Committee (3rd Day) (Continued)
Clause 14: Establishment of integrated care boards
Debate on Amendment 25 resumed.
My Lords, the group of amendments to which noble Lords spoke before the break deals in various ways with the appointments processes for integrated care boards. I will deal first with Amendment 32 in the name of the noble Lord, Lord Hunt of Kings Heath, which is designed to ensure that the chair of an integrated care board can be removed only by the integrated care board and not by NHS England. This is a worthwhile issue for debate, and while I recognise the spirit in which the amendment is offered, the noble Lord, Lord Hunt, and I are coming at this from rather different perspectives.
It is worth reminding ourselves that ICBs are accountable to NHS England and thereby to Ministers and ultimately to Parliament. That link is fundamental, given the amounts of public money involved. It is therefore right that the appointments and removals process should involve these bodies. In contrast, the noble Lord’s amendment would effectively break that accountability link, because under this amendment, neither NHS England nor the Secretary of State would be able to remove a chair who was acting inappropriately. We cannot have that.
I understand the concern that there should be a safe and robust process for the appointment and removal of the chair of an ICB. I can assure noble Lords that there will be. The chairs of ICBs will be public appointments and therefore managed in line with the Governance Code on Public Appointments and regulated by the Commissioner for Public Appointments. I regret that the Government cannot support this amendment, but I hope I have explained sufficiently why.
Amendment 33 would ensure that the chief executive is appointed by the integrated care board rather than the chair and not subject to the approval of NHS England. I am afraid that, once again, this amendment is not one we can accept. As your Lordships are aware, the chief executive is the accountable officer for the ICB and a crucial person for ensuring that the board is operating effectively. It is therefore right that the appointment should be ultimately made by the chair and approved by NHS England. This approach ensures that we bring together local knowledge and a commitment to ensuring the board is appropriately constituted, while also ensuring that golden thread of accountability from ICBs to NHS England and then ultimately to Parliament. Making the ICB the sole appointing body would break that chain of accountability.
I also remind the Committee that in order to ensure that ICBs can be established and formed in time, NHS England has carried out a selection process for intended designate chief executives which, subject to the passage of the Bill and commencement of the relevant appointment provisions, it expects to be appointed by the chairs of ICBs. All provisional ICB chief executive designates have been agreed by the NHS England appointments and approvals committee, and all candidates were subject to a fair and open recruitment process.
While the current process for appointing designate ICB chairs has primarily been managed and agreed by the NHS England appointments and approvals committee, chiefly in the interests of ensuring that ICBs will be ready to begin work, I reassure your Lordships that we would expect future appointments of chief executives to involve significant engagement from the ICB as a whole to ensure that all chief executives command the confidence of both the ICB and NHS England.
I would also like to address two other significant points the noble Lord raised in his speech: first, the question of conflicts of interest. I can assure the noble Lord that ICBs will have robust duties in relation to conflicts of interest and will be required to maintain and publish a register of members’ interests and make arrangements for the management of conflicts or potential conflicts of interest. Furthermore, part of the purpose of the chair’s veto is to ensure that candidates for the board who are unsuitable or have unreconcilable conflicts of interest are not appointed to the board.
The issue of conflicts of interest brings us to the important question the noble Lord raised about the role of members of the board. We believe that the value of these members is in bringing their experience, knowledge and perspectives to the board, rather than acting as delegates of their organisation or sector. ICB members will be considering the interests of the whole system rather than those of their organisations. I recognise that that will require a degree of cultural change; we are working with NHS England to support ICBs to build and develop these effective and collaborative working cultures. It is worth saying, though, that this work is currently ongoing—we are already in discussion about it. So, once again, and for similar reasons, I am afraid that this is not an amendment I can accept.
Amendment 34 in the name of the noble Baroness, Lady Merron, seeks to mandate
“the involvement of the integrated care board and the integrated care partnership in the appointment of the ICB chief executive.”
We agree on the importance of the board and partnership being involved in the appointment of the chief executive, and we would expect chairs to listen to any views expressed by other appropriate persons in taking a decision relating to this appointment. ICB chief executives must be able to command the confidence of both their chairs and their boards. However, it would not be effective or proportionate to place a statutory duty to consult here, as this would establish an extra bureaucratic step in the appointments process. One thing we hope to achieve in the Bill is to cut through layers of bureaucracy. We have worked closely with NHS England, the Local Government Association and a range of system partners to develop the proposals and ensure the minimum amount of disruption with maximum effectiveness. I fear that this amendment would create the type of bureaucracy the Bill is seeking to move away from.
I shall not speak to Amendment 34A in the name of the noble Lord, Lord Young of Norwood Green, as he was not here to move or speak to it. So, I turn now to Amendments 25, 31, 36 and 187; I am grateful once again to the noble Lord, Lord Hunt of Kings Heath, for tabling them. They seek to establish an NHS appointments commission for the appointment and removal of the ICB chair and ordinary members. Although I understand the spirit behind the amendments, I hope to convince the noble Lord that they are unnecessary.
First, and most importantly, a point that I have already made: ICBs are accountable to NHS England—and hence Ministers and, ultimately, Parliament. As a matter of principle, therefore, it is right that the appointment and removal process for ICBs should involve NHS England and Ministers. An NHS appointments commission is not only unnecessary but would cut across the appropriate accountability lines for ICBs. Adding another arms-length body to this landscape would create unnecessary bureaucracy and undermine the aim of merging NHS England and NHS Improvement to create a more joined-up approach across the NHS.
Further, it would also move us away from well-established approaches that, by and large, work well for other NHS bodies. For example, with CCGs, NHS England appoints the accountable officer and the members of the governing body are appointed by the CCG. We are proposing a similar approach for ICBs, through which NHS England appoints the chair, with the approval of the Secretary of State, the chair then appoints the chief executive, with the approval of NHS England, and the statutory ordinary members are appointed through a nomination process. Beyond that, local areas will have the flexibility to determine any further representation on the board in their area, the process for which is to be laid out in the ICB’s constitution.
I understand, of course, the presentational attraction of an independent appointments commission, and I am the first to agree that good governance arrangements are essential for managing appointments. However, I gently suggest that a separate appointments body can be remote and lack the local knowledge to ensure that every appointment is a success. In that sense, it would carry risk, and the ICB is too important a body to get this sort of thing wrong.
With a good deal of regret—I do not like to disappoint the noble Lord, Lord Hunt—I am afraid that the Government cannot accept these amendments. However, I hope that I have given the noble Lord some reassurance about the appointments process for the ICB, and that he will feel able to withdraw Amendment 25.
My Lords, I am very grateful to the Minister for his response, which he has clearly put a great deal of thought into. At the end of the day, what is being proposed is a very top-down, hierarchical approach to running the health service. ICBs may be accountable to NHS England and, through NHS England, to the Secretary of State, because the Government are taking power of direction through this legislation. However, it becomes abundantly clear that ICBs do not look outward to their local communities; they look upward to the hierarchies above them.
This is the problem with giving NHS England such power over the chief executive and the chair. Anyone who has worked in the NHS knows that, in the target-laden, panic-ridden approach from the centre to local management, the ICBs will be under the cosh right from the start. For all the wonderful words that have been used about what they will do, the reality is that they will be beaten up by the centre in the traditional “target” approach to running the service. Of course, it did not have to be this way. While it is perfectly proper to have boards making their own decisions and appointments, and being held to account for interventions where necessary, this is such a top-down approach that I do not think it will work. I believe and hope that the House will seek to amend it in some of the ways suggested in these amendments. That said, I beg leave to withdraw my amendment.
Amendment 25 withdrawn.
Clause 14 agreed.
Schedule 2: Integrated care boards: constitution etc
26: Schedule 2, page 136, line 23, at end insert—
“(ba) a director of digital transformation (see paragraph 7A), and”Member’s explanatory statement
This amendment, and the other to page 137, line 10, ensure that a director of digital transformation is appointed to the integrated care board.
My Lords, in moving Amendment 26 I will also speak to Amendments 70, 73, 84, 134, 140 and 160. I start by warmly thanking the noble Lord, Lord Hunt of Kings Heath, for allowing me to speak to and lead on this set of amendments, to which his is the leading name. By the same token, I am delighted to see that he is now back in his place and able to advocate much more knowledgeably than I can the merits of the amendments in this group, which relate to the digital aspects of the NHS and the importance of digital transformation in the health service. They are designed to ensure that a digital transformation duty is set out, five-year plans are made, digital issues are high up on the agenda of the ICBs, and progress in this area is assessed and reported on.
I am sorry that I was not able to contribute at Second Reading on digital or data matters. However, as Chris Hopson, chief executive of NHS Providers, said in his Observer piece two Sundays ago,
“we need a national transformation programme that embeds modern technology, 21st century medicine, integrated care closer to home and much greater emphasis on prevention at the heart of our health and care system.”
There is huge potential for technology to help health and care professionals to communicate better and to enable people to access the care they need quickly and easily when it suits them. Quite apart from its impact on planning and administration, the technology, as the NHSE digital transformation website emphasises, goes all the way from ambulance iPads through fitness apps to digital home care technology. It ranges from websites and apps that make care and advice easy to access wherever you are to connected computer systems that give NHS staff the test results, history and evidence they need to make the best decisions for patients.
As the recent Wade-Gery report points out:
“Digital technology is transforming every industry including healthcare. Digital and data have been used to redesign services, raising citizen expectations about self-service, personalisation, and convenience, and increasing workforce productivity.”
It says that the NHS should be in the vanguard. It goes on to say:
“The pandemic has accelerated the shift to online and changed patient expectations and clinical willingness to adopt new ways of working.”
It also says that
“the vaccine programme, supported by so many brilliant volunteers and staff, was only possible through the use of advanced data analytics to drive the risk stratification, population segmentation and operational rollout.”
However, the review also says:
“The need is compelling. The NHS faces unprecedented demand and severe operational pressure as we emerge from the coronavirus pandemic, and we need new ways of working to address this. Now is the moment to put data, digital and technology at the heart of how we transform health services … Effective implementation will require a significant cultural shift away from the current siloed approach in the centre with conscious management to ensure intentions translate to reality … This system leadership should be responsible, in a partnership model between the centre and ICSs, for setting out the business and technology capability requirements of ICSs and the centre with the roadmaps to realise these, and for determining the appropriate high level technical standards, and blueprints for transformed care pathways.”
I have quoted the Wade-Gery review at length but the What Good Looks Like framework set out by NHSX last year is an important document too, designed as it is to be used to accelerate digital and data transformation. It specifies in success measure 1:
“Your ICS has a clear strategy for digital transformation and collaboration. Leaders across the ICS collectively own and drive the digital transformation journey, placing citizens and frontline perspectives at the centre. All leaders promote digitally enabled transformation to efficiently deliver safe, high quality care. Integrated Care Boards (ICBs) build digital and data expertise and accountability into their leadership and governance arrangements, and ensure delivery of the system-wide digital and data strategy.”
Wade-Gery recommends, inter alia, that we
“reorientate the focus of the centre to make digital integral to transforming care”.
In the light of all this, surely that must apply to ICBs as well.
We need to adopt the measures set out in the amendments in this group; namely, specifying in Amendment 26 that there should be a director of digital transformation for each ICB. ICBs need clear leadership to devise, develop and deliver the digital transformation that the NHS so badly needs, in line with all the above. There also needs to be a clear duty placed on ICBs to promote digital transformation. It must be included as part of their performance assessment—otherwise, none of this will happen—and in their annual report, as set out in Amendments 84, 134 and 140.
The resources for digital transformation need to be guaranteed. Amendment 160 is designed to ensure that capital expenditure budgets for digital transformation cannot be raided for other purposes and that digital transformation takes place as planned. It is clear from the Wade-Gery report that we should be doubling and lifting our NHS capital expenditure to 5% of total NHS expenditure, as recommended by the noble Lord, Lord Darzi, and the Institute for Public Policy Research back in June 2018. We should have done that by June 2022 to accord with his recommendations but we are still suffering from chronic underinvestment in digital technology. Indeed, what are the Government’s expenditure plans on NHS digital transformation? We should be ring-fencing the 5% as firmly as we can. As Wade-Gery says:
“NHSEI should therefore as a matter of urgency determine the levels of spend on IT across the wider system and seek to re-prioritise spend from within the wider NHSE budget to support accelerated digital transformation.”
It adds up to asking why these digital transformation aspirations have been put in place without willing the means.
I am also mindful of the other side of the coin of the adoption of digital transformation: there needs to be public information and engagement. That is why my noble friend Lady Barker and I have tabled Amendments 70 and 73, designed to ensure the provision of information about the deployment of treatments and technology as part of ICBs’ patient involvement and patient choice duties. Without that kind of transparency, there will not be the patient and public trust in the NHS adoption of digital technology that is needed. Rightly, success measure 1 of the NHSX What Good Looks Like framework includes that an ICS should, inter alia,
“identify ICS-wide digital and data solutions for improving health and care outcomes by regularly engaging with partners, citizen and front line groups”.
Success measure 5, titled “Empower citizens”, says:
“What does good look like? Citizens are at the centre of service design and have access to a standard set of digital services that suit all literacy and digital inclusion needs. Citizens can access and contribute to their healthcare information, taking an active role in their health and well-being.”
So in the NHS’s view the engagement and provision of information about the deployment of new technologies is absolutely part of the delivery of a digital transformation strategy.
In essence, the amendments would enshrine what is already there in Wade-Gery and best practice guidance where it relates to digital technology and transformation. We should be making sure that our NHS legislation is fully updated in line with that report and with the guidance on what success looks like for the digital age. I hope the Minister agrees to take the amendments on board, and I look forward to hearing his reply. I beg to move.
My Lords, I am grateful to the noble Lord, Lord Clement-Jones, for speaking so eloquently in support of this group of amendments. There are a number of amendments relating to data in this Committee and they fall into three categories. The first category, the group that we are debating today, is about the prioritisation of the digital transformation in the NHS. The second group looks at specific patient groups and the potential of data to improve their care outcomes. The third set is about confidentiality of data as far as patients are concerned. My view is that all three run together.
Like the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Cumberlege, I am enthusiastic about digital transformation in the NHS; indeed, I believe it is the only way we can hope to meet the challenges that healthcare faces over the next 20 or 30 years. However, there are two conditions. One is that the integrity of patients’ data is assured for individual patients. That has not always been the case in the past, and the debacle of care.data is a salutary warning of what can happen if we do not protect patient information in an appropriate way.
The second condition is resources. I was very glad that my noble friend referred to the issue of resources and to the Wade-Gery report, which is the most recent report looking at the arrangements to support digital transformation in the health service. Wade-Gery reported that
“transformation funding is … split between revenue and capital and dispersed across the organisations. Tech funding is variable, often diverted and not necessarily linked to strategy and outcomes, incentivising either monolithic programmes or small-scale initiatives.”
“The requirement for digital transformation in other sectors has driven up the proportion of their spend on digital and technology”.
It has been well-known, for many years, that the NHS locally has not been spending sufficiently on data and data transformation. The latest estimate from NHS England is that the NHS spends less than 2% of its total expenditure on IT, while the noble Lord, Lord Darzi, and the IPPR suggest that this should be nearer 5% by 2022. I say to Ministers that, unless they can find ways to ensure the NHS starts to spend at that level, we are simply not going to achieve the kind of transformation we want.
One way to do that is to ensure that, at the ICB level, there is an official charged with driving this forward at the local level. We know, in general, in relation to boards of the health service, that the data/digital leadership often does not have a seat, in contrast to many organisations. This is why we think that needs to change. Overall, we believe this set of amendments would enable the Government and Parliament to show how important it is to prioritise the kind of digital transformation that we want to see.
My Lords, I support these amendments but first I believe in putting right wrongs. I failed to declare my interests in last Tuesday’s debate, so I took advice from the registrar. He assured me that I do not have to give a full account of my life and times, which is a great mercy to everybody, but I do have to declare what I am currently involved in and the remunerations. I serve on the Maternity Transformation Board, which is owned by NHS England, and the maternity Stakeholder Council, which is also supported by NHS England but is much more of a free agent.
I thank the noble Lords, Lord Clement-Jones and Lord Hunt of Kings Heath; it was a very rounded, fulsome and clear introduction to these amendments. I want to pick up the issue of trust, because both noble Lords linked trust and confidentiality. That is absolutely essential. We will not get the support or trust of the public if we do not respect their confidentiality, and I will say a word about that in a minute. I support Amendments 84, 134, 140 and 160—I have added my name to them. I also support Amendments 70 and 73, and wish to comment on those.
