard in the Bill to ensure what we would do if the relationship breaks down. The amendment is a version of what Sir Robert Francis from Healthwatch said about one possible way in an evidence session. I am not prescriptive about this, but I am keen to hear what the Minister might suggest to give us comfort on this. If the ICPs are to function as promised, their plans ought to have some sort of status, so that if the integrated care board chooses to diverge, it must make a public statement that it is going to within 30 days and then publish its reasons with evidence within 60 days.
There is an equivalent provision in NHS England for responsibilities held at a national level. If nothing else, this is basic accountability. It does not restrict any activity, so there is no risk in it. Even if a partnership does not like the decision made or value the reasons given, it cannot remove the chair of the board. Although the constitution has already prevented that, at least we will know what has happened, so the safeguard is quite modest. There is a blizzard of different ways to do it, but I hope that we can have some comfort on ensuring a balance between the partnership and the board, if not at this stage, then by the time we come back on Report.
I will confine my comments to amendments 47 and 83, because we will address the wider themes when we have the clause stand part debate.
Amendments 47 and 83 stand in the names of Opposition Members. The shadow Minister, the hon. Member for Ellesmere Port and Neston, has asked a number of questions, which I will try to address before turning to the substance of those amendments. I am not personally aware of any analytical piece about the impact and effectiveness of health and wellbeing boards, but anecdotally from my background in local Government before I came to this place—and, indeed, as a Member—I certainly see the value that they bring to their communities through their work. The shadow Minister is perhaps being a little inadvertently unfair to the legal profession in suggesting that the phrase “have regard to” is weasel words, because my understanding is that “have regard to” is a well-known, much-used legal phrase in drafting, and it carries with it an obligation to do exactly what it says: to have regard, and to show that.
Finally, the hon. Member has pressed me again, and I fear I will give him the same answer—he and I have done this before—as I have given the other shadow Minister, the hon. Member for Nottingham North, in various delegated legislation Committees over the past year relating to our exit from the EU. I think the Prime Minister has been entirely clear in what he has set out: this legislation lays important foundations for the closer integration of local authority and NHS-provided care, on which we will of course build, because we are an ambitious Government with a clear agenda to further improve our health and care systems.
With those points made, I will turn to the detail of the amendments, which address the relationship between ICPs and ICBs—as certain Opposition Members have touched on—and address divergence from health and wellbeing board and ICB assessments and strategies. Amendment 47 would require the Secretary of State to establish a procedure to resolve any disputes between the ICP and the ICB, while amendment 83 would add an additional requirement on NHS England, integrated care boards, and local authorities to make a public statement and publish their reasons when they deviate from the integrated care strategy prepared by the proposed integrated care partnership, and the joint strategic needs assessment and joint local health and wellbeing strategies prepared by health and wellbeing boards.
I do appreciate the concern—the genuine concern, I think—from Opposition Members about the need to ensure that ICPs and local authorities are genuinely closely aligned to both the ICP and the health and wellbeing board plans. We do intend for these assessments and strategies to be a central part of the decision making of these bodies: that is why, as I say, we are introducing a duty for those bodies to have regard to them. However, we do not think the additional conditions suggested by these amendments are necessary, as we believe there are already means in place to avoid such disputes. First, the ICB will be a required part of the ICP. It will be intimately involved in pulling together the integrated care strategy, so it should be fully signed up to the elements of the plan that fall within its area of responsibility, as it will be partly drafting that plan. As a result, we consider the likelihood of disputes in that context to be low.
Secondly, there are already duties on both ICBs and local authorities to have regard to the strategy in discharging their functions. The duty to have regard means that to diverge from the plan, they must be able to reasonably explain and justify why they have done so. If they cannot, they would be open to challenge, and in the case of an ICB, they could be open to direct intervention from NHS England for having failed to discharge their functions to have due regard properly. Thirdly, we would also expect that both health and wellbeing boards and ICPs would consider how their strategies and assessments are applied in the system, and would want to keep progress under regular review. Those committees themselves provide an appropriate framework for regularly assessing and considering how to address any divergence.
We are also concerned that it would be difficult to rigidly determine if and when NHS England, an integrated care board, or a local authority had diverged from these strategies and assessments in the exercise of their functions, especially if plans were high-level and strategic. By creating this specific requirement and setting a specified timeframe, I fear we would risk creating a great deal of bureaucracy as these bodies attempt to determine if, when, and to what extent they may have diverged. Instead, we believe it is more appropriate to leave it to ICPs working with the ICB and local authorities to develop and design mechanisms to review progress locally.
