Integrated Care — [Dame Cheryl Gillan in the Chair]

– in Westminster Hall at 1:30 pm on 6th September 2018.

Alert me about debates like this

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons) 1:30 pm, 6th September 2018

I beg to move,

That this House
has considered the Seventh Report of the Health and Social Care Committee, Integrated care: organisations, partnerships and systems, HC 650, and the Government Response, Cm 9695.

It is a pleasure to serve under your chairmanship, Dame Cheryl. I thank all those who contributed to our inquiry in writing and in person, my fellow Select Committee members, and the Select Committee team, which was ably led by our Clerk, Huw Yardley, with special input from Lewis Pickett. I also thank our special advisers, Professor Sir Chris Ham, Dr Anna Charles and Professor Pauline Allen.

We are all immensely grateful to the South Yorkshire and Bassetlaw sustainability and transformation partnership, the Doncaster Royal Infirmary and the Larwood practice, not only for allowing us to meet them and their teams, but for facilitating the Committee’s meetings with local and national leaders from across the healthcare system, the third sector and many other providers to hear evidence during our inquiry. Without them, the report would not have been possible.

I will start by setting out what we are talking about, and why it matters. It is one of the greatest triumphs of our age that we are living longer but, as that happens, many more of us are living with complex, long-term conditions that require support and input not only from dedicated family and formal carer networks, but from across the health and social care system. If those systems do not join up, if they do not share information, or if they are poorly co-ordinated or inaccessible, patients’ care is poorer and everyone has a worse experience. Don Redding from National Voices, said that patients and the public

“want to feel that their care is co-ordinated, that the professionals and services they meet join up around them, that they are known where they go, that they do not have to explain themselves every single time, and…that their records are available and visible.”

That is essentially what we mean by integrated care.

Integrated care can happen at three levels. It can happen directly, in the teams around the patient who deliver care in the patient’s home—for example, through joint assessments. It can happen at the service level—for example, with services brought together in a one-stop clinic. It can happen at an organisational level—for example, in commissioning or the pooling of budgets. We should all be clear, however, that none of that matters unless we keep the patient at the front and centre of those discussions. If the result is not delivering better care for patients and their families, it is not worth doing.

Integration does not save money in the short term or, sometimes, in the medium term, which acts as a key barrier to putting in place integrated systems for the long-term benefit of patients. Unfortunately, particularly with the current financial pressures, we have a system that is sometimes dictated and hampered by short-term pressures to deliver financial savings—I will come on to that later. In essence, we have to keep sight of the fact that integration is about people and families. Although our report focuses on organisations, partnerships and systems, we have tried to relate it back at every stage to why it matters to patients, rather than it being a dry discussion about systems.

Photo of Diana R. Johnson Diana R. Johnson Labour, Kingston upon Hull North

We are very ably led by the hon. Lady on the Health and Social Care Committee. The Committee’s approach to the public was the right one, and I hope that, in its future communications with the public, the Department of Health and Social Care might learn that lesson about having the patient at the heart. That is what this is about, because it is so complicated and difficult for the public to understand.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

I thank the hon. Lady, my fellow Committee member, for her input. We on the Committee heard that there is a complex spaghetti of acronyms—STPs, ICPs, ACOs—and nobody knows what they mean. Even those working in the system struggle to keep pace with them and with the changes. We have to keep bringing it back to plain English and why it matters to people and hold our attention there.

The integration of health and social care has been a long-term goal for successive Governments for decades, so we might ask why it is not happening everywhere if we have been striving for it for so long. We saw and heard about many fantastic examples of good integrated care, but they sometimes felt like oases in a desert of inactivity. It is also possible to have an area that does some things very well but others not so well.

Photo of Luciana Berger Luciana Berger Labour/Co-operative, Liverpool, Wavertree

I commend the hon. Lady for the way she is making her remarks on our report, which I welcome. I looked closely at the Government’s response, in which they said that they

“remain keen to consider how to build political consensus on the case for reform and funding as part of the development of the NHS”

10-year plan, but we have heard no reference to exactly how any mechanism for reaching such a consensus might be pursued. We have heard a lot of talk about integrated care for many years, but we now find ourselves at a critical moment. The Government are about to launch their 10-year plan, and it must be front and centre of what they put forward.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

I will respond further to the hon. Lady’s remarks when I comment on legislative change and how we can get legislative change through a hung Parliament. I will also comment on the importance of engaging with the service and why that needs to come bottom-up from the service, and the importance of politicians from across the House listening to the service and being focusing on its message and the message from patients and patient representative groups. I thank her for her constructive input. The Committee has been successful in building consensus about how this should go forward. I hope the Minister has heard that intervention and that he will respond specifically to that point in his closing remarks.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

Coming back to why integrated care does not happen, there are many deeply ingrained structural divides. Since the inception of the NHS 70 years ago, we have had a system that is free at the point of use for the NHS, but means-tested for social care. That presents an extraordinary hurdle when systems are trying to join up. It is not just that; it is different contractual arrangements and working practices. Good integration comes down to individuals and teams being prepared to work together, but it often feels like they are working together to achieve integration despite the systems around them, not because of them.

We need a system where everybody is focused on helping the right kind of integration to take place, and we need to go back and look at that fundamental structural divide between the systems. I ask the Minister to look again at the joint report, “Long-term funding of adult social care”, because that is an important issue that goes to the heart of the barriers to joining up services. It is about contractual differences, different legal accountabilities and payment systems that work against the pooling of budgets, and financial pressures within the NHS.

A certain amount of financial pressure can encourage systems to come together to pool their arrangements and provide a more efficient service, but as the Minister will know, when the elastic is stretched too tight and the financial strain becomes critical, we see the opposite—systems are forced apart. I have seen that happen in my area, where people suddenly feel that they have to retreat to their organisational silos to fulfil their legal obligations. There is no doubt that, for the process to work effectively, we need the right amount of funding—and sufficient funding—and tweaks to the legislative arrangements to allow people to come together, so it does not feel as if they are working together despite the system.

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

I am grateful to the Chair of the Committee for giving way. Does she agree that when there is an attempt to elicit change through turning off the financial tap, what happens in fact is that people cut what they think is easiest to cut, which is often the most innovative solution, rather than step back with a clear head to consider where they want to get to in the end? Does she also agree that we often find that the result of that kind of cost-cutting is a backward step rather than a forward one?

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

I thank the hon. Member for that intervention and for her own service to the Committee previously—she is very much missed. Her remarks are typical of the constructive input that she has always made to the health debate in emphasising the need to take the long view. Financial pressures so often force us into short-term solutions, not only in the way she set out but through the salami-slicing of services.

