Health and Care Bill (First sitting)
The Committee consisted of the following Members:
Chairs: Steve McCabe, † Mrs Sheryll Murray
† Argar, Edward (Minister for Health)
† Churchill, Jo (Parliamentary Under-Secretary of State for Health and Social Care)
† Crosbie, Virginia (Ynys Môn) (Con)
† Davies, Gareth (Grantham and Stamford) (Con)
† Davies, Dr James (Vale of Clwyd) (Con)
† Foy, Mary Kelly (City of Durham) (Lab)
† Gideon, Jo (Stoke-on-Trent Central) (Con)
† Madders, Justin (Ellesmere Port and Neston) (Lab)
† Norris, Alex (Nottingham North) (Lab/Co-op)
† Owen, Sarah (Luton North) (Lab)
† Robinson, Mary (Cheadle) (Con)
† Skidmore, Chris (Kingswood) (Con)
† Smyth, Karin (Bristol South) (Lab)
† Throup, Maggie (Lord Commissioner of Her Majesty's Treasury)
† Timpson, Edward (Eddisbury) (Con)
† Whitford, Dr Philippa (Central Ayrshire) (SNP)
† Williams, Hywel (Arfon) (PC)
Huw Yardley, Sarah Ioannou, Committee Clerks
† attended the Committee
Danny Mortimer, Chief Executive, NHS Employers
Dr Navina Evans CBE, Chief Executive, Health Education England
Amanda Pritchard, Chief Executive, NHS England and NHS Improvement
Mark Cubbon, Chief Operating Officer, NHS England and NHS Improvement
Public Bill Committee
Tuesday 7 September 2021
[Mrs Sheryll Murray in the Chair]
Health and Care Bill
I have a few preliminary announcements. Please switch off all electrical devices or turn them to silent. Tea and coffee are not allowed during sittings of this Committee. I encourage Members to wear masks when they are not speaking; this is in line with Government guidance, and that of the House of Commons Commission. Please also give each other and members of staff space, both when seated and when entering and leaving the room. Members should send their speaking notes by email to email@example.com, and when officials in the Gallery communicate with Ministers, they should do so electronically.
We will consider first the programme motion on the amendment paper, then a motion enabling the reporting of written evidence for publication, and then a motion allowing us to deliberate in private about our questions before the oral evidence sessions. In view of the time available, I hope those matters can be decided without debate.
I call the Minister to move the programme motion, which was discussed yesterday by the Bill’s Programming Sub-Committee.
1. the Committee shall (in addition to its first meeting at 9.25 am on Tuesday 7 September) meet——
(a) at 2.00 pm on Tuesday 7 September;
(b) at 11.30 am and 2.00 pm on Thursday 9 September;
(c) at 9.25 am and 2.00 pm on Tuesday 14 September;
(d) at 11.30 am and 2.00 pm on Thursday 16 September;
(e) at 9.25 am and 2.00 pm on Tuesday 21 September;
(f) at 11.30 am and 2.00 pm on Thursday 23 September;
(g) at 9.25 am and 2.00 pm on Tuesday 19 October;
(h) at 11.30 am and 2.00 pm on Thursday 21 October;
(i) at 9.25 am and 2.00 pm on Tuesday 26 October;
(j) at 9.25 am and 2.00 pm on Wednesday 27 October;
(k) at 11.30 am and 2.00 pm on Thursday 28 October;
(l) at 9.25 am and 2.00 pm on Tuesday 2 November;
2. the Committee shall hear oral evidence in accordance with the following Table:
Date Time Witness Tuesday 7 September Until no later than 10.30 am NHS Employers; Health Education England Tuesday 7 September Until no later than 11.25 am NHS England and NHS Improvement Tuesday 7 September Until no later than 2.30 pm NHSX Tuesday 7 September Until no later than 3.15 pm NHS Providers; NHS Confederation Tuesday 7 September Until no later than 4.00 pm Care Quality Commission; Healthcare Safety Investigation Branch Tuesday 7 September Until no later than 4.45 pm Local Government Association; Faculty of Public Health Tuesday 7 September Until no later than 5.15 pm Welsh Government Thursday 9 September Until no later than 12.15 pm UNISON; British Medical Association Thursday 9 September Until no later than 1.00 pm Royal College of General Practitioners; Royal College of Nursing; Academy of Medical Royal Colleges Thursday 9 September Until no later than 2.45 pm The King’s Fund; Nuffield Trust Thursday 9 September Until no later than 3.15 pm Gloucestershire Integrated Care System; NHS Confederation’s ICS Network Advisorate Thursday 9 September Until no later than 4.00 pm Centre for Governance and Scrutiny; Centre for Mental Health Thursday 9 September Until no later than 4.30 pm Healthwatch England Thursday 9 September Until no later than 5.15 pm Association of Directors of Adult Social Services; British Association of Social Workers
Tuesday 7 September
Until no later than 10.30 am
NHS Employers; Health Education England
Tuesday 7 September
Until no later than 11.25 am
NHS England and NHS Improvement
Tuesday 7 September
Until no later than 2.30 pm
Tuesday 7 September
Until no later than 3.15 pm
NHS Providers; NHS Confederation
Tuesday 7 September
Until no later than 4.00 pm
Care Quality Commission; Healthcare Safety Investigation Branch
Tuesday 7 September
Until no later than 4.45 pm
Local Government Association; Faculty of Public Health
Tuesday 7 September
Until no later than 5.15 pm
Thursday 9 September
Until no later than 12.15 pm
UNISON; British Medical Association
Thursday 9 September
Until no later than 1.00 pm
Royal College of General Practitioners; Royal College of Nursing; Academy of Medical Royal Colleges
Thursday 9 September
Until no later than 2.45 pm
The King’s Fund; Nuffield Trust
Thursday 9 September
Until no later than 3.15 pm
Gloucestershire Integrated Care System; NHS Confederation’s ICS Network Advisorate
Thursday 9 September
Until no later than 4.00 pm
Centre for Governance and Scrutiny; Centre for Mental Health
Thursday 9 September
Until no later than 4.30 pm
Thursday 9 September
Until no later than 5.15 pm
Association of Directors of Adult Social Services; British Association of Social Workers
3. proceedings on consideration of the Bill in Committee shall be taken in the following order: Clause 1; Schedule 1; Clauses 2 to 13; Schedule 2; Clauses 14 to 16; Schedule 3; Clauses 17 to 25; Schedule 4; Clause 26; Schedule 5; Clauses 27 to 38; Schedule 6; Clauses 39 to 41; Schedule 7; Clauses 42 to 59; Schedule 8; Clauses 60 and 61; Schedule 9; Clauses 62 to 66; Schedule 10; Clause 67; Schedule 11; Clauses 68 to 72; Schedule 12; Clauses 73 to 93; Schedule 13; Clauses 94 to 106; Schedule 14; Clauses 107 to 118; Schedule 15; Clauses 119 to 125; Schedule 16; Clauses 126 to 135; new Clauses; new Schedules; remaining proceedings on the Bill; and
4. the proceedings shall (so far as not previously concluded) be brought to a conclusion at 6.00 pm on Tuesday 2 November.—(Edward Argar.)
That, subject to the discretion of the Chair, any written evidence received by the Committee shall be reported to the House for publication.—(Edward Argar.)
Copies of written evidence received by the Committee will be circulated to its members by email and made available in the Committee Room.
That, at this and any subsequent meeting at which oral evidence is to be heard, the Committee shall sit in private until the witnesses are admitted.—(Edward Argar.)
If everyone is agreed, we will go into private session to discuss lines of questioning.
The Committee deliberated in private.
Examination of Witnesses
Danny Mortimer and Dr Navina Evans gave evidence.
Some of our witnesses will be giving evidence today by video link, while others will appear in person. It is helpful, particularly when witnesses are giving evidence by video link, if Members could direct their questions to specific witnesses. Before calling the first panel of witnesses, I remind all Members that questions should be limited to matters within the scope of the Bill and that we must stick to the timings in the programme motion that the Committee has agreed. We have until 10.30 for our first panel. Do Members wish to declare any relevant interests in connection with the Bill?
I have no relevant interest to declare, but we are unable to see a screen. Would it be possible to erect a screen so that we can see those giving evidence?
Yes, we can do that. As there are no witnesses giving evidence in person, it would be okay for Members to sit at the witness table, if that would be better.
That would be great.
I want to declare an interest as a medical practitioner, although not commonly practising, and as a member of the British Medical Association.
Likewise, I declare an interest as a serving general practitioner in the NHS, a member of the BMA and as a member of the Royal College of General Practitioners.
Thank you. I am very keen that we continue this session as quickly as possible. We will now go to our witnesses. Good morning and on behalf of the Committee, thank you very much for agreeing to give evidence. Please introduce yourselves for the record.
Dr Navina Evans: Shall I go first?
I think that would be good; ladies first.
Dr Navina Evans: My name is Navina Evans and I am chief executive at Health Education England.
Danny Mortimer: Good morning. My name is Danny Mortimer and I am the chief executive of NHS Employers, which is part of the NHS Confederation.
Thank you very much. Members who wish to ask questions should please indicate that.
Dr Navina Evans: Thank you very much for the invitation to give evidence today. I am really pleased to note the prominence the Bill gives to the workforce, and the important focus on systems working together, and working together with social care. I think that implementation will work well because we can build on what we are already doing. There is a great deal of collaboration between all parts of the system, and I can give you lots of examples if you wish of how we have developed the workforce over the past few years, particularly through the pandemic. We can build on what we have done together with other parts of the system. HEE plays a unique role because we have relationships with educators, providers of healthcare, the regulators, the professional bodies and NHS employers and other partners, as well with NHS England and the Department of Health and Social Care. We play a convening role, and we have already used that experience, ability and capacity to develop the workforce so far. We think the Bill will enable us to build on that.
Danny Mortimer: Navina captures really well the work that is already going on, not least, as she has said, through the pandemic. My members, who are the trusts and ICSs around the country, are already trying to find ways of developing joint approaches to developing their workforce, not least with their colleagues in social care, but also by thinking about different ways in which they can recruit and perhaps make employment in the NHS more accessible to people from harder, under-served communities. Some fantastic work has been going on with the Prince’s Trust, for example, around the NHS, and that has increasingly been done through the organisations that are being formalised through this Bill.
I also think that the commitments that the Government are expected to make later today, not least around investment in social care, will help organisations to work together. We have a pressing need in the health service to invest in the longer term in our workforce, but that is even truer for our colleagues in social care. Again, that is a significant step forward today, which we hope will go even further in the spending review, in helping employers to ensure an adequate supply of people in the longer term, not least with the support of Navina’s organisation, and also by being able to innovate together in developing roles that better meet the needs of the communities they serve.
Dr Navina Evans: Yes, I do. I think they build on what we have already done well and strengthen our ability to go further.
Danny Mortimer: I agree with that. I think there are some risks. At the heart of the Bill, it is formalising organisations that can lead, innovate and perhaps do things differently from each other in local areas. We have a very centralised healthcare system in this country, and one of the risks is that the vision in Bill of integration and devolution to local areas is not realised, because the centralising impetus is very strong. However, the Bill absolutely captures what has now been many years of growing collaboration and integration between health organisations but also, importantly, with our colleagues and friends in local authorities and social care.
I now call Mary Robinson.
Dr Navina Evans: I can give you three areas of learning that we in HEE were really pleased to see. One is around flexibility and better collaboration, which meant that our students and learners had a different kind of learning experience and also were able to contribute in a very real way to the care in service. This has led us to build on the reform agenda for education and training, and we are working with partners in education, the professional bodies and the regulators to see how we can use what we have learned to enhance that.
That is the first thing; the second thing is that we have seen quite a lot of barriers between organisations and systems being broken down. Again, that is something that we in HEE feel we should make the most of, together with partners, for future ways of working. The third area is the use of technology, digital and new ways of working. We have really moved quite significantly in how we work, including in how we learn, teach and train. Again, those are areas that we are very excited to build on. In many of them we had started before, but we accelerated during the pandemic, and we will not be going back. We will only be moving forward.
Danny Mortimer: I think that Navina captures really well that catalysing effect that the pandemic has had. I think that in many parts of the country there has been a much greater sense of there being one team within localities and communities. There have been some fantastic examples of health and social care teams coming together to respond, given the particular impact of the pandemic on social care settings and on the most vulnerable members of our communities. There is more to do, but the recognition that actually there is one workforce and one team, cutting across the NHS and other health organisations in other parts of the public service, is absolutely growing.
I think that the Bill, by formalising arrangements and stretching what is expected of systems, provides real opportunities for those systems increasingly to inform the kind of national work and planning that Navina and her colleagues lead, as well as the kind of informed work that the Secretary of State and the Minister want to take forward for health and social care.
I call Dr James Davies.
Dr Navina Evans: HEE has recently been given a ministerial commission to lead on developing a strategic framework for future workforces planning. We think that this is really timely in relation to the Bill. What we feel really matters in workforce planning is driving actions and solutions. We need to be able to identify future needs and shortages, and then ensure that the systems develop plans, but these plans need to be able to access all levers at all levels. It is quite a complicated business, but we feel that it is timely for us to pay particular attention to it.
There are a number of areas to consider. We need to look at service redesign; workforce redesign and transformation; employer roles, in terms of retention and recruitment; other supply interventions, such as international recruitment; and then—this is particularly relevant for HEE—future supply through education and training. We then want to pull the system together, through our convening role in HEE, and to have two principal ways of thinking about this: the future needs more and different, in terms of workforces and people; and we want to focus on skills, not necessarily just roles. The really critical point about this commission is that it asks us to ensure that we include the regulated social care workforce in our planning, which is a real step forward. We are looking to ensure that planning should track long-term trends in demand, that we should not be too tied to short-term fiscal cycles, and that we are prioritising supply for the whole health and care workforce.
Danny Mortimer: It is very welcome that the Department has commissioned HEE to do the work that Navina has described, but the NHS Confederation is clear, alongside a whole range of other organisations that work on behalf of the health service in particular, that clause 33 is insufficient for the task that the NHS faces in workforce planning. What it sets out, as Committee members will know, is a requirement for the Secretary of State to describe the process of workforce planning every five years. We have proposed to Parliament that that needs to move from setting out the process to actually setting out the requirements that health and social care have, and to do that much more regularly—we propose every two years.
For us, what is in the Bill is positive, because it is good to have the process described for the first time, but actually, as Dr Evans has just touched on, we need to spell out what the health and social care systems need in the longer term, but also in the immediate term. In some ways, that would mirror the work of the Office for Budget Responsibility in terms of advising the Government and Parliament about likely health and social care spending. We then need a corollary that sets out what is needed to respond to that in terms of people. Health and social care is fundamentally made up of the 3 million people who work in it. We sometimes fixate on the buildings and the technology, but it is fundamentally, in its essence, a people business. We think that that is a pressing issue, not least because of the pressures we face. That is not to say that the Government have not and do not invest in workforce numbers—significant decisions have been made in recent weeks around expanding medical school places, for example. But what we do not have is one coherent, single plan that is presented to the country and particularly to Parliament, which sets out what the NHS and our friends in social care will need to meet the demands that are being placed on us by the population, their health needs and quality of life, and also of course any priorities that the Government might set for social care and health services.
Thank you. I call Karin Smyth.
Danny Mortimer: It is absolutely the case that the individual organisations in the NHS, social care, charitable organisations and local authorities that make up the partnership as well as the board will remain separate legal entities. We do not see that it is desirable for the NHS to move from having 250 separate employers to having 42 employers. What we have in the NHS is a set of national terms and conditions. My organisation has a particular responsibility on behalf of the Secretary of State to negotiate those with our trade union colleagues. We see that they work well for the NHS and I detect no movement among my membership to move large scale away from those national terms and conditions, which cover the vast majority of staff who work in the statutory NHS.