As a further safeguard, NHS England has the general power to issue guidance to ICBs on the discharge of their functions, which could be used to set out how an ICB should consider the integrated care strategy, joint strategic needs assessment and joint health and wellbeing strategy in exercising its functions. Guidance may also suggest ways of resolving any issues that arise in the ICB in the exercise of these functions. We would expect NHS England to consider doing so, if that was necessary.
Before I close, I will make one further observation. The relationship between the ICB and ICP is very similar in reality to that between CCGs and health and wellbeing boards. Our experience there has suggested that disputes are rare, and in the vast majority of cases they have been resolved locally, without the need for any external intervention. Where that has been necessary, it has been mostly supported by peer brokering or collective compromise, not appeal to an outside authority. Although what we are doing here clearly moves us significantly further forward in integrating health and care in this country, we would want that sense of joint endeavour from the current regime to continue in and percolate through the new system.
I hope my comments give hon. Members a degree of reassurance and, as I have frequently done this afternoon, I will try to tempt Opposition Members not to press their amendments to a Division.
The Minister has made some interesting points. I will have to come back on the reference to “weasel words”. I was a lawyer for a number of years, and when it comes to their use, I think that lawyers are probably second only to Members of Parliament in being able to use them.
There were many occasions when we were negotiating and drafting documents. Once, I wanted something to happen and another person said, “Well, we don’t want to actually make that an absolute commitment, but we intend to do it.” We always ended up with the compromise of reasonable endeavours. Best endeavours was another one. Often that led to one side being slightly disappointed, but that was usually the point of compromise. But that, I would suggest, is actually going further than what is in the current legislation, which is to “have regard”. That really is the nub of this, because we do not think that is enough to give the ICPs the teeth that they need and the strength and leverage that they might need if they are to be truly effective.
The Minister said that if there was a divergence, he would expect an ICB to put forward reasonable explanations as to why it was not going to follow a particular strategy. But that would then lead to the conclusion that if it was not able to do that, it was acting unreasonably, which of course could give rise to judicial review. That, I am sure, is a road that the Minister does not want ICBs and ICPs to go down. I do not think that would be in anyone’s interest, so we are actually, once again, trying to help the Minister out by coming up with a solution that avoids litigation and dispute and gives us confidence that we will not see a repeat of the lack of genuine engagement that we have seen in some areas in the past, but will see a real force, in legislation, to encourage the wider public sector to have real influence on the modelling of health policies and strategies in the future. Therefore we will—with your permission, Ms Elliott —press amendment 47 to a vote.
The clause introduces the integrated care partnership known as an ICP, as a joint committee of the integrated care board and local authorities in its geography. It gives the partnership its core function of preparing the integrated care strategy. The ICP was developed with the Local Government Association and NHS partners in recognition of the fact that the system has been calling for two different and important types of integration: integration within and across the NHS to deliver healthcare services within a defined locality, and integration between the NHS and local government and wider partners.
The ICP is intended to bring together health, social care and public health to develop a strategy to address the needs of the area also covered by the integrated care board. If the ICP wants to go further, it can also involve representatives from the wider system where appropriate, such as voluntary and community groups, and social care or housing providers. That will be up to the ICP, and we will welcome locally driven innovation to reflect local circumstances.
When preparing the strategy, the integrated care partnership must take into account the NHS mandate, any guidance from the Secretary of State and any relevant local joint strategic needs assessment. The ICP must also involve the local Healthwatch, as well people who live and work in the area. The strategy will need to look at how local authorities and NHS bodies can work together using arrangements under section 75 of the National Health Service Act 2006.
Local authorities, integrated care boards and NHS England, when providing services in the area, must have regard to the relevant integrated care strategy when exercising their functions, as well as, more locally, any joint strategic needs assessment or joint local health and wellbeing strategies. This will enable more joined-up planning and provision, both within the NHS and in local authorities. As a result, we would expect to see more integration of the services people receive, more efficient and effective commissioning, and closer working between local authorities and the local NHS.
The clause makes it a legal requirement for all ICBs and local authorities to establish an ICP for their area. These partnerships will promote and facilitate integration across health and care throughout England, thereby contributing to delivering on the ambitious aims put forward in the Bill to further integrate health and care systems.
We can never be too ambitious, can we? I will be interested to see those working practices. As hon. Members can probably gather, we are somewhat sceptical that the ICPs will really be the transformative and influential bodies that we want them to be. I will keep a close eye on what kind of partners end up on them. If we started involving every potential body in the Cheshire and Merseyside one, we would probably need to hire out Anfield to fit everyone in. It might be more entertaining than the football fare on there—we could have a Division on that. We will probably revisit this in future days, weeks and months. We will not oppose the clause but we wish to put on the record where we think its shortcomings are.