I strongly support digital transformation. Amendments 84, 134 and 140 place a duty on integrated care boards to promote digital transformation and to produce their own five-year plans. It will need money, so Amendment 160 requires the NHS to spend at least 5% of its capital allocation to achieve it. That is right, as digital needs sustained resource—it is not simply a “nice to have”; it is absolutely essential for the future of our services. I have talked to visitors from the USA and cannot believe how antiquated they think our systems are. In many places, they are still in the dark ages, so we have to invest in digital.
I support the increased use of digital technology in healthcare largely because of my involvement in two major inquiries into NHS services in the last few years. One evening in 2014, I had a telephone call from Simon Stevens, the chief executive of NHS England, before he was knighted and welcomed into your Lordships’ House, where he has already made a very significant contribution. He invited me to chair an inquiry into maternity services for England. The noble Lord has a sense of humour: he gave me nine months in which to deliver.
I set up a panel and we delivered in time, calling our report Better Births. Our 28 recommendations were accepted by NHS England, which then set up the Maternity Transformation Board and the Stakeholder Council, on which I have declared my interests. The Stakeholder Council is interesting because it is full of a wide range of people. A lot of charities, in particular, are on that council, and add a lot to the work that we do.
Two of the 28 recommendations are particularly relevant to this Bill and these amendments. We recommended that every mother should have her own digital maternity record, which she would create with her midwife. This record would set out the plans for managing her pregnancy, the birth and aftercare, which is so necessary for the baby, the mother and, I would add, the family. The mother’s record would then be accessible, with her permission, to all those contributing to her care. In future, we could see it being part of the child health record, and possibly the lifetime health record of the mother.
Although some progress has been made on improving access to NHS health records, we are still some way from achieving this, or the ambition set out in the NHS Long Term Plan for every citizen to have their own personal health record. We need to galvanise the NHS to move quickly and capitalise on the enormous potential that digital offers. That is what these amendments are designed to do. I am sure my noble friends on the Front Bench will consider them carefully and assess the potential that they offer.
I also recently had the privilege of chairing an investigation into the safety of medicines and medical devices; our report was called First Do No Harm. Thousands of women and children suffered avoidable harm relating to the medicines and one of the medical devices which we reviewed. They continue to live with the terrible consequences today. This harm did not take place in one isolated moment; it has spanned years and even decades. Why was it not detected and stopped? Many people could have been spared the misery it has been for them and their families.
Part of the answer to that lies in the absence of data. We found that data was not collected or that, when it was, there was no attempt to link data to identify patterns of concern. Paper records, such as there were, were incomplete, dispersed, archived or destroyed. The healthcare system could not tell us how many women had taken the epilepsy drug sodium valproate and gone on to have damaged babies. It could not tell us how many women had pelvic mesh implants, or which implants were used, or where and when.
We were astonished and deeply worried: the system was flying blind. We said that basic information about implantable devices such as mesh was so important that it must be collected, and it must be mandated. We need the name of the patient, the unique device identified, the surgeon, the hospital, and so on. At least then, if a concern about the device is subsequently raised, it will be possible to trace those who have been affected.
The previous Secretary of State agreed with us and issued a mandate for a database. Some noble Lords will remember the Medicines and Medical Devices Bill. It involved a great deal of discussion and persuasion in this House, but many of our amendments had government support and were enacted. Through these debates, the concept of the independent patient safety commissioner was discussed and strongly acclaimed. I am delighted that last week, an advertisement was published on the role, context and responsibility of the commissioner by the Department of Health and Social Care. I thank the department, the Ministers and the previous Minister for their unstinting encouragement and support, which have enabled this to happen. We hope that some outstanding candidates will apply for this position.
Of course, mining data will be an essential tool for the commissioner’s office. It is only by linking access and linking across that we will be able to say: “Stop. This doesn’t look right. We need to investigate and ensure that we achieve a safer service.” Digital data is powerful; it is an enabler and it can be a force for good. But we must treat patients’ records with care and we must respect the person to whom they belong. That is not the doctor or the NHS: that is the patient themselves. Later in Committee, we will consider amendments that address the sharing of records and consent. I am sure that we will have a lot of debate on that.
Amendments 70 and 73 are very important too. They would ensure that patients are made aware of new technologies and treatments and, crucially, that patients are involved in decision-making about these treatments and technologies. I know from the experiences that we heard about and the huge amount of evidence that we received in our review that that did not happen. That contributed to avoidable harm on a really shocking scale. Likewise, I have no doubt that if greater progress on digital records had been made at that time, the questions that we had in our review about how many people had been harmed, when and how, would have been answered. Digital records enhance patient safety, so I strongly support these amendments.
My Lords, I too stress the importance of digital transformation in our health and care services. I thank the noble Lords, Lord Clement-Jones and Lord Hunt, and my noble friend Lady Cumberlege for their contributions and for enabling us to have this debate.
The way that the noble Lord, Lord Hunt, has characterised this as three different issues interwoven is an extremely good way to think about this. I completely agree that the integrity and confidentiality of patient data, and having the resources to lead transformation, are essential components. I would just like to add a contribution on the third element, the prioritisation of digital and data. I too am going to cite the Wade-Gery review. It is really important that those of us who have worked in digital transformations in other sectors also encourage our health system to look outside. All health systems are probably 10, perhaps 20, years behind other sectors—financial services, retail and, dare I say, even politics—in their digital journey.
This is not just an NHS issue: it is a health sector issue. One reason why that is the case is that we have tended in health to think that digital is “other”, something separate from healthcare itself; whereas, actually, healthcare is that most human of services and digital is an enabler. It is the means, not the end, and it is hugely important that we think of prioritising digital and data as prioritising the overall transformation of care, rather than the digital transformation. This is not just semantics: it is important that everyone owns that transformation, most importantly our front-line clinicians, and that it is not something that is parked separately.
When I was growing up, my parents’ generation abdicated responsibility for the family VCR to the children. Certain business leaders, 10 or 15 years ago, abdicated responsibility for their technology transformation to their chief technology officer. If we really want to see the benefits of digital transform our health and care system, we must not abdicate that transformation to a digital transformation team. It needs to be the business of everyone—most importantly, our leaders. I hugely support the spirit of these amendments and particularly the amendments looking specifically at funding and a duty to lead transformation, but I caution against creating a post of digital transformation because that needs to begin with the chair, the chief executive and the medical and nursing directors, not just an individual with digital in their name.
My Lords, my colleagues and I built the first online facility for the voluntary and social enterprise sector in this country in 1997, called CAN Online. We learned rather a lot from doing that, and I actually came to many of the conclusions that the noble Baroness, Lady Harding, is telling us about. When we started this, we naively thought that this online environment was going to solve all our problems, as if it sat “out there” somewhere. We bought 12 computers: they came in very big boxes at that point, as noble Lords might remember. We put them in a room in a conference centre—we were in the Cotswolds—and I invited 12 entrepreneurial people working in the social sector to come and share a few days with them. We connected them all up. We thought it was about technology, but we actually we discovered that it was all about people and relationships; that this technology was simply a tool—an enabler—to facilitate a marketplace that we needed to build between us.
We began to understand that this was not about large systems up there that you plonk in the middle of things in some separate way. It is actually organic: they are very connected, and you need to co-create it and invent it together around the real needs and opportunities that are presenting themselves. I think this technology is telling us something about what needs to happen to the health service. It is organic; it is entrepreneurial; it is about creating a learning-by-doing culture. My colleagues and I have seen examples in the NHS and other parts of the public sector where millions of pounds have been spent on systems that have landed from Mars and have not worked.
First, we must understand the detail of this technology, and the opportunity that it brings. Later on, as we go through the amendments, I will share with noble Lords some technology platforms that we are working with across the country that have absolutely understood this. When they are engaged with the NHS, instead of the system getting behind them and building on their success and knowledge, it never follows up on the conversation with them. They never heard from the NHS again. There is a disconnect going on, and a fatal misunderstanding of how this new world now needs to work.
I welcome these amendments and this conversation, but we must understand—from those of us who built some of this stuff, even in the clunky old days of 1997 —that it is all about the relationship between people and technology and a learning-by-doing entrepreneurial environment.
My Lords, I, too, praise the noble Lord, Lord Clement-Jones, for his analysis and for rightly identifying the important connection between trust and confidentiality, and the noble Lord, Lord Hunt, for his diagnosis. In particular, I double up on the praise for Laura Wade-Gery and her report, which provides a huge amount of insight for this debate, and praise also my noble friend Lady Cumberlege, who has been a pioneer and remorseless champion of safety. She is entirely right that we are talking here not just about productivity but safety. Data saves lives, and her report made that point extremely well.
Basically, I just want to repeat absolutely everything that my noble friend Lady Harding said about ambition. My concern about this debate is not the analysis, which I think is spot-on; it is the level of ambition. I have lived through digital transformations. I lived through one in the music industry, and it did not just come from digital transformation officers—although I know that that is not the point of these amendments—but required the commitment of everyone from the superstars down to the roadies. Everyone in the industry was affected; it was a massive revolution; it led to an incredible improvement in the industry; but it was hard fought and a difficult thing to go through.
I have also lived through a revolution in digital in healthcare. Over the past two years, we saw amazing breakthroughs in individual areas, the vaccine rollout being a really good example to which my noble friend Lady Cumberlege referred, but also in non-present appointments with GPs and in other areas. But it took a pandemic to drive that progress as quickly as it did, and I never again want to see such a horrible emergency be required to create change.
The message to the Minister is that the Bill is a remarkable enabling document that helps the healthcare system in the UK make important progress across the board on many different areas, but the big challenge of our generation is digital transformation. It does not require a lot of legislative change. These amendments are not what will make a difference. My noble friend needs to have the energy, passion and determination to see through that transformation when he gets back to the department, and I hope that the Bill gives him the tools to do that.
I thought noble Lords would have more to say about digital matters. I shall respond to this group very briefly, because my noble friend Lord Hunt, the noble Lord, Lord Clement-Jones, and others have very adequately covered the issues: the potential for digital transformation, the need to use patient data, the need for resources and, as the noble Lord, Lord Bethell, just said, enthusiasm and leadership.
The noble Baroness, Lady Cumberlege, as she always does, brought us practical applications of the reasons why the amendments are necessary, and it brought to my mind that my digital interface with the NHS is a good example of someone who is absolutely at the coalface. I am part of UCLH’s digital patient management system. It does not talk to my GP and it does not talk to the Royal Free, which is where one has one’s tests in the part of London I live in, and I think, “For goodness’ sake, we really ought to be able to do better than this”.
My Lords, I am very grateful to the noble Lords, Lord Hunt of Kings Heath and Lord Clement-Jones, the noble Baroness, Lady Thornton, and my noble friend Lady Cumberlege for bringing these amendments for debate before the Committee today.
Once again, we are dealing here with an important set of issues. First, Amendments 26 and 35 would ensure that integrated care boards appointed a director of digital transformation. The Government fully agree with the spirit behind the amendments, ensuring a strong local focus on digital transformation. However, looking at the pros and cons, we must balance the desire to go further—which we all want—with the important principle that I have articulated before: that the provisions in the Bill should not be too prescriptive when it comes to membership requirements. As we have discussed, it is an essential principle of the Bill that there must be local flexibility to design the board in a way most suitable to each area’s unique needs.
As your Lordships will be aware, local areas can, by agreement, go beyond the legislative minimum requirements to appoint individuals with the necessary experience and expertise to address their needs. As such, prescribing particular roles in these provisions is not necessary. What I can say is that developing the digital capability of local health and care services is one of the areas that we would expect ICBs to prioritise. It is an area of significant investment centrally, as I shall come on to explain in a moment, and of similar investment by local commissioners; it needs good local leadership, undoubtedly.
To buttress this investment, the NHS has been set a very clear set of expectations in relation to digital transformation. This set of expectations is even called What Good Looks Like, and it will be the benchmark for integrated care boards. It sets the criteria against which they will be assessed for their effectiveness in using digital technology to support improved outcomes for patients.
The first measure of success is that the local system has a clear strategy for digital transformation and collaboration, with the right leadership. Integrated care boards are expected to have digital expertise and accountability in their leadership arrangements, but, as the noble Lord, Lord Mawson, brought out so well, we also expect a general development of digital competence in the board, and investment across the local system in expertise in building digital capability. That process certainly could be assisted through a chief information officer and other roles.
We will provide resources, including a non-statutory assessment framework for organisations to measure their level of digital maturity against the characteristics set by What Good Looks Like. It will help identify gaps and prioritise areas for local improvement. Assessments will be repeatable annually so progress can be tracked year on year.
We are not just setting expectations; we will be testing progress. This is obviously where the strength would lie in any expectation-setting process, rather than whether or not it was in statute. The Committee may like to know that my right honourable friend the Secretary of State and my noble friend Lord Kamall have regular meetings with NHSX, NHS Digital and NHS Transformation about the safe and ethical sharing of data and appropriate ways to break down silos. Ministers are in no way distancing themselves from those important issues; quite the reverse. Data Saves Lives is the name of the draft strategy that we published, and it is a title that vividly reminds us of what is at stake here.
I just say to my noble friend Lady Cumberlege that I am also especially pleased that we are in the process of appointing the first ever patient safety commissioner for England. The role is currently open for applications until Tuesday 25. As she knows, the patient safety commissioner will be responsible for promoting good practice, for calling the healthcare system to account and for identifying and monitoring potential problems across the system.
While on the topic of digital transformation, let me turn to Amendments 84, 134 and 140, which seek to place a duty on ICBs to promote digital transformation, accompanied by the publication of a five-year plan for digital transformation, with an update at least once every five years. The use of digital technology has been crucial to meeting the demands which Covid-19 has placed on health and care services. It has given renewed impetus to an area which in the past, as the noble Lord, Lord Hunt, will know from his considerable experience, has been problematic for the NHS.
Leading the process of digital transformation locally is a significant role for the integrated care board, but this should be part of its general duties rather than a separate duty. I am afraid that I do not think it would be proportionate or effective to have a stand-alone statutory duty, as it would require the creation of a separate planning and reporting process, which we do not think is necessary. As I have made clear, we will test the progress of ICBs in this area against the expectations we set.
There is a broader point, which my noble friend Lady Harding brought out cogently: digital transformation is most effectively done as part of wider service and pathway transformation rather than looked at as a separate activity. Integrated care boards will be required periodically to produce strategic plans, which we would expect to include digital transformation and its interaction with other aspects of planned transformation. A separate statutory duty is therefore unnecessary and risks misalignment between digital transformation and wider service transformation when we would want them to go hand in glove. Rather than risking this, I ask the noble Lord to agree with our approach of placing digital transformation at the heart of the ICB’s general duties.
Of course, any efforts to promote digital transformation must be incentivised through effective funding. Amendment 160 would ring-fence 5% of NHS organisations’ spending to be dedicated to digital transformation. The noble Lord, Lord Clement-Jones, asked about the amounts of money that we are earmarking for this. Over the next three years, we are investing centrally £2.85 billion in capital, with £2.9 billion of revenue on top of that. Within this, more than £2 billion has been set aside for digitising the front-line NHS, in addition to local investment by commissioners. However, noble Lords will understand that we have a long-standing and well-tested principle of not ring-fencing investment in the NHS. It is fundamental to the flexibility of local commissioners and to the principle of local, clinically led decision-making. We would not want to tie the hands of local trusts specifically to spend a certain amount of money in one area and not in other areas, nor would we want to be prescriptive about whether NHS organisations should use capital or revenue spending to deliver digital transformation, particularly as the market is in the process of moving towards revenue-based products.
I can also inform the noble Lord, Lord Hunt, that consideration has been given to whether a minimum tech investment policy for NHS organisations could helpfully support digital transformation. The conclusion was that such a policy would face practical challenges, including difficulties in monitoring and enforcing compliance, and could cause a range of unintended consequences, including encouraging organisations to focus on hitting the target rather than maximising value from appropriate investments in digital technology. We also felt that it would not address many of the underlying causes of low levels of digitisation. Instead, we would advocate a flexible approach, giving local organisations the ability to spend the money in the areas which are urgently needed. This must be accompanied by clear national standards defining what a good level of digitisation is and guidance and support, including for local skills development, so that organisations are supported to invest effectively. If local NHS organisations fail to meet the required standards of digital transformation, there are other levers at our disposal to enforce compliance, including the oversight arrangements used to manage organisations’ operational performance, financial sustainability and the safety and quality of care delivered.