What we see with ICSs is that organisations are increasingly coming together to address shared challenges. We observe that those challenges are not about pay and conditions but about supply. They are about working together to think about how to promote a specific area for people to come and work in, whether that is Nottinghamshire or West Yorkshire and Harrogate, where there has been some fantastic work in promoting careers in the sector as a whole. We see people coming together to work with directly elected Mayors around the skills agenda. There has been some really fantastic work, for example, in the west midlands, with health and social care organisations coming together with local authorities. We see similar work and engagement with the Mayor of London on the skills agenda that he is taking forward. Again, that is being done by organisations working together. That helps partners—local authorities are engaging with health and social care as a team rather than dozens of separate organisations. It also helps us promote careers that span the whole range of settings that we operate in and speaks to the particular priorities of our colleagues in social care. We see some really fantastic examples of that in various parts of the country.
Finally, we see a real opportunity to take forward the work that I have just talked to Dr Davies about. Systems, as they look at their services and their knowledge of the things that they are providing in their communities to your constituents, can inform the national plans that Navina described in her answer to Dr Davies. We can have a much greater connection between local priorities and some of the decisions that are made nationally about how we invest longer term in education. Of course, the NHS workforce is about 50% degree educated or degree equivalent. So there are significant investments that the Department of Health and Social Care, the Office for Students and the education sector make in our workforce. Being able to root that in what it is that local services need and how they are developed seems to us like a fantastic opportunity, and would help us to avoid the problems that we have got into in the last couple of decades with pressure points in various parts of our workforce.
Dr Navina Evans: I will build on what Danny has just described. You have given some really good examples of how local employers are coming together in systems to address workforce issues. I would add a bit more about how we do it and how we can do it even better going forward. Health Education England has a role in developing careers and attracting young people—all people—into the health and care workforce. We play a really big part in that. First, we have found that doing that locally, at a very local level with the communities and organisations that really understand their local populations, has been a really good thing to do. Some of the examples that Danny gave have built on that and we will move forward on that.
Secondly, we have structures in which people boards, at integrated care system level and definitely at regional level, now bring collections of the different organisations together. We have systems that are starting to think about themselves as anchor systems, which means that they can influence employment, the economy and the success of local communities.
Finally, the population health issue has been something that we have really woken up to, and we are cognisant of the fact that we have to focus on and rebalance the health and wellbeing of the population. Through the pandemic, we have learned a lot more about where we need to target our efforts to reduce inequalities. That can only be done really well through collaboration at a local level. Organisations such as mine need to work closely with our partners in NHSE, with the Department and with other national organisations to make sure that we support those local efforts to be sensitive to the needs of their particular population. It is bringing the national priorities, principles and policy into life at a very local level by making sure that we have the systems and structures in place to deliver what is needed locally. We had already started working on that—the work is well under way—and the Bill will enhance our ability to get on with doing that.
“must assist in the preparation…in this section,”
“if requested to do so by the Secretary of State.”
You have talked about locally led decision making and planning. Do you both agree that we need better co-creation? My amendment covers the fact that a plan should be developed and agreed by stakeholders in particular. Would your organisations welcome this amendment, which would result in an annual workforce strategy and require it to be developed by all other healthcare organisations working in this sphere?
Dr Navina Evans: From HEE’s perspective, we will deliver on the duties that Parliament decides that we ought to deliver. We feel that we have the capacity and the capability. We can organise ourselves to deliver whatever is required of us by the Bill. The work that we do is lithe—it is iterative. We do iterative planning, in a meaningful way, at the national and system level, so we will be able to respond and fit in with whatever is required of us by the Bill and Parliament.
Danny Mortimer: Thank you for the question. Absolutely, there is an opportunity for the Bill to define a wider range of stakeholders. The systems at the centre of the Bill—integrated care boards and integrated care partnerships—are central to that, and their perspectives, as we have just talked about with Ms Smyth, in terms of the needs of their population and the services they need to put in place to respond to them, need to be at the centre of the process that Navina and others would lead on behalf of the Secretary of State. That is the first thing. Secondly, there is an opportunity through those systems to broaden our conversation to include social care as well as health. That is really important to us on this day of all days, in terms of the announcements later.
In terms of the regular appraisal, we absolutely believe that five years is absolutely insufficient for the task. We also believe that it cannot just be about process. It has to be about setting out clear requirements and clear specificity about those requirements over different time periods. There is something about the short-term need, and there is also something about five, 10 and 20 years. It needs to be regular. We have proposed two years because it is a huge amount of work and that feels to us to be a minimum in terms of how regular the perspective could be, but it may well lend itself to an annual update, as you have described.
We also see that organisations such as Health Education England and Skills for Care, which operates in the social care sector, absolutely have the capacity and capability to lead this work. Their way of working, similar to the Department’s way of working throughout the preparation of this Bill, is about engaging, convening and trying to bring stakeholders together to get a broad range of perspectives. That is our experience of the long-term process that Navina and her colleagues are leading on behalf of the Department at the moment. The Bill confirming that would confirm ways of working that we are starting to see develop with stakeholders in a really healthy and constructive way.
Danny Mortimer: There are important links with Wales, and of course with Scotland as well, in many parts of the country. There are a couple of things to say. The first is that there are undoubtedly things that the English system can learn, and is learning, from our colleagues in Wales, Scotland and Northern Ireland who are taking similar approaches in terms of how they respond to the challenges we face in social care and health. In my own organisation, we represent organisations in Wales and Northern Ireland, and there is a really rich learning that we can do there.
Secondly, in practical terms, there are good lines of communication and liaison between healthcare organisations that operate along the borders that you have described. It will carry on being really important that those lines of communication, that liaison, the financial arrangements and the sharing of care between different teams on various sides of the borders continue, and we see nothing in the Bill that prevents that. If anything, we see opportunities through better co-ordination in England at a system level to be able to help patients who travel across from Wales into England, or patients who travel from Scotland into England. If anything, I think we can improve the planning and liaison through what is in this interesting Bill.
Dr Navina Evans: We already have very strong four-country relationships, particularly in the education and training space, where we make sure that we share standards, that we do planning around the curriculum and the reform of education, that we ensure quality and that we go for improvements in the way in which we support and train our future healthcare workers. In the regulation space, we work very closely with the General Medical Council, the Nursing and Midwifery Council and other bodies, to make sure that that happens. They obviously have four-country oversight, so we already work very closely with them. Also, all our professional bodies, such as the royal colleges, have to represent members from across the whole UK. In that space, there is a lot of good work that we can continue to build on, learn from and share as a result of this Bill.
There is one other point I would make, and this is more philosophical than practical. The Welsh Government’s approach to health is based on a wellbeing model. It is much more proactive than other models. I hope that, philosophically, that sort of approach is useful and interesting for you, and that you will be taking full notice of it.
Danny Mortimer: The second point, in particular, is really well made. That is absolutely the focus that we see integrated care systems taking. The engagement with population health that Navina described is about trying to gear a system much more to long-term investment in the quality of people’s lives.
We have become, in recent years—even before the pandemic—much more geared towards crisis response. That is not in the best interests of the long-term health of the population. It does not help us to address the inequities that we see in our population, and that we saw very starkly during the pandemic.
Navina may be aware of the issues around workforce mobility between the four countries. The co-ordination that Navina leads, and that we have with our professional regulators, is really important. We have a shared workforce, and we have shared approaches to education as well as things such as pay and contracts. That is really important to ensuring that the job market is stable, particularly if we experience supply issues in particular geographies or parts of the workforce.
Dr Navina Evans: I have nothing to add on the movement of the workforce between the four countries, but I take the point that this is something we need to be mindful of, and I will make sure that the issue is a priority in our conversations with our counterparts in the four countries.
On wellbeing services, that is absolutely the way in which the reform of education and the curriculum is moving. Health Education England is working with partners to develop that. Our integrated care systems, and our colleagues running services who are closest to the point of care, and who know their populations best, have been saying for some time that we need to focus on wellbeing, prevention, intervening earlier and keeping people well. That is a priority for our partners in NHS England and NHS Improvement as well. We already have programmes of work to take this forward.
Dr Navina Evans: I will give you three points that are really important. One is the absolute priority, focus and prominence given to looking after our workforce. Again, we will build on work that we have already been doing in the last few years. For example, in the interim pupil plan, there is a very strong focus on wellbeing, culture, leadership and retention. We have been working, together with Danny’s organisation and others, on thinking with staff about retention. One thing that is really important is looking after people. There are lots of good examples of work being done all around the country to improve wellbeing and therefore retention, and to minimise or prevent burnout. This is quite high on the agenda for our partners in NHS England and NHS Improvement. It is very high on the agenda for us in HEE, because we look after our students, trainees and learners, who are also part of the workforce, and they tell us what helps to keep them well and prevent burnout. We need to start doing that work, which is part of our business, very early on.
I am pleased to say that our partners in the universities, royal colleges and other professional bodies are really mindful of this. They all have work streams around wellbeing and preventing burnout. In the Bill, we can highlight the importance of this, and build on work that is already being done to look after our staff.
Thank you. I intend to move to the SNP spokesperson at 10.15 am, and to the Minister at 10.25; the session ends at 10.30. If we can keep questions and answers succinct, that would be appreciated.
Danny Mortimer: Noted, Mrs Murray.
I agree with everything that Navina has said, and it is a huge focus for the health service. In terms of supporting the health and wellbeing of staff, I think the Bill can go further under the terms of clause 33—it represents the conversation that we have had with them a couple of times. Absolutely we should support people and absolutely we should care for them, but if there are gaps in their rotas and in their teams that only increases the pressure on people who are already working flat-out. The pandemic has shown us starkly where those gaps and needs are, but we were experiencing them before the pandemic. There are parts of our workforce—mental health, learning disability nursing and some of our smaller allied health professions, such as therapeutic radiography—that absolutely need urgent long-term investment. We need that investment in staff as well as in the pressing need that we saw covered in social care settings and in hospitals during the pandemic. The requirement for a regular assessment of what the health and social care system requires to meet the needs of the population would help us to support that.
Danny Mortimer: I do not know to what extent Parliament is able to, or is willing to, pre-commit Governments to funding decisions such as you have described. Absolutely, that would bring clarity for us all in terms of what was needed, and it may well offer clarity in terms of the prioritisations that we have to make on investment in the workforce. We have seen a massive expansion in our medical workforce, particularly in hospitals, in the past 20 years, but we have not seen a similar expansion in the nursing workforce. That is not something that was clearly set out for us and for a Government to help make decisions about. I think a clearer, more effective clause 33 would help a Government to do that, and in turn help a Parliament to support a Government in that.
Dr Navina Evans: We expect to go back to the Minister with our findings by early March. After that, we will have a clearer understanding of when we will publish our framework.
Dr Navina Evans: From our perspective in Health Education England, our input is quite confined to the workforce planning. We are able to manage within our existing resources and to redefine and redeploy them. We are also able to work collaboratively with partners who are very willing to help us in this work.
Danny Mortimer: I cannot give you an exact figure, Mr Madders, but I can reassure the Committee that the way in which the proposed change will be implemented is much more about minimising the organisational disruption change that we have experienced with previous reforms, either the one 10 years ago or the one a decade before that. We are seeing a clear commitment to move staff who are currently employed in clinical commissioning groups—the Bill will disband those groups—to the new ICS organisations. That is a very positive way of managing the change rather than that experienced previously, which was hugely time-consuming in terms of management time and hugely unsettling for vital staff in terms of planning services. We are avoiding the problems that we faced in the past. Amanda and her colleagues at NHS England are to be commended for the proportionate and sensible manner in which they are looking to implement the changes, especially in terms of how they impact on people and organisations.
Thank you. For the last minute, I am going to hand over to my colleague.
Danny Mortimer: We have a really constructive set of relationships in the NHS with our trade unions, on both terms and conditions and the social partnership forum, which the Minister’s colleague Helen Whately chairs and which brings trade unions and employers together.
There is an interest in how the health service organises itself, and there is an interest in how the health service and our friends in social care can better work together to relieve the pressure that our colleagues were experiencing even before the pandemic. Of course, there are other things that people are interested in as well. There are outstanding questions about long-term pay strategy, and there are other issues around working environments and support that Navina touched on. Those are really important as well.
There is a recognition, when I speak to trade union leaders and representatives, of the opportunities available through system working to improve service delivery, and therefore to help their committed members do their jobs better and relieve the pressure that they have been under for far too long.
I call Dr Phillipa Whitford, the SNP spokesperson.
Dr Navina Evans: Thank you for the question. It is for Parliament to decide what goes into the Bill. We will, of course, work accordingly with the duties. We already work with the four nations around the foundation year programmes, we share a lot of intelligence and recruitment work and we are continuously looking for ways to strengthen that. It is an important priority for us to share learning and recruitment between countries.
Dr Navina Evans: I see that we are addressing exactly those problems around where people go to do their jobs and where the placements are. Having to travel to get the right training jobs is something that we have been grappling with for a very long time in Health Education England, and I remember that we were grappling with it when I was a trainee. That is something that we focus on anyway, and if it were to be strengthened in the Bill we would, of course, look at the duties that were expected of HEE in terms of working across the four nations to solve this issue. We would be building on what we are already doing to address that.
Danny Mortimer: Thank you, Dr Whitford; there are a couple of things there. On the geographical changes, what ICS leaders wanted was clarity. They have now been given that by the Department and NHS England, and they will move forward and can adapt accordingly.
On the impact on the frontline, throughout the pandemic, and increasingly before it, we saw a much greater sense of teamwork across some of the boundaries that we can create between parts of the health service, and between the health service and other public services. There is an opportunity to accelerate that in lots of our settings. That will be a positive. It will help people care better for their patients. Most importantly, it will help patients and their families to have a much more seamless experience.
This is not a magic thing—you know yourself how complicated the hand-offs and transitions between different teams can sometimes be—but this Bill formalises the recognition that we have had over recent years in England that to start to properly and truly focus on what individuals need, we have to have better co-ordination between our teams. It is not about the institution first; it is about the team first, and obviously most importantly the patient first. The absolute opportunity for us is to do those things better for the patients in between our services.
I think we are getting close to the last question.
This is the last question.
On the health services safety investigations body, I was on the pre-legislative Committee, where there was an aim of protecting the safe space disclosures quite thoroughly to ensure staff had the confidence to discuss very sensitive issues. In the version that is in this Bill, much more is covered by safe space protection, but then there are exemptions such as the coroner. Although staff can be summoned and made to give evidence, if they feel that that will end up being shared through a lot of disclosure exemptions, do you think they will really believe that that space is protected, in the way it is in the airline sector?
Danny Mortimer: There is a very difficult balance that health service leaders know they need to strike. The requirements around transparency to the public are much higher for the health services and for people such as you and Dr Evans, as health service practitioners. The coroner’s ability to review what happened is a really important step for families, and we are very respectful of that.
What the Bill does—this is how it describes the investigations branch—is to build on work that the NHS and the Government have been taking forward since Robert Francis’s inquiry into whistleblowing to ensure that we have cultures, practices and processes that enable people to be candid and open without fear of consequence, in terms of what has happened. We realise that that is how we learn and improve. We also realise that have a lot of work to do to help all parts of our workforce—clinical and non-clinical—feel much more comfortable and supported to raise concerns, give feedback and be honest about what happened. As you will know, there is an enormous amount of work going on across the four countries to create those kinds of cultures, but at the same time, we also recognise that we have that responsibility in terms of transparency to the public, and to patients and their families.
Thank you. I call the Minister.
Dr Navina Evans: I will start with the opportunities. We in HEE are really pleased to see that workforce is prioritised in the way that it has been. For us, that means that there is an expectation and an understanding of the need to tackle complex issues of future workforce planning, and that is hugely important. We can do it; it is a difficult task, but through collaboration and bringing people together, it is something that we simply must do, so that we can have more and different, and we can be really future-focused and progressive in the way that we deliver health and care. It is all down to our workforce. So that is the huge opportunity, as we see it.