One of the points that our Committee feels strongly about and that I was going to make to the Minister is the need to ring-fence transformation funding, because it is so easy for that funding to get lost. I welcome the uplift in funding—a 3.4% increase will be very helpful—alongside a 10-year plan. However, we have to be realistic about what that uplift can achieve, because there are very many demands on that budget, as the Minister will know and as we have seen in the past. We saw it with the sustainability and transformation fund, which tended to get sucked into sustainability and not into transformation. That has been the pattern of recent decades. There is good intention to ring-fence money for transformation, but that money disappears because of other priorities around deficits and, as I have said, the many other calls on the funds available.

That is why we feel that, in order to prevent the continuation of that cycle of past mistakes, it is important that the pattern is recognised and that funding is earmarked for transformation—not only for capital projects but for things such as double-running.

I will give an example from my area. There will be a complete destruction of public trust in new models of care if money is not set aside for double-running. The community was prepared to accept that there would be a new facility—nobody wanted the closure of the local community hospital in Dartmouth, but there was an assurance that there would be a new facility. Unfortunately, despite many of us opposing the closure of the old facility, what happened was that it was closed and then there was a breakdown in the arrangements for the new facility. The community was left with nothing and there has been a huge destruction of public trust in the process, which unfortunately will have ripple effects across other communities. Had we received the money to keep the existing service while the new service was built and got up and running, it would have left us in an entirely different situation. I am afraid that we see that too often across health and social care. There is good intention, but without double-running, which is part of having a ring-fenced transformation fund, I am afraid that the system has broken down too often in the past. I would like the Minister to focus on that when he makes his remarks.

The Committee is also looking forward to the 10-year plan—we look forward to working alongside both NHS England and the Department of Health and Social Care to examine how that plan emerges—but is important to draw attention to legislative changes. Our Committee made a recommendation that legislative proposals should come from the service itself rather top-down from the Department, which would immediately run into difficulties. However, as a Committee we also offered to subject such proposals from the service to pre-legislative scrutiny.

As Diana Johnson pointed out in her intervention, we need to build cross-party consensus at every point. As it has not been covered in the formal response to the Committee’s report, will the Minister say in his closing marks whether the Government would support the Committee conducting pre-legislative scrutiny?

I am pleased to have had a conversation with Simon Stevens, the chief executive of NHS England, who has confirmed that, as it emerges, the NHS assembly will consider that within its remit—NHS England hopes to produce proposals in draft form before Easter 2019. Nevertheless, as I have said, it would be helpful to receive the Minister’s assurance that proposals will come to our Committee for pre-legislative scrutiny as part of the process of building consensus.

Photo of Diana R. Johnson Diana R. Johnson Labour, Kingston upon Hull North

Like me, the hon. Lady was in Parliament when we went through the 2012 reforms. We had to have a period of pause because of the complexity of the legislation. Pre-legislative scrutiny is absolutely essential and I wholeheartedly support what she has said as the Chair of the Committee.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

Hon. Members know that a lack of proper pre-legislative scrutiny that responded to concerns expressed led to many of the barriers. We have to go back and address them when they could have been addressed in a more collaborative process during the passage of the Health and Social Care Act 2012. I am thinking of the need to reconsider the legal basis for merging NHS England and NHS Improvement, and how we establish a better statutory basis for the process so that provider partnerships do not always have to go back to separate boards to gain their approval. It is about considering how we address issues such as geographical arrangements so that they make more sense to local communities. The Committee could play a constructive role in a host of areas but—I say this to the Minister—unless proposals are subjected to pre-legislative scrutiny and unless a cross-party consensus is established, proposals are likely to fail.

My final point—other Committee colleagues will probably want to develop it further—is this: what will happen around establishing a legal basis for integrated care providers? For two reasons, the Committee welcomes the change of name from “accountable care organisations” to “integrated care partnerships”. First, the original name confused the debate about Americanisation. The “accountable care organisations” proposed were not the same as those organisations in the States, and the original name caused a great deal of unnecessary anxiety. We do not see the process as Americanisation.

A concern raised with the Committee was that the process will be a vehicle for privatisation. We did not agree. In fact, we thought the opposite: we agreed with the witnesses who told us that the process provided an opportunity to row back from the internal market and away from endless contracting rounds, and move towards much more collaborative working. We would like that change to be properly reinforced within the legal status of health bodies, and are disappointed that the Government have not agreed to say categorically that these bodies would be classed as NHS bodies. When the Minister sums up the debate, I would like him to reflect on whether any form of wording can put the matter beyond doubt and ensure that these health bodies will not be taken over by large, too-big-to-fail private sector organisations.

It is not a concern that groups of GPs might want a leading role in the bodies. The Minister will know that the public concern is more about them being taken over by very large too-big-to-fail private sector organisations. It should be possible to come up with a solution. The Committee heard—the Minister knows this—that those working in the service have the view that that the bodies are not likely in practice to be taken over by private sector providers. However, that public concern exists and is a barrier to change. If we can put this matter beyond doubt, we should try to do so.

Photo of Luciana Berger Luciana Berger Labour/Co-operative, Liverpool, Wavertree

I would add a bit of clarification on that point about the size of private organisations that might become involved. My concern is that, irrespective of size—whether private organisations are big or small—the threat of a takeover happening within our NHS has distracted the debate. Anything that would categorically rule it out would be very helpful.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

I thank the hon. Lady for her helpful clarification. I was trying to distinguish GPs, who are private contractors to the NHS. Sometimes that status is used as a reason why integration cannot be done. I do not think there is concern about that level of leadership involvement but, as she rightly points out, there is concern about other aspects of the private sector. It is acting as an unhelpful distraction when there should be a consensual approach to ensure, as I said at the beginning, that we keep focused on the purpose, which is to provide better services for patients. Anything we can do to facilitate making it easier for that to happen—rather than feeling like we are wading through treacle—will be a positive way forward.

I thank my colleagues and all who helped with the inquiry.

Photo of Paul Williams Paul Williams Labour, Stockton South 1:50 pm, 6th September 2018

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I thank Dr Wollaston for securing this debate and for her outstanding leadership of the Health and Social Care Committee. As a GP and a public health doctor, I have a lot of experience of care that has not been adequately integrated. Too many times, I have seen patients repeat their story again and again to different health and care professionals. Too many times, I have seen doctors, nurses, managers and secretaries waste time searching for information that has not been passed from one part of the system to another. Too many times, I have seen dedicated community nurses, social workers, GPs and therapists all providing care that either overlaps with or contradicts care provided by other health workers.

Integrated care, as the Committee has acknowledged, is a very laudable aim, and the Government have some credible plans on delivering more integrated care. I will use my speech to focus on where those plans need to be strengthened. I will talk about resource, about what success should look like, a little bit about legislation and governance, about keeping the NHS as a public sector organisation, and about leadership.