Amendments 70 and 73 specify that patients should be involved in decisions relating to the provision of information about the deployment of new treatments and technologies, and the provision of this information to enable patients to make a choice with respect to aspects of healthcare provided for them. I believe that the Bill, as is, achieves what the noble Lord and noble Baroness seek to achieve through these amendments. An integrated care board, in the exercise of its functions, must promote patient involvement in decisions relating to their care and treatment, and this would likely cover providing information about available new treatments and technologies where there is an impact on the care received. The Bill also includes duties to promote research and innovation on matters relevant to the health service and the use of evidence obtained from research, so I believe that the Bill will allow local NHS bodies to best engage and involve patients and the public, supported by national guidance.
Turning to Amendment 78, the first part of the amendment requests that integrated care boards review all innovations. I completely appreciate the intentions behind the amendment, but it is unclear to me what additional benefit such a review would produce. As noble Lords know very well, the National Institute for Health and Care Excellence already plays an important role in ensuring that patients have access to promising new innovations by making recommendations on whether health technologies represent a clinically and cost-effective use of NHS resources. Where NICE makes a positive recommendation, NHS commissioners are under statutory obligations to fund the technology. This requirement will carry over to integrated care boards.
The second part of the amendment seeks to appoint a dedicated innovation officer to each board and develop and maintain a system to keep up with innovations. The Accelerated Access Collaborative, or AAC, the umbrella organisation overseeing the health innovation ecosystem, is working with NHS partners to look to embed research and innovation objectives within the new statutory ICBs. For example, as articulated in their job descriptions, a clear requirement will be placed on ICB chief executives and chairs to foster a culture of innovation. We also have existing reporting tools at our disposal to monitor the use of innovative medicines and medicinal products. This includes NHS Digital’s innovation scorecard and the AAC scorecard. Finally, alongside work that is under way to strengthen our ability to monitor progress, the AAC is scoping the development of an overarching innovation metric to help identify and address unwarranted variation.
Against that background, I hope that I have said enough to persuade my noble friend to move her amendment when the time comes for it to be called and to persuade the noble Lords, Lord Hunt and Lord Clement-Jones, not to press theirs.
My Lords, the Minister is much in agreement with others that the leadership being enthusiastic for progress is important. I understand that nominations have already been made for the various positions that are likely to come up. To what extent has enthusiasm for digital transformation been a criterion in nominating those people? It is vital that the leader really believes in what is to happen if it is to happen at all. Therefore, it would be useful to know to what extent that consideration has applied in the prospective nominations of people for the local positions.
Noble Lords will remember that, even 10 years ago, when I was appointed as a Health Minister, there was an acronym, QIPP, which stood for “quality, innovation, productivity and prevention”. While I think the acronym has largely fallen out of use, those four principles remain alive and kicking in the strategic thinking that happens at the top of the health service, and indeed in the department.
I can say to my noble and learned friend that the importance of innovation is absolutely at the heart of the way in which the leaders of the ICBs are being chosen. They need to be people who look ahead, think strategically and value innovation, not just for itself but for the way in which it can transform care. Not all innovation is good; we must remember that. We should look only at innovation that has a positive effect on the care of patients and service users, but digitisation is undoubtedly one of those areas of innovation on which we must concentrate. I am confident that the leaders that are now lined up have that ambition very much in mind.
My Lords, I thank the noble Earl, Lord Howe, for his very considered response. We have had a very rich debate, and I thank all the speakers. It has been a privilege to take part in what I think the noble Lord, Lord Bethell, called this “conversation”, because we have heard huge experience and authority, right across the board, about the way we might digitally transform the NHS.
In a sense, I think it is about means, not ends: we are trying to reach the same end but we disagree on how to get to that objective. At the core of that disagreement, and no doubt where we will have considerable debate later on in the Bill, is where the digital transformation aspect fits with data confidentiality and data sharing—all of which is necessary as part of digital transformation. I listened with enormous interest to what the noble Baroness, Lady Cumberlege, had to say on that. We have to get this equation right, and we have to build public trust. I say “build” public trust because I do not think it is completely there, post the GP data grab, as it has been called, of last year. We will come on to that on future occasions.
I feel somewhat that the noble Earl, despite his mellifluous approach to these matters, was rather throwing the book of arguments at the need for any form of amendment to the Bill. He always does so with great style, but I was not totally convinced on this occasion. He mentioned the principle that we should not be too prescriptive—in that case, why are we legislating? We are trying to legislate for what the priorities for the health service are in the current circumstances.
Absolutely. I think the noble Lord, Lord Mawson, talked about a disconnect in another context, but that is probably the word I would use in these circumstances. The Government say that they are going to prioritise good local leadership but do not want to be too prescriptive about who is on the board of the ICB; that they want a clear strategy for digital transformation but do not want to make it a duty; and that a general level of competence and expertise is required but, again, “Oh, no, we don’t want any digital duty; that would be a little bit too prescriptive”.
We need a level of digital maturity, and a regular set of digital maturity assessments. I liked the sound of that, but faced with all the other duties that ICBs will have, which ones are they going to prioritise—the ones that are built into statute, or the ones that are part of a What Good Looks Like programme? The noble Earl quoted exactly the same document that I had access to. It is a splendid document but, without some form of underpinning by legislation, it is very difficult to see ICBs giving priority to that.
Of course, the other argument the noble Earl made was that if we had a separate duty, we would have to have a whole separate planning process. That is not how these things work. When you have a set of duties, you try to do it in a holistic fashion. You do not say that we need one plan for this duty and another for that duty. If you are going to use your resources sensibly and the capabilities within your organisation in the right way, you need to do it in a planned programme, right across the board.
On the whole issue that having a separate statutory duty risks misalignment, I thought that was where somebody had really been creative and woken up with the inspiration that this was the final killer blow in the arguments being made.
I listened with great interest when the noble Earl came to the question of funding. I have not done any calculations in my head, but I bet that £2.85 billion cap ex spending over three years does not equate to 5% of the NHS budget. As my noble friend intimated to me, when you look at the cost of some of the digital developments that have taken place over the last year or two, you will see that they are highly expensive, in both revenue and capital spending. The noble Earl talked about not ring-fencing We all know the problem of distinguishing between capital and revenue in public spending. That is not to say that that is necessarily right.
Finally, on the idea that we must not tie hands—what is legislation designed to do but to set out parameters?
I thought that the aspect of patient engagement was quite interesting, and I will need to re-read what the noble Earl had to say, because it may be that the current set of duties within the Bill provides for that. That may be a glimmer of hope. Indeed, the whole question about the duty to foster a culture of innovation is a kind of fig leaf. What board is going to treat that as an absolute duty that it needs to plan in and set particular duties to its team for? In a sense, it will be an optional extra if we are not careful.
To tell your Lordships the truth, I am not entirely convinced that we are going to be able to—in the words of the noble Baroness, Lady Cumberlege—“galvanise” the NHS. I thought that was a splendid word; it has a certain electricity about it. I do not think anything in the current Bill is going to deliver that galvanising impact, and we will be left with the disconnect that the noble Lord, Lord Mawson, talked about if we are not careful. But in the meantime, I beg leave to withdraw my amendment.
Amendment 26 withdrawn.
Amendments 27 to 36 not moved.
36A: Schedule 2, page 137, line 23, leave out “one member” and insert “two members”
Member’s explanatory statement
This amendment would strengthen minimum clinical representation on Integrated Care Boards by ensuring there are at least two primary care members.
My Lords, I must declare that I am an elected member of the BMA ethics committee and a past president. The BMA has been particularly concerned about ICB membership. I know we have already debated this, so I expect this group to be quite quick—I am sure the Committee would also hope that.
The Bill sets out a core minimum membership of integrated care boards, but this does not go far enough. We have just discussed not being prescriptive, but there are dangers in that. There is no guarantee of clinical leadership on the board and there is a real danger of undercutting truly representative clinical leadership by failing to retain some of the positive elements of clinical commissioning groups. Clinicians are already demoralised and a failure to give space to their voice and enthusiasm will only worsen this.
ICBs should have clinical representation from primary care and this amendment suggests that there should be two people for this, given the wide area that the boards cover and the very different types of practice within each area. Boards also need a secondary care clinician who is in a front-line, not a management, role and a public health representative. As we have already discussed, without public health representation on the board, there is a real danger that the evidence of health gain and the potential to reduce inequality will not be adequately voiced. The board needs public health input to be able to act as a population health organisation.
Some boards have acknowledged the shortcomings and allocated additional positions for general practice, secondary care and public health within their draft constitutions, but others have not. They appear to be ignoring the voice of the very people who work in front-line healthcare. Unless these voices are heard, along with the voice of public health, there is a real danger that the boards’ decisions will be distant from the reality and that they will become bad decision-makers themselves by losing clinical trust and confidence. I hope that the Government will rethink and ensure that the boards are able to have members who can provide a solely professional view of the whole population for whom the board has responsibility. I know we have already debated much of this, but I want the Government to think again, given the dangers of a further demoralisation in both primary and secondary care. I beg to move.
My Lords, it is essential that the board have available to it the skill set that you find in people at the clinical front line. I was interested to see that, putting the amendments from the noble Baroness, Lady Finlay, together, we have three people who are not representing one of the big acute hospitals, and one who is. Given the danger referred to by a number of noble Lords that the big acute hospitals will continue to have more influence in an integrated system than perhaps they should, that is a good element of putting the two amendments together.
As I said, it is important that clinical knowledge and experience be available to the board, but I would like to know that there is a balance and that this does not overwhelm other skill sets which all of us want to see represented; that became clear in the discussions we had last week about who should be on the board. With that caveat—the noble Baroness, Lady Finlay, might respond to that if she chooses to withdraw her amendment—I offer qualified support to what she is suggesting.
The two amendments put forward by the noble Baroness, Lady Finlay, add to those we have already discussed about who should serve on the board and what range of experience its members should have. Of course, we all agree that it is important to have clinical experience brought to the board. However, if this is about integration—I may have said something similar to this last week—mental health, social care, primary care and public health need to be part of the planning on these boards. In that respect, I give these amendments my support, but I think we need more discussion about this. At the moment, as far as I can gather—perhaps the noble Lord can enlighten me—the boards are pretty much made up and I do not think they fulfil the criteria of things we will need to bring to bear to have properly integrated planning in the places covered by these ICBs.
My Lords, I am grateful to the noble Baroness, Lady Finlay, for bringing these amendments before the Committee today. I am also grateful to all noble Lords, who have offered me two bits of advice thus far: first, “You can make your life a lot easier if you just accept our amendments”; and secondly, “Don’t worry about the other amendments, just accept mine; that’s who needs to be on the board”. I hope all noble Lords understand the sort of advice I have been given, as I consider my response.
The noble Baroness, Lady Finlay, raises an important point and there is clearly understanding and support for ensuring that there is primary care representation on ICBs. This is a topic that we have both discussed and are likely to return to. I am in danger of sounding like a scratched record, for those who remember vinyl—I am told it is making a comeback—but I hope not to, or to labour the point too much, by repeating the arguments we have already discussed at length.
We fully agree that the membership of ICBs should include individuals from a number of places and this is why we have set a requirement that ICBs should have at least one member nominated by the primary medical care providers on the board. The noble Baroness, Lady Walmsley, made a couple of very useful points here. The board should have available to it the talent and skill sets that it needs, but there should also be a balance that does not overwhelm any one set of skills. That is one of our concerns as we look at not overprescribing the make-up of the ICBs.
The noble Baroness, Lady Thornton, is absolutely correct that, given the debates we have had up to now, there will have to be more discussions on the ICBs between this stage and the next. I accept that; we will have meetings and roundtables to discuss this, and I know there might well be more amendments on the membership of the ICBs. Before those discussions, I would just reiterate at this stage that this is a floor, not a ceiling; it is a minimum requirement. ICBs are able to appoint individuals with those skills as they see fit, and we would hope that they would, to make sure that they meet the health requirements and tackle the health challenges of the local areas they cover. As the noble Lord, Lord Mawson, and my noble friend Lady Harding of Winscombe said last time we discussed these issues, it is important not to be overprescriptive and close off the opportunities to tailor boards to each local area. The noble Lord spoke very eloquently about his experience of building a board in a particular place, which might have been quite different, had it been in another place.
Turning to Amendment 41B, the noble Baroness, Lady Finlay, raised an important point about ensuring there is sufficient representation of clinicians with experience of public health and secondary care. We fully agree that ensuring that sufficient clinical expertise is available to the ICB is critical. We do so through a duty imposed on ICBs to seek advice from persons with a range of professional expertise in, for example, prevention, which noble Lords have said we should focus on, diagnosis or treatment in illness, and the protection or improvement of public health. This applies at every level of the ICB and impacts how it discharges its functions. As a result, I can assure the Committee that the clinical voice will be heard loud and clear at every level—not just at the ICB or ICP level, but in the health and well-being boards.
For the reasons I have discussed, I am afraid that I do not agree at this stage that the best way to ensure this would be by requiring two additional members of the ICB. This would take away the flexibility provided to ICBs and potentially inhibit their ability to respond to their own area’s local needs. Finally, I would not want to risk ICBs believing that their duty to seek clinical advice would be discharged solely by appointing two clinicians to their board—saying, “Okay, we have those two clinicians, that box is ticked”. The noble Lord, Lord Scriven, made a point about a staff member called Gladys, whose role ticked a box. We have to be very careful that we do not repeat that mistake with two tick boxes. Instead, ICBs should seek appropriate advice from subject matter experts. This may mean seeking advice from different clinicians for different issues and developing different models of seeking advice for different types of decision.
As I said earlier, we will have discussions about the whole ICB composition between this stage and the next. In that spirit, I hope the noble Baroness, Lady Finlay, will be a little reassured and feel able to withdraw her amendment.
I am most grateful to both the noble Baronesses, Lady Walmsley and Lady Thornton, for their comments, which I share. In the previous debate, I argued that we should have people from the allied health professions, and I do not dissent from that. This is not to replace them at all. I also completely recognise the Government’s comments that we need talent and a skills set. Having a balanced board means that you have to have the range of skills. Some people may bring several skills to the table, but they do not automatically bring them because they have a label on their head saying where they come from.
The other difficulty that we will face is that boards need to have contemporaneous experience in an area—and people go out of date remarkably quickly in different areas. The pandemic has shown how some areas have changed enormously in a very short space of time. The representations that I have had from the BMA, at a professional level, have been about how we make sure that the ICBs will be up to date with that contemporaneous input coming through all the time. I am glad to hear that the Minister plans to discuss all of this further. With that, I beg leave to withdraw the amendment.
Amendment 36A withdrawn.
Amendments 37 to 41 not moved.
41A: Schedule 2, page 137, line 30, at end insert—
“(d) one voting member nominated by place-based partnerships to represent their collective views in delivering their strategy.”
My Lords, the noble Lord, Lord Young of Cookham, reminded us last Thursday that we have been talking about the social determinants of health and health inequalities for 40 years. It is now time to act. I want to get practical, and my three amendments are all about the practical detail—the “how” questions—about the transformation of the health culture and about new ways of thinking and working. My focus is on the first small, necessary steps on this journey.
Following my speech at Second Reading, I begin by thanking the noble Lord, Lord Kamall, for agreeing to meet with me and the chairman and CEO of Ashford and St Peter’s Hospitals NHS Foundation Trust in north-west Surrey and allowing us to share with him and his colleagues, in more detail, the work that we have been doing there in recent years. This is set out in Hansard. This work builds on 37 years of work that my colleagues and I have been doing at the Bromley by Bow Centre in east London on the integration and place-making agenda.
The principles of the work in Bromley-by-Bow are now well known and are being shared with communities right across this country, and this work is now starting to have a national reach, through the Well North Enterprises programme, which I lead. I declare my interests. The work in north-west Surrey is one further practical example of what happens when you start to take these principles to scale and apply them to the place and neighbourhood agenda, which I suggest needs to be strengthened in this legislation.
The Minister thought that it might be helpful to the House if I first set out the background to my three amendments, which are focused on the importance of place and the local neighbourhood, before dealing specifically with the first amendment on the Order Paper. What does a modern integrated health service actually look like, and how do we take the first faltering steps towards it? I suggest that the clues are in the micro: in the place and the local neighbourhood.
The NHS is in some difficulty, and much of the narrative that underpins it is from the last century and now well out of date. The chairman of Ashford and St Peter’s hospital describes it as a “financially unsustainable illness service”, not a health service. Science and modern understanding of the integrated nature of life and health have, in recent years, taught us a great deal about the social determinants of health. Ironically, the pandemic has forced all of us—the nation, if not the world—to return to the simple question: what is health? Nowadays, we all know that health is no longer simply a biomedical matter for doctors and hospitals—indeed, it never has been. The Peckham experiment on the social determinants of health was telling us all this early in the last century, but the NHS in 1948 thought that it knew better and chose not to continue with this approach.