There are risks. For us, one risk is that too much bureaucracy and added layers of hoops will get in the way, and the other risk is that we have to work hard to make sure that we address culture and collaboration to make this truly successful.
Danny Mortimer: The opportunity, we believe—along with colleagues across the health service—is in clause 33, going further and deeper there in terms of the assessment of need, as well as an assessment or a description of process. Clearly, what legislation cannot do is set out the kinds of behaviours that make that a well-informed and inclusive process. To reassure the Committee, though, what I do see is that the way of working we experienced during the development of this Bill, the way of working we are experiencing with Dr Evans in terms of the process she is leading at the moment—the long-term framework—is inclusive. It is trying to bring different voices in. Difficult decisions may well need to be made about prioritisation, and we understand that, but that is much easier to do and much easier to understand if it is based in that kind of process and behaviour. However, clearly, that is one of the risks.
As I have already said, we have had an increasingly centralised healthcare system over these last few years, and that is also one of the risks. If we stifle the local leadership and local innovation, and if we do not seek that local input in terms of how the development of local services needs to inform, in particular, the long-term planning for workforce, then that is a real risk for the legislation.
Dr Navina Evans: We in HEE think this is absolutely the right time to be doing this. We are at a moment where we have a lot of learning from what we have been through this last year. We have a real opportunity where many different pieces around innovation and improvement are coming together, and we have learned a lot from our previous experience of delivering the Health and Care Bill. For us, we think that this is absolutely the right moment to be doing this work.
Danny Mortimer: We would agree. NHS Confederation members were clear about the need for this approach before the pandemic, and I think that is even more pressing because of the pandemic. Actually, given the announcements that the Prime Minister is expected to make later today, it reinforces that need to better integrate health and social care, so the timing is very good.
Thank you both. Thank you, Mrs Murray.
Thank you, Minister. As there are no further questions from Members, I thank the witnesses for their evidence. We will now move on to the next panel.
Examination of Witnesses
Amanda Pritchard and Mark Cubbon gave evidence.
We will now hear from Amanda Pritchard, the chief executive of NHS England, and Mark Cubbon, the chief operating officer of NHS England and NHS Improvement. Both witnesses are appearing via Zoom, and we will run this session until 11.25 am. Could the witnesses please introduce themselves for the record?
Amanda Pritchard: Good morning. I am Amanda Pritchard, the chief executive of NHS England.
Mark Cubbon: Good morning. My name is Mark Cubbon, and I am the interim chief operating officer at NHS England and NHS Improvement.
Thank you very much.
We have just heard some interesting evidence, and I want us to be very specific about our terminology when we refer to integrated care systems, integrated care partnerships and the integrated care board. In your view, who is accountable for the spending in my local area under the new arrangements? Approximately £1.5 billion is spent in the local area. In the new system, who is accountable for that spend?
Amanda Pritchard: Thank you. If I start, Mark can come in and add. In the new proposals, the integrated care board carries the statutory responsibility, on behalf of the NHS, for the allocation of spending, performance management and the delivery of NHS services within the system. That, of course, has a delegated set of responsibilities, as per the current commissioning arrangements, down to individual organisations—be they groups of GPs, hospitals or community services— for the spend within those organisations, but the accountable part of the system is the integrated care board. As the proposals set out, it has a very important relationship with the integrated care partnership, but without the line accountability for the funding flowing through that part of the structure.
Amanda Pritchard: In the current structure, they are accountable through the NHS—sorry, not the current structure, because you are talking about the future structure. In the proposed future structure, they would be accountable to a combined NHS England and NHS Improvement structure. At the moment, we operate that through seven regions, and then through to the national NHSEI executive. We are, in turn, accountable to Parliament.
Amanda Pritchard: We have a clear accountability to Parliament through the Secretary of State in the current structure, and the Bill is not proposing that that will change. The other thing that we should say is that CCGs have a clear accountability to involve the public and patients in their decision making. Again, in the current proposals, that responsibility would transfer through to the new integrated care system, and particularly the integrated care board. While we just talked about formal line accountability, that does not detract from the clear expectation that flows through, that the integrated care board would have accountability to involve the public and to consult with them. The transparency that is expected now of the CCGs and NHS organisations is written into the expectations and would flow through to the expectations of the new integrated care boards.
Amanda Pritchard: I do not believe, although I may ask Mark to come in on the detail, that there is any proposed change to those arrangements. Mark, would you like to pick this one up?
Mark Cubbon: Thank you, Amanda. I am not aware that there is any significant change proposed by the Bill to the arrangements in place at the moment.
Amanda Pritchard: I will give you a headline answer, because I think this is really important. Part of what we would welcome in the Bill is that, by working as a system, one of the things that all partners will want to do is to come round the table together to make some of those important decisions about where the investment goes. In particular, if we are thinking about capital, I know there are examples already of where organisations have chosen to invest in community estate, additional diagnostics facilities or other parts of primary care estate. In fact, Mark and I were on a visit a few weeks ago to an ICS where they were telling us about some of the work they have done on that.
Moving to looking at system funding envelopes, particularly around capital, allows much more flexibility about how some of that resource is used in the interests of the whole population and the whole health system, rather than, at the moment, where putting things into slightly more siloed funding arrangements can end up being detrimental to certain parts of the system.
That comes back to some of the guiding principles of why the NHS has welcomed, certainly, the thrust of these proposals where integrated care is concerned, because it is all about building on some of the direction of travel that has been in the NHS for some time about trying to work much more collaboratively together. This helps remove some of the barriers that currently exist, for local systems to do that.
Amanda Pritchard: Through the existing capital allocation processes. Rather than just going to each individual organisation to then make their own decisions about how they spend it, it would now go through the ICB, so there is a process that allows consideration in the round of how the system spends that money most effectively on behalf of its entire population.
Thank you. We now go to Jo Gideon.
Amanda Pritchard: Again, I will ask Mark to add to this if he would like to. At the moment, the proposal is that funding would go formally through the integrated care board. The expectation is that, in developing the constitution and the detailed ways of working for each integrated care board, they would describe how the decision making is done, at not just the ICB level, but the place level, with the expectation that part of the principle would be subsidiarity.
If you are looking at the most sensible place for making decisions, for big, strategic investment the oversight of the overall allocative decision making may well sit best at ICB level; if you are talking about something that might have more of a borough footprint—thinking about London—you would want a lot of the decisions about local services, community primary care services and capital decision making to support those local initiatives to be made there. There would be a number of layers within the ICB involved in that decision making, but ultimate accountability would sit with the ICB itself.
Mark Cubbon: The only thing I would add is that this is essentially why we are bringing leaders together to form the ICS body. The key thing will be how the resources allocated to that ICS can be deployed in such a way that strategic objectives can be delivered. The allocation down to place, as you have said, is important so that decision making can be as local as possible to where the service is, so clinicians and frontline staff can make the changes they want in order to deliver improved outcomes for their patients.
Amanda Pritchard: I will start off, but Mark has led the work for NHS England and NHS Improvement on developing guidance to support local systems exactly in the area you ask about, on how to bring this to life and plan now for what we hope will be legislation coming into effect in April ’22. I do not want to steal his thunder on any of this.
One thing we warmly welcomed in the proposed legislation, and something we have heard about time and time again from our key stakeholders, is the flexibility. There is a minimum mandated legal set of requirements and structures, but, as you say, also an expectation that local systems will develop for themselves the structures and ways of working that make most sense for them. This is an obvious point, but what will work in Devon will by necessity look quite different from what you would want to put in place in somewhere such as Greater Manchester.
On behalf of our stakeholders, we have already welcomed the flexibility around that that has been described, but we have rightly said that, in addition to the suggested roles written into the legislation, there are some roles we would expect to see included on boards—we describe this as “mandatory guidance”. We have used that partly as an opportunity to pick up on exactly the point you make about clinical leadership and clinical representation. As a national health service, it is clearly right that we ensure that we have that strength of clinical voice.
At the moment, the mandatory guidance describes the need for a medical director and a director of nursing in addition to the expectation written into the legislation, which is that there would already be a representative from primary care as part of that ICB. Mark, you have done all the work thinking about how this is going to work in practice; do you want to pick up on that?
Mark Cubbon: Right at the core of the new working arrangements, we believe that clinical decision making and clinical input and engagement are an essential part of how the new arrangements will be put in place, so that frontline clinicians can shape how services should look and be involved in the planning and delivery of those services. In the guidance that we have put out, we are leaving a lot of flexibility for the ICB to bring in the appropriate number of clinical professionals to support those endeavours, and that is in the shaping of services, the planning and the execution of plans to deliver them.
While we talk a lot about doctors and nurses, there are 14 other allied health professions, and it is quite difficult to allow everyone to have a seat around the top table. We are strongly encouraging all ICBs to ensure that they have the right level of engagement and the right forum in place to ensure that the voices of all those professionals can be incorporated in the development of plans to deliver better services for patients and improve outcomes for members of the community. That is what we are asking all the organisations to do, and it has all been built on evidence that we have gathered from the clinical community over quite an extensive period of engagement. In fact, we published the guidance that Amanda referenced only last week, and it refers to the importance of clinical leadership at all levels: where the services are delivered at place; where services are planned for more local arrangements in the way that we have described; and then sitting more strategically at the ICS board as well.
Thank you. I call Dr James Davies.
Amanda Pritchard: On a positive, it is great that so many people want a seat on the boards, because I think that actually shows the level of engagement in ICSs. In practice, this is a very organic development from where the NHS has been since 2016, when we first started talking about STPs, as they were known then. This has been very pragmatic, bottom-up and testing as we go, and it now feels as though it is very much with the grain of where the NHS is.
I am not surprised, but I am really pleased, that so many different groups want to be involved. The balance that Mark has just described, which I think the legislation gets right at the moment, is in recognising that to be functional, we have to have the right number of people around the table. At one point we added up how many there would be if you allowed everybody who wanted one a formal seat at the table, and I think Cheshire and Merseyside ended up with 63 people who would be formal members of the board. That is completely unworkable.
It is about trying to find a balance that says, “Let’s be clear what you must have. Let’s use the opportunity that we have through NHSEI to introduce both mandatory guidance—things that people have to do—and guidance that sets out what we would consider to be best practice.” We have been very clear about, for example, the need to have arrangements in place to hear from all those terribly important stakeholders, and indeed for some of the duties, as I have mentioned already, that CCGs continue to carry around engagement with patients and the public, which is the other critical voice that we do not want to lose in any of this. That is the right balance, because it allows us to use some of those tools to keep some safeguards in place to give some clear direction, but it does not try to end up with either a one-size-fits-all solution for ICBs or something that is just unworkable because of the scale.
Thank you. I believe Mr Edward Timpson indicated that he wanted to ask a question.
Amanda Pritchard: This absolutely, again, falls into the category of formalising, in large parts, the way NHSEI already works, but removing some of the slightly more bureaucratic and legal barriers that we have in place at the moment. I came in two years ago as the chief executive of NHS Improvement and into Mark’s role as the chief operating officer of NHS England at the same time. Certainly, my experience over the last two years has been that, in practice, NHSE and NHSI really do work, to all intents and purposes, as a single organisation—but, as I say, with some of the bureaucracy that is still around that—and that has been absolutely essential over the last 18 months, particularly through the pandemic.
NHS leadership absolutely has to speak with one voice and has to be able to have consistent decision making. We have to have a way of managing, where this comes up, the tensions that sometimes arise between different parts of the system, but also leading in practice that integrated working and joined-up approach, right from the top. It was really only, I think, the 2012 Act that brought in the separation formally, legally, so in a sense what we are doing is stepping back to something that was always the way the NHS worked prior to that. As I say, we are really now just formalising the way things currently work, and have needed to work over the last 18 months or two years.
Thank you. Now we will hear from Mr Chris Skidmore.
Also, I wanted to ask for your views on the duties for the ICBs, particularly around research and innovation. It may be a terminology issue, but the duty to promote innovation and to promote research, through the ICBs, is only
“on matters relevant to the health service”
“in the provision of health services”.
It does not cover the care system. I would have thought that when we look at the very definition of an integrated care board, it should actually be promoting research and also innovation when it comes to the care system, as well as health services. I would greatly appreciate your thoughts on that.
Amanda Pritchard: It is a very good reflection on the importance of education as one of the key partners that would absolutely come round the table. I think that is where the ICS structure really helps us as well, because it allows that broader partnership construct, including education and local authorities. I would say—again, from some of the visits I have done recently—that people are really clear about the importance of things such as housing as part of the partnership, as colleagues would expect. Lots of people with different perspectives and different important roles in the system absolutely need to come together around that broader ICS structure, I think, to really give us the maximum benefit from the legislation that is proposed.
To pick up specifically on education, you are right to say that there are two parts to it. Clearly, there is a role for education providers, whether that is schools, universities or other providers. Part of what we have written into the expectation of ICSs in this core role, which is about contributing to the broader economic and social inequalities agenda within their own area, speaks directly to that. That is as much about education, training and employment within health and care as it is, of course, about the wider economy. The NHS, as an anchor institution in many parts of the country, can be an important player in that as well; so it is very clearly our expectation that education will be a key partner in all those different ways.
On research and innovation, as you have rightly noted, there is again a carry-over from the CCG responsibilities, which carry over into integrated care. We have made it clear in guidance that we see this as a really critical opportunity. Certainly, that is not and should not be limited to health. However, again, we have seen during the pandemic in the last 18 months that the power of bench-to-bedside translational research could not have been clearer, as well as the opportunities now to write in, right from the start—certainly through what we have been doing on guidance—the expectation that that research would be strongly supported and encouraged by integrated care systems as they go forward. Again, that is absolutely with the grain of what the health service wants to do and intends to do. Mark, did you want to add to that?
Mark Cubbon: Just two key points. With universities, we would expect them to be heavily engaged at place level. We have recently published some guidance with the LGA, which considered how we get place-based activities and partnerships so that we have places thriving—the guidance is called “Thriving places”. We also talk about the benefits of the university sector being involved with place-based arrangements, to do all the things that Amanda just set out.
Therefore, we certainly expect that local arrangements and local dialogue, co-ordination and planning around education for local communities can help with recruitment and the workforce contribution that it can make, but also for the betterment of the local community itself.
We would also expect, probably at partnership level, some university input, whether from an academic health science network or indeed colleagues at NIHR. We have recently been doing sessions with NIHR to talk about how to ensure that our clear ambition for this translational research and this health and care research can really be brought to the fore. It is a key pillar of activity that has seen us through some really difficult times during the pandemic and one that will also be essential as part of our recovery.
Thank you. We now move to the shadow Minister, Mr Justin Madders, and Mr Alex Norris.
Amanda Pritchard: One of the really important things in all of this, of course, is that we do not over-claim for what the Bill will achieve. If I look at what has happened in the NHS over the last 18 months to two years, it is absolutely clear to me that the ability to work together has been critical to the ability of the country to respond to covid, and the opportunity now to strengthen those arrangements, write them into legislation and remove some of the barriers that exist will be an important factor in helping the health service now, in partnership with local government, education and others that we have talked about, absolutely to recover from the challenges of the last year and to continue to build on those really strong local arrangements that have been such a hallmark of the way that things have worked over the last couple of years.
But of course, that is only one part of what it will take for the NHS to respond to the challenges that we have at the moment. It is absolutely right that the NHS staff, who have worked so tirelessly over the past two years and of course beyond to look after what we now know are over 400,000 covid in-patients, get the backing and the funding they need, not just to deal with what is very much still with us, with covid in our hospitals and communities right now, but absolutely to make sure that we are as front-foot as possible in tackling the inevitable backlogs that have built up over the past couple of years.