First, integrated care needs to be properly resourced. The new care models pilots have had significant resource to facilitate change, as the hon. Lady indicated, and that may be a key factor in any reported success. Greater Manchester has also had significant investment of extra funding. Can the Minster assure us that, as other areas move towards integration, we will not see what usually happens: the pilots get extra resources and then the roll-out fails because of a lack of extra resource?

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

I am glad that the hon. Gentleman has highlighted that problem, which we have been seeing for literally decades. Early adopters are well resourced and well supported and have the ear of the health board or the Government, but during roll-out, all the people who did not have that experience are told to do it out of existing budgets, and it fails.

Photo of Paul Williams Paul Williams Labour, Stockton South

I thank the hon. Lady for emphasising that point.

My second point is on what the broader health goals of an integrated system should be. The NHS is focused on reducing unplanned hospital admissions. Although that is important—it is especially important because of the financial costs to the service of unplanned hospital admissions—I want to see integrated care providers trying to achieve broader health goals. Success should not be measured by a reduction in secondary care activity alone, although I agree that in many cases the use of unplanned secondary care is a failure of prevention. ICPs will provide healthcare for a population of people. They need to take a population needs-based approach to healthcare, and they need to be prepared to invest outside the traditional medical model of care, including investing in the voluntary and community sector. We know that loneliness, social isolation and bereavement can have a huge impact on health, and we need integrated care not to be integrated medical care, but integrated holistic healthcare. I consider that integrated care providers will have succeeded if resources are focused on improving the health of the members of our population who have the greatest health needs.

Health needs are often not expressed. The inverse care law tells us that those with the greatest needs often have the least access to healthcare. A clever healthcare system does not just react to the people who turn up; it works with communities to identify and address needs within communities. For example, many people with mental health problems simply do not access healthcare, and it is not only their mental health that suffers as a result; their physical and social health suffer, too. On average, people with learning disabilities die 15 years younger than those without. They do not die because of those learning disabilities; they die because they are not accessing healthcare, both preventive and curative. We know about the health issues suffered by people living in poverty and other vulnerable people, including those with substance misuse problems, homeless people, veterans and vulnerable migrants.

Overall, I will consider integrated care to be a success if the share of healthcare expenditure that goes to preventive care, community care and mental health care increases year-on-year. Also, prevention must be prioritised, and I am pleased it is one of the three named priorities of the new Secretary of State for Health and Social Care. We need prevention at all its levels: better early detection, better immunisation and screening coverage, better prevention of falls, and better prevention of mental health problems, including investment in prevention right at the beginning of life—the first 1,000 days—where it has the greatest impact.

My third test for success is that performance, quality and safety are all maintained within a system that is taking out competition. There is a genuine risk that taking away some of those internal market forces might take away some of the incentives to keep waiting lists and waiting times down and to improve quality. As we integrate care, we need to ensure that we maintain those things.

Photo of Luciana Berger Luciana Berger Labour/Co-operative, Liverpool, Wavertree

I am listening closely to my hon. Friend’s remarkably informed remarks. Taking him back to his second priority, prevention, does he agree that the Minister should be thinking about what he should be doing beyond his own Department? The Minister and his colleagues in the Department of Health will not on their own be able to do what is needed on prevention as well as tackle this country’s mental health crisis and increasing lifestyle-related disease. If we are to address those challenges seriously, it will also be about what happens in our communities, our schools and our workplaces. That comes from local government and is what will ultimately make the difference.

Photo of Dame Cheryl Gillan Dame Cheryl Gillan Conservative, Chesham and Amersham

I remind colleagues that interventions are meant to be short. I hope Members will be able to keep them a little briefer.

Photo of Paul Williams Paul Williams Labour, Stockton South

I thank my hon. Friend for her informed comments. I agree with her. We need a cross-governmental approach, particularly for children. There is a glaring absence of a cross-governmental strategy that would enable us to focus on all the things that have an impact on children.

The third area I want to mention is legislation. Under current rules, clinical commissioning groups will remain the statutory accountable bodies, even as the relationship between commissioners and providers starts to evaporate. At the moment, STPs, where the providers and commissioners are getting together, are making decisions—often behind closed doors—which are then rubber-stamped by the accountable bodies, which are the CCGs. That does not feel to me like particularly good governance. Legislation needs to follow the new provision arrangements.

We might also need to consider legislation to improve information sharing. The duty to share information—the eighth Caldicott principle—is often forgotten. In my experience the biggest barrier to integration is the fear that NHS providers have about sharing information with other parts of the system, and their resistance to do so. We are not necessarily doing enough in legislation to protect that duty to share information in the interests of providing good quality clinical care.

The current situation on procurement is very difficult for CCGs. The law says that many services have to be procured if they are over a certain value. CCGs, as small organisations with accountability for their local pot of NHS funds, genuinely fear legal challenge. When they ask lawyers they are, unsurprisingly, advised that they have to follow the law, but the political and NHS England leadership strategy is to integrate care, which often cannot be achieved when care is fragmented by putting services out to tender, and provided by numerous different organisations. Many CCG governing bodies want and need to be cautious. They are just not going to take the risk given the current legislative framework.

Quite simply, if we, as elected politicians, want the NHS to collaborate, we should legislate for collaboration. In my view, the Health and Social Care Committee should be an enabler of that process. We would like to provide pre-legislative scrutiny, but we would like first to ask the health and care community what changes in the law would enable them to achieve their goal of providing integrated care to patients. I would like to know whether the Minister agrees with that proposition.

My fourth point is that integrated care providers should be NHS organisations—a recommendation the Committee made in its report. There is a well-founded concern in the health and care community that, under current legislation, private companies might bid to win contracts to provide significant chunks of our health services. That concern could be alleviated if it were made clear that integrated care partnerships need to be NHS bodies. In their response to our report, the Government did not accept that recommendation, arguing that ICP contracts could be held by GP-led organisations. It would be a very good thing to have GP-led organisations running primary and community care and other parts of the health service, but I see no reason why those GP-led organisations cannot be NHS organisations.

It is a barrier to progress in the NHS that there are not community-based NHS organisations that GPs can lead and work for. I urge the Government to look seriously at the recommendations in the Institute for Public Policy Research report “Better health and care for all”, published in June, which suggests the creation of integrated care trusts in communities and a right to NHS employment within such organisations, which would provide all non-hospital care in an area.

My final point is about leadership. My hon. Friend Rosie Cooper, who is a member of the Health and Social Care Committee but cannot be here today, has done significant work shining a light on leadership failures within the NHS. Integrated care is possible only if we have the best and most talented managers in the NHS. As was evident in the failure of management in Liverpool Community Health NHS Trust highlighted by Dr Bill Kirkup, we are far from achieving excellence and need to be certain we have the right mechanisms in place to ensure that we have only the best and the brightest. Will the Minister assure us that the Kark review will be expansive in its remit and that those NHS leaders charged with fixing the mess in Liverpool have been consulted for their expert views?