Health is everybody’s business. It is not just the domain of health professionals, hospitals and just one government department. If 70% of the determinants of health are social, and if our present business model for the health service is unsustainable, we desperately need to return to the central question: what is health? What changes to the narrative on services and provisions does the state now need to make to respond to this modern understanding of what health is all about? We need to get upstream towards prevention and early intervention. For this modern generation, which takes integration for granted, the siloed approach of the state will no longer cut it.
Over the last 37 years, my colleagues and I have built practical working pathfinder projects in real neighbourhoods with local people. Others may well refer to these in this debate, so I will not waste the Committee’s time now. The Bromley by Bow Centre is in London’s East End and is well known nationally and internationally, but we have been involved in other projects. Today, the Bromley by Bow Centre is responsible for 43,000 patients on four sites in Poplar. Working with local partners, we have built the first independent housing company, which is resident controlled and has connected health, housing, education and jobs and business skills. Today, it brings together people from many nations of the world who live there, around practical place-making, health and social projects. This housing company now owns 10,000 properties, owns 34% of the land in Poplar and has in play a regeneration programme worth many millions of pounds.
Today, the Bromley by Bow centre is visited by over 2,000 people from the public sector and across the world, who we find are desperately asking the same questions as us. These are the practical questions—“how” questions—about how we bring together the health services, local authorities and voluntary and business sectors and generate a 360 degree response to people’s health needs and lives and the opportunities in local communities. This is not a simple matter, but I suggest that the place to start is not in the macro but in the micro: in local communities and neighbourhoods, where lots of talent and opportunity lie that are not being tapped and never will be if you do not join them up and develop a very different approach.
In 2015, Duncan Selbie, who at the time was CEO of Public Health England, asked me to take this place-making work and the working principles of the Bromley by Bow Centre into towns and cities in challenging communities across the country. In partnership with the NHS, local authorities and business and voluntary sector partners, we created 10 innovation platforms in Bradford, Rotherham, Skelmersdale, Doncaster et cetera. We did not write policy papers or research documents, which, in my experience, often few read; we created practical learning-by-doing environments. The clues that we have found are local—in people and relationships—and not necessarily national.
My three amendments seek to use this legislation to tap into this local talent to take the first steps on the road to integration, with a necessary focus on the local, the place, the neighbourhood and the community. Health is a social matter: it is not just about private individuals, and we now desperately need to get upstream on the health agenda in this country and move forward.
This legislation, and the integration White Paper that is soon to follow, can help us all take the first steps in this century in the transformation of the NHS. I suggest that the micro is the way into the macro; it is not the other way around. In local neighbourhoods across the country, at a human level, we now need to create innovation platforms in local places and neighbourhoods, with public sector leaders and local people willing to support and generate new integrated approaches to health, and learn from them. Let a thousand flowers bloom.
As we expand our work across the country through practical engagement, we are finding that lots of people already get all of this. Many of them are in the public sector and the NHS and are desperately frustrated with the present state of affairs. They want to be health creators, but the system is not harnessing their creativity and energy—so, often unintentionally, it is pouring treacle into their projects and disempowering them, creating an ill organisation.
This Bill and the forthcoming White Paper on integration provide us all with an opportunity to start to lay the foundation stones of a new modern health service which understands that health is no longer a matter for one department called the NHS. If what we eat, how we live, whether we have a job, et cetera, is as important—if not more so—than the doctor, this is a matter for every government department. The place to begin to understand what is now needed is local neighbourhoods across this country, to understand the significance of place, neighbourhood and local people and to use this legislation to help us take the first steps along this road.
The three amendments I have put down, focused on place and neighbourhood, are not perfect. This Bill is not perfect, but it might give us an environment to harness the energy out there in local communities and generate a health-creating society and a learning-by-doing culture. We need to create a solution-focused culture that is entrepreneurial by nature. The modern world is all about facilitating people and relationships in local communities. This is how entrepreneurial solution-focused communities emerge. It is not about central process, strategy and documents any more. It is not topdown or bottom-up; it is about an inside-out approach. As my colleagues and I have got inside local communities through the Well North Enterprises programme, we have spotted real opportunities to strengthen life and health that the present structures are failing to see.
In my Second Reading speech I set out what is happening in one place in north-west Surrey, where the local hospital, four local authorities, the voluntary sector and the business community are starting to build working relationships and do things together. Health is now everybody’s business. The three amendments are not the last word. They are simply an attempt to get this place-based discussion rolling and empower people at the front end in local neighbourhoods and places across the country through this legislation.
I will briefly deal with this first amendment. ICBs must be clear about what a place or neighbourhood is. Neighbourhoods across this country come in different shapes and sizes, be they a place such as Cranleigh village in east Surrey, where my colleagues are working on a new integrated leisure and health campus, with its population of 11,000, or Addlestone, where, with the local authority and health systems in the small town, we are working together on a possible health campus on the street—here, we are looking at 50,000 people. It is not the size that matters, but the local neighbourhood needs to feel real to local people and not an invention of the NHS and the public sector. It must be decided locally.
My professional colleagues in the NHS in north-west Surrey suggest that place-based groups are health and care partnerships at the level of places of a population of about 500,000, encompassing the key providers, which for my colleagues and I means at least NHS-commissioned health providers in that area, including primary care, social care and local government. The neighbourhood is more local and they would work with local partners to agree these. Only those living and working there can possibly know.
The ICS design framework published by NHSEI deals extensively with place-based collaborative partnerships as part of the structure of ICSs, so they are already recognised as part of the structure. For example, on page 23, the framework states that
“as part of the development of ICSs, we now expect that place-based partnerships are consistently recognised as key to the coordination and improvement of service planning and delivery, and as a forum to allow partners to collectively address wider determinants of health.”
Their contribution is acknowledged. My proposal is that they are formally recognised on ICBs as voting members.
We suggest that ICBs need to serve the needs of place and be led by a true understanding of health inequalities at a granular level. This can be done only through strong representation of those who are tasked with leading a place and thus come with an appreciation of those needs. This is about ensuring that an appropriate person, with real practical experience of delivering the necessary innovation in local neighbourhoods, has voting rights on the ICB. ICBs need to avoid intervening where it would be more appropriate to do so at a place-based level. Balanced judgment on this cannot take place without voting place-based members with appropriate skill and local knowledge. If the micro is now the way into the macro, this knowledge on the ICB is crucial.
The restructuring of CCGs into emerging ICBs has led to a high proportion of senior ICB posts being occupied by previous CCG officers. Moving to the new model will require new perspectives and behaviours to be introduced. This will require those who can balance a primary NHS commissioning paradigm and culture with one representing communities, the wider determinants of health and a wider range of sectoral interests. In reality, this will likely need to be quite disruptive for a time to achieve the change in approach that is now needed.
Through my discussions with health and care organisations, it is clear that, in aiming to deliver against the aims of the strategy, the details of implementation, procurement, practicalities, working relationships, understanding of local issues, specifics of local organisations, funding arrangements, et cetera, often get in the way of achieving what was actually intended. In setting strategies aimed at improving public health and decreasing pressure on the health and care services, strategies may particularly fail to specify the practical ways in which bringing together broad collaborations of local organisations to work on the social determinants of health will deliver measurable improvements in public health.
The people who work in these individual organisations and are, or will be, part of the place-based partnerships envisaged by the Bill are well aware of these issues of implementation. If the strategies designed by the ICPs are to succeed rather than be frustrated by implementation issues, it is important that they are set within an understanding of these issues. Mandating inclusion of a voting member on the ICB who is nominated by the place-based partnerships—a person of real local experience and track record—to represent them collectively in bringing these implementation details into the design of the strategy will enable better strategy to be set and better connectivity between strategy and implementation, bringing benefits faster to those whom the strategies intend to help.
I apologise for taking so much of the Committee’s time on this, the first of my amendments, but I thought it important to set out clearly the rationale behind them, based on practical experience on the ground over many years. I beg to move.
My Lords, I support these amendments and I especially support the noble Lord, Lord Mawson. It was typical of him that he started our thinking about what health is; I am sure there are many answers, but I think one of them might be integration—not just integration on the biggest scale but in terms of neighbourhoods, communities and what we now call place. That is so important. Those are the building blocks of all we are trying to do in the hierarchy of the National Health Service.
I am inspired by the noble Lord. He is a man of infinite resource and sagacity, an entrepreneur and, above all, a great achiever, based on solid principles which he believes in and, like a man of the cloth, is anxious to spread to others. He does so with really good effect.
It is no accident that I entitled my first report to the Government, many years ago when I was Mrs Cumberlege, Neighbourhood Nursing: A Focus for Care, as I believe the neighbourhood—or, in today’s parlance, the place—is all-important. This is what colours how people think, behave, succeed and, sometimes, fail. The noble Lord, Lord Mawson, has shown how even the most deprived areas can be rejuvenated and thrive with strong leadership, purpose and commitment. The noble Lord’s deep unshakeable philosophy is that patients, people and the local community should be the movers and shakers and be in control.
I want to mention Bromley by Bow, because it was a really innovative and new way of thinking about things. I remember visiting it years ago, not quite when it first started but when it was beginning to really thrive. Bromley by Bow was the first health centre in the country to be owned by the patients. Founded in 1984, it began with just 12 elderly patients, a rundown church, and just £400 in the bank. Today, by applying entrepreneurial principles to challenge social and health issues, it now has more than 250 staff. It is responsible for 43,000 patients, as the noble Lord said, and four health centre sites across Poplar. It operates on 30 sites even more widely across east London. It has supported local entrepreneurs. What is really interesting is that it has built 93 small and medium-sized enterprises. This is people helping themselves and ensuring that there is employment through a charitable structure, a housing company, which is controlled by the residents and now owns 10,000 properties and 34% of the land in Poplar.
This is a remarkable achievement in a very poor part of London. It is effective because it recognises that health and wealth are profoundly connected—not in huge municipal buildings and ivory towers remote from their populations but by the people who live and work in that area. The schemes are intertwined with the population. They are neighbourhood schemes and recognised as such. They are valued by being part of the destiny of a place in which local people live and work.
I visited Bromley by Bow in the early days, as I said, and I am really disappointed by my GP practice in the village in which I live and grew up. My father, one of two GPs, knew his patients literally inside and out. He knew who was getting off with whom. As his children, the first thing we learned was confidentiality and how to respect it, because we heard all sorts of things. He managed to get a health centre built. It is called that: above the entrance to the building it says, “The Health Centre”, but today it has been renamed the medical centre. It is a service that is not about health but about transacting to patients what the doctors think they need. The practice even shuns social prescribing, which is prevalent in many areas. It is also very careful not to involve the community. The friends of the health service have become disillusioned. They were established about 20 years ago and they are fed up with what is going on. Two weeks ago, they closed that organisation.
The noble Lord, Lord Mawson, in his Amendment 41A seeks to use the new world of integrated care boards to ensure that local representation is guaranteed. We have had a lot of debate in this Committee about who should be on what board and so on, but in listening to those debates—there was a big one last Tuesday—I was very struck by people talking about the big battalions. I could see that people were trying to ensure places on the integrated care boards that were represented by the big battalions. That is understandable. They are the component parts of the NHS. There are parliamentarians who see this as the only way forward.
The noble Lord, Lord Mawson, has shown us other ways, but it is a struggle. Today, the Bromley by Bow Centre has to deal with far too many sources of funding from the public sector. The money from the Treasury is disbursed to the silos: education, local government and other agencies. The centre spends too much time trying to put it back together again to deliver integrated projects. The centre runs hand to mouth, even after all these years, because mainstream funders in government do not recognise what the centre actually does. Schools, treatment centres, tertiary colleges, hospitals and traditional health centres are well understood, but Bromley by Bow does not fit any of these traditional silos.
I welcome the amendment and the others that follow it. The noble Lord is trying to free up the claustrophobic, traditional ways of not only working but, equally importantly, thinking. But the dilemma we face is this: warm words are given that we must not stifle innovation, but innovation is challenging. It is uncomfortable. When Henry Ford was describing his new invention, the motor car, he asked the public what they thought of it and what they would like. The reply he got was, “Just give us faster horses.”
We have a serious dilemma, as big government departments, especially the Department of Health, are about providing the same standard of health and the same provision across our nation. Again, we have a debate on that concerning Scotland, Wales and Northern Ireland. But even the nation grumbles as soon as it perceives a postcode lottery appearing.
Trying to square this circle is really difficult. The department seeks change through laborious systems. Those are the tools it has. Big departments deliver to the nation through their own power lines. This amendment threatens a short circuit that might set the structure alight or give the department an electric shock. That is no reason not to try. People of stature and proven trustworthiness who are competent and prepared to take responsibility for their innovations and to report to the department, say, every two or three years an audited evaluation of the scheme’s progress and outcomes, should be supported. It might help to square the circle, because if the funders of public money have to be accountable, this is one way of doing it.
I support not only innovation but these amendments. I urge both Ministers to risk their all: to let new ideas for places in need, through special workable collaboration, have their head. If we want to level up, then let us be brave and let sparks fly, because it is time to get behind people with a proven track record who are entrepreneurial, not people who talk and write reports about it.
The noble Lord, Lord Mawson, has taught us that the future is about creating a learning-by-doing culture, as he mentioned in his introduction. That is the culture that we want in the NHS, where the whole system learns through best practice on the ground, in real places with real people. Where things are not working, let people such as the noble Lord intervene and turn problems into opportunities. He has spent his life doing just that.
Seeing is believing. I encourage my noble friend on the Front Bench to visit Bromley-by-Bow, as a past Minister, Sir Brian Mawhinney, did. He ensured the future of this enterprise for a few more years and enabled it to flourish. I know that ministerial diaries are a real challenge, having had one, but I assure my noble friend that a visit to Bromley-by-Bow will never be forgotten and will make a deep impression.
Might I have some clarification from the noble Lord, Lord Mawson? He and the noble Baroness, Lady Cumberlege, have referred to three amendments and I can see only one. I would be grateful if he could enlighten me on which the other two amendments are that we might be addressing in this debate.
My Lords, it is a huge pleasure to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Cumberlege. I have signed and strongly support all the amendments tabled by the noble Lord to ensure that integrated care boards are closely connected to local communities. We have riches yet to come: the noble Lord’s later amendments ensure that local solutions are prioritised, and that procurement is firmly rooted in local communities, but I will speak only to Amendment 41A.
I will give an example of when the noble Lord and I have been involved in another project, beyond the very important Bromley-by-Bow project that the noble Baroness, Lady Cumberlege, talked about; namely, the St Paul’s Way Transformation Project, the health, education, jobs and skills, and community campus which started in 2006. It is a great example of a response to the local challenges faced in an east London neighbourhood very close to Bromley-by-Bow, with failing health and education services and community relationships. This transformation project was focused on integration from day one and has been a huge success.
The noble Baroness, Lady Cumberlege, talked about the extraordinary track record of the noble Lord, Lord Mawson, as a social entrepreneur. He launched this project in partnership with the NHS and Tower Hamlets Council, and brought together the local authority, the local school, the GP network, the local housing association, Poplar Housing and Regeneration Community Association, and the diocese of London, to bring about transformational change in and around St Paul’s Way, a main street running through Poplar. Together they built a new secondary school, new primary school, new health centre, new mosque, new community centre and restaurant, new park, new street scene and 595 new homes. In parallel with this, the quality of the local leadership, and hence of local service provision, was transformed. The failing secondary school moved to Ofsted outstanding, the failed GP practice was replaced and its successor became CQC outstanding, and the independently monitored residents’ satisfaction level is currently 85%.
The St Paul’s Way project has been a great success story of local partnership with other local actors. For example, near neighbour Queen Mary University of London, the governing body of which I chair, with two campuses in Tower Hamlets, and which is intimately involved in the governance of St Paul’s Way Trust School, helped design and develop the school’s new science labs. They are in the health building, which the school uses and where we have taken space for our school of dentistry and DNA research.
Partners in the local schools, the GP practice and the housing association have played an important role in recent years, as they have shared their work and experience with communities in towns and cities across the north of England and now beyond. However, the project faces major challenges, as outdated NHS procurement systems are now in danger of undermining the good work that it has been doing for over a decade. Amid this project being put together, the PCT procured a primary healthcare provider with no London experience, let alone any local experience. After two years, it surrendered the contract because it had not understood that primary healthcare is very different and costs a lot more to deliver in Poplar than in affluent suburbs. This experience is an illustration of the importance of there being a neighbourhood voice in the making of decisions by the NHS, which, if they are got wrong, can damage the ability of local integrated partnerships to function and develop effectively at the neighbourhood level. There is an opportunity to address this in legislation.