There is a complex set of things. Workforce is critical: the support we give to the people who have already done so much for us—we continue to invest in them and support them, so that we have the right pipeline for new staff joining, the right skills and the right support. Then there is the funding that we need to do the work that we have, and the capital funding to invest in some of the transformation that has already begun and needs to continue. But also, I think the Bill provides us with the framework to continue to support that really powerful local joint working that we have seen over the last two years, and which we are already seeing really at the heart of the covid recovery within the NHS and more broadly.
Amanda Pritchard: It is worth saying that there are some big unknowns in the position at the moment. We just do not know, really, how covid is going to play out over the next few months and years. One of the things that colleagues have talked about, and are very aware of, is that a lot of people did not come forward for care over the past two years. One of the messages that I would like to give again is that, for anyone who is concerned about symptoms, the NHS is absolutely open for business. Please do come forward and seek diagnosis, treatment and support.
We do not know, as we sit here today with two big variables, quite how things are going to play out. What we can say for certain is that today we have over 6,000 people with covid in hospitals. It is costing the NHS more both to care for those patients safely, with all of the infection control arrangements that need to be in place—
Thank you for that, but I just remind the shadow Minister to keep within the scope of the Bill.
Amanda Pritchard: Actually, in some ways that does link to what I was just saying, because—you would expect me to say this—just to reflect the reality of where we are now, covid is still with us, but we also have a real commitment and opportunity to lean in now to that recovery of routine services. I think success looks clearly like we now have the platform right to be able to continue to evidence that local partnership working is really making a difference. What does that mean? It means partnership in practice, both to deal with the current challenges that the NHS is facing and will continue to face, and to start to show that we can really eat into the backlog of routine care that we know is with us and make the commitment, which I know is felt so deeply across the NHS, to tackling inequalities and really trying to think about some of those long-term planning commitments that talked about prevention and outcomes.
We want to see progress against all those things, but we also want to continue to support local systems, as they have been all the way through, to partner together to continue to deliver things such as the vaccine programme in really innovative ways. For me, this is all about putting the NHS on a firmer statutory footing, whereby partnership becomes the way that we do things, building on what has happened over the last few years and removing any remaining barriers that we know exist and which stop us progressing with the really important job now of improving care for the population and for our patients.
Amanda Pritchard: Thank you for that, because from the NHS perspective, the reason we have been supportive, particularly of the integration parts of the Bill, is that it is all about what it enables us to do for patients. Mark and I have done a lot over the last few weeks and months. We have seen so many examples in practice of where it is about the ability to work in partnership, whether that is about mental health crisis lines that are partly delivered through the voluntary sector, with a bit of funding from the NHS, but with support from specialists and mental health trusts as well as primary care. It is about coming together to create those sorts of innovative services, whether it is children’s and young people’s services, such as in south-east London, or whether it is in schools, picking up where children and families have medical and health problems. It is about linking them to the right support within local government, housing and so forth.
That is the sort of thing that we have seen develop over the last few years. As I say, it has been turbocharged through covid, but what we now want to do—this is the critical part of the legislation—is to make that easier. We want to make it the norm and allow people the right opportunities to come together and think about what their population needs and what will make services. It is back to the triple aim of improving the health of the population, the quality of care for patients and the sustainability of services. But ultimately, it is about being able to work together to set up those sorts of innovative arrangements, to see them embedded in practice and to see the NHS working in an integrated way around individuals as the norm. Let me bring in Mark, because this is absolutely his operational space.
Mark Cubbon: Thank you, Amanda. Going back to what patients can expect to see, I think they can expect our local integrated care systems to continue all the efforts to engage with our communities and talk about how we are planning to provide more joined-up care for our communities, because that is one of the key benefits that we will get from the new arrangements. There will be fewer hand-offs in care and fewer organisational boundaries for patients to bump into occasionally, so that we can have joined-up conversations and talk about how things are going to be better. Our local systems, leaders and clinicians will be better placed, so that we really face into and talk about how we will reduce the inequalities and deliver better outcomes. That engagement will be really important, and I think we will build on what works well at the moment and continue to make sure that the patient point is front and centre of all that we are trying to do. We have clinicians leading the charge, in terms of the delivery of those services.
Is there time for a quick question?
Amanda Pritchard: Mark, do you want to pick this one up? I know you have been leading on this issue for us.
Mark Cubbon: I will indeed. This is definitely a different change from 2012, and probably different from any other changes that have been put in place in previous times as well. We are very much approaching this in the way that we have done. From the outset, we have given a clear message and reassurance to staff who are working in CCGs on job security, so that they know that almost all posts, and the individuals holding those posts, will transfer over to the new organisations. There are not big redundancy bills attached to these changes. We very much want to make sure that the job security is there and that the roles are transferred—
Mark Cubbon: We do not have a figure for all the changes, but we know that the CCG cost envelope, which is attributed to every CCG as it stands at the moment, is the cost envelope that will be allocated to each of the ICSs as well. We are not expecting the running costs to be significantly different from those that we have for CCGs.
Mark Cubbon: The ICB is essentially how the NHS leaders come together specifically to oversee how resources are allocated and how the NHS delivers its side of the bargain, in terms of how the rest of the ICS works and is able to support integration. The ICP—the partnership—is where we bring together other partners who will have a view, an input and a role to play in that integration agenda. That is essentially, at a very high level, the separation of the partnership and the ICB itself.
On how we get representative views from the whole breadth of the clinical community, again this was published in our guidance—we have further guidance that was published last week—which talks about the clinical community, based on all the engagement that has been done so far. The kind of arrangements that we are very likely to see are where we have clinical reference groups and clinical boards that start to shape all the representative views that give a holistic perspective on how services should be planned and how we should be delivering services for our patients and communities.
Although not every individual will have a seat around the board or partnership table, we are advising the boards and clinicians across the whole footprint to ensure there is deep-rooted engagement. We are trying to galvanise the clinical community and get consensus on the direction of travel in terms of how services should be delivered for patients to deliver better outcomes. That is what we are encouraging our local ICSs to do. We are giving as much guidance as possible, but it will be down to this local flexibility so that our clinicians locally can start to work out how they best come together to do all the things I just set out.
Amanda Pritchard: I am happy to, and Mark may well want to add. You are absolutely right that when the NHS went out to consult as part of the exercise that we undertook back in February, we were describing a single board structure at that moment. It is a change that we proposed to Government on the back of the stakeholder feedback that we had, particularly from the LGA, which suggested the dual board structure, partly because it gives the real clarity, as we talked about earlier, about where the money flows and where the accountability for NHS service delivery sits. It therefore allows a wider partnership to play in, with a particular view to all the other aspects of population health and the wider agenda. That is not where we started, but it is where we now feel very comfortable, in response to the strong stakeholder feedback.
Amanda Pritchard: Again, you are absolutely right, and that is a risk, which is why we started where we did. What is now described—the requirement to have regard to and respond to that overarching strategy—is the safeguard that means you cannot have the NHS in any way separated from that broader ICS structure, and from that wider strategy for which the partnership will be responsible. As we have discussed, I am not expecting that that will necessarily be the only way in which wider partners are brought into the ICB, but the fact that there will be a local government seat on the ICB is another important way that stops the NHS just working on its own.
Amanda Pritchard: It has quite a specific, technical meaning, so from our point of view we would understand that to be a very clear direction.
Amanda Pritchard: I might let Mark come in on this, because it is something that we have thought a lot about. You are absolutely right that the purpose of all of this is to make sure that we are improving care and services to patients, but with regard to that triple A, it is also of course about the sustainability of services and the broader population health challenge. Part of the structure that the Bill will allow us to put in place on things such as the provider collaboratives absolutely begins to put back firmly at the core of how we do our business procedures such as the clinical peer review.
We have now got the data through things such as GIRFT, which means that we can incorporate it formally in a structure that brings together the providers and also crosses pathways, so that we are not dealing with acute on its own, or with mental health or primary care on its own. We can then look at each against best practice and see how different parts of the system are performing, assess some of the challenges and collectively think about how to come together to secure improvement. That is already happening, but the Bill will allow us to make that much more at the core of how the systems approach local improvement. Mark, would you like to add to that?
Amanda Pritchard: Yes. There is still a huge amount of national audit work that does take place. Thank you for mentioning GIRFT, because we do have some other really important improvement programmes that are very data driven, which have an important place in this conversation. We certainly see the proposed legislative changes as a real opportunity to bake that way of working in, not just nationally but through systems coming together to do it as part of their local activity as well.
Mark, do you have anything to add very briefly?
Mark Cubbon: One of the major changes is a move away from competition to much more collaboration, and that is one of the things that the Bill sets out. That is what we believe in and what people are looking for, from what we hear from the service. With that collaboration what we start to see is much more accessible input from people and organisations, so that we can share and learn from each other and start to instil the best practice that we see in one part of an ICS, and have the opportunity to discuss that and see how it can benefit other parts of the ICS, and so reduce variation and deliver much more consistent care to patients.
Before I started my job at NHSEI, I was chief executive of an acute hospital on the south coast. While there have always been opportunities for colleagues to come together and discuss how best to approach a challenge, and to ensure opportunities for sharing good practice and learning from each other, the Bill starts to take down barriers and is much more enabling than what came before. Yes, of course clinicians have informal ways of coming together to look at how changes can benefit patients, but these structures are intended to allow a much greater exchange of ideas, which will be of great benefit to patients; hopefully we can start to implement those ideas at greater speed.
Before I call the Minister, I remind Members that there will be a hard stop at 11.25 am. If witnesses could keep their answers as brief as possible, it would be much appreciated.
If I recall correctly, your predecessor, now Lord Stevens, says that about 85% of provisions in the Bill were things that the NHS asked for in its 2019 consultation. Do you recognise that figure, and how would you characterise the approach that has been adopted to the development of the Bill?
Amanda Pritchard: Thank you. I would struggle to give an exact percentage, but the Bill certainly contains widely supported proposals for integrated care. We have been working very closely with our stakeholders, colleagues across the system, you and others to ensure, as far as possible, the same approach to consultation, listening and hearing. You cannot please everybody all the time, but we want to reflect what feels genuinely like a consensus view about what will best help the NHS deliver on all the challenges we have discussed. That is reflected in the Bill, so thank you for that. As it goes through Parliament, we very much want to continue to see that spirit of joint working, consensus building and engagement, so that when it hopefully becomes legislation in April ’22, it lands with all the support that I think it currently has.
Amanda Pritchard: As I said, I genuinely think that our experience across covid has strengthened the argument for moving to legislation now, because our way of working in the past two years has been characterised by integration and partnership, and that is how the NHS and partners need and want to work—now and as we head into next year, facing that set of challenges that people are so very committed to continuing to tackle together. Yes, Minister, I think this is an important Bill. The integration agenda is not the whole answer, but it is an important component of it, and the sooner it comes, the better.
Mark Cubbon: All I would say is that collaboration and partnership work is a key feature of our response to covid. It is ever more critical, in the light of the question of how we will approach our recovery. Fantastic working has been enabled locally through necessity; now, we hear from the whole service that we want to build on that. We look forward to the future with that in mind; the Bill allows us to do that.
As there are no further questions, I thank the witnesses for their evidence. That brings us to the end of our morning sitting. The Committee will meet again at 2 pm in this room to take further evidence.
That further consideration be now adjourned.—(Maggie Throup.)
Adjourned till this day at Two o’clock.
Health and Care Bill (Second sitting)
The Committee consisted of the following Members:
Chairs: † Steve McCabe, Mrs Sheryll Murray
† Argar, Edward (Minister for Health)
† Churchill, Jo (Parliamentary Under-Secretary of State for Health and Social Care)
† Crosbie, Virginia (Ynys Môn) (Con)
† Davies, Gareth (Grantham and Stamford) (Con)
† Davies, Dr James (Vale of Clwyd) (Con)
† Foy, Mary Kelly (City of Durham) (Lab)
† Gideon, Jo (Stoke-on-Trent Central) (Con)
† Madders, Justin (Ellesmere Port and Neston) (Lab)
† Norris, Alex (Nottingham North) (Lab/Co-op)
† Owen, Sarah (Luton North) (Lab)
† Robinson, Mary (Cheadle) (Con)
† Skidmore, Chris (Kingswood) (Con)
† Smyth, Karin (Bristol South) (Lab)
† Throup, Maggie (Lord Commissioner of Her Majesty's Treasury)
† Timpson, Edward (Eddisbury) (Con)
† Whitford, Dr Philippa (Central Ayrshire) (SNP)
Williams, Hywel (Arfon) (PC)
Huw Yardley, Sarah Ioannou, Committee Clerks
† attended the Committee
Simon Madden, Director for Data Policy, NHSX
Saffron Cordery, Deputy Chief Executive, NHS Providers
Matthew Taylor, Chief Executive, NHS Confederation
Ian Trenholm, Chief Executive, Care Quality Commission
Keith Conradi, Chief Investigator, Healthcare Safety Investigation Branch
Cllr James Jamieson, Chair, Local Government Association
Professor Maggie Rae, President, Faculty of Public Health
Eluned Morgan, Minister for Health and Social Services, Welsh Government
Lyn Summers, Head of Health and Social Services Central Legislation Team, Welsh Government
Mari Williams, Senior Lawyer (Health), Welsh Government
Public Bill Committee
Tuesday 7 September 2021
[Steve McCabe in the Chair]
Health and Care Bill
The Committee deliberated in private.
Examination of Witness
Simon Madden gave evidence.
This is the third panel. We will now hear from Simon Madden, the director of data policy at NHSX, who is appearing in person. We have until 2.30 pm for this session. Good afternoon, Mr Madden. Could I ask you to introduce yourself for the record?
Simon Madden: Good afternoon. I am Simon Madden, director of data policy, NHSX.
Simon Madden: We have obviously set out the position. The Government have set out the position in respect of GP data for planning and research, in terms of taking a pause and having a conditions-based approach, rather than a clear timeline for the commencement of that. Above all else, I think that the overriding need for trust and transparency—to build public trust in the use of health data—is vitally important, and the ways in which this is governed need to be transparent in such a way that the general public can see quite easily how their data will be used.
Indeed, I think it is a responsibility on Government and those of us in the health and care system more broadly to really promote the benefits of sharing data. It is a public good and, while putting in place sufficient safeguards and then giving the public the opportunity to opt out of that process if they are not convinced by those safeguards, it remains a public good and contributes to the broader health, if I can put it that way, of the health and care system.
Simon Madden: Essentially, they are separate in terms of process. The general public will not make a distinction between any things to do with their health data. Whether it is the draft data strategy that we published earlier in the year or the GP data for planning and research programme, to the general public it is about their health data.
It is incumbent on us to make sure that we have a strong narrative that reflects all aspects of health data. We need to reset the relationship between the patient—the citizen—and their health data, so that a perception does not arise that we are taking their trust for granted, because that is certainly not the case. The provisions in the Bill around data are meant, to some degree, to provide clarification where there is some confusion in the current framework about how and when data could be shared.
Building on that point—
Hang on a second. I had better give somebody from another party a chance.
Chair, I have another question.
I will come to you in a second, Karin. I am just trying to balance it between the respective parties.
Simon Madden: I completely understand that. We have to be very clear about what we mean by “commercial companies”, because pharmaceutical companies that develop treatments and vaccines are also commercial companies.
Simon Madden: I get that, but there is no doubt that, in order to improve treatments, we need to contribute to research in some way.
You are absolutely right. It goes back to my trust and transparency point. One of the things that we signalled in the data strategy particularly was a movement towards trusted research environments. That is crucial. In some ways, what we have announced on GP data for planning and research is an acceleration of that work. We have said that data will not be shipped around or disseminated; it will be accessed only within the confines of a secure, trusted research environment, with full transparency about who has access, who runs what queries, and so on. It will be held and will not be shared. That is the general direction of travel that we want to see, and that is why we set that out in the data strategy.
We do not have to make a choice now between enabling access to data, or sharing data, and protecting privacy. Technology has allowed us to create environments where it is perfectly possible for data to be accessed safely and securely, with strict safeguards, without privacy being compromised.