To conclude, the purchaser-provider split has not always achieved the best NHS care for patients. I welcome the step towards integrated care, but I do not think it will succeed when the legislation promotes, and sometimes mandates, competition. There is political will—certainly from the cross-party Committee—to work with the NHS and care system, including the NHS assembly, on proposals to change legislation, keep integrated care providers within the NHS, improve governance and remove mandatory competition. I hope the Minister will respond positively to those concerns. Integrated care has the potential to transform the lives of millions of patients in our health service. I commend the Committee’s report, and I thank the Government for the changes they are making.

Photo of Jim Shannon Jim Shannon Shadow DUP Spokesperson (Human Rights), Shadow DUP Spokesperson (Health) 2:04 pm, 6th September 2018

It is a pleasure to speak on this matter. I commend Dr Wollaston for setting the scene, and Dr Williams for making such a valuable contribution. I do not have the expertise of those two hon. Members—far from it—but I have a deep interest in the health service, and the treatment and service that is provided, which is why I am here. I thank the hon. Member for Totnes and all those who made a contribution to the Health and Social Care Committee’s seventh report, “Integrated care: organisations, partnerships and systems”.

We are ever-mindful of the anniversary of our own NHS. A lot of minds have looked back over the past 70 years, and we have all looked back over the years that we have been here, and we are thankful for the institution, which has been a beacon of the best of British by far. Just last weekend, I was present as my local council, Ards and North Down Borough Council, conferred the freedom of the borough on the NHS as a gesture of good will and a vote of thanks to those who work so hard in adverse conditions to provide care to those we love. As an active representative, I speak to those who work in the NHS and are recipients of NHS services every week. The hon. Member for Totnes made many telling comments, but one that I took from the very beginning of her contribution was that the purpose is to deliver a better service for patients. That really is the core of what we are about in the NHS, and at the core of the report’s recommendations.

Until recent years I had little cause to visit doctors or use the NHS but, as often happens, with age came complications, and diabetes was one of those. The doctor then said, “You need a wee tablet for your blood pressure. Well, you don’t really need one, but we’ll give you one anyway, just to keep you right.” Along with that, last year I was in hospital on three occasions for surgical operations. Not having been there for more than 40 years, suddenly finding that I was almost a regular visitor to the hospital gave me a really good idea of what our NHS is like today. I put on record my thanks to all those who made valuable contributions to those operations. I know it was down to the skills of the doctors and surgeons, but it was also down to people’s prayers.

We all know that the NHS is hanging on by a thread in many cases. It sometimes seems like that, but when I hung in the balance the NHS rose to the challenge. Sometimes we think that the NHS cannot deliver, but very often it does, and it delivers well. Any discussion about the NHS must begin with thanks to those who make it work against all the odds and who make what should be impossible possible. All of us here—myself in particular—say, “Thank you.”

I thank every person involved in the report, and I thank the Minister who is here to respond to it; I know he will do so very positively. As I began to read the report, the massive amount of work that went into it became abundantly clear. We need to bring on board the people with the vision for the NHS, as put forward in the report. I can see the vision for the NHS—I can read it on paper anyway, and then picture it. I understand the rationale behind the vision, but I also see the fear of secret privatisation, which people believe to be taking place. Some of the hon. Members who intervened referred to that.

We have all seen what happens when things move from public to private, and people fear a lack of services. That is easy to understand when talking about the loss of a rural bus link, but not when discussing whether a mother who is 72 years of age and has cancer will get treatment on the NHS. There is a fear among the general public that risk assessments will mean that we do not give such people a chance. I know that that is not the case, but we have to consider public opinion, and how people assess and see the situation. People see things quite simply at times. It is good to see things simply, because it makes it easy to follow through with the solution—those are my feelings anyway.

My feeling is that something has to change in the NHS. We all understand that bandages are not enough—it needs clinical surgery and massive intervention, some elements of which are in the recommendations. However, in order to be able to do that, we need to first prep the patients—the general public. We need to convince them that the proposed changes are for the better. We need to do a better job of preparing the public and explaining exactly what the plans are.

As the report was at pains to show, people do not fully understand how the NHS works. Information is not shared between emergency services and GPs in the detail and with the connections that it should be, and healthcare is provided from different sections who are not working together as well as they should. The integration referred to in the report can only work through partnerships that are truly trying to work together. When there is no understanding there is fear, and while people may not understand the current system, by and large they trust it. They trust that when they dial 999, an ambulance will arrive and bring them for care to their local emergency unit. When we tell them things are changing and we abbreviate terms using initials that save time but increase complexity, they fear that the very thing that they can trust no longer exists, because it is different from what it was five or 10 years ago, and they do not quite understand what is being said. That is why it is important to keep it simple. Of course, however we change the NHS, an ambulance will always be sent in response to a 999 call, but the simple fact is that people do not trust to that, so they will be unsure about what will unfold.

As a lay person, without the expertise that many on the Committee have—I bow to their knowledge and expertise—it is my humble opinion that we must do better in informing people how things are working now and how they can improve with changes, but understanding takes time and it is better to bring the public along, clarify uncertainties and address the issues at an early stage. Such corrective surgery has to take place, but the theatre must be prepped. People must be allowed to understand and that has to come with co-ordination and better working relationships with the press, as well as one-on-one discussions with patients when possible. It must happen with easy-to-understand information and it must happen before the changes are implemented.

I congratulate the hon. Members involved in preparing the report. I look forward to the Minister’s response, as well as the contribution of the shadow Minister.

Photo of Andrew Selous Andrew Selous Conservative, South West Bedfordshire 2:12 pm, 6th September 2018

It is a pleasure to contribute to this important short debate this afternoon. As has been said, for most of our constituents, this world of ICPs and various other acronyms is a bit of an enchanted forest or secret garden that they do not really understand—they just want their healthcare to go on being delivered properly and professionally—but it does of course matter. I completely agree with the Chair of the Health and Social Care Committee, my hon. Friend Dr Wollaston; we need to keep seeing this from the patient’s perspective.

Like many others, I was struck by the clarity with which Don Redding, the director of policy at National Voices, explained how this should look from the patient’s perspective. He said that patients

“want to feel that their care is co-ordinated, that the professionals and services they meet join up around them, that they are known where they go, that they do not have to explain themselves every single time, and, therefore, that their records are available and visible.”

That is a succinct, powerful way that encapsulates what we are all trying to achieve—what the Government are doing and the purposes in this debate this afternoon. The last part of that sentence—making sure that their records are available and visible—is highly topical, given what the new Secretary of State for Health and Social Care said this morning. He is absolutely right to make sure that the NHS has the technology so that its brilliant workforce get the information they need to give first-class patient care, and that patients can use that technology to their own benefit and to the benefit of the health service generally.