In this light, how can the Government make integration a reality? This is a clear example of disconnects that will be replicated on other streets across the country, and a demonstration of what happens when the NHS procurement systems and policy do not take place and neighbourhood seriously. Health is about bringing people and communities together, not undermining them. The solutions are often local and not in large outdated systems and processes. This local approach must be embraced. It is at the 50,000-person neighbourhood level, not an enormous eight-borough ICS where integration aimed at innovation in prevention and recovery can be most effective. Neighbourhood must be understood, valued, and given leverage in the system and flexible use of budgets. It is at this level that the actual practical interventions can happen. It is here that schools, housing, job opportunities and community action can happen. Neighbourhoods can act with speed and agility.
The noble Baroness, Lady Cumberlege, suggested that the Ministers visit Bromley-by-Bow; equally, I suggest a visit to the St Paul’s Way transformation project. This amendment is as much about creating the right culture as the right representative structure. I hope that the Government accept this important amendment and the other amendments tabled by the noble Lord, Lord Mawson, on this subject.
My Lords, I too was very happy to sign this amendment. I will speak only to it. I congratulate the noble Baroness, Lady Cumberlege, on her very moving speech, and the noble Lord, Lord Mawson, on a very comprehensive speech. I will be brief. In view of the logic of everything that I have heard in debates on previous amendments this afternoon, this amendment is even more important than I thought. When the Committee is discussing how to make the ICBs as effective, powerful, salient and comprehensive as possible for the people that they are bound to serve, all these factors must be taken into consideration, but the power of place itself and the opportunity that the ICB creates to make this manifest, just as the noble Lord, Lord Mawson, has made manifest in Bow, is a unique and highly innovative opportunity, and one which may not come again.
What the noble Lord proposes is extremely modest. It is to give just one person from the partnership voting power. However, it is essential, and it is in the spirit and the logic of what place-based partnerships are intended to do. It means that on the ICB there will be people who can bring nearsight, access and reach into the community to the decisions of the ICBs. They can help to inform those decisions, to bring that knowledge and sensitivity of the lives that people live, what they are faced with, and their specific choices. They are one of the most optimistic partnerships and ideas that we have had in this House for some years.
I have spoken many times in this House on the power of place, what it can achieve and how it affects people’s lives, particularly their health. The noble Lord, Lord Clement-Jones, and I published quite a useful report on building better places when we were on the same committee a few years ago. We diagnosed the relationship between good design, good buildings, good environments and good health. Maybe it is time to get that back off the shelf.
What is also useful is that the partnership principle is alive and well and is generating good practice. There is increasing evidence that it works and that there is an increasing exchange of ideas and skills, and we are learning all the time about what is possible. There is nothing to be said against this.
The expertise that the partnership can offer to the ICB may come from different partners. I am particularly interested, for example, in the role that housing providers could have, and I am sure the noble Lord, Lord Best, will speak to this in his amendment. They will bring a perspective from the point of view of the tenant, and the diseases of poverty in poor housing, which the board will need to hear, and act on.
Equally, there could be a role for mental health providers who know why young people cannot access mental health support. They know where the bottlenecks are, and what is needed. The partnership will choose for itself who will represent it, who has the most effective voice and who knows the place, as has been said this afternoon. But the essential criterion is that they know what will be delivered best.
I hope noble Lords will indulge me for a moment as I share a bit of history, because this has a very long history. In 1889, Charles Booth in his maps in Life and Labour of the People in London literally mapped disease against places and housing conditions—the stews of London—in a graphic illustration of where the worst concentrations of poverty were. In so doing, he redefined both health and poverty. Significantly, the first evidence came from the school boards and the local policemen: real partners in place. He certainly understood that you could not reduce inequalities or promote good health unless you had decent housing, fresh air and a decent wage. The geography of poverty has not changed that much—it is still the geography of disease and premature death—and the prescription has not changed at all. This amendment is an opportunity to put that into immediate and direct practice.
I hope that the Minister does not need much persuasion on this. It is a very simple and a very necessary amendment, and he would certainly have the support of the Committee in entertaining it.
My Lords, I declare my interest as an adviser to Well North Enterprises, which was mentioned by the noble Lord, Lord Mawson. I congratulate him, and other noble Lords from different parts of the House who have spoken on this amendment, on making the whole issue extremely clear.
I will make a few very specific points. First, we have heard about great big projects making a massive different. Everyone in your Lordships’ House, I am sure, knows of smaller examples that are making a real difference, as well as the larger examples, and how the small examples are important and add up.
Secondly, this is about change happening locally, but it is also about what is happening globally. I have previously quoted, in this House, a saying by a friend of mine, who used to run the Ugandan health service, that “Health is made at home, hospitals are for repairs”. It is a powerful expression, and one might say that health is made at home and in the community, and in the workplace and in the school. It also contains the notion that health can be created; it is not just about preventing disease.
Noble Lords may like to know that, more recently, globally, the WHO published the Geneva Charter for Well-being at the end of December, which explicitly talks about the creation of a “well-being society”. So this is a global movement we are talking about, not just a local one—although, as the noble Lord, Lord Mawson, has continually emphasised, this is about the importance of practical changes at the local level.
I will make two final points. The big one is that when we think about the membership of the ICBs, it is important we have the insiders there—the clinicians and the people who know how the systems work—but we also need some outsiders there. Referring to the debate on the last group, this is not just about different skill sets; it is about different behaviours and doing different things in different ways. Those of us who have worked within the system are bound by the system and think in terms of the system and its regularities.
The sort of people the noble Lord, Lord Mawson, is talking about do not start by thinking about the system; they start by basing things on relationships and learning by doing—a point that he emphasised. So there are different ways of doing things, and it is important that, as these boards are constructed, they bring in people with that different approach, alongside the great knowledge and skill that NHS and other clinicians bring to this. I know that we will really achieve success by bringing together insiders and outsiders, and getting people working together and understanding how to do things.
My final point is that this amendment proposes having a person representing or drawn from these groups on the ICB. I recognise the debate that has been going on about tying the hands of local people about what is happening on these ICBs. I understand that as these things get larger not only are you including more voices but also, implicitly, you are including more vetoes. The health service has, over the years, suffered from having too many people with too many vetoes in terms of making change happen.
I understand the complexity and difficulty here, but the final part of my point is to ask the Minister a question. I asked him a question earlier, because—I do not know whether I am alone here—I am not sure that I understand how, in reality, all these bits will fit together and work together in this new structure. I know he committed, in an earlier part of the debate on the Bill, to providing us with a diagram and perhaps more of an explanation of how it will all work. I can see how the complexities of everything we are talking about here can be difficult.
The single point I want to reinforce is the importance of not just having insiders in the decision-making process, but also having more disruptive influences. It is not just about skill sets; it is about different ways of thinking and behaving, and a focus on relationships, not just on systems.
My Lords, I also rise to support the noble Lord, Lord Mawson, in his amendment, and congratulate him and his colleagues on the extraordinary work they have done.
I support the Bill precisely because integration will be key to delivering the health outcomes that we all seek. But I worry that, if the Bill is just rearranging the organisational deckchairs, with exactly the same people in different organisations with different three-letter acronyms, we will not change anything at all.
I think that, over the course of the nearly three days we have spent in Committee and on Second Reading, there is cross-party agreement on the nature of the problem we are trying to solve. In each debate we have had over the last two and a half days, whether on health inequalities, mental health, the social determinants of health, or person-centred digitally enabled care, there has been extraordinary cross-party agreement on the nature of the problem. As the noble Lord, Lord Clement-Jones, said, we are debating and disagreeing more on the means to the ends than anything else.
One of the means to the ends is local—genuine local ownership and leadership. Like many in your Lordships’ House, I have made the pilgrimage to Bromley by Bow and I have also been to St Paul’s Way. When I first joined the NHS, about five years ago, I was told to go to Bromley by Bow, and I was told by a number of NHS insiders how brilliant it was, but how impossible it was to replicate anywhere else. “Go and have a look at it, Dido,” they said, “because you’ll be amazed and impressed, but no one’s worked out how to spread it”.
What I have actually discovered, as we have heard today from people with far more experience of place-based leadership than I have, is that brilliant though Bromley by Bow is, it is not alone. There are fantastic place-based leaders in communities across the country. It is those local groups and leaders who we owe the exit from Covid to more than anyone else, I suspect.
I have had the privilege of working alongside them. I have been to north-west Surrey with the noble Lord, Lord Mawson, but also to Wolverhampton, to the Guru Nanak Sikh gurdwara, one of the first local testing sites for NHS Test and Trace. I have been to Gloucester and spent time with Gloucester FM, a local community radio station that for the first time in its existence got funding to run an advertising campaign to encourage people to come and get vaccinated in the local community. That was the first time it had succeeded in working collaboratively with the local NHS.
I have been across the country in the last two years talking to people from groups who feel excluded. Whether it is the Roma Gypsy community, Travellers, refugees, taxi drivers or faith leaders from a whole host of communities, all have told me—in both my previous role as chair of NHS Improvement and as executive chair of NHS Test and Trace—how in different ways they felt excluded not just from the NHS but from society in general. They also said, generally to a man and a woman, how hard the NHS is to work with when you are from a small, outside local group, as those of us who have worked in the NHS know.
It is with that knowledge base that I wholeheartedly endorse the spirit of the amendment of the noble Lord, Lord Mawson—but with a “but”. I have been consistent in the last two and a half days of Committee in being nervous about adding specific roles and experiences to what is now a growing list of characteristics and past experience we would all like to see in this new three-letter acronym NHS entity, the integrated care board.
I would like to post a question to the Minister. It is clear that we need these local voices—the grit in the oyster, as my noble friend Lady Cumberlege described it; the difference that the noble Lord, Lord Crisp, is referencing; people from outside the system—if this new reorganisation is going to be anything more than a rearranging of the deck chairs. How will we ensure that those local voices are genuinely heard in an integrated care board?
My Lords, I rise to support the amendment in the name of my noble friend Mawson and others, and in so doing congratulate him on his thoughtful introduction. It is clear that one of the most important aspects, and the purpose, of this Bill is to ensure integration at a local level. But the purpose of that integration must surely be—as has been confirmed by the Minister—to improve health outcomes for the entire population. It is well recognised that that can happen only if the social determinants of health in local communities are addressed appropriately and effectively, in a way that our health system has not been able to do to date.
If we accept that to be the purpose, then local integration—that focus on and understanding of the social determinants of health—and responding to local needs must be secured in the organisation of the integrated care systems and their boards. As we have heard from the noble Lord, Lord Mawson, and others, to achieve that, one must not only understand, appreciate and hear the local voice, but be clear that the culture that is established in these systems is responsive to those voices and is determined to act on them and the understanding of the local situation—particularly those social determinants that extend far beyond what has been and can be delivered through healthcare alone—and focus on other issues such as housing, education and employment. It would be most helpful if the Minister, in answering this debate, could explain how that is going to be achieved in the proposed construction of the integrated care boards.
Of course, one recognises that Her Majesty’s Government are deeply committed to this agenda. But it is clear that if these boards are not constructed in such a way that they can change the culture and drive, in an effective and determined fashion, a recognition of those social determinants and create opportunities at a local level to address them, much of the purpose of this well meant and well accepted proposal for greater integrated care at a local level will fail.
My Lords, I did not originally intend to contribute to this debate. However, I would like to thank the noble Lord, Lord Mawson, for his Amendment 41A, which, although modest in scope, has initiated an extremely useful debate and raised a lot of important issues. I do not want to add a lot of material to the debate, but I want to focus on the questions that have emerged from it.
It will not surprise noble Lords to know that I have been to Bromley by Bow, as shadow Secretary of State, and as Secretary of State in the company of Sam Everington, now Sir Sam, who was and is an advocate for clinical commissioning. I put on the record that we must not lose sight of the value of clinically-led commissioning in delivering best-quality outcomes in healthcare. I do not think it is the Government’s intention to lose that, but we need to make sure it is not lost sight of.
Taking the example of Bromley by Bow, where did it get to? It had the Tower Hamlets clinical commissioning group, which was once CCG of the year, an exemplar in this field. That CCG and others eventually came together in a large conglomerate operation—I think the noble Lord, Lord Kakkar, will know it very well—the seven CCGs in north-east London. A population of about 2 million eventually came together in one large organisation.
We started out with clinical commissioning groups whose understanding was that they need to work with local authorities through the health and well-being boards. They needed additional powers for the integration, which is absolutely fine. But as I said on Second Reading, we have ended up with the NHS and its management getting themselves in a terrible twist in terms of organisational structures and geography. The noble Lord, Lord Mawson, talked about place-based partnerships with a population of half a million. The noble Baroness, Lady Cumberlege, talked about place and localities with a 50,000 population. My point is that the 2012 legislation, even if it did not achieve what was intended, at least said that clinical commissioning groups could determine whatever population they like—they could set it at whatever level made sense. They ended up with about 300,000, on average, but the range goes from 30,000 to 800,000.
I do not think we should get obsessed with geography. We should still, even at this late stage, be letting the ICS achieve what it needs to by being a relatively large organisation with the capacity to do population health management and to manage commissioning at a higher level. Going back to what my noble friend Lord Hunt of Wirral said, it should be bigger—this is the key to why size matters—in the jungle than the big provider trusts, making sure that conflicts of interest do not arise and the providers do not run the commissioning. But then, if you have a big ICS, there is a big gap. How is place and local leadership going to be incorporated? The noble Lord, Lord Mawson, rightly talks about it being represented on the integrated care board. But where is it in the Bill? I know that NHS England, NHS Improvement and the Local Government Association have produced guidance and referred to place-based partnerships being an integral factor in the Bill. But I do not see it in the Bill. It is not there. How are we going to put it in the Bill? How are we are going to make sure it happens? How are we going to achieve the objective that the integrated care boards genuinely integrate health, social care and the whole range of those services, which in my view is what they should do, in order to deliver health?
The integrated care partnership, incorporating health and well-being boards, should be about achieving the social determinants of health. I depart from the noble Lord, Lord Kakkar, in that I do not think it is the job of the health system to deliver the social determinants of health. It is the job of government to deliver the improvement in well-being and health that is implied by moving in the right direction on the social determinants. The integrated care partnership is where that should happen.
I see no reason why the clinical commissioning groups cannot be a place-based, clinically led basis for creating place—they are going to be abolished, but in that sense, why are we doing that, since they already exist? Secondly—to repeat a point—health and well-being boards to my mind are the basis for creating an integrated care partnership that is the essence of well-being. That seems to me a much simpler structure. I was accused a decade ago of making it all too complicated; it is now at risk of becoming even more complicated. Let us at least start with what we have, which is exactly what they did in north-east London. They came together and said, “Look, for the three boroughs of Newham, Tower Hamlets and Waltham Forest we can create something that is large enough to work, and inside it we have the borough-based relationships which are the method that we ourselves apply locally to deliver the health and well-being that we hope to achieve”.
So I ask my noble friend, at this stage—as we are just starting out on this—whether he would be kind enough to show us where in the Bill the essential element of place is to be inserted. Then we can debate it further and put it into the Bill in its right form.
I thank noble Lords for what has been a very interesting and important debate. I thank the noble Lord, Lord Mawson, for his amendment, and I look forward to further development of the thought process that he has put before the Committee. Of course, it is not new. I started my working life working for Michael Young, the great sociologist in Bethnal Green, and we talked about ethnographic research in our neighbourhoods and places. It was about giving people who lived in those places power and developing their own leadership of what they wanted to happen. Of course, in those days, when he started doing his work, it was about regenerating inner London—the bomb-strewn East End. I had the great privilege of running the Young Foundation: a few years ago, I took a couple of years off from this job here to go and run it, and we were doing exactly the place-based work that the noble Lord, Lord Mawson, talked about.
The noble Baroness, Lady Harding, is completely right: there are many Bromley by Bow-type programmes across the country—and thank goodness for that. If the Minister decides to go on trips to places, Bromley by Bow is of course important. I went there when it started out, when I was the founding chair of Social Enterprise UK, and the noble Lord, Lord Lansley, is quite right: it is brilliant, it is wonderful, it does great work —but why has it not been replicated? That is a question I have discussed with the noble Lord, Lord Mawson, on and off over many years. But there are many other types, and I suggest that the Minister might go to Manchester, Bradford or Nottingham, where there are some brilliant programmes where this place-based delivery of healthcare and other care is thriving.