Simon Madden: Data will not be handed over in a trusted research environment; it is only accessed in one place.
Simon Madden: I completely understand. That is why I mentioned that it is incumbent on us to have not only the right safeguards in place but the right narrative and to engage with the public so that they understand what those safeguards are, how they operate and how they can opt out of the system. One of the things we have been looking at in developing the final version of the data strategy following the engagement is how we can do much more on public trust and transparency. It is not just about a one-off marketing campaign; it is about an ongoing public dialogue and involvement of the public in future policy considerations. Again, it goes back to that resetting point; I think this is a reset moment. Technology now allows us to go that bit further than we have ever been able to go before in terms of protecting privacy, but we have to be in a stronger position to explain that to the public and how it all works.
Simon Madden: Forgive me, but I will take full advantage of the fact that I was not there and have not seen the statement that the Prime Minister made. A feature of our plans set out in the data strategy—not so much in terms of the Bill itself—is for each integrated care system to have a basic shared care record, so that throughout their whole health and care journey a patient or citizen does not have to do simple things like repeat test results or repeat their prescriptions, and so that their care journey between health and social care, with provisions for safeguarding and safeguarding information, is seamless.
I will ask a couple of questions, if I may, Mr McCabe, and then perhaps the hon. Member for Nottingham North can come back in if we have time. Moving away from what has been explored by colleagues so far on the extremely important protections around data sharing and data use, can you set out how the changes set out in the Bill relate to and will help you deliver the data strategy that you have in place?
Simon Madden: It is important to set out that these provisions alone, while they do much within the Bill, must be seen in the context of that wider data strategy. They support our ambitions, and the integration and collaboration that is described in the Bill will be a huge enabler for the ambitions set out in the strategy itself.
The provisions themselves focus to some extent on tidying things up and providing a degree of clarification. I mentioned the provisions for clarifying NHS Digital powers: currently, there is sometimes confusion around what data NHS Digital can share and in what circumstances it can share it. Sometimes, that leads to problems when data may need to be shared for very good reasons—for justifiable reasons—but NHS Digital is sometimes not convinced that it has the legal power to be able to share the data. This puts beyond doubt its ability to share data appropriately.
Another provision is on information standards. We are making a provision in the Bill to mandate standards for the storage and collection of data. That is important to ensure that data can flow between different IT systems and organisational boundaries in the health and care system. That will then help individual patients and improve health outcomes. We want to ensure that providers of health and care services purchase only technology that adheres to that set of standards, so that we have that interoperability, and those improved outcomes for patients, through that mandation of information standards.
We have also put in clauses around sharing anonymous health and care information, which help to essentially set a duty to share anonymous information when it is legally permitted to do so. One of the lessons that we have learned over the pandemic has been that, although it is perfectly permissible for data to be shared—it is legally permissible to do so—the shift from “can” to “should” has a great impact within the system.
Our invoking of the control of patient information regulations under existing legislation, to enable that sharing of data and to say, “You should share data in these circumstances,” has significantly helped the free flow of data safely and securely within the health system. That has had an impact on patient care. I think that the duty to share anonymous data will help to put on a more permanent footing some of those provisions that we have seen during the pandemic.
Simon Madden: I think it is a fair reflection, to a certain degree. I think that the thing that we must always be conscious of, particularly in the field of data and technology, is that we see advances but legislation often does not keep up with those advances. It is about ensuring that everyone understands their responsibilities—not just that the public understands the responsibilities of organisations that are safeguarding data, but that those organisations themselves have the right powers to be able to share data safely and securely. I think it is evolutionary in that sense, but it is also about making sure that the provisions in the Bill are keeping pace with the development of technology and how data is used in the real, modern world.
Simon Madden: I should perhaps caveat my previous comments by saying that they very much are, in our mind; it is all about health data. The focal point for us at the moment, which we are working through with Ministers, is the formulation of the final version of the data strategy. Of course, the legislative provisions are within the data strategy. It is very much the case that the publication of that document, I think, is the right moment for that reset where we have more intensified engagement with the public and we really step up the narrative around how health data is used. As one of your colleagues said, the real detail comes in regulations, if there are any regulations around that; and of course there would need to be consultation before the regulations were put in place.
Simon Madden: Obviously, interoperability is absolutely key. The information standards piece that I spoke about is part of that, but also, outside the legislative piece, work is going on to create a unified data architecture. This is not about driving or having everything from the centre, so that everybody uses the same things, but about making sure that the architecture enables that interoperability so that the systems can speak to each other. There is certainly a degree of levelling up to do in terms of digital maturity, which is another area in which NHSX is involved, supporting the Department and NHS England. But yes, interoperability is key. We are not there yet; we have some way to go to make sure that everything will flow as it should and the systems speak to each other.
Simon Madden: The best example is something that I have already cited to a certain degree, which is the shared care record. To some degree, that would happen irrespective of whether ICSs and the Bill were in place, because health and social care need to come together; that is something that needs to happen in any event. But what the Bill does is create the proper framework of integration and collaboration. There are other powers in the Bill, for instance the duty to co-operate and collaborate, that I think are going to be absolutely crucial. From a public perspective, they see the NHS and see one organisation, whereas we all know that it is a confederation of organisations, each sometimes with different aims, pulling together. The ICS structure set out in the Bill, plus the data provisions that support that broader approach, will help provide that free flow of information so that clinicians and care professionals have access to the information they need to be able to treat patients in the most effective way.
Anyone else? I will assume there are no more questions. Mr Madden, I thank you very much for your evidence.
Examination of Witnesses
Saffron Cordery and Matthew Taylor gave evidence.
This panel is mixed. We have Saffron Cordery, the deputy chief executive of NHS Providers, who is joining us remotely via a video link, and Matthew Taylor, the chief executive of the NHS Confederation, who is appearing in person. Can you hear us okay, Saffron?
Saffron Cordery indicated assent.
In that case, Saffron first, then Mr Taylor, can you introduce yourselves for the record, please?
Saffron Cordery: Yes. I am Saffron Cordery and I am deputy chief executive at NHS Providers.
Matthew Taylor: I am Matthew Taylor and I am chief executive of the NHS Confederation.
Good to see you both. Thank you for coming. I want to talk about accountability. I asked NHS England this morning about how accountability works in the new system and it was clear that local accountability lies with the integrated care board—the chief executive and the finance director, in the first instance. We were then taken through the system up to NHS England and Ms Pritchard then said “through Parliament”, which she corrected to “through the Secretary of State through Parliament”. I asked at what stage the Secretary of State becomes involved in the accountability, a question that she did not answer and which I would like you both to answer for me.
We have also heard that the Bill is something the NHS asked for. I have not met a single person working at any level in the NHS who says that the powers given to the Secretary of State directly, added to the Bill after conversations with the NHS, are a good thing and are clearly workable. That is my pretext.
Perhaps I can give the example of a constituent who came to me about ear wax removal, which was a subject that concerned him greatly. Will I write to the Secretary of State as a Member of Parliament to ask him about the lack of ear wax removal services in my integrated care board area, or will the chief executive be the final arbiter of such decisions? Mr Taylor, do you want to go first on behalf of the confederation?
Matthew Taylor: Yes. There are two points here. The first is around the structure of accountability at the centre and while that is important, ultimately, it is a less important consideration for health service leaders than the relationship between central accountability and local accountability. That is the focus of the major concern we have about the Bill: the extension of the Secretary of State’s powers in relation to reconfiguration, which we think is a mistake. We think the system, as it is, is not perfect but works pretty well. For the Secretary of State potentially to be embroiled in making decisions not just about major reconfigurations, but really relatively minor reconfigurations runs the risk not only of delaying necessary changes in the system, but of putting less emphasis on the views of local people and of clinical advice.
Representing my members, while the question of the relationship between the Secretary of State, Parliament and NHS England is one that we take an interest in, the issue of the relationship between the centre and local accountability is stronger. Where constituents write to their MPs, the Secretary of State or wherever when they have a problem, they will continue to do so, but I hope in such a system that the first thing to happen to such a letter is that it would be sent back to people locally who could address that issue in a local way. It would be ill-advised for a Secretary of State to try to involve themselves in a question like that.
Saffron Cordery: I agree with Matthew’s point. It is this central-local relationship that is absolutely critical to those who are working on the frontline—trust leaders from my perspective, and from NHS Providers’ perspective. Coming back to some of your points about the NHS supporting the legislation, I think that is absolutely right. The NHS has come together to support the direction of travel of this legislation, but I think it is worth saying that that agreement was based around an August 2019 set of proposals, when the whole NHS came together on the basis of some recommendations from the Health Committee. It is important to remember that the legislation has changed somewhat since then. We have had a number of elements added to the Bill that sit around the central bit that the NHS agreed with, which probably changed the context somewhat. It is worth remembering that the local reconfigurations issue that Matthew Taylor raised is a very important one.
There are elements as well in the nature of the relationship between the Secretary of State and NHS England in terms of the operating context and its ability to intervene in what goes on nationally, and the knock-on effect locally on trusts. There are some really big issues there, which come together.
The other thing to say is that, often, Secretary of State powers may seem like small elements, but taken together, the cumulative impact can be seen to erode that local accountability. We would hope, whatever happens, that if someone has an issue with ear wax removal, they speak to someone at the most appropriate level to get something done. That is what subsidiarity is about: the delegation of powers to the most appropriate level, and it is really important. It is also important for accountability, because you cannot have a Secretary of State saddled with taking a thousand tiny decisions in an organisation and a system as complex as the NHS. That is one of the challenges of this local reconfiguration issue that is arising.
Chair, can I come back?
I will come to you if there is time, but I want to move on. Dr Davies.
Saffron Cordery: The experience of the pandemic, which is a seismic and far-reaching event, really put the frontline of the NHS and other local public services in the frame for delivering for their local communities, and for supporting each other and helping each other out with mutual aid. What we saw there was one very good and important example of how local partnership working, local collaboration and local integration was working in very different ways up and down the country.
We had some common features of all integration, something you would expect at a time of crisis, where there is a lot of command and control and procedures that go on in a state of civil crisis such as this one. We also saw different communities responding in different ways. That is one of the most important points that I want to make about this legislation. In terms of collaboration, we have to see a piece of legislation that is as enabling and permissive as possible. Obviously, legislation has choices. You go down different routes. Really prescriptive legislation will not help in this situation, though. We have to reflect the progress made in some areas and the need for encouragement and support in other areas to get where we want all ICSs to be: that is, really effective and delivering what local populations need. A permissive framework is critical. Going back to your question, it is right that the pandemic has shone a light on both the potential of ICSs and collaboration in particular and the challenges we face right now in implementing any new proposals due to the operational pressures facing the NHS, local government and other public services.
Matthew Taylor: I agree with Saffron. There have been some very good examples of local collaboration, such as the vaccination programme and reaching out to communities where initial take-up may not have been what we had hoped. There is some really impressive work there. That work presages the wider commitment within the health service to a strategy of population health, which addresses not only those people who express demand but those who do not. We wish that they would, because that is one of the things driving health inequality.
I have been at the confederation only three months, so I look at the legislation from the perspective of a wider interest in public policy over 30 years in government and outside it. This is a very interesting and innovative example of policy making. We have these integrated care systems in large parts of the country, so the policy has already been enacted ahead of the legislation. Though that may raise democratic issues, it enables us to see in practice how people are taking the principles of service integration and focusing them on population health. Despite the challenges of covid, a challenging funding context, and the issues around social care—which are hopefully being addressed in one way or another—we see across the country that there has been a whole array of interesting bits of innovative, collaborative work around issues of population health, prevention and addressing health inequalities.
I want to emphasise a point Saffron made. If you look around the country, you see some systems that are well advanced in their collaboration and other systems that are not. This is for a variety of reasons; in some cases there are issues to do with boundaries and such. Like Saffron, I think it is really important we have a permissive regime that allows these systems to evolve at a pace that is right for them and the places in which they operate. Over time, the systems will move forward, but it is actually a really effective way of working. It would be a mistake to try to impose exactly the same way of working on every part of the country. It would mean those who were ahead will be pulled back and those who are not quite ready to make integration work will be compelled to tick boxes, as it were, rather than work on the development of the relationships that we need.
Matthew Taylor: That is an important point. Let me be completely open about the conversation within the confederation about this issue, for example. We have a mental health network representing mental health providers. Their preference would be to specify the need to have a mental health leader on the board. We as a confederation recognise that view and represented it, but that is not our view overall. Our view is that, partly because configurations differ from place to place—in some places, mental healthcare and community are together, for example—but for a variety of reasons, we would not want to specify further the membership of those boards. Again, that is to maximise local flexibility.
If people feel their voice is not being heard, then that is something they are going to say. We will have to see how this system evolves, but let us start with—going back to a word used earlier—the permissive regime and see how that goes, because after all it is in the interests of everybody in the local health system that they hear the voices they need to hear.
Saffron Cordery: I agree. This is a thorny issue but I suppose it is one of either, depending on how you look at it, the opportunities or the casualties of creating another level of governance in a local system. When you are thinking about putting collaboration on a statutory footing, you have to surround it with some kind of governance to ensure the effective operation of that body.
It is a tricky issue. You cannot have an integrated care board—the board that will govern how funding flows through and how priorities are agreed, decided and implemented—that is so enormous that it becomes unworkable, but there has to be a clear balance between making sure it is not only the big and the powerful who are represented there, but also all the rights and appropriate interests. There are a number of positions specified in the ICB board arrangements, and it will be interesting and important to see how different ICSs use those roles, particularly the non-executive or wider partnership roles that are specified, in order to have a broad range of voices around the table.
It is worth remembering that many other organisations and structures will be taking part in the ICS arrangements. You will have things like provider collaboratives, which are not in the Bill but feature heavily in the guidance that comes from NHS England and NHS Improvement, which are precisely about organisations working together to deliver on local priorities. Many of those are led by mental health organisations focusing on what they need to deliver.
There are other structures within these arrangements, but no one would say it is ideal. It is not the most ideal solution, but it is very difficult to get to a final configuration that is both workable in terms of numbers and reflects the multiplicity of voices in a locality. It is important to have the right engagement at every single level and the right channels feeding up information and priorities, and to understand what is really important in a system.
Matthew Taylor: Today the Government have been talking about the importance of integration in the context of its announcement on health and social care. One of the big questions is going to be about the powers that are devolved within systems to places, and I think it will be at the place level that we will see service integration. The evolution of place level forms of accountability is an important part of that, and again a reason why it is really important to allow these structures to evolve locally. I suspect that in some areas more power will be held at the system level and less at the place level. In other places, it will be the reverse, with most of the action taking place at place level. That reflects the nature of places, the legacy of those places and the relationships that have built up.
Matthew Taylor: My area of expertise before coming to the NHS Confederation was work and the future of work, on which I advised the Government, and one of the things I know from that work is how quickly the world of work is changing. It is impacted by a whole variety of things—not least, of course, substantial technological change. In a world where work is evolving very quickly and population needs are evolving, five years is simply far too long. If it were one year, we would be happy. We have fastened on to two years. That would be the minimum that we would want as a gap between assessments of workforce need.
It is also—to emphasise the point that I think you are making—important that this review gathers evidence from a whole variety of bodies, because an enormous amount of extremely good work is taking place around work. Predictions of workforce need are imprecise, so hearing from a variety of voices is important. This should be an independent process, in which independent expertise is brought to bear; there should be wide consultation with those who think about these issues; and a two-year plan would, I think, be an improvement on what is in the Bill.
Saffron Cordery: We also support this amendment and the work that has been done by the confederation and others on this. There is one other element that I would add to this that supports this perspective. It has been really hard, across NHS workforce planning, to light upon one version of the truth, in terms of workforce numbers. Anything that starts to move towards a collective perspective on workforce needs and workforce planning will be absolutely critical.