I remember a Department for Work and Pensions initiative from some time ago that was called “Tell us once”. In terms of benefit claims, all of us as Members of Parliament will have had constituents who come in and recount giving their details, endlessly, to different parts of the Department for Work and Pensions. The principle should be the same in health. Our constituents’ time is precious. It is not just Members of Parliament who are busy people; our constituents lead highly busy, demanding lives, juggling work, family and everything else. The more we can make it simpler to capture what they say once, the better for them and the better for hard-pressed NHS staff, and it has to lead to a better outcome. I hope that is part of what our excellent new Secretary of State, who follows the last excellent Secretary of State, is looking to achieve, in light of his speech in Manchester this morning.

There were various highlights in the Committee’s inquiry. The one that stood out for me above all others was our visit to the Larwood practice in Worksop. I have spent a large part of the summer speaking to every single general practice in my constituency. I asked them to tell me about the pressures they face and what the NHS and the clinical commissioning group can do to help them, because I am very aware that general practice is under a lot of pressure. I know the Government are recruiting 25% more doctors, which is brilliant, and last year 3,157 of those doctors went into general practice, which is also brilliant, but we have to retain them as well and some of the workload pressures are challenging.

When the Committee arrived at the Larwood practice, it was incredibly exciting and invigorating, because we saw a practice that was joining up primary care, secondary care, social care and the voluntary sector. It was using paramedics and had its own pharmacy on site, so that people are not sent down the road in the rain to get their prescriptions. There was a buzz about the place. The GPs who worked there were bright-eyed and bushy-tailed, because I think they knew they were delivering a good service and serving their patients well. I am aware of the variability across general practice. If integrated care is going to mean something, the Larwood practice—which was selected for us by NHS England because it is doing well—and practices like that show the way. My challenge to the Minister is, how do we help all those other GP practices to rise up and perform in the same way?

Although not the direct subject of the report, the other huge area of integration that is so important that I cannot fail to mention it is the join-up between health and social care. The Committee wrote a separate report on that earlier in the summer, jointly with the Housing, Communities and Local Government Committee, which I thought had excellent recommendations. I am absolutely convinced that integrated care providers will not succeed in providing the integrated care we want unless social care has been put on a proper and sustainable financial footing so that it really does work hand-in-glove with our NHS at every level, primary and secondary.

Our report has been really useful in slaying a few myths about privatisation. Some of those myths have been around for a very long time. When Simon Stevens gave evidence to the Committee, he did a particularly good job—he went back through some of the allegations of privatisation of the past 20 years or so and showed that, over that period, those various allegations had not proved well-founded.

I very much welcome the Government’s commitment to amend the legislation where necessary, and where helpful to provide better-integrated care. That is a sensible and pragmatic step, which I would expect from the Prime Minister and the Government. It is very welcome

I very strongly agree with what Dr Williams said about prevention. He said something very true about the Committee that I have never forgotten: he said that we are a Health and Social Care Committee, but sometimes we could be mistaken for an NHS Committee. That is not because he and I do not think that the NHS—the organisation that is there to look after our health—is absolutely brilliant, but because health is wider than the NHS.

Unless we are absolutely passionate about dealing with childhood obesity—I am the chair of the all-party parliamentary group on obesity—and improving air quality levels in our inner cities, where children with asthma and other illnesses are deeply affected by breathing in poor air every day; unless we get more of our fellow countrymen and women walking and cycling; unless we do something about reducing the proliferation of takeaways, which sell highly calorific food; unless we do something about getting our supermarkets and big food producers to do better in producing healthier food, we will not succeed in this key area of prevention.

It comes down to detailed things such as planning policy for local authorities, which should not have to fight a rearguard action against the Planning Inspectorate to limit the number of takeaways in an area. They absolutely need to ensure, as we build new houses—which we desperately need to do—that cycle routes are built into new housing developments so that as many people as possible, including children, can cycle to stay fit and healthy.

It is worth noting that the integrated care partnerships are helping that to happen. The Committee heard from Ian Williamson from Manchester Health & Care Commissioning. When we were in Sheffield, he said that he thought conversations were now starting up about how Manchester could reduce childhood obesity and reduce the emissions and pollution that harm the local population. Such conversations are happening, but we need more than conversations; we need action, and we need to join up these different policy areas and produce results, because they are urgently needed.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care) 2:22 pm, 6th September 2018

I, too, welcome the opening speech of Dr Wollaston, who is a superb Chair of the Committee. The marketisation in NHS England goes back more than 30 years—it has certainly been happening for most of my career. It started with terms such as “resource management”, and in 1990 the internal market—the purchaser-provider split—was introduced. In the early 2000s under Labour, private companies started to introduce independent treatment centres. The Health and Social Care Act 2012 turned it into a massive external market and created the pressure to put all possible contracts out to tender.

The problems are well known. If we base a system on competition and not on collaboration, we inevitably create fragmentation and destroy integration. That has broken up patient pathways and made the system very confusing, to the point that CCGs were looking to employ what they called primary providers, which would have been another layer of cost and health organisation, to try to join things up for patients. Thankfully that has been shelved, because there is a sense of going in a different direction, but up to now there has been a repeated sense that everything can be solved through a healthcare market. That is why, in Scotland, we have grave concerns. One of the 24 powers coming to Scotland is power over public procurement—we do not see the market as the solution to everything.

Just five years on from the actual on-the-ground changes of the Health and Social Care Act, NHS England is facing another big reorganisation. As other Members said, unfortunately the rushed sustainability and transformation plans and the lack of consultation with both the public and staff has created anxiety and fear. As is now recognised, the term “accountable care organisations”, which was copied from the American system, was a PR mistake of the highest order.

In 1999 in Scotland—after devolution—we simply went in a different direction. We merged trusts and then abolished them in 2004. We got rid of primary care trusts in about 2009. We already had an area-based health service for the entire population—not just for people registered with their GP—based on per-capita funding. That meant that we could start to look at how to integrate acute hospitals with community hospitals and even local village hospitals for step up and step down—not everyone who is unwell and cannot be at home needs to be in some big, shiny 10-storey block, and might just need a bit of extra care for a few days, so there is an argument for community hospitals.

In 2014, we started looking at integrating health and social care. Because of the fragmentation in NHS England, it will be necessary to integrate health first, and then integrate social care. Integrating social care is much more challenging because it is made up of different players in the market and is done in a different way. As the hon. Member for Totnes pointed out, the overarching difference between free healthcare and means-tested social care creates major challenges.