The consensus breaking out between myself and the noble Lord, Lord Lansley, is of course that this Bill is an opportunity: how and where in the Bill can that place-based initiative be expressed? Where is it and how can it be encouraged? The King’s Fund did a piece of work developing place-based partnerships as part of the process leading up to the Bill, which was published last year. It has some interesting and useful things which express the sorts of sentiments—but in NHS-speak—that the noble Lord, Lord Mawson, talked about today: the importance of connecting communities, jointly planning and co-ordinating services, making the best of financial resources, supporting the local workforce, and driving improvements through local oversight and quality provision. There are certain elements of this which need to be there and need somehow to be built into the Bill, possibly in enabling form, because they mean building multiagency partnerships which involve local government, NHS organisations, voluntary service organisations, social enterprises and the communities themselves.
The noble Lord, Lord Mawson, rightly asks in his amendment for one voting ICB board member to be nominated by place-based partnerships. That may or may not be a good way forward, but we are trying to do systems change and, whether or not putting one person on a board is the way to do that, it is a very good place to start. So we on these Benches are very interested in how this develops and want to be part of the discussions across the House about how we do that.
My Lords, no one is better placed, whether inside or outside your Lordships’ House, to advocate place-based partnerships than the noble Lord, Lord Mawson. I know he will remember that one of my first visits as a Health Minister in 2010, at his invitation, was to Bromley by Bow. What I learned that day made a deep impression on me, so I, like many noble Lords, need no convincing of the case that he and other speakers have made today.
I am aware that the noble Lord, Lord Hunt of Kings Heath, has tabled Amendment 165 on place-based arrangements, to be debated by this Committee later in our proceedings, so no doubt we will cover the issues in more detail then. For now, I say that the Government absolutely agree with the importance of having strong place-based elements in ICBs. Place-based structures will play an important role in delivering healthcare services for their population groups and we expect there to be open and clear lines of communication between the board of the ICB and place-based structures.
How is a sense of place given—as it were—tangible substance and meaning? I would argue that we do not necessarily need the Bill to articulate the reality. At a very basic level, an ICB will cover a geographic area. We would expect ICBs to be closely linked to their places via bodies such as health and well-being boards, where they will sit as the successor bodies to CCGs, and local authorities. ICBs will sit on the integrated care partnership as well as the health and well-being boards. Both bodies are vital in bringing together health, social care, public health and, potentially, wider views as well. That will be part and parcel of delivering their duty to involve patients, carers and the public when discharging their functions.
We expect ICBs to have place-based structures in place, but we do not want to prescribe what those structures are. As the noble Lord, Lord Mawson, said himself, we do not want ICBs to think that place-based partnerships are achievable via a central blueprint, or that a set of instructions from above is likely to be a substitute for learning by doing and local relationships. What we shall insist on is that an ICB sets out the arrangements for the exercise of its functions clearly in its constitution. Different areas have different needs, and I hope it is a point of agreement across the Committee that a one-size-fits-all model would not be appropriate.
I heard what the noble Lord, Lord Mawson, said about the need to join up strategy with implementation and having an individual whose job it is to oversee this. That may often be the way that ICBs choose to go, but we feel that requiring voting rights for place-based partnerships is simply not necessary and would come at a bureaucratic cost. Our view is that we should not attempt to overlegislate for the composition of ICBs. Instead, we should let them evolve as effective local entities to reflect their local needs. I hope the noble Lord, Lord Mawson, will forgive me for not wanting to pepper the Bill with requirements and duties for ICBs. If we want to make a thousand flowers bloom, I do not think this is the way to achieve that. I fear that the amendment would risk making the boards less nimble, undermining their ability to make important decisions efficiently.
Having said that, I am not at all suggesting that the centre should wash its hands of this agenda. In answer, in particular, to my noble friend Lady Harding, NHS England will be keeping a close eye on the constitutions of ICBs, and we expect the assessment that NHS England makes will include whether there are suitable place-based structures and whether there is clarity about the expectations and roles of those structures, including what they are responsible for commissioning, what powers have been delegated to them and what resources they are responsible for.
With those points in mind and looking forward, as I say, to our further debates on the subject, I hope that this assures noble Lords that the Government have this agenda very firmly in their sights and that NHS England has equally. Therefore, I hope that the noble Lord will be able to withdraw his amendment, in the knowledge that I am sure we shall have further things to say on this important subject.
My Lords, I thank the Minister for those thoughts and comments. I also thank noble Lords who have supported this amendment and this very encouraging debate. The purpose of today was to open up a discussion about these issues. They have been very well aired and I think the discussion needs to go further. Certainly, I would like to take further with the Minister and his colleague the discussion around the implications. My concern is to ensure that the significance of place and neighbourhood and that the role of the micro is absolutely clear at an ICB level. Senior colleagues in the NHS where I am working warn me to be very careful about this. The danger is that fine words will be used, but as others have said, this is not about words; this is about understanding the actions that now need to take place to really transform the health service. The micro and the macro need to learn to dance together, and that will not happen unless there is greater clarity on it. It has been a helpful conversation and one that I hope will be taken further.
I have a few final thoughts. It has been good to have colleagues from different parties and very different backgrounds in this discussion, which I have found very helpful. This is not a party-political matter; this is about the next 20 or 30 years of the National Health Service. There are likely to be different Governments and different parties with responsibility, but laying the foundation stones correctly and getting the detail right—it is all about the devil in the detail, in my view—is really important.
It was very interesting to hear bits of the history. It was Lord Michael Young who came to see me, many years ago, in Bromley by Bow, precisely because he got very interested in what we were doing. It was not just that he joined us as a community and became our patron—we have had patrons from different parties; Lord Peyton from the Conservative Party was a patron for many years, as was Lord Ennals from the Labour Party. Lord Young ended up asking me to marry him and his new wife. I had to do the marriage, and eventually the baptism of his child, so there is a long history. Allison Trimble, my former chief executive, was called to work in the King’s Fund precisely to help it understand the devil in the detail of what we were discovering, so this debate brought back many memories for me.
One of the last few things to say is that it is important in this journey that we create a learning-by-doing culture. This culture is very well known to science. In part of my life, I work with Professor Brian Cox, who knows a thing or two about science. I think the reason we get on is that we both understand that science and entrepreneurship are profoundly connected. It is not just the health service, in my view, but the whole public sector that needs now to embrace a learning-by-doing culture that moves beyond strategy and process into learning from the practical things it does and does not do.
Finally, I thank Suzanne Rankin, the chief executive of Ashford and St Peter’s Hospitals, and the chairman, Andy Field—Suzanne is a brilliant chief exec and Andy is a rather excellent chairman—for joining in this conversation with the Minister. I also thank colleagues from the hospital, who I think we would agree have been very brave, and who have now, with four local authorities, set out on a journey to lead the way in Surrey on what this might mean when you start to move it to scale. Having said that, I beg leave to withdraw the amendment.
Amendment 41A withdrawn.
Amendment 41B not moved.
We come to Amendment 42, where the noble Baroness, Lady Masham of Ilton, will be taking part remotely.
42: Schedule 2, page 137, line 43, at end insert—
“(7) The constitution must provide for one non-voting member to be appointed by the local healthwatch organisations whose areas fall wholly or partly within the area of the integrated care board.”Member’s explanatory statement
The amendment provides for local healthwatch organisations to be represented on integrated care boards in a non-voting capacity.
My Lords, I have a number of amendments in this group concerning Healthwatch and, although it is important, I shall attempt to be brief.
We debated this, of course, in the Health and Social Care Bill 2012. I remember the noble Lord, Lord Patel, led a debate in which he called for the national Healthwatch to be made independent. He said then that embedding Healthwatch in England in the CQC was a mistake. I agreed with him then and I agree with him now. I would argue to the Government that there would be a big advantage in making Healthwatch fully independent. Of course, I am also concerned about local Healthwatch, to make sure it has enough influence in the new system as well.
It is right to pay tribute to the work of Healthwatch. I think it has done a good job since it has been established. Recent reports of national Healthwatch have been about access to dental care, on which I have an Oral Question in a week or two’s time. It undertook a very interesting analysis of the Government’s social care plans compared with proposals, and compared that with what people had told Healthwatch would make social care better.
Locally, my own Healthwatch in Birmingham has done some excellent work. I particularly mention a recent report on digital exclusion during the pandemic, when there was a sudden shift—like everywhere—towards remote access to care. Birmingham Healthwatch identified five principles for post-Covid-19 care, to ensure that everyone has access to the appointments they needed. This included a commitment to digital inclusion by treating the internet as a universal right. I believe its work has contributed more generally to the way in which this is being taken forward in the system. I think that, under the circumstances it has been operating in—not without difficulty and not without some tensions with local authorities—it has made a good start.
I want to just push Healthwatch on a little further and I want the Government to help. First, I am absolutely convinced that national Healthwatch should be an independent body. I have never understood the thinking that it should be a statutory committee within the CQC. I assume it is because, at the time, the Government were going through one of those wearying bonfire of the quangos that all Governments go through before they set up new quangos, to then have another bonfire a few years later. It just makes no sense. Clearly, they have complementary roles, and I am sure that the CQC takes note of what Healthwatch says, but they are different roles: one is the statutory regulator; the other has a responsibility for raising issues on behalf of the public who use the health services.
The question then arises of how we can strengthen Healthwatch at the local level. Will the systems, the integrated care partnerships and integrated care boards, listen to what Healthwatch has to say? A recent survey of ICS leaders—all there, in position—for Healthwatch England and NHS England shows that 80% would support Healthwatch having a formal seat at the table of the ICB if it were set out in legislation or guidance. What about the other 20%? Should it really be down to the vagaries of local leadership to exclude Healthwatch from those local bodies? I really do not think so.
I do not know if the noble Earl, Lord Howe, in answering, is going to be of a centralist or localist philosophy, or both, but it is always interesting to discuss. He and I have been discussing NHS structure for some 25 years now, and somehow the arguments tend to go on. It would be a real advantage for boards and partnerships to have Healthwatch around the table. It need not have voting members—indeed, I do not think it should. It is doing incredibly good work and has not been given enough publicity or recognition by people in the NHS. This surely is a way in which we can do this.
The Government also need to look at the budgets of Healthwatch England, which is going to have to support extra work and will need to be given more resources. Through local authorities, we need to make sure local Healthwatch has enough resources to deal with the pressing issues and challenges it is going to face. Having said that, our job today is just to encourage national and local Healthwatch to build on what they have done. I hope we can do this in as positive a way as possible. I beg to move.
The noble Baroness, Lady Masham, is now able to speak and I invite her to do so.
My Lords, I am pleased to see that the noble Lord, Lord Hunt of Kings Heath, is taking part today. He has been involved in a family emergency, which shows how important grandparents are in the care of children.
I have added my name to some of the amendments in this group but support them all. The Bill will be improved if the patient voice is included in both the integrated care boards and integrated care partnerships by Healthwatch, which could collect data from different sources representing patients. There should be co-operation and working together throughout the NHS, co-operation with the CQC and better integration throughout so that standards are kept high across the country.
The recent report, chaired by the noble Baroness, Lady Cumberlege, First Do No Harm, also demonstrates how important the patient’s voice is. As Healthwatch is spread so thinly at the moment across England, it will have to be bolstered so that it can do the job. The Bill should set clearer expectations for local systems on the need to use the views and experiences of their local communities to inform decisions. The aim is to establish Healthwatch as an independent body rather than a sub-committee of the CQC. The voice of patients will provide so much first-hand experience, and public involvement is so important to help improve standards throughout the country.
Patients can highlight good experiences and services that need improving. Often, communication needs improving, as does hospital food, which differs across the health service, waiting times, late diagnosis, ambulance provision and many other concerns. Many patients want to give something back to the health service when they have had to use it. Being a dedicated member of Healthwatch could be a solution. I hope the Government will appreciate the benefit of the public working with them rather than against them.
My Lords, I am glad to see the noble Lord, Lord Hunt, in his place. I welcome him back and am pleased to hear that things are good with his family. As he mentioned, in 2012 I led on the amendment arguing for Healthwatch to be made independent. I did not succeed—it was defeated by 22 votes—but we had a coalition Government at the time, so I did not stand much chance anyway. I will try again today.
My name is attached to all the amendments in this group. They are the key amendments relating to local and national Healthwatch, and they address public and patient involvement in the Bill. The Bill says a lot about how patients will be centre stage in the whole reorganisation, so it is important that the patient voice be heard. How will we do that?
Amendment 220 is about the independence of Healthwatch England in statute and its ability to get the information about health services it will need to do its job. The Government’s genuine aspiration to establish an effective system of public involvement requires that Healthwatch England be strengthened by making it truly independent. In fact it deserves it; it has grown into its role and proved its worth. Healthwatch England should provide a national vehicle to drive standards of health and social care and identify areas of poor practice. It has a very special mission that is quite different from that of the regulator, the CQC, of which the Government want Healthwatch England to be a committee. Healthwatch England should be the voice of the people, the voice to which the Secretary of State listens, working in close collaboration with the CQC but also able to hold it to account.
Healthwatch England should be the voice of the abused patient—of the forgotten person with dementia on the second floor of a nursing home, of the child with a learning disability who is getting poor care on a children’s ward, of the people waiting for excessive periods for emergency care in an A&E department. When a local Healthwatch or member of the public raises their voice because of a persistent local problem, as occurred in Mid Staffordshire, Healthwatch England must hear it and respond immediately. To do so, it needs to be independent.
Embedding Healthwatch England in the CQC is a fundamental error, as the noble Lord, Lord Hunt of Kings Heath, said. Calling it “a committee” is a fundamental error: it diminishes its power and influence. The only people who think a committee is important are the people who sit on it. Having sat on so many of them, I might agree. It has been argued that locating Healthwatch England within the CQC puts it at the centre of regulation, where it can have real power and influence. However, it cannot have power and influence if it is a committee of the regulator. To have power and influence it needs independence and the ability to challenge the regulator, and to have influence with every local authority in England. It must be seen to be independent, not just called independent. Being independent and being seen to be so requires Healthwatch England to be run by a board that has public trust and confidence, meets in public and speaks to the public, not the board of the CQC.
With the development of the ICS, it is even more important that Healthwatch England is an independent voice of patients and the public. I agree with the noble Lord, Lord Hunt of Kings Heath.
My Lords, I support this group of amendments in the name of the noble Lord, Lord Hunt. My name is attached to Amendment 149, but I want to talk more generally about this group. Like the noble Lord, Lord Hunt, I am very supportive of the work of Healthwatch, at both national and local level. It provides very helpful and important insights about what it is like to be at the receiving end of our healthcare system. We sometimes do not hear quite enough about that. The national-local structure is helpful, ensuring that local bottom-up insights are then reflected in national-level reports.
Like the noble Lord, Lord Hunt, I have found some of the reports produced by Healthwatch recently, and during the pandemic, extremely helpful. I am thinking of its work on mental health—particularly, children’s mental health. It has also done a series of projects on social care that are very relevant to the current situation. One project particularly dear to my heart involved engaging with care home residents and their loved ones, and feeding insights into the development of national visiting guidance—very practical, important work. Another recent report, which I have already quoted in your Lordships’ House, looked at vaccine confidence and, particularly, what might need to be done to help support those communities with a higher degree of vaccine hesitancy; again, Healthwatch does some really important work.
I turn now to the amendments more specifically. In the recent survey of ICS leaders for Healthwatch England and NHS England, 80% of respondents said that they would support Healthwatch having a formal seat on the ICB if this was set out in legislation or guidance. We have already heard the question: what about the other 20%? Should noble Lords have the time, I recommend a quick look at the Healthwatch document and the survey, mapping the relationship between local Healthwatch and integrated care systems. There is a lot of important information in it. I particularly noted in the survey that 100% of ICS respondents said that they would support a mandated seat for Healthwatch on the integrated care partnership. That was one of the main reasons that I wanted to add my name to Amendment 149.
Fundamentally, why I think this so important is that I am not convinced that, in all our important deliberations so far, sufficient weight has been given to what we might call the service user voice or the individual patient voice more generally. These deliberations have, understandably, been very much about structures and how these new integrated care systems will work. I feel that there is scope for the Bill to set out some minimum requirements to ensure that the patient voice is heard at the decision-making table. It is fine to have lots of other sentiments about patient voices but, are they there, and are they heard at that table?