Getting an agreed perspective on how we create that figure will be fundamental. In my time working across the health service, there have been many different perspectives on workforce—on the gaps, the numbers who are in roles, and what those roles need to be. It is important to have lots of views, but I think this is also important. Although, as Matthew says, it is not a precise science, we need to light upon a version that is independently agreed, but that we all sign up to as the numbers we are working to.
The Bill falls apart because of the governance arrangements and the accountability, which does not follow the logic of place-based commissioning. My solution for the Government, should they wish to take it, is something around a good governance commission, based on the previous appointments commission-type process. It would bring in skilled people, with clear role descriptions, clear skills and a degree of independence. It would have the trust of local people, and would bring these very powerful chief executives together with local leaders to explain why, in Bristol, you cannot have ear wax removal, or why you are closing certain provision and opening it in Derbyshire or wherever. Have you had an opportunity to look at my proposal for a good governance commission and locally accountable chairs—perhaps elected, or appointed? What do you think of that as a solution that would bring power and accountability closer to local people?
Saffron Cordery: The issue of accountability is absolutely fundamental. One of the things we have not talked about much in this sitting, and which is not talked about that much, is the presence of two bodies in the system. We have the ICB, but also this partnership body that brings together a number of wider partners—particularly local government—with democratic accountability, which I think is really important.
I am wary of adding too much into the structures in the Bill. I understand your perspective on permissiveness, and we need to make sure that there are checks and balances across the whole system, but I would be wary of adding in another structure alongside everything we have. One of the features of this legislation, as I have said throughout the process—we have met the Department of Health and Social Care and talked to their Bill team, who have been very open and helpful—is that it does not really streamline in the way that it thinks it might. It adds to existing structures and processes, rather than starting from a clean sheet of paper and building something that might be deemed to be a good enough model; we will never get to the perfect model.
Right now, what we do not need is a root-and-branch dismantling of NHS structures and something wholly new put in their place, but I think there has been a missed opportunity to look at where we could streamline more. On that basis, I think it is important not to add more in, and it is fundamentally important that we look at the different roles and structures that already exist. From a trust provider perspective, working both at place and within provider collaboratives, and looking at the governance of unitary boards with non-executives and in some places also with governors and members, we see that there is that element of engagement with the community that you perhaps do not see in other places. I do not think it speaks entirely to your cartel point, but it is a step along the way that is well established and well used in many places.
This is a thorny and tricky issue. Using existing structures of accountability will be really important, as well as using the new ones, but I would not want to see anything new added in there.
Matthew Taylor: I largely agree with that, but another point is that if there is a broad policy thrust in this legislation, it is away from a medical model of health towards one that focuses more on social determinants. In the best partnerships—we talk often about West Yorkshire and Harrogate, for example—there is an incredibly strong relationship between health service leaders and local authority leaders. That will be a critical factor in the success of the system. When I look at the best practice emerging in the integrated care systems on issues such as prevention and population health, I see leaders starting to talk about issues such as housing, employment and public space, recognising their importance to health. In one way, that is a progressive move, and one that will probably lead to a louder voice for a variety of local interests, if we understand health much more in these socially determined terms, rather than simply through the medical model.
We had a big announcement today about social care reform, and there is a set of issues that are not in this Bill—issues around health and social care integration, how it will work and how accountability will work. It remains to be seen how the Government address that question.
Matthew Taylor: It is a challenge.
Matthew Taylor: Whenever Government are faced with issues of boundaries, there is no solution that will not upset a lot of people, and this of course has been a vexed issue. I go back to the need for local flexibility. I will not name particular systems, because I do not want to speak for them, but I am thinking of two systems. In one, there have been many years of integration and collaboration, and an enormous amount of collaborative work. There, boundaries are probably much less important than they were in the past. In the other, an ICS is being established that will oversee two places—a city and a county that do not have an enormous amount in common. There, the ICS will have to develop its own proposition about the value that it will add. It would be a mistake for that system to want to draw up an enormous amount of power from two places that are working pretty effectively and would not benefit a great deal from deep integration.
The pattern is different from place to place. That is why we need to allow things to evolve in the light of local circumstances. It is always difficult when boundaries are not coterminous or shift. All I can say is that health services are used to these kinds of challenges, and most who have reached the top have probably worked through at least one of these challenges in the past, and know how to go about it as best they can.
Matthew Taylor: That is a fascinating question. My view, which goes back many years, is that you need the right combination of strategy from the centre and identification of the right thing to do, where there is clearly one best thing to do, although Whitehall has a slight tendency to exaggerate the number of areas in which there is one best thing to do. Then you need peer-to-peer, or horizontal, learning. Providers and the confederation do a lot of work with our members to share best practice. A week will not pass without one of us publishing something around good practice, and bringing our members together to share that. This is another reason why it is important to have local difference. It is in a system of local difference that you will get more innovation. As long as you have innovation coming through, really strong organisations spreading good practice and a centre that focuses on where it can add value, you have the capacity for a self-improving system.
But how do you—
I am wondering if we should hear from our other witness.
I was going to ask Matthew all my questions, and then go to Saffron with them all.
Well, you only have about two minutes.
Matthew Taylor: By the way, I think it is important for us to learn from Scotland. We have been having a conversation in the confederation about the importance of recognising that we have different health systems now across the UK, and that there is an opportunity here for good learning.
Saffron Cordery: In the interests of time, I will say that I do not have a huge amount to add. Peer learning, peer challenge and peer support are absolutely critical. Variation, in its broadest sense, is important, and you can call that innovation or whatever you want. How you respond to local circumstances is critical. That is why cookie-cutter mode does not really work. Going back to your point on boundaries, they are, of course, a vexed issue. I know from my time in local government how vexed an issue it is there. Any kind of local government reorganisation can tie you up for years and years. It is worth remembering that boundaries were challenging at the start of this process. A number of STPs, which were the forerunners to ICSs, had boundaries imposed on them, rather than choosing those boundaries.
There have been a few policy developments that perhaps have not been as widely discussed as they might have been, including the fact that coterminosity with local government, although not necessarily the wrong step, was brought in relatively late in the day and did lead to some of the later boundary changes, as we have seen. I am not saying that that is wrong, but it demonstrates the need for wider discussion, consultation and engagement with the NHS and local government system as a whole before the decisions are made to help understand how best to do it. Sometimes just saying that it must happen and decreeing that is not the best way of making something a smooth operation that gets the best out of local systems. On occasions, there is something in the process of policy-making that could be looked at.
We had better move on.
Matthew Taylor: I defer to Saffron on that one.
Saffron Cordery: I think this is one of those elements that we have seen quite a lot of throughout the legislation in terms of where is the recourse—that is not the right word, but I cannot think of another one right now—if things go wrong. Collaboration by its very nature is a positive process where willing parties come together to reach agreement. Everyone’s hope and aspiration is that that is how ICSs will work overall, and that is how the ICB and ICP will work together. It is not currently clear how there will be recourse to arbitration or dispute resolution, if you like, in the process of this legislation. We have seen an optimistic approach to how this legislation has been brought together—rightly in some senses—and of course we do not want a situation where we are anticipating that the evolution of a new way of working will not be functional. At the same time, the role of legislation is to anticipate what can go wrong, as well as to support what needs to be done. It is not yet clear how some of this will shake out in terms of where ICBs and ICPs need to turn to should there be challenges, issues and disagreements. We have to remember that those bodies, once they have their independent chairs and accountable officers and chief executives, sit within the NHS system, so they sit within the regional NHS England system and within the overall NHS system. Routes will be pursued, but at the moment it is not clear to me how disputes, for want of a better word, will be resolved.
Matthew Taylor: The only thing I would want to add is that during covid, we have understood the scale of health inequalities. The evidence has been that those inequalities are growing. That has demonstrated that we need a conversation between the health service in relation to how it deals with the demand that is presented to it and the wider question about how we address population health. In some cases, that might mean that you have some creative tension between those two levels. As Saffron said, it will come down to the quality of relationships, and if those relationships break down, I am sure that the centre will need to intervene to address that because the system cannot work if it breaks down. But the fact that those two bodies might have a slightly different emphasis and focus is probably a good thing because this debate about how we best use our health resources to address population health and health inequalities is an important debate for us to be having nationally and locally. Let us face it, we have not got this right up till now.
Matthew Taylor: Yes, unfortunately that is our understanding, and we think that it would be a retrograde step. It is not a power that I would want if I were a Secretary of State and I wanted to focus on strategic policy questions. I would not have advised the Secretary of State to want those powers.
Our view would be that we should remove the extension of the Secretary of State’s power entirely, but, failing that, we should put some guard rails on in relation to hearing the views of local health overview and scrutiny committees, getting local clinical advice on what is best and having a public interest test that should be passed. If those guard rails were in place, we could cope with this.
What we do not want is a chilling effect on the capacity of local leaders to make the decisions that they need to make to use their resources effectively. The third element of the triple mandate is the effective use of resources, and that involves making decisions at a whole variety of levels around how you configure services. If you feel you are going to go through that process and potentially engage local populations in difficult conversations, and then at the end of the day a local MP, for whatever reason, is going to kibosh that by appealing to the Secretary of State, why would you embark on the process in the first place? That is why, while we are very supportive of the Bill, as you have heard from both Saffron and me, we do think that the powers of reconfiguration are the Achilles heel. I appeal to you to recognise that that is unnecessary and goes against the spirit of the Bill.
Saffron Cordery: I wholeheartedly support what Matthew says, and it speaks to a point I made earlier about adding to existing structures in a way that really is not necessary. I notice that you have representatives from the Local Government Association as witnesses later on. I am pretty sure that they will have some strong views about what these measures do for the powers of local health overview and scrutiny committees, because they already have the power to refer to the Secretary of State should they need that to happen. The powers that are currently in place are a really effective way of doing it. People getting something past a local health overview and scrutiny committee is a really important hurdle for any service change. It is already well respected, well used and very effective. This is one of those elements that at best is redundant and at worst is going to create a lot of work and a lot of unnecessary tension and friction where we already have challenge.
Saffron Cordery: As we see a change in the system, obviously the nature of how we have procured services in the past does have to change. It is obviously a complex area, but one of the things that we really need to look at is the effectiveness of the current contracting regime, which for certain parts of the provider sector in particular is incredibly burdensome. If you sit in a mental health or a community trust, you are subject to a whole host of retendering, which can have a potentially far-reaching impact on your trust’s sustainability or the future operation of key services. For many bits of the system, that will be very important.
The procurement regime is fundamental. It underpins how this will operate. We need to make sure that the elements of fairness are upheld and that it does not disproportionately put a burden on any one part of the system in particular.
Matthew Taylor: I agree with that. It is important to remember that one of the goals of the Bill is to reduce the weight of bureaucracy in the system. If we can reduce the weight of bureaucracy as it applies to procurement, that is only a good thing.
Matthew Taylor: Of course, one of the most challenging questions in all parts of central Government is to get that balance right. The one point that I want to make is about the nature of system leadership. If you lead an organisation—I lead an organisation—the parameters of what you do are reasonably well defined and you lead that organisation as best you can, and you can be regulated as an organisation in relation to its objectives. The thing about system leadership is that it involves developing a concrete and specific account of how you want to add value in a particular local circumstance—how is it that, working as a system, you will make a difference?
By looking towards population health and engaging local people, that proposition will vary from place to place. It is important that, when we look at how systems work, we allow them to develop a value proposition that is specific to their local circumstances and their local needs. That is why, for example, we would be very resistant to any kind of Ofsted inspection regime for systems, because systems are not the same as hospitals or as schools; they are very different and their aspirations will be very different.
When you look at the Bill, the reality of central-local relations is that rules are set out in legislation, but then there is the custom and practice of how Departments and other bodies actually work. Sadly and inevitably, the drift of custom and practice tends to be towards centralisation. That is why it is important to avoid things in the Bill that create an opening—this is why we can have our concerns about reconfiguration—which can get ever wider and thus undermine the key principles that lie at the heart of the Bill. So we are happy with the intentions of the Bill, but we are worried that there are certain elements of it and certain elements that might be involved in the operationalising of it that could undermine its intentions.
Thank you. Saffron?
Saffron Cordery: I go back to a point that I made earlier in this session, which is that this balance between permissiveness and prescriptiveness is critical. The August 2019 agreement, when all the stakeholders came together to look at how we might legislate for an integrated care system that got that balance right, I think is there. You have to remember that what sits around a set of proposals will have a massive impact on it, so the Secretary of State’s powers as we have seen them, and the operating environment overall, will have an impact on how these proposals will be implemented, and how effectively they will be implemented.
We cannot forget covid in this. We cannot forget the extreme financial pressures that we are seeing. We cannot forget demand. We cannot forget an incredibly tired workforce. That is not going to change any time soon; that is going to be for the next few years, so we are implementing something against that backdrop. But if we go back to the slightly lighter touch of the August 2019 proposals, we will probably get to a place that would hit the spot, as it were. I reiterate that we support collaboration in systems and the direction of travel.
Given the time, we will leave it there. I thank our witnesses, Saffron Cordery and Matthew Taylor.
Examination of Witnesses
Ian Trenholm and Keith Conradi gave evidence.
We will now hear from Ian Trenholm, the chief executive of the Care Quality Commission, and Keith Conradi, the chief investigator at the Healthcare Safety Investigation Branch, both of whom are appearing in person. We have until 4 o’clock for this session. May I ask you both to introduce yourselves for the record?
Ian Trenholm: Good afternoon. My name is Ian Trenholm and I am the chief executive of the Care Quality Commission.
Keith Conradi: I am Keith Conradi, the chief investigator for the Healthcare Safety Investigation Branch.
Ian Trenholm: The Bill will add value to patients in a number of different ways. There are four areas that we have particular interest in. The first is around the work we expect the Government to ask us to do on oversight of the individual ICSs. Building on the comments that have just been made, our contributing to the assurance around ICSs will be an important part of how we can add value. We will do that by drawing to the attention of local communities both the good work that is going on in a particular place, and areas where there are some challenges. We will also be able to look across the country, demonstrate where things are going well and help with improvement, as we do with the regulation of individual providers.
The Bill also contains a provision for us to provide assurance regarding the way local authorities discharge their Care Act 2014 duties. Again, that gives local people the certainty that local authorities are discharging their responsibilities. If you bring those two things together and connect local authority duties around the Care Act and social care with what is going on in healthcare, you get a whole-system view, and we are able to give an independent overview of that, which we report to Parliament and the public.
There is also a provision in the Bill relating to food standards in hospital. It is well known that people’s recovery is aided by good-quality hydration and nutrition that is appropriate for the social and cultural needs of that particular place. As part of our work, we will be asked to look at that.
Finally, building on the comments Mr Madden made a couple of witnesses ago, the miscellaneous provisions within the Bill on data sharing and the requirement to co-operate are also powerful and enable us to do our job as an intelligence-driven regulator. From the point of view of reducing bureaucracy, they mean that we collect data once and then we can share it among the many partners involved in regulating different parts of the health and care system. Those are four particular points where I think the public would see value in the work we do.
Keith Conradi: From our perspective at the Healthcare Safety Investigation Branch, we welcome the introduction of this part of the legislation. We have been working in shadow form for the past five years, without any real powers, and the things we have missed there are likely to be introduced in the Bill, such as power of entry, so that we can access people quickly in an investigation. Any investigator will tell you that the quality of the investigation evidence, particularly interviews, degrades quickly over time, so the ability to go in quickly is hugely important. Also, not being able to access data that we know people hold has been quite frustrating in our current guise. We have sometimes had to wait for months and months for data in order to be able to complete an investigation.
The other thing that we are particularly keen on is being able to properly protect information that people give us in a protected environment, so that we can ask them to be as candid as possible with their experiences. We want to be able to protect that information from being released more publicly.
Can I ask just one more question, Chair?
I am not being flooded with a whole array of hands, so why not? On you go. I will come to you in a second, Edward.