Photo of Andrew Selous Andrew Selous Conservative, South West Bedfordshire

The hon. Lady used the term “village hospital”, as well as the term “community hospital”. “Village hospital” is a new one to me. Could she elaborate on what it means?

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

It is not a particularly formal term. I simply mean that there has been a tendency to think that, because community hospitals cannot provide the full range of acute healthcare, they have no place, whereas someone might require only a low-level of in-patient care, such as an elderly person who has a urine infection and lives on their own may need intravenous antibiotics, fluids or extra care. Such hospitals allow us to have much more healthcare—things such as minor injury units—close to the public. The more we take forward to people, the less worried they will be about the fact that we are coalescing specialist services. If they see services coming towards them, they will not have the sense that everything is being taken away. We have utterly failed to impress on the public that healthcare is not about buildings, but very much about people and services. That is what integrated care should be about.

Photo of Diana R. Johnson Diana R. Johnson Labour, Kingston upon Hull North

I am very interested in what the hon. Lady is saying about Scotland. Does she know that areas of England have integrated financial plans involving local government and health to try to bring together that continuity and put patients at the centre?

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

That is exactly what we have in Scotland—it was introduced in legislation in 2014, and all areas were up and running by the beginning of 2016. More than 60% of the budget goes to what are called integrated joint boards, which use innovative solutions to deal with all sorts of local groups to try to prevent people who do not need to be in hospital from ending up there, and to try to allow people to come out of hospital when they are ready. It has led approximately to a 9% per year decrease in things such as delayed discharges. Those two measures—acute admissions that could have been avoided and delayed discharges that lead to people being stuck in hospital—are very much looked at. In my early career, if someone was in a bed and ready to go home, they would be told, “Well, it’s your problem. We don’t have room.” There was always friction between secondary and primary care, and between health and social care. That is where we are, but it is not easy—it is not even as easy as integrating within health.

There is no escape from legislation. Some legislative change is critical for NHS England to be able to take the barriers out of the way. At the moment, as the hon. Lady mentioned, people are trying to work around those barriers, but when things change in an informally integrated care system, the acute hospital is put into financial difficulties. It is being asked not to admit people, but the existing tariff system rewards the hospital only when it admits people, so when it starts to get into difficulties, we are asking it informally to sacrifice its budget line for the greater good. I am sorry, but tariffs need to be reformed. It is a bizarre system if the aim is not to admit. Hospitals make money on the people who almost do not need to be there and lose money on the sickest, who do need to be there.

Photo of Diana R. Johnson Diana R. Johnson Labour, Kingston upon Hull North

Again, that is very interesting. A good model of that, which is already happening in England, is in my own backyard Hull. The hospitals have agreed that they will take a sum of money and will not look for additional money from the CCG if they need to treat more people. That is an integration of social care—the local council—and the acute sector, which is important in making this work. It can be done without legislative change, but overall I agree that change is vital.

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

That is fine in one place with good leadership and good relationships, but if things got tight it would be very difficult for one chief executive to accept the failure of their budget in order to keep the whole system going. Legislative change is crucial, towards more per-capita funding and away from tariffs, and towards more area organisation of that integrated care partnership.

Reform of section 75 of the Health and Social Care Act 2012 is crucial, because it pressures CCGs to put out to tender all possible contracts. In Surrey, six CCGs were sued by Virgin not for breaking a contract but for not renewing one. We estimate—actual figures are hidden behind commercial confidentiality—that more than £2 million ended up away from the frontline, instead going into Virgin’s pockets, which is not helpful.

In fact, the administration of the bidding and tendering market is estimated to cost between £5 billion and £10 billion, which contributed to the debt that NHS England got itself into by 2015, a mere two years after the changes in the Act came into effect in 2013. Before that, by looking down the back of the sofa and scraping around, and with a little bit of moving money around, the NHS in England usually managed to get to the end of the year in balance.

Moreover, that debt has led to rationing. The problems are not hypothetical ones on a piece of paper. They result in older citizens—we will be having a lot more of them—being held back from hip or knee replacements, cataract surgery and other things that allow them to see or walk, get out and meet friends and keep active, which is crucial.

Finally, it is critical for the accountable care organisations or whatever they are called now to be statutory. The model contract published last August would still allow a private company to bid for and run an entire integrated area. The report states that that is unlikely, but it should be simply ruled out in order to get rid of a huge amount of concern about a threat that might lie around the corner or down the line. Without that statutory basis, a company could hide from freedom of information requests and use its commercial sensitivities even though it is being handed billions of pounds of public money and getting to decide what is delivered to the population in its area. I am sorry, but that cannot be a private company and has to be a statutory body.

There are challenges ahead and we all face similar ones—increased demand, workforce and tight budgets—but we have talked about that before. At the moment, however, the structure for NHS England is hampering the staff on the frontline who are trying to look after people. The challenge of merging a free system with a means-tested system will not go away; it will have to be addressed. In Scotland, we have a slight advantage because we have free personal care, which takes away one of the problems, because it allows us to keep more people at home—in their own home, where they want to be—rather than in hospital.

Even though it is only five years since the last big reorganisation, NHS England is at another major crossroads, so there will be a lot of upheaval. It is important to get that right and to do it in a measured way in the House. Legislation should allow innovation in different parts of the country but get rid of the barriers. We should be radical and, as Members have said, to put the patient or the person right in the middle of the design. That involves more than just the delivery of treatment. Health is not given by the NHS—the NHS catches us when we fall and ought to be called the national illness service, but we would have even worse workforce challenges if we called it that. I echo the call for health in all policies, within the integrated systems and in the House, so that we are actually investing in the health of our population.

Photo of Justin Madders Justin Madders Shadow Minister (Business, Energy and Industrial Strategy) (Labour), Shadow Minister (Health and Social Care) 2:35 pm, 6th September 2018

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I congratulate Dr Wollaston on her knowledgeable and measured introduction to this extremely important debate. I also thank the Health and Social Care Committee for an extremely useful and detailed piece of work on a rapidly changing area. In her speech, the Chair of the Committee set out from a patient’s perspective why it is so important for us to have a more co-ordinated approach than we do. “Having to tell the same story over and over again” was a phrase mentioned by not only the Chair but a number of other Members, and we all recognise the frustrations that we and our constituents have when that occurs. She was right to say that it is important that we look at the subject primarily from the point of view of patients. Their experience has to be at the very front and centre of all our plans for the future.

The hon. Lady articulated clearly how the financial pressures in the existing legislative framework, which we have all talked about many times, can inhibit transformation. She was right to say that an earmarked fund for transformation has to be protected, and it should not just be a capital pot. She set out clearly the need for a degree of flexibility.