The principle is really quite simple. Patient choice at an individual level—that is, in relation to the patient’s own healthcare—has changed radically. We have moved from a situation where the doctor knows best and will tell you what is happening to the doctor setting out the options and you making a decision with the doctor—almost a co-produced decision. We need to think more about that approach, at the community level, the local level and then the integrated care system level. This will be particularly important in relation to tackling health inequalities because, frankly, if people are not involved in the decision-making or feel that their voice is not being heard, they often do not trust the outcome.
A recurrent theme in our discussions so far has been who should be on what body. We have had those big debates about whether there should be public health and mental health representatives and so on, which are very important, and those conversations still have some way to go, and we have just had this very interesting debate about place-based partnerships and “insiders” and “outsiders”. Again, that has quite a long way to go, but it would be ridiculous if the patient was seen as the outsider; patients need to be front and centre of all this and the reason we are undertaking a restructuring in the first place.
My main plea is that in all our discussions we consider the user voice and how it can be heard. I think that Healthwatch is an obvious way of doing it; it has the existing infrastructure. There may well be other ways of doing it, but that was the reason I was keen to support the noble Lord, Lord Hunt.
My Lords, I refer to my health interests as declared in the register; in particular, I chair the General Dental Council, but I should make it clear that I am not speaking on its behalf in Committee.
Almost exactly 35 years ago, I became director of the Association of Community Health Councils for England and Wales, which was then the national statutory body representing the interests of the patients and the public in the NHS. Since then, both local and national representation of patients has gone through a series of iterations—indeed, the number of occasions on which I have been sitting on the opposite side of the Chamber from the noble Earl, Lord Howe, talking about patient representation seems too many to recount. After community health councils, we went through a series of iterations of which local Healthwatch is the latest version. I admit that when we had the debate which my noble friend Lord Hunt began by referring to, I was extremely dubious about whether local Healthwatch would be able to flourish and the national body be effective. I have to say that my worst fears have not been founded, but it has to be recognised that the way in which it was structured, in particular the late changes introduced by the Government during that legislation, made it much more difficult for Healthwatch, both at local and at national level, to be as effective as it might be.
The context of this debate is the centrality of patients and service users in delivery. Every time the NHS is reorganised, whether it was the reorganisation of the noble Lord, Lord Lansley, or the reorganisations we have every three years or so, there is always a grand White Paper which says, “Patients will be at the centre of this new structure”, but it is never quite like that. In the new arrangements being brought forward, the Government need to make sure that the local patient voice is represented and articulated and that, at national level, those voices can be aggregated and put forward. That is why this group of amendments is so important.
We have just had a debate which ended up revolving around how many separate interests should be represented on the various bodies that we are creating. I can see the problems if we add and add, and how difficult that is going to be. However, what I hope the Government will take away from the consideration of this amendment and look at before Report is how they can make the patient representative structure within the future arrangements better and more effective. I think that a number of things could be done.
The first is about the budgets. The budgets for local Healthwatch go through a complicated, notional process. It is very difficult to define why the allocations are what they are. It would be far better if it was clear what the expectations were to run a local Healthwatch and to deliver what is needed.
The second thing that can be done concerns the degrees of independence: from the local authority, health providers and health commissioners, at the local level, and from the CQC at the national level. The noble Lord, Lord Patel, talked about the problems of Healthwatch England being a sub-committee of the CQC. I understand that the relationship has actually worked quite well, but that is probably because of the good will of all concerned. It might be that, in the future, Healthwatch England has serious criticisms of the regulator. How can it do that, as a sub-committee of that body? Whether formally or informally, you can see the difficulties.
Similarly, because of the way in which local Healthwatch organisations are created and their relationship, ultimately, to local authority funding, you can see again how, when we are talking about increasing the integration of health and social care, the independence at local level may be compromised. So the question of getting this budget and the constitution right is very important to ensure that you have that independent voice.
I hope that the Minister will take away from this afternoon’s discussion the need to look at how they can ensure the future of the patient voice, ensure that it is done effectively and ensure that it is independent and properly resourced. Only by having that independent voice will you improve the quality of healthcare and health services.
I remember that, back in the dim distant days when I was director of the association, and even when I was a community health council member 10 years earlier than that, 45 years ago, it was often the local community health council representative sitting there at meetings with the professionals and managers, all of whom speak their own language, which is rather different from that of the patients. They were being told things about the way in which the local service was operating and being delivered at the local level, which they would not have heard otherwise. That is why, at the centre of our deliberations, at both local and national level, the patient voice must be heard and properly supported and resourced.
My Lords, I strongly support that. It seems to me that the National Health Service is devoted to looking after patients. Therefore, it is very strange that there is no national voice for patients to speak to it. In a way, Healthwatch England fulfils that—but in a very awkward position.
I do not know exactly the relationship within the constitution of the committee and the CQC. For example, it may be important that knowledge that Healthwatch has goes to the CQC, but it must be much better for it to be independent at every level, national and local, and to not take part in any of the particular arrangements but rather independently give the pure voice of the patients, which it has received, as it were, from the people who have been served by the National Health Service, whether that is complimentary or otherwise, according to what has actually happened. That seems to me to be essential. I cannot think that it is effective to have a National Health Service with no voice to be heard at the centre from the patients.
My Lords, I quite often buy things online and, a few days after the product has arrived, I often get an email saying, “How did we do? Give us one, two, three, four or five stars.” That can be very irritating, and I suspect that, on the whole, people do not respond, unless the service has either been dreadful or brilliant—that is certainly so in my case. The voice of the patient is far more important than that and, if we are to assess the performance of different ICSs, the voice of the patient is absolutely fundamental to gathering the evidence, using which we can compare their performance.
A few years ago, I had to be in hospital, just for a few days. At the end of my treatment, when I was about to go home, I was handed a little slip of paper. I do not know if they still do this, but it had some kind of snappy title like, “Tell us how we did”. I thought it was totally inadequate, because here was I, as a patient, having had a general anaesthetic, feeling a bit wobbly, but crucially, having had only the experience of that particular treatment in that particular hospital. The beauty of Healthwatch is that it can compare the experience of patients, heard directly from those patients, of a lot of different treatments in different settings. It can bring together the voice of the patient and—absolutely crucially—it has the ear of the people who deliver those services and can authoritatively explain to them where they are doing well and where they are doing badly.
In this group of amendments, the noble Lord, Lord Hunt, and others have got it right in their suggestions about the level at which Healthwatch should have a voice: non-voting membership of the ICB, voting membership of the ICP and, crucially, independence from the CQC. The noble Lord, Lord Harris, put it very well: how on earth could Healthwatch criticise the CQC as the regulator if it is part of it? It is a little bit like asking a civil servant to criticise the Prime Minister, is it not? The noble Lord, Lord Hunt, and others who have spoken have got the level right at which Healthwatch should play its part in this great new world of integrated services. The view of the patient of the experience that they received at the hands of all the health and care services is absolutely crucial to being able to compare the performance of these bodies that we are setting up.
My Lords, I strongly support my noble friend Lord Hunt and other noble Lords in their quest in this suite of amendments to underline the important and crucial role played by Healthwatch, particularly at local level, and to ensure that the new NHS structures and processes in the Bill fully recognise this.
Under the 2012 Bill, the noble Lord and others who have put their names to the amendment and who have spoken in today’s debate were all strong advocates of Healthwatch, and clearly remain so today. The concerns deeply expressed then of the Government’s decision to make national Healthwatch a sub-committee of the CQC, and not the independent organisation that it needed to be, have again come to the fore. Amendment 220 would add a new clause after Clause 80, seeking to establish Healthwatch England as a body corporate that provides an annual report of its activities to Parliament; it has the full support of these Benches. As the noble Lord, Lord Patel, has strongly emphasised, failing to provide for the independence of Healthwatch was a fundamental error that needs to be put right. He set out a particularly strong case, as have other noble Lords this time around.
Amendment 42 to Schedule 2 seeks to ensure that Healthwatch is a non-voting member of the ICB, so that there can be a genuine championing of patients’ voices and views, which many noble Lords have spoken so strongly about today. These are views fed back from evidence and surveys conducted by both national and local Healthwatch organisations. At the very least, it is crucial to seek to ensure—as set out in Amendment 103 to Clause 20—that the ICB is obliged to fully consider Healthwatch reports and that that body leads any local consultations proposed in the ICB forward plans.
Amendment 149 to Clause 21, seeking to ensure that ICPs have a Healthwatch nominee in membership, is also important, given the local Healthwatch links to both the NHS and local authority bodies, patients and clients.
Key questions on how Healthwatch, both at national and system level, is to be funded were raised by my noble friends Lord Hunt and Lord Harris, particularly about the whole process of allocating funds. This is important in view of the increased role of Healthwatch in the additional 42 ICSs. I look forward to the Minister’s response.
Finally, I also endorse noble Lords’ comments on the excellence of the reports produced by national and local Healthwatch organisations. Their guidance on access to social care, mentioned by several noble Lords, and comments on the detailed proposals later in the Bill on the care cap and the recent White Paper, are clear and accessible to service users, and closely examine the impact for them, and for the thousands of people currently waiting for assessment and access to key services. However, those are issues for another day. I hope that the Minister has listened to the debate.
My Lords, these amendments deal, in their several ways, with the role of Healthwatch both locally and nationally. I begin with Amendment 42, in the names of the noble Lords, Lord Hunt of Kings Heath and Lord Patel, and the noble Baroness, Lady Thornton. This amendment would require ICBs to make provision in their constitutions for a non-voting member to be appointed from local Healthwatch branches.
I lay great importance, as do other noble Lords, on Healthwatch’s work on patient advocacy. However, as I said in relation to other amendments on the membership of ICBs—I know this is turning into something of a mantra—we want to avoid the Bill’s provisions being too prescriptive. It is essential that we provide local leaders the flexibility to design the board in a way that best suits each area’s unique needs. Even a non-voting member risks making the boards less nimble, undermining their ability to make important decisions efficiently. As I am sure the Committee is already aware, the ICB can appoint more members, including a Healthwatch representative, if it wishes, and I am sure many of them will. What is key is that local boards should be able to decide for themselves to appoint individuals with the necessary expertise to address local needs, and we want to allow them as much scope as possible to do so by not prescribing who all those members should be.
That said, I recognise that the growing complexity of health and care demands that we listen to the voice of patients, carers and the public. We want to ensure that they are heard throughout the system. I contend that there is adequate provision in the Bill to ensure that patients and the public are appropriately consulted and involved in decisions made by the ICB. I draw noble Lords’ attention to new Section 14Z36, regarding the duty to promote the involvement of each patient, and new Section 14Z44, regarding public involvement and consultation by ICBs.
I listened carefully to the noble Lord, Lord Harris of Haringey, as I always do, about the particular need for adequate and appropriate funding of local Healthwatch. If I may, I shall take away the points he made on that issue and others and write to him about them. We would expect Healthwatch to be closely involved with ICBs in carrying out their engagement and involvement duties. On what do we base that expectation? Many systems already have some system-level arrangements in place with Healthwatch. Indeed, NHS England has published guidance, which would apply to ICBs, on working with people and communities that encourages working closely with Healthwatch. Therefore, given that ICBs will already be required to engage patients closely in their decision-making process, and that we expect Healthwatch will be closely involved in that, we consider it unnecessary to require in legislation a member drawn from Healthwatch.
Amendment 103 would alter ICBs’ duties in relation to public involvement to require them to make adequate arrangements for the receipt and consideration of any relevant Healthwatch reports. As I said, the existing ICBs’ duties in relation to patient involvement are already comprehensive, and the amendment could unintentionally limit ICBs’ ability to form relationships with Healthwatch and other organisations appropriate for their area. As was the case for CCGs, ICBs will be required to make arrangements to involve patients in the planning of commissioning arrangements in areas that may impact the manner in which services are delivered, or the range of services available. This will ensure that patients receive appropriate representation where decisions are being made that could affect them.
I previously mentioned that NHS England, in its guidance to ICBs, has encouraged close working with Healthwatch. This guidance comes with the acknowledgement that what an appropriate relationship with Healthwatch looks like will vary from system to system. For this reason, we are seeking to establish comprehensive duties and requirements in the legislation while leaving the specifics of local relationships with organisations such as Healthwatch for ICBs to determine for themselves.
Amendment 118 would alter the consultation requirements placed on ICBs and their partner trusts in the development or revision of their forward plans to explicitly include Healthwatch as a facilitator for consultations with the people in the ICB’s area. Again, this amendment would create an unnecessary additional restriction on the ICB’s ability to carry out its functions in a way that best suits its area.
The provision in question sets out a requirement for ICBs and their partner trusts to consult the people for whom the ICB has responsibility when it seeks to develop or amend its forward plan. This is already a comprehensive requirement, which, in addition to ICBs’ general duties relating to patient involvement in decision-making, will ensure that people will have ample ability to have their say in how their ICBs plan and commission.
As I said, and as we all appreciate, local needs will vary, so different approaches for this engagement will be appropriate in different areas. Again, we want to maximise ICBs’ ability to conduct engagement under the legislation in a way that best works for them. We would expect Healthwatch to be closely involved in this process for the reasons I gave earlier. The central point is that we want to empower ICBs to work out the relationships with Healthwatch and local people generally that are appropriate for their areas, rather than creating constrictive requirements from the centre.
Amendment 149 relates to the integrated care partnership, which each integrated care board and its partner local authorities will be required to establish. This partnership is intended to bring together representatives from across the system and is tasked with developing a strategy to address its health, social care and public health needs.
To effectively fulfil the statutory requirement to produce a strategy, each partnership will need to involve a wide range of organisations and representatives from across the system, and we would expect a representative of Healthwatch to be a member of an integrated care partnership. However, once again, it is right that local areas should be able to determine the model and membership that best represent their area. As the footprint of many integrated care partnerships will sit across many Healthwatch areas, it would not be prudent to specify that only one representative should sit on the board, rather than give local areas the flexibility for each partnership to make their own arrangements appropriate to their circumstances—they may want more than one, in other words.
Amendment 220 would establish Healthwatch England as a body corporate and allow Ministers to use secondary legislation to set out its functions, board and funding. It is important to seek the perspectives of health and social care users. We value the voice of patients and use their views and experiences as a driving force for improvement. Healthwatch England is already well established as the independent champion for people who use health and social care services. It has a duty to understand the needs, experiences and concerns of service users and to speak out on their behalf.
Under existing arrangements, Healthwatch England already has the ability to exercise its four main functions: to provide leadership and support to local Healthwatch organisations; to issue recommendations and warnings to local authorities in England; to escalate concerns about health and social care services to the CQC; and to provide advice to the Secretary of State, NHS England and Monitor, and English local authorities. Healthwatch also has a duty to report annually to Parliament on how it has exercised its functions.
I listened with care, as I always do, to the noble Lord, Lord Patel. We believe that Healthwatch England is appropriately set up to carry out this important role effectively. As a statutory committee of the CQC, it has a separate chair and a committee of members who oversee strategy, provide scrutiny and oversight, and approve policies and procedures. The department provides funds annually to support Healthwatch England and local Healthwatch. In 2019-20 alone, over 350,000 people shared their views about health and social care services with Healthwatch England, and local Healthwatch helped over 960,000 people access advice and information. The Healthwatch network used this to make over 5,870 recommendations to improve services, based on people’s experiences of care.
I confess I was surprised to hear the noble Lord, Lord Patel, argue that Healthwatch England lacked public trust. I do not agree with him that it is not seen as being sufficiently independent. We have already heard from noble Lords about how well received the reports published by Healthwatch England have been and how authoritative they are seen to be. Healthwatch England is a genuine, and now proven, national voice for patients and I would suggest that it is valuable for the CQC, which has to opine on the outcomes experienced by patients, to have the voice of patients in its midst.
The Bill requires integrated care boards to make arrangements to involve patients in the planning of commissioning arrangements and we expect Healthwatch to be involved in this process. Further, Healthwatch will have a key role to play in integrated care partnerships. It is our expectation that a representative of Healthwatch would be a member of integrated care partnerships. In addition, new Section 116ZB, inserted by the Bill, requires ICPs to involve local Healthwatch organisations in the development of their strategies.
I hope I have given the noble Lord, Lord Hunt, and other noble Lords some reassurance that Healthwatch England is already established, is performing effectively under the CQC and has the ability to perform its duties, purpose and functions. It has had a positive impact on health and care services by ensuring that NHS leaders and other decision-makers hear the user’s voice and use feedback to improve care—that is what it is all about. This has been a good and wide-ranging debate. I hope I have reassured your Lordships about the value we place on Healthwatch. However, we must balance this with the values of flexibility and local determination. For those reasons, I ask the noble Lord to withdraw the amendment.