Ian Trenholm: We will be inspecting against the hospital food standards—is that what you mean? We are not going to be setting individual nutritional standards; we will be inspecting against the NHS’s food standards. We are going to deliberately make sure that our work does not overlap with organisations such as the Food Standards Agency, for example. To be very specific about it, we are not going to be inspecting vending machines or taste-testing food in canteens. What we are going to be doing is looking at the hydration and nutrition strategies that, say, a board in a hospital has set for its particular area. As we go around the hospital, we will be looking at whether that strategy is being enacted for the cultural and social needs, in particular, of the people in that hospital. Does that answer the question?
Yes. Well, it was more from a medical point of view than from a vending machine point of view. That is absolutely helpful. Thank you.
Do you have anything to add to that, Mr Conradi?
Keith Conradi: I think that is outside the HSIB’s experience.
Keith Conradi: Having come from the air accident investigation branch as my background, the whole idea of these investigations is that we do not apportion any blame or liability, and that we are really looking at why an event took place when somebody came into work planning to do a good job, and what the circumstances around the environment were that allowed a tragedy to occur. We use a lot of investigation science methodology to ask those why questions, really looking at systems-type thinking, so we do not mention anybody’s names in the reports. We do not, at the moment, mention where the actual occurrence took place, because in our view that is almost irrelevant. It is the system that we are trying to change, and the safety recommendations that we make are, by and large, to the national bodies—often the regulators—because we think they are best placed to make the changes that we think are necessary.
Do you want to add anything to that, Mr Trenholm?
Ian Trenholm: No, thank you.
Could I also ask about the regulatory role? With regard to whistleblowers who raise these issues—we are talking about safety and the best interests of patients here—will this enhance the powers and abilities that you have, or is more needed still.
Keith Conradi: One of the clauses actually will require people to speak to us, so there is a compulsion on people to provide evidence. In a way, that might help some people who are undecided about what they should be doing. But to balance that, it is very important to be able to protect the evidence that is given, and there are protections within the clauses. I think they could be improved. But the whole idea is that we create this space, where really the only safety valve is the High Court, and I believe that is appropriate as the only place where that information can actually be released.
I think it is worth saying, however, that when people talk to us and use this sort of safe space, the whole idea is that it is not a place where they are going to unload stuff that will never see the light of day again; we use that information, either in our final reports or to help us further the investigation. It is just that it is non-attributable, so we do not mention people’s names. The idea is that we use it to further patient safety.
My concern about the way the Bill is currently written is that there is a provision for coroners—some coroners—to be able to see this information. I think that will inhibit some people from speaking to us—and the whole point is that people are uninhibited from doing so. Having that potential release of information into that sphere will, I think, degrade the ability of the investigation to do its job.
Ian Trenholm: Building on what Keith has just said, I think we would see the Bill as giving an opportunity to create a safe space. It creates an opportunity for people to talk about things that they may not otherwise have wished to talk about. What Keith’s team can then do is look at that information. We need to make sure that we have the right data-sharing protocols in place. Keith’s team can then talk to my team about what is happening on the ground. They can do whatever anonymisation is necessary. So we might get to hear about things that we perhaps would not otherwise get to hear about.
That is a real positive at provider level, but if you click up a level, you quite often find that, from a safety and quality point of view, people’s poor experiences are driven as much by their experience of it as a system and the way they transit between different providers as it is about the experience in an individual provider. So if you have a person who perhaps is working between providers or in some kind of community provision, they will see multiple providers and they will become, if you like, better whistleblowers. Our work on systems and our assurance on systems will help as well, I think. Of course, Keith’s team make recommendations to us as a regulator, in the way they do to other people. So I think this is generally a move in the right direction.
Keith Conradi: We currently have a maternity programme that investigates about 1,000 cases a year, based on quite specific criteria. At the moment, the Department is deciding what it wants to do with that programme—where its future lies. As far as we know, it will stay with us, certainly until the HSSIB—the health service safety investigations body—starts, but I think a decision has yet to be made on whether it will actually just fall into the work that the HSSIB does, or whether it will do something separately with it, so I am not aware of that at the moment.
On the second point, I am aware that the ombudsman would like the same power to access the statements that we take under safe space. I think that is a major concern. Over the last five years, the ombudsman has been able to investigate any complaint brought against us in our current guise. It has not seen fit to do so, so I would suggest that on the rare occasion that might be necessary, the provision for the High Court to carry out the balancing test and decide whether to disclose information or not is the appropriate way ahead.
Ian Trenholm: Can we not call it a CQC-style rating? There are two separate things. The Bill currently contains an explicit provision about providing assurance on how a local authority is discharging its responsibilities in relation to the Care Act. That is important because the way in which care is commissioned is as important for outcomes as the way in which it is delivered. That is one part and that is a discrete piece of work. There is a broader piece of work that we are expecting Government to ask us to bring forward on assurance on ICSs. It will look at the ICS partnership board, how that works, the ICS strategy and so forth. They are two complementary pieces of work, but they are separate, as you describe.
Keith Conradi: I totally agree with you. I think it will have a major impact on people’s wish to speak to us. It is not just me that thinks that; the medical unions have said that their members are concerned. The whole idea is that you want people to talk about, as you say, the “soft” things. They tend to be things like the culture of an organisation and the pressures that are brought upon them to do various pieces of work. In the past that has been a bit of an Achilles heel in terms of safety in the NHS. People have often been blamed for these things. They have been disciplined for speaking out—we talked about whistleblowers earlier.
Anything that we can do to bring that information up to an investigation body, which is not about blame and liability, is going to help patient safety in the long run. They will find their way into our final reports—that is the whole idea of getting this information. We want to encourage that as much as possible. I do not think this helps. I think a previous Joint Committee looked at a similar piece of legislation, and that came to exactly the same conclusion. As you say, what is the problem with other bodies such as coroners conducting their own interviews to get the same piece of information or any information they require?
Keith Conradi: Yes. In a way, the powers are so sweeping that they go well beyond what we think we would need, and well beyond what is used in other sectors—the transport sectors. We know that parallel investigations will take place into many of the things that we look at, and that is fine. The problem is that if we have these sweeping powers, which pretty much say that anything we touch or come across we then have to protect, and that we can then unwind and release some of them with a fairly bureaucratic process, that will be difficult in terms of transparency and our ability to share the information with others who have a legitimate need. The key things that we absolutely want to protect are statements given to us by witnesses and any draft notes, opinions and reports that we generate from doing the investigation. It is the final report that is our piece of work that we want to produce at the end of the day, and that is it.
Thank you. In the interests of time, I am happy with that.
Ian Trenholm: If I could make just one point, I think you are absolutely right: the broader responsibilities of an individual provider, particularly around such things as duty of candour, would still stand. Therefore, at an institutional level, people will still need to do the things that they always needed to do, but there is a very specific set of circumstances that Keith was describing where safe space may apply.
Ian Trenholm: I do not think that there is at an individual provider level. What you have just described is our normal registration regulation process at an individual provider level. As we start to look across individual places and ICSs, we might be able to talk to individual partnership boards about people who are operating locally, but I do not think the Bill explicitly gives us more powers to look at individual providers in any more detail than we already would as part of our normal registration process.
Ian Trenholm: Not yet. Obviously, as the Bill goes through Parliament the breadth and size of what we will be asked to do will become clear. We are talking to a range of different stakeholders at the moment. The NHS Confederation and NHS Providers are on our list, as are the Local Government Association, the Association of Directors of Adult Social Services and, of course, various representative groups that represent people who use services, so we are having those conversations now around what they would expect from good-quality assurance at a system level—but no, we have not really got to the point of assessing this in any detail.
Keith Conradi: We see ourselves as very much an independent and impartial investigation body that can sit outside the system and look into it. We would not want to have any barriers really on where we might look to see where patient safety could be improved. As I mentioned earlier, we tend not to dwell on the incident at the trust level, but try to work our way up through the system. Ultimately, we end up making recommendations to the Department of Health and Social Care, and in the future I would like to ensure that we have that complete freedom to be able to make recommendations wherever we think that they most fit. That independence of the system is crucial for the success and the credibility of the organisation.
Keith Conradi: At the moment, they are monitored fairly informally. There is a part of NHSEI—a patient safety team—that looks at whether the actions that were promised in the response to the safety recommendation have actually been carried out. We believe that that might sit more appropriately with this body in the future—NHSEI receive a rather large number of our safety recommendations, so I do not know whether they are the right body to monitor the actions that are taking place, whereas I think that could sit with us. It is important that that is just monitoring the actions, not judging the outcome, and I think that there needs to be a separate, probably pan-regulation-type body that looks at whether the outcome at the end of the day mitigated the patient safety risk that we first went out to investigate.
Keith Conradi: Informally, we have a good working relationship, so we are interested. We get the response to the safety recommendation and we internally look at that and consider whether we are happy with it. If we are not, we would send out letters to say that we would like further information. We want to put this on a more formal footing to see that in the future.
Do have anything further you want to add? No. Minister.
You will have heard in the evidence just before, Mr Trenholm, the comments by Matthew Taylor about the difference between assessing a system versus a provision. How do you see how the CQC would square that circle, because he highlighted the very different approaches and his reservations about some of that? How do you see that issue being resolved, or what would you like to see in that space?
Ian Trenholm: If I compare one large hospital with another large hospital as a comparison in terms of what we do now, one would argue that they are quite different enterprises, differently run and serving different communities. There are some common themes, but equally there are some differences. We built a methodology that was able to be applied to both of those very separate entities and to provide a common rating at the end of it.
I would see a version of that at a system level: there would be things that we would want to see that would be common and necessary— decent quality governance, for example—as well as a lot of things that many of you were raising as questions and concerns. But equally we want to see some evidence that the partnership board was cognisant of its local community and it was genuinely delivering a suite of services that its local community genuinely wanted and that was consistent with the needs of that community.
Over the next 18 months or so, we will be building our methodology in collaboration with the people who are also building the ICS boards and frameworks. I am hopeful that we can get to a point where we have a methodology that gives you, as parliamentarians, and local people the assurance that things are working well locally. However, it is not just about what is not working, but about looking for really good practice and looking to accelerate that. Previous people have made the point that doing things differently often leads to good practice and innovation, so how can we help accelerate that innovation through the work that we do. That is broadly how I see it working.
Keith Conradi: Absolutely.
Keith Conradi: I certainly think so. My previous experience in aviation is that we had a similar space, and only the High Court could overturn or order disclosure. It was used on a handful of occasions, and it produced very interesting debate. The balancing test—testing whether the benefits of the disclosure outweighed the adverse reaction that there might be to future investigations—was well argued in each of the cases. I think that is the appropriate place to do it.
Ian Trenholm: We do work at the moment in terms of registering and regulating individual providers, and we do that right across the country, so we have a picture of health and social care right across England. Part of the Bill will give us enhanced powers looking at the way in which individual systems and individual ICSs work. Our view is, if you like, a broad and moderately shallow view, whereas I think Keith’s team do more in the way of specific investigations. I am sure Keith can talk to that.
Keith Conradi: I would characterise the relationship as a healthy tension. We make very few recommendations to the CQC, but the vast majority of recommendations we make will, we hope, have an impact on the work that is going on across the system. The ideal people to have a look and see whether that is having an effect will be the CQC, from time to time, as it comes across things that have changed as a result of what we have done. I think the relationship works very well, in that respect.
Thank you very much.
Mary, did I see you trying to come in with another point?
Keith Conradi: I would probably need a lawyer to give you the proper answer, but I do not think any of this would trump anything else. We would still need to acquiesce and accept those disclosures as they happened, so I do not think that would be an issue for us.
Anyone else? It does not look like it. I thank both our witnesses for their evidence.
Examination of Witnesses
Councillor James Jamieson and Professor Maggie Rae gave evidence.
We now move on to our sixth panel of witnesses. We will hear from Councillor James Jamieson, chair of the Local Government Association and Professor Maggie Rae, president of the Faculty of Public Health, both of whom are joining us remotely. Could both witnesses introduce themselves for the record, please?
Professor Maggie Rae: Good afternoon. It is a great pleasure to be able to join you today. My name is Maggie Rae and I am currently president of the Faculty of Public Health.
Cllr James Jamieson: It is a great pleasure to be with you today. Thank you very much for inviting me. I am James Jamieson and I am chairman of the Local Government Association. Until January, I was leader of Central Bedfordshire for nearly 10 years.
Cllr James Jamieson: Certainly, we are very pleased that we have repealed some of the legislation, which basically made people focus on targets rather than what is best for the patient. Focusing on discharge to assess at hospital led to some at times frankly perverse incentives just to get people out, often into care homes, when the right solution was to assess after they had left hospital, in their normal setting, not in the setting where they were in maximum need. That change has given much better solutions and outcomes for our residents, which is what we want.
Professor Maggie Rae: Obviously, from my position as president of faculty, I want more emphasis on prevention, so I am very pleased to see that focus on it, but I do not think it is quite enough yet. I think we would all recognise that part of the reason why we seemed to take the biggest hit on covid in terms of deaths and the effects of the virus was the ill health of our population. We are recognised as having one of the most unhealthy populations in Europe now, and that was not always the case. Yes, it is very pleasing to see the measures on obesity, but we need to recognise that most of the influence could come from the very local level.
I am sorry to say to colleagues and this eminent Committee that we could probably spend the whole meeting talking about fluoridation. I recognise the attempt to tackle the problems of oral health. Children’s teeth being extracted under general anaesthetic is a national disgrace; that money is so wasted in the NHS when we desperately need it to be spent on other health matters, and the time it takes for that operation is so dangerous for children. It is good to have this recognised, but I think it will be quite a slow burn, even with the legislation.
Some areas have tried to implement fluoridation. It has taken them years and they still have not succeeded. Could we perhaps persuade people? As well as focusing on fluoridation, could we have just a small investment in other methods to tackle oral health? One that is really effective, which I used myself as DPH, is simple toothbrushes and toothpaste. Sometimes we think public health measures take a long time, but I can guarantee that if that measure were implemented effectively you could see the changes within 12 months and would also end up saving the NHS a lot of money. I work closely with Councillor Jamieson in his role at the LGA and I hope that he would agree with me.
Cllr James Jamieson: I am going to agree with Maggie. I think that that is a general point we would make. Better healthcare does not start in a hospital; it starts in the community and it starts before you are born. It is about prevention, early intervention, public health, good food and all those things. We welcome measures to support that.
On the point about obesity, I would particularly say that although, yes, it is nice to be able to produce advertising, there is so much more we would like to do. This is not necessarily within the scope of the Bill, so I am not suggesting that, but, for instance, in licensing legislation, being able to take account of public health, which at the moment is specifically excluded, as well as being able to do so in planning legislation as regards where fast food places are and so forth, would be immensely helpful. This is a start; it is a small but positive step.
Even more remarkable as regards reducing health inequalities is the absence of any detail, duty or provision to tackle alcohol harm and tobacco control, which of course are the greatest factor in determining a person’s life expectancy—and further down the line they have the greatest impact on local authorities’ social care bills. Do you think they should be included in more detail in the Bill, with a duty to reduce health inequalities rather than just having “regard” to reducing them?
Cllr James Jamieson: I think we need to be cognisant of the fact that this is a Bill providing a framework. I completely agree with the comments made about health inequalities, good housing, green space and all those things—absolutely. I am a full advocate of the idea that health is three quarters determined by somebody’s environment and choices, and probably only a quarter by what the NHS does. That is really important. My slight concern is that if we get very prescriptive in legislation, it limits the ability to do the right thing.
The really important thing about this legislation is all the guidance and so forth that will come out of it, and where the funding goes. Our preference is to say, “Try not be too prescriptive in the legislation, but really engage with local government and public health on the guidance that comes out of this legislation.” A real priority has to be better places, better communities, better jobs, less pollution and all those things, but I do not think that that is something for legislation; I think it is very much about getting the guidelines right, and they will be different in different parts of the country. The issues that might be faced in a rural area are very different from those faced in an urban area. I do worry that if legislation is too prescriptive, it hampers rather than helps.