As always, it was a pleasure to hear my hon. Friend Dr Williams. He made a pertinent point about the challenge for integrated care partnerships: to be considered successful, they should make a difference for those with the greatest health needs. He is right that we need to do much better as a nation on health inequalities, but how we approach prevention and health generally in this country does not necessarily lend itself to that. It would be most welcome if we can tackle that as part of integrated care.

My hon. Friend also expressed the genuine concern about the risk that changes could affect performance quality and safety, which are the pillars of an excellent health system. He made a strong point about governance and how existing decision-making processes are probably the wrong way round. The report acknowledges that they are certainly cumbersome and do not lend themselves to streamlined decision making. He highlighted well the dilemma faced by CCGs when tackling that agenda. This place needs to take a lead on that. He concluded by saying that integrated care has the potential to transform the lives of millions of patients—that really underscores why it is so important for us to get the integration right.

Jim Shannon made a typically thoughtful contribution. I agree with him about the need to bring people along with us when we set out our vision for the health service. The report touches on how that has not been as successful as we might like in recent years. His comments on the use of acronyms were particularly perceptive—they may initially save time, but they actually increase complexity. Although I agree with the sentiment that we should keep things simple, anyone who looks at the Health and Social Care Act will realise that at the moment we probably cannot achieve that readily.

Andrew Selous made an important contribution. No one will disagree with what he said about putting patients at the centre of all this and the quote he gave about the kind of care they want. I was very interested to hear about his visit to the Larwood centre in Worksop; that sounds like the kind of model that we need to showcase what a good new procedure looks like.

It is clear from reading the report that I am not alone in being critical of the way some of the proposals in the past few years have been communicated. I do not underestimate the damage that has done to public confidence in the aims of the policy.. Releasing the new draft ICP contract in the middle of the summer with no publicity has not increased transparency about the Government’s agenda. It was interesting that the report described how public understanding of the proposed changes has been seriously compromised by the “acronym spaghetti,” which a number of Members mentioned. At another point in the report there was a reference to the acronym soup of

“changing titles and terminology, poorly understood even by those working within the system.”

That highlights well the difficulty we all get into sometimes when acronyms can take over—that will resonate with anyone who is a member of a political party. The use of food terminology in the report shows that perhaps the author was a little hungry when they wrote it.

To reinforce the point, since the report was published we have ICPs on the horizon—yet another acronym. Although I appreciate that the change was made to avoid conflation with the American model of ACOs, it is clear that we do not need new acronyms, but a clear explanation from the Government along with a timeframe for what they are seeking to achieve and, importantly, the criteria they will use to determine whether those objectives have been achieved. The chief executive of the Nuffield Trust, Nigel Edwards, described this as

“perhaps the biggest weakness, not just with the STP process but arguably with the ‘Five Year Forward View’.”

It is clear from both the evidence sessions and the report itself that confidence in the Health and Social Care Act 2012 is at an all-time low and that the current direction of travel is really an admission that the Act has not worked. As we know, the last top-down reorganisation put in place a siloed, market-based approach that created statutory barriers to integration. Now, there is a lot of tiptoeing around the current legislation but we need an admission that that legislation has had its day. We need new proposals that are properly scrutinised.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. The Government acknowledged in their response to the report that perhaps that was done rather too quickly. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others there was a vast and unwieldy network of commissioners and providers with completely different approaches put together at very short notice. They were told to produce plans in private, again very quickly, which were focused not on integration but on organisations balancing their budgets. The only beneficiaries of this process seem to be the private consultants who were drafted in to complete those hastily arranged plans. As Professor Chris Ham pointed out,

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Will the Minister set out what his plans are for those areas, as the local bodies appear to be working in a vacuum? They want to work together, but at the moment they have a legal duty to compete.

The report makes it clear that being asked to solve workforce and funding pressures caused by national decisions exacerbates tensions and undermines the prospect of each area achieving its aims for its patients. The report also makes clear, as my hon. Friend the Member for Stockton South said, that where support has been provided towards integration, it has been directed at those who are furthest ahead. Those at the bottom of the curve, sometimes through no fault of their own, have lost potential funding that they need to work together to improve services. The chief executive of the NHS Confederation, Niall Dickson, told the inquiry,

“There is a sense in which some organisations find themselves in a really difficult position. Just taking their STF money away…is like somebody digging a hole. Instead of…helping them to get out of the hole, they jump in with a larger spade and dig even faster.”

That is a colourful and alarming analogy.

Where local areas are able to proceed to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean. The integrated care provider contract has the potential to radically alter the entire health and social care landscape, but is continuing without any parliamentary scrutiny. Despite assurances that it is unlikely that a private company will win the contract to be an ICP, it remains the case that it will be possible, as a number of Members have said. As we heard, not long ago the NHS was forced to pay out millions of pounds to Virgin because it lost out on a contract. I am concerned that we will face similar challenges if this process continues without legislation.

It is not scaremongering to say that the Government are introducing a contract whereby a private company could be responsible for the provision of health and social care services for up to 10 years—it is a fact and a possibility under the legislation. The Chair of the Select Committee was right to say it would be extremely helpful to have a clear statement from Government to rule that out. It is within the gift of Ministers to say there will be no private involvement in those bodies in future. Will the Minister make such a commitment today?

It is clear in the report that staff are concerned about the lack of engagement in a process that in some areas has excluded them completely. They are also concerned about their jobs being transferred to non-NHS organisations; hopefully the Minister will deal with that today. Almost half all NHS providers were in deficit last year and we are entering uncharted territory in budget setting, so what steps will be taken in the event that an ICP reaches a significant deficit position that it is unlikely to be able to resolve alone? Given the recent news that loan repayments to the Department for Health are now a bigger financial burden to providers than private finance initiatives, will the Minster confirm that deficits caused by structural funding issues will not be resolved through further loans being issued?

It is also clear from the draft contract that the ICP rather than the CCG will be responsible for managing demand. That raises questions about accountability and transparency. What safeguards are in place to prevent further rationing of services and who will be accountable in the event that patients want to challenge such a decision? These are important questions that I hope the Minister will respond to. Will he also commit to set out in full the direction of travel, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for primary legislation, which just about everyone across the sector believes is needed?

Photo of Dame Cheryl Gillan Dame Cheryl Gillan Conservative, Chesham and Amersham

Before I call the Minister I remind him, although I am sure he knows, that we like to leave two minutes for the Member leading the debate to make her closing remarks. I call the Minister.

Photo of Steve Barclay Steve Barclay Minister of State (Department of Health and Social Care) 2:47 pm, 6th September 2018

Thank you, Dame Cheryl, it is a pleasure once again to serve under your chairmanship. I join Justin Madders in paying tribute to my hon. Friend Dr Wollaston as Chair of the Health and Social Care Committee, and to all the members of the Committee, for a very good report and for raising important issues regularly on behalf of the NHS and the wider health fraternity.