Professor Maggie Rae: Would you mind if I added some comments please, Chair?
Professor Maggie Rae: Just building on those comments from Councillor Jamieson on what I think is a very important question, there is a line in the Bill saying that the ICSs have to take note of advice from directors of public health. If we want ICSs to be population health organisations, we have to make sure that the legislation is strong enough to ensure that the advice is acted on. Our directors of public health have been highly trained and are able professionally to identify the needs of the population, identify where the health inequalities are and make sure that they can provide the ICSs, in terms of both the NHS-side board and the partnership board, with all the evidence they need about what will make a difference. It is the action that will make a difference and improve those outcomes that we all want. It would be very helpful to ensure that the Bill, if possible, is more explicit about that advice and which source it is coming from. We have worked very closely with the legislative team and the Bill team. I do not think anyone could fault the amount of hours they have spent discussing with stakeholders the details of the Bill, and Councillor Jamieson is also right that we cannot have everything in the Bill, but we want a true population-focused organisation.
That has to be the change that this legislation brings; it has to be an enabling legislative framework. We then need to ensure that the guidance, and, most importantly, the assurance process, allow some of the public health expertise to determine whether it is fit for purpose. It is possible that these organisations, and the excitement of the changes, could result in our having a more place-based population focus, but that will only be the case if we get it right and take account of those wider determinants such as education and housing—all the things that contribute to good health.
Cllr James Jamieson: Looking at the current situation with health and wellbeing boards and so forth, that has worked well in some places and not so well in others. That is largely down to local factors, relationships and the willingness of the NHS to participate in a place-based approach. Our hope and expectation is that this formalises it, not in absolute terms, but in emphasising the role of local government and other partners that the NHS has to take account of. In essence, it is strengthening our ability to influence the NHS.
Why is that so important? I come back to the comment that I made earlier about how much health outcomes for an individual are based on non-NHS factors. I have forgotten who raised the question of health inequalities, environment and so forth, but those are all place-based factors. Getting more investment in public health, less pollution, better community health care, a better GP service and better occupational therapists will make huge differences to people.
At the end of the day, nobody wants to go to a hospital; they would far rather be healthy and not need to. Therefore, empowering local councils and partners to have a greater say in how we improve the health outcomes of our whole population has to be a good thing.
Professor Maggie Rae: To add to what Councillor Jamieson has said—he is making some excellent points on that agenda—it is important to get the balance right. In England, we had the legislation on health and wellbeing boards. One of the principles should be not to ride roughshod over legislation we already have just because we like the new bright and shiny legislation. On the commitment to stakeholder engagement, we managed to get the Bill team to understand that we have legislation already.
Some of that legislation is still there—we still have directors of public health and the powers in local government—and those things are important, but we also know that if we do not get this legislation right, we will not be able to get right the ambitions on health inequalities and on improving health either. The detail of this is really important. As I think was indicated in what Councillor Jamieson was saying, we know that legislation alone does not always fix problems. I do not know how we can get good relationships just through legislation. We can enable things to happen, but we need to ensure that the legislation is enabling and that there is some holding to account for the standards that the legislation is trying to set.
We cannot afford for the health of our populations to be affected by unhelpful variations. I am very supportive of place-based—action happens at the local level and it can be effective at the local level. We need good national legislation, but if we want to do justice to the population in this country, we cannot have unhelpful variation, because that is what will undermine this legislation. We have to make sure that everyone is working for the same aims and that at the heart of everything is the commitment to reducing health inequalities and improving health outcomes, regardless of where you are. Whatever your own organisation, whether a hospital, a local authority or a mental health trust, we have to have something that overrides loyalty to the organisation—to put the population first.
My point to Councillor Jamieson, which I made to earlier witnesses, is about the integrated care boards, which are the decision-making and accountability bodies locally—the ICPs are essentially a committee of these boards. The accountability, responsibility and decision making lie very clearly with the integrated care boards, which are essentially, as I have called them, a cartel of local healthcare providers—largely the acute sector trusts, which are responsible for vast sums of money. Councillor Jamieson, you have gone to the effort of putting your name on a ballot paper and persuading local people to put their cross by your name. Should you fall foul of them, or make decisions that they do not agree with, you will soon no longer be Councillor Jamieson. That is very clear accountability. With that hat on, can you talk us through your understanding of the role of local government status wise—beyond “Let’s all work together in partnership”—when we reach that real decision-making, push-comes-to-shove crunch about where accountability to local people could lie for decisions if we improve this Bill?
Cllr James Jamieson: In the ideal world, one would probably like one board. However, that would mean that all members of that board had equal status and so forth. Obviously, the NHS partnership would have budgetary responsibility for hospitals, and there is a technical issue with, “Can you have a bunch of non-NHS people having budgetary responsibilities for the NHS?” We understood the difficulty, and that is why there is the need for two boards. The clear point here is that this legislation provides us with a framework that enables that to have real traction.
But I come back to my earlier point, which is that this is a framework; this is not a solution in itself. Legislation does not solve all the problems. This is about how budgets are managed; it is about all the guidelines and regulations that come out. One of the big requests that we have as local government—I am sure Maggie will have it as well—is that we are deeply involved in those guidelines to make sure that they work. I have to say that, so far, we have been, but many more bits of guidelines will come out. That is the crucial bit.
There are some changes we would like to the legislation, but they are not that great—I will come to them later, because they do not refer to this point. We want statutory and non-statutory guidance around things such as the implementation of the Bill, a comprehensive list of guidance that will be issued and clarity about the flexibility. We want some statutory guidance on health and wellbeing boards to ensure that they are at the heart of this. So there is a lot going on, and I am pleased to say that we have been involved in some of the guidance that has already been issued, such as “Thriving places”. As Professor Rae said earlier, engagement has been very good so far, and we would like that to continue, because this is our chance to get this right. We will do that through getting the statutory and non-statutory guidance correct and making some changes, no doubt, to the Bill. But I do not think that this Bill can accomplish everything, so the LGA would certainly not be in favour of significant change to the Bill.
Can I just clarify—
Actually, in view of the time, I am going to ask you not to, Karin. I am sorry, but if we are going to hear from Professor Rae and give Chris Skidmore a chance, we had better just move on.
Professor Maggie Rae: Again, it is good that you have asked for some specifics and related this to governance, because it is very important that we understand how the legislation will be implemented and that the governance is right.
The concerns that members of the faculty would have are quite broad based. While people might be genuinely pleased that we are moving away from a market economy on health, some are very concerned about opening the door to further privatisation. I want to give you some detail on specific public issues on which you said you would like more information. The legislation includes some public health hooks that will make it easier for us to ensure that we have good public health, but I question whether they are explicit enough.
The issue of taking advice on the needs of your population is a fundamental skill of public health. Whether nationally, regionally or locally, the professional job of directors of public health is to assess the needs of the population and provide organisations with the evidence about what will make the biggest difference—cost-effectively, of course. The idea of “taking advice” is a little vague, but strengthening the need for that advice to come from the statutorily appointed directors of public health—the regional directors of public health have been trained to do that and put the needs of population first—might give some strength to the Bill.
In my day job I do a lot of ICS development for the organisation I work for so I have experience of working with ICSs, and many current ICS leaders—I know there has to be an appointment process—are passionate about health inequalities and public health. We have to make sure, as we said earlier, that we have something substantive that guarantees that public health is not down to individuals and personalities, and that we have a framework. We cannot expect Cornwall to be the same as Newcastle, but we cannot have the population suffering from unwarranted variation. If I had a bit more confidence that the role of directors of public health—and the regional directors of public health—would be instrumental in the legislation, the guidance and the assurance process, I would be able to give you more guarantees that things will be better in the future. At the moment, it is a little vague.
Professor Maggie Rae: Again, that is an excellent question. I strive for excellence in our country in relation to all matters covered by the Bill. It is with great sadness that I see that health outcomes have plummeted since the start of my career. Early in my career we had the best health outcomes for cancer in the whole of Europe. I am sorry to say that that is not the case now, and ensuring that the scientific underpinning of this is seen as essential will make us more leading edge.
There are many examples in the covid pandemic in which we have been leading the world, and that is certainly true of the vaccination programme. I heard in a meeting this morning about some amazing research that is just about to start.
There are lots of areas of cancer where we have not progressed in the last five years. I could name the different cancers; we do not have time to go into them. If this research was going to test people’s blood early to get earlier diagnosis, as Councillor Jamieson said, it does not all have to be high-tech, high-cost NHS services. Lots of interventions are low cost. You will not find anything more cost-effective than getting people to give up smoking. That is a classic low-cost intervention. We want our country to be leading, and we want to put everything behind these new organisations and ensure that there is that scientific underpinning and that we do not fall behind other countries. I tend to side with your view that we may need to strengthen that.
The problem with this sort of legislation is that you want to be very enabling, but then you are very dependent on what the biggest problem is in the NHS today. Many of these organisations are trying to balance the books. We have tried to say that it is not all about targets. We can hit the targets and miss the point. The thing is, we are not hitting the targets at the moment either. Thank you for speaking up about the scientific underpinning. I would like us to remain where we are, and do better on science.
Professor Maggie Rae: That is right at the heart of health inequalities. If we did not know that before covid, we certainly know it now. An area where we could strengthen the legislation is in having that responsibility for all the people in your population. I led on health inequalities in the only time we have narrowed the gap, so health inequalities are not something that are just there and that we cannot do anything about except talk and say how sympathetic we are to them. We can deliver these changes. If we get the legislation and the organisational functionality, we will not change this unless we engage with communities. That is absolutely right, and we must engage with the local authorities.
Unless we target every intervention that we apply to the most disadvantaged and ensure that they have a good opportunity for uptake, we are widening health inequalities. I could take you to any health intervention, whether it is the covid vaccine, the flu vaccine, any uptake on health programmes or cancer screenings. They are all skewed to the most affluent population. In our country we want general population services, because we need everyone to be healthier, but we have to try to ensure that these organisations understand population need and know where the deprived populations are.
I have never met an MP or councillor who did not know where their deprived populations were, so we need those organisations to know that, but just knowing it is not enough. You have to then see the pattern of services and service delivery change to give a better chance to the people who need to take up these services. We have all understood that it is not that those people are hard to reach; it is just that we do not run the services to suit them and get a better uptake. I would like to see us concentrate on that. We probably cannot mention every single intervention, but for me it would not be enough to concentrate on obesity and fluoridation and think that the job is done on health. We have higher drug deaths than the rest of Europe—Scotland, as you know, is probably one of the worst in the world, if not the worst—and alcohol and all the other issues there, but I believe we can make a difference, and it will not take us 25 years if we focus on the right things, having the right interventions and making them readily available for people, and have a nice balance with what the NHS can do.
The NHS is the greatest service in the world and it can really help with health inequalities, but it cannot do it all. I am not an either/or person; we need the wider determinants and everything we can do that is place based through the local authorities, but we need the NHS to do that too.
Cllr James Jamieson: This is where the legislation is helpful, because it is enabling. The more we can move away from the NHS pound, the local government pound, the health pound or the DEFRA pound, and towards, “This is the pound for Newcastle or Cornwall; how can we achieve the best outcome for it?”, the better. I know that is difficult and, as you say, things such as housing, getting someone into a job or promoting active travel can make a massive difference to people’s health. They can make big differences, and having that forum and the opportunity to have those discussions is very helpful. A forum where we can start moving from investment in, as you rightly say, curing someone to preventing them from getting ill or, as Maggie said earlier, getting early cancer diagnoses is critical.
This Bill does provide a framework, but the important stuff will be the statutory and non-statutory guidelines and where the money is spent. That is very important, and we hope to see more spending on preventing and less on fixing a problem that need not happen.
You mentioned there—
I am really sorry, but we had better move on to Alex Norris.
“appointed by NHS England, with the approval of the Secretary of State”.
Under paragraph 5, only NHS England can remove a chair if they are unpopular and not doing the job, and there is nothing that you can write into your local decision making to get around that. Are you comfortable with not having any say over your chair when they are appointed or whether they carry on in the job?
Cllr James Jamieson: Clearly, there are two chairs in this scenario, and one of them, as you say, is NHS appointed in effect and the other one could be anybody—it could be a councillor, a local government representative, or a local director of public health. There is a role. I think this is a difficult area, but that is the reality, because ultimately that chairman will be the person who is financially responsible for the NHS trusts in his or her area. I have some sympathy with it; if I could find a better solution, I would seek to find one.
Professor Maggie Rae: I am still a fan of the fact that you need public health and local government. I started my career there and moved to the NHS; I moved back to local government; and now I am moving back to the NHS. What we need is flexibility, so professional groups can work there. I would highly recommend all my public health colleagues and public health registrars to get experience nationally, regionally and locally. That makes you a much better, capable public health practitioner. However, you cannot deny that you can do the same for half the money.
I know that when the announcement was made about public health moving into local government, I did do the rounds saying that it would be a really good thing. I have to say that some very experienced people from councils were saying to me, “Well, I know what will happen. We will get the responsibility, and then they will take the money from us.” I said, “No, no, that won’t happen because public health has always been ring-fenced.” When we were in the NHS, the public health funding was ring-fenced. I have to confess that I was naive, wasn’t I, because actually the grant was cut. I do believe that every pound you spend at the local level in that local government setting you will get back tenfold because of all the social capital you can get from it. That is the reality. If your plans are ambitious, you do not need a lot of money. Lots of the interventions on obesity, smoking and all the other things do not take a huge cost in comparison with some of the high-tech NHS ones. If you have the ambition, you need to follow it through with the necessary resources to do it.
I have been public in saying—I am probably with Councillor Jamieson—that in the ideal world, and I have been a director of adult social care, as well as a director of public health, we are not in camps with our bags of cash. We actually put all of our money together for the resources of the population. I would like to see the ICSs mandated to spend so much on prevention and health inequalities wherever the money comes from, because if we continue with what we are doing at the moment—waiting too long to intervene—none of us will be able to afford the mountain of the problem that you will build up. There is no money available in the world to do that.
There have been some early positive signs that we mean business this time with prevention and health inequalities, but we have to deliver. Having just looked at the social care paper today, I struggle to find prevention. I know from being a director of adult social care that if we do not intervene early and get people to be ageing well and healthy, we will not have the carers in the world who can look after them. Again, I make the plea for the resources. It does not take a lot—I am not asking for billions—but a small amount of resource could make a huge difference. If we continue to cut the public health grant, well, we will continue to have poor health, I think.
Professor Maggie Rae: My experience is that there are some things you can legislate for—seatbelts would be the classic example, or smoke-free places—that work really well, but for most things, if you really want to get action, you need to take the public with you. Certainly, if you fluoridate the water, you will have some very direct oral health benefits. Dental decay, for example, is a classic. However, you probably will not fix every little problem you have got, because it takes more than just fluoridation. Most people’s teeth fall out because of gum disease, so you have to have a wider educational programme with the public.
I also know from my work as the director of public health at the local level and my early days work in Scotland that I could take you to lots of families where they do not drink water, so it is not that obvious to me that that is just going to fix the problem as easily as we think it will. I think you need an all-encompassing programme. While we wait for any implementation of the fluoridation, today children will be having their teeth taken out—children of four or five. That is unacceptable because, alongside that, we should be ensuring that there are the educational programmes and the supply if people cannot afford toothbrushes and toothpaste. That would be a nice easy fix for something to do.
We obviously have a huge population who have already lost their teeth, and one of the biggest problems of the elderly is pure nutrition because they simply cannot eat. It is a problem that sometimes you think legislation will fix it top-down, but I think in everything you do it is much better to see public health people as being responsible to the population. In my experience, you really have to take the population with you to have any chance of implementation, whether you have legislation from the Secretary of State or not.