As a country, we are living longer, which clearly is to be celebrated. However, it means that people live with multiple long-term and more complex conditions. For the NHS to continue to deliver high-quality care as it has done for the last 70 years, it is increasingly important for NHS services to work closely with social care. We got a flavour of that from a number of the remarks made in the debate.

I very much welcome the Committee’s conclusion that fears that integration might lead to privatisation are unfounded. Indeed, the Chair of the Committee said,

“The evidence to our inquiry was that ACOs,”— now referred to as integrated care partnerships—

“and other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”

That relates to some of the points I will make on pre-legislative scrutiny and points to the value of the work done by the Health and Social Care Committee to provide a cross-party view of proposals, which has allowed us to address some of the myths built up in the past. The Committee has done the House a service by slaying some of those misconceptions.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

I thank the Minister for referring to my remarks, but does he accept that the Committee went on to say that we felt the issue of privatisation should be put beyond doubt in legislation?

Photo of Steve Barclay Steve Barclay Minister of State (Department of Health and Social Care)

The Chair of the Committee is absolutely right. We have always been clear that integration is about improving patient care, and that the NHS will remain free at the point of delivery.

A number of key points arose from the debate. Remarks were made about ensuring that the service is patient-centred, and concerns were expressed about whether transformation funding may be diluted. I will come to pre-legislative scrutiny, to which the Chair of the Committee referred, and primary legislation.

Dr Whitford raised concerns about private firms and the role of GP-led organisations. Dr Williams and my hon. Friend Andrew Selous referred to focusing on prevention and taking a wider needs-based approach. A number of Members referred to information sharing, leadership and the lessons from Liverpool Community Health NHS TrustRosie Cooper performed a great service by highlighting that. That is reflected in the work I have commissioned from Tom Kark on the fit-and-proper test.

[Ms Karen Buck in the Chair]

Members focused on the need for a patient-centred approach, which Diana Johnson emphasised in her intervention. In our approach to integrated care, we seek to build a healthcare solution around what is best for the patient and, in the words of the Chair of the Committee, why it matters to patients. That is very much the Government’s intention.

As the Committee Chair said, financial pressure can both incentivise and impede integration. She will be aware that the up to £20 billion a year that will go into the NHS as part of the Prime Minister’s commitment to funding the service will be front-loaded—there is more in the first two years in recognition of the importance of the double-running to which the Chair of the Committee referred. According to past National Audit Office reports, there have been a number of cross-party initiatives under successive Governments. As she and other Committee members set out, sustainability trumps transformation, which is one of the key challenges for the NHS family as it brings forward its 10-year plan. For the first two years, an extra £4.1 billion will go in, with front-loading of 3.6% compared with the average over the five years of 3.4%, which very much reflects the concerns she articulated.

The tone of the debate was one of broad consensus, and we will realise that first by asking the NHS itself to lead on the legislative changes required. The NHS will bring forward its proposals through the 10-year plan. We will not mandate, but let local areas decide what fits their locality best. That will be informed, for example, by health and wellbeing boards. I met the chair of the Lancashire health and wellbeing board yesterday—that speaks to the concern raised about the need for Health Ministers to take a wider approach rather than, as the hon. Member for Stockton South said, looking purely at the NHS element. We are looking much more widely and bringing in local authorities. Indeed, the Department’s name has changed, and the work of the Care Minister reflects the wider integration in our approach.

Although we welcome the Committee’s work on testing the NHS proposals as part of the long-term plan, we will wait for the NHS proposals before confirming the specific pre-legislative scrutiny arrangements. I hope the approach I have taken in discussions with members of the Committee underscores the importance I place on working in a cross-party way. The approach we have set out very much reflects that.

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

Can the Minister able commit to looking at legislative change? It is fine for designs to come from the NHS, but if those designs are based on existing barriers, they will not reach their full potential.

Photo of Steve Barclay Steve Barclay Minister of State (Department of Health and Social Care)

The Prime Minister has set out that it will be for the NHS itself to come forward, rather than for the Government to specify legislative change in a top-down way. As part of the long-term plan, the NHS will determine what can be done within the existing framework and whether change is needed. That will flow from the work that comes forward later in the autumn from Simon Stevens, Ian Dalton and others in the NHS, who are best placed to lead.

Photo of Paul Williams Paul Williams Labour, Stockton South

In the short time the Minister has left, will he will address the invitation he was given categorically to rule out integrated care providers being private sector organisations? Does he accept that the language he has used—he said the NHS will continue to be free at the point of use—increases concerns about private sector provision?

Photo of Karen Buck Karen Buck Labour, Westminster North

Order. Minister, in responding, will you be mindful of the time and the need to leave the Chair of the Select Committee a couple of minutes to respond?

Photo of Steve Barclay Steve Barclay Minister of State (Department of Health and Social Care)

Indeed I will, Ms Buck.

I draw the hon. Gentleman’s attention to the Committee report, which states:

“There is also little appetite from within the private sector itself to be the sole provider of…contracts…There are several reasons why the prospect of a private provider holding an ACO contract is unlikely…Integrated care partnerships between NHS bodies looking to use the contract to form a large integrated care provider would have an advantage over non-statutory providers that are less likely to have experience of managing the same scope of services”.

The hon. Gentleman himself referred to the desire not to rule out GP-led organisations, which are independent. He also mentioned GP-led organisations becoming NHS bodies. I am happy to meet him to explore exactly what he means. It is not the Government’s intention for private firms to run ICP contracts.

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

The Minister says that that is unlikely and that private firms do not want to run such contracts, but we are talking about a 10-year plan. Does he therefore recognise that it should be ruled out to give surety? We do not want another Hinchingbrooke, where a private company takes a contract on and an entire area faces a private provider walking away from an integrated care partnership.

Photo of Steve Barclay Steve Barclay Minister of State (Department of Health and Social Care)

These arguments were explored at the Committee, which addressed that question. The fear of privatisation has been overplayed.

We are taking a people-centred approach and letting the NHS lead on shaping it. We have said we will respond to the points the NHS raises and act on them, but integration will enable services holistically to deliver better care for patients—as Jim Shannon said, that includes better data sharing—and put the needs of patients front and centre. That is reflected in the report and in the cross-party consensus on how we want to take integration forward.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons), Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons) 2:58 pm, 6th September 2018

I thank the Minister and other Members who contributed to the debate. They spoke passionately and reminded us why this matters, particularly to patients. Everything will be judged by whether integration delivers a better service for patients and those around them. I look forward to meeting the Minister and to his appearing again before our Committee—there are a number of areas in which we would like to press him a little further, but I welcome his comments.

Question put and agreed to.


That this House
has considered the Seventh Report of the Health and Social Care Committee, Integrated care: organisations, partnerships and systems, HC 650, and the Government Response, Cm 9695.