I am grateful to the noble Earl, Lord Howe, and all noble Lords who have taken part and been supportive of this group of amendments. I very much take what the noble Earl said about the general recognition of the importance of the work of Healthwatch, both nationally and locally, and the way it has gone about doing it. With Sir Robert Francis as the current chair of Healthwatch England, we have someone who commands a great deal of respect and gives the leadership one would expect from a person of that calibre and experience.
What we are looking for, though, is a visible sign of the Government’s intent on the importance of Healthwatch, both nationally and locally. Frankly, as the noble and learned Lord, Lord Mackay, suggested in his very helpful intervention, having the status of being a committee of a regulator does not give the right appearance of the importance and independence of this body. My noble friend Lord Harris is absolutely right that there could be circumstances in which Healthwatch criticised the work of the CQC. Indeed, the more the CQC takes on system responsibilities, the more likely that is.
In relation to ICPs, the Government “expect”. It is a very short journey between the Government expecting something and putting it in legislation—I hope they will give that some thought.
On the noble Earl’s concern about the size of ICBs, given what he said about conflict of interest issues earlier today, he must recognise that the seats will be empty most of the time, as NHS trusts and local authorities will clearly have to excuse themselves from most of the current debates within ICBs, because the boards will be talking about resources, commissioning, the development of services and the forward plan, all of which those organisations will have a direct interest in. That is why the whole structure of ICBs needs looking at again.
I am very grateful to the noble Earl for taking back the issue my noble friend raised about resources and the way the money flows down to Healthwatch. There is a suspicion here; I think the money goes nationally to local government and then you depend on local authorities to decide how much they will give to each local Healthwatch. I am afraid we know, as we have seen in other services, that some of that resource tends to get—how shall I put it?—diverted into other areas. I never understood why the Government thought that this was a good way to fund Healthwatch. If you set it up nationally as an independent body, the obvious thing to do is give the resource straight to national Healthwatch to allocate locally. I suggest the Government give that serious consideration.
This is one issue that we will want to bring back on Report, as it is important that Parliament gives a very visible indication to the NHS that we think Healthwatch is doing a great job but we want to see it have more influence in future. Having said that, I beg leave to withdraw my amendment.
Amendment 42 withdrawn.
Amendments 43 and 44 not moved.
Schedule 2 agreed.
Clause 15: People for whom integrated care boards have responsibility
Amendment 45 not moved.
Clause 15 agreed.
Clause 16: Commissioning hospital and other health services
46: Clause 16, page 13, line 28, leave out “it” and insert “the Secretary of State”
Member’s explanatory statement
This amendment, with the new Clauses before Clause 35 in the name of Baroness Bennett of Manor Castle, restores the duty on the Secretary of State to provide or secure the provision of services to that in the National Health Service Act 2006.
My Lords, in moving Amendment 46, I will speak also to Amendments 168 and 169 in my name. In an earlier group this morning we were talking about democratic accountability at the local or ICB level, particularly in relation to Amendment 23 from the noble Baroness, Lady Thornton. We were also, through the agency of Amendment 45 from the noble Lord, Lord Davies of Brixton, looking at the risk that people in England could be left without NHS cover. Those amendments were about the ways in which this Bill could go horribly wrong—certainly, I have no doubt, in terms of what the public want, if not necessarily in the unintended consequences of where the Health Secretary and the Chancellor are apparently thinking of taking our NHS.
A couple of hours ago, the noble Lord, Lord Hunt of Kings Heath, talked about how the Government are centralising power, with ICBs having to look upwards to the hierarchies above them. He used the phrase that they will be “beaten up by the centre”. As he was saying that, I was struck that a briefing arrived in my inbox at that moment from the NHS Confederation, NHS Providers and the King’s Fund, which very much focused on that concern about the Secretary of State’s power to direct. It is clear that the Bill will give the Secretary of State enormous power potentially to interfere in the most minute aspects of healthcare locally. That concerns a great many people. I think it is already clear that your Lordships’ House will keep talking about this and, very likely, try to change it in future, but we know we are unlikely to be able to entirely transform this Bill and the relationships between the centre and the local.
I come to a phrase: with power comes responsibility, and with great power comes great responsibility. I went looking for the origins of that phrase and it can be attributed back at least to the French revolutionary national convention or possibly to the King James Bible. The fact that it is to be found in many political contexts across the political spectrum perhaps shows that it might be considered uncontroversial.
I ask the Minister: where is the attribution of central responsibility in this Bill? That is a serious question. Where does the Minister think the responsibility of the Secretary of State to ensure that healthcare is available to every person in England resides in the Bill, or does he want to say that such a responsibility does not exist? If Americanisation steams ahead—and let us not forget the US has astonishingly high healthcare costs, with results resembling those of countries with vastly less funds—who will be held to account for that? That is what this group of amendments seek to achieve; to ensure that the Secretary of State is responsible for the outcomes of the Government’s Bill.
This group of amendments aims to restore the NHS in England as a public system as it continues to be in the rest of the UK and as it used to be in England. I do not want to get too far into the weeds and noble Lords can read the amendments and explanations for themselves, but I am aware that the meaning of the amendments is not particularly obvious in the text, particularly the first, so I will briefly run through them.
Amendment 46 replaces the word “it”, which refers to integrated care boards and their duties, so the amendment makes it the duty of the Secretary of State to commission health services
“to meet the reasonable requirements of the people for whom it has responsibility”.
That means the Health Secretary having responsibility for the people in England.
Amendment 168 restores the wording of Section 1 of the NHS Act 2006, giving the Secretary of State the duty to promote the comprehensive health service. It very closely echoes the wording in the founding National Health Service Act 1946.
Amendment 169 says that the Secretary of State must provide, to a level
“necessary to meet all reasonable requirements”,
services including hospital, medical, dental, ophthalmic, nursing and ambulance. I note particularly proposed new subsection (d), which refers to
“the care of pregnant women … and young children”
and picks up some of the issues we were referring to in the first group today. On reflection, we could perhaps improve the wording of that, but it is a start in terms of acknowledging the needs of children in the Bill.
The wording in both these amendments very closely reflects what was found in the 1946 Act, and in every Act up until 2012. I think it is worth reflecting a little on why that wording disappeared from the 2012 Act. It was because there was a move towards market-based structures and so we were relying on the market to provide. That has in this case, as in so many others, proved to be a disaster. Indeed, in bringing forward this Bill in this moment the Government are acknowledging that disaster.
The timing of this Bill is very interesting. As both Opposition Front-Benchers have noted, it comes at a time when the NHS is struggling to cope, yet it is facing this massive reorganisation. In terms of Amendments 168 and 169 I find myself in a situation I am not in very often; I am advocating to the Committee that we revert to the old, the tried and the tested—the kind of NHS that there is bountiful evidence the public actually want.
Similar amendments to these were moved in the other place. I note that in the discussion there it emerged that in the 2012 Act there was a compromise amendment. This arose, at least in part, out of the Constitution Committee. The compromise wording was:
“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.”
I cannot see similar wording in this Bill, but it is long and complex, so I would be interested if the Minister could point me to anything that he sees as similar to that 2012 compromise.
In the debate in the other place, the Minister said that this change was
“unnecessary as law. The Secretary of State has the duty to promote the competence of the health service in practice. He is accountable to Parliament for the comprehensive health service”.
Those words, “in practice”, are rather telling. We find ourselves, as we so often do, hearing from the Government, “Don’t worry; things will work out. You can trust us. This does not need to be on the face of the Bill”. That is something your Lordships’ House very often—I would say rightly—expresses great scepticism about. We want to see things in law to which the Government can be held to account.
We know all too well how creaky parliamentary accountability can be: how stretched and limited scrutiny in your Lordships’ House can be, let alone in the other place, where 44% of the vote in 2019 delivered 100% of the power to the Government. There is brilliant work done by Select Committees and brilliant questions asked by individual MPs to highlight issues, but the practical reality is that the Government can just ignore all those things and bulldoze through, and very frequently do.
I note that in the other place, the Minister further said that
“we should be wary about being overly prescriptive in primary legislation.”—[Official Report, Commons, Health and Care Bill Committee, 14/9/21; col. 183.]
But surely being prescriptive about the fact that we have a National Health Service is what the public unarguably want. The Government are being prescriptive about how they can control ICBs to control local services, but I would say that we have to be prescriptive about what the Government must do. That is a responsibility we must live up to. This is surely not overly prescriptive. I beg to move.
My Lords, the noble Baroness, Lady Brinton, is taking part remotely, and I invite her to speak.
My Lords, I am speaking in support of the amendments in the name of the noble Baroness, Lady Bennett, starting with Amendment 46. After many helpful discussions both today and earlier on in Committee looking at membership, structures and representations of ICBs, these amendments take us back to the first principles and ask your Lordships’ House to look at what should be in scope for the provision of NHS services. This is a really valid question.
The noble Baroness, Lady Bennett, referred to maternity services, but if I were to pick one of the services listed in Amendment 169, it would be dental services. There are millions of people in the country who cannot access an NHS dentist. The result is a worsening of dental health, which is especially worrying for children and young people. I am sorry to say that, over the years, Ministers have ignored the wider needs of the public regarding dental services. I think the point about specifying the provision of services such as this puts a very particular duty on the Secretary of State to force Ministers to make sure that they are also holding other parts of the health service to account.
The amendments turn our focus on to whether we still have an NHS that is a public health system or one that perhaps is paid for mainly by the public but run by a disparate number of bodies, including unaccountable private companies increasingly not based in the UK. They are particularly important in light of the report today in the press that the Secretary of State is planning to create the equivalent of school academies for failing hospitals and says that there will be a White Paper in due course. Just as an aside, do we need yet more reforms? Surely it would have been better to have a full range of Green Papers with an overarching vision of what the NHS in the 21st century should look like and how the structures should work. We are now waiting for two White Papers, while the passage of this Bill is irrevocably changing the structures of our NHS system.
Today’s announcement rings a number of alarm bells because there is an analogy with the education sector that is quite helpful. I remember that, in the 1990s, academies were going to be free from local authority control and that that, on its own, would inevitably make them improve—but that has not been the case. Various reports over the last 20 years have shown that a number of failing schools taken into multi-academy trusts and free schools have remained low performing. Structures on their own do not necessarily resolve this. Indeed, some multi-academy trusts have failed in their entirety, and one of their issues is the lack of public accountability—because Ministers have direct responsibility in the public realm for academies, and I worry that the Secretary of State may be proposing the same. If I was a senior leader in NHS England, I would be very concerned about that.
I am grateful for the earlier comments of the noble Earl, Lord Howe, on the need for Ministers to have the ability to appoint and, presumably, remove senior personnel on ICBs. But would the Secretary of State have responsibility for these academy equivalents and give them the right to access separate funding for capital expenditure and special projects? I raise this because part of the problem that we have at the moment is a diversity of funding mechanisms, structures and strands, which often take the eye of a leader—whether a Minister or one in the NHS—away from the provision of services.
The foundation of a public system was essentially removed by the 2012 Act, and, as the noble Baroness, Lady Bennett, said, the Constitution Committee suggested that there needed to be an interim remedy. It is important that we have reassurance that this Bill will not weaken it any further at all. I hope that the Minister can reassure your Lordships’ House that the Government want to protect the provision of NHS services, as part of a truly public health service.
My Lords, I thank the noble Baroness, Lady Bennett, for moving her amendment and other noble Lords for their contributions, particularly on the specific points about particular services, such as dentistry. All three amendments look back to the Health and Social Care Act 2012 and the National Health Service Act 2006 on the powers and duties of the Secretary of State in relation to the NHS and the services that it provides, restoring certain provisions in the 2006 Act.
Under the Bill, the ICBs and NHS England will have the duties to secure the provision of the services that make up the comprehensive NHS. There are probably noble Lords here today who were Members of your Lordships’ House in 2006. I came in in 2010, just as the equally marathon Health and Social Care Act from the coalition Government got under way, when the whole issue of the Secretary of State’s powers and duties came to the fore. As explained at the time, the aim was to separate the political from the operational responsibility and to better align the language to the reality of the purpose of the NHS, in “securing the provision of services”.
The arguments in 2010 and 2011 were fierce and passionate, centred around the subtle changes in the way that the duties were defined, as compared to the words in Sections 1 and 3 of the 2006 Act. They caused suspicion, confusion and fears that the NHS would be changed forever. These arguments remain a bit of a blur in my memory, but I recall the overwhelming view among leading experts on NHS law that the changes were technical and did not involve any substantial change in practice. We know that, in respect of this role, no change has happened.
I also recall the 2012 consideration of the issue by our Constitution Committee and the compromise recommendation subsequently adopted in the 2012 Bill of what became Section 1(3) of the 2006 Act, as amended:
“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.”
No matter what is in any Act, this is and will always be the political reality.
Currently, the law places the duty on the Secretary of State to
“continue the promotion in England of a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and … in the prevention, diagnosis and treatment of physical and mental illness”—
very much in the spirit of the NHS’s founding 1946 Act.
Amendments 46 and 168 seek to continue the 2006/2012 debate. It was claimed about the 2012 Act, and now about this Bill, that the change in wording implies that people will be denied access to treatment from the NHS because, for example, a particular ICB decides to exclude a service and because there is no duty on the Secretary of State to prevent this happening. However, there is no evidence that anyone has ever been denied access to an NHS service or that any service has been refused in general simply because of the change in the wording of the responsibilities of the Secretary of State. Amendment 169 returns to the same point, seeking to place a duty on the Secretary of State to “provide” a list of services, with some general headings such as ambulance services. But the reality is that this is not how the NHS functions or indeed ever has.
I endorse many of the comments made by the noble Baroness, Lady Brinton, about today’s announcement of yet another restructuring on the academy front, but, again, that is a debate for another day.
We could go back on the Secretary of State issue to the 2012 arguments and spend a lot of time on it. While we fully understand the concerns and fears that the current wording could engender among those who suspect a deeper reason for the changes in language, continuing to argue over this issue would not be very productive or get us anywhere. We need to get on with scrutinising the sweeping delegated and Henry VIII powers later in the Bill that our current Constitution Committee and Delegated Powers Committees have expressed such deep concern about.
My Lords, I too am grateful to the noble Baroness, Lady Bennett of Manor Castle, for bringing forward this group of amendments. As many of the Committee will remember vividly, and as the noble Baroness, Lady Wheeler, has reminded us, accountability for the health service was a topic of considerable debate at the time of the Health and Social Care Act 2012 as it went through Parliament. The constitutional position of the Secretary of State was closely scrutinised and the current wording in the Act is very much the product of those discussions. I remind the Committee especially of the hard work done by the noble Baroness, Lady Jay of Paddington, who was at that time chair of the Constitution Committee, her colleagues on the committee and many others, including my noble and learned friend Lord Mackay of Clashfern, who did so much to develop the current wording of the clause. The coalition Government accepted the Constitution Committee’s recommendations in full.
I am afraid that I do not agree with the noble Baroness’s characterisation of the reasons why it was thought appropriate to modify the wording that described the Secretary of State’s responsibility for the health service. As noble Lords will be aware, the idea that the Secretary of State himself provides services has not for many years reflected the real world. As the noble Baroness, Lady Wheeler, rightly said, and as the Committee will remember, it was decided in 2012 that it was better that the law reflected the reality of the modern NHS rather than retaining outdated language. I do not think that the last 10 years have proved that proposition wrong. The current legislative framework allows some of the health services in England to be provided by entities, such as NHS foundation trusts, that are legally distinct from the Secretary of State. That will continue to be the case and should be recognised in the law.
I understand the concerns that Ministers might somehow avoid being responsible for ensuring the continuation of a comprehensive health service. However, there have been many vigorous debates in Parliament about the NHS in the years since those changes in 2012, and they have demonstrated that there has, quite rightly, been no loss in the strong sense of governmental accountability for the NHS felt by both government and Parliament. Indeed, the House amended the Act in 2012 to put beyond doubt that:
“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.”
That has not changed in this Bill; the wording will remain set in statute.
I would gently caution against recreating the fiction that the Secretary of State provides services directly. It is much better to be clear that the role of the Secretary of State is to set strategic direction, oversee and hold to account NHS England and the other national bodies of the NHS and, occasionally, to intervene—as the noble Lord is doing.
I thank the noble Earl for giving way. Given what he has said—and I know that we will debate this later—I point out that it is curious that the Government wish to take on a power of direction over NHS England, if that is so. I guarantee that that power will never be used because the Secretary of State’s power of direction never has to be used. Once this is passed, that changes the relationship; NHS England will know that the Secretary of State has that power of direction. Although I have tabled some amendments to try to modify it, I have no objections to the general principle, since I do not think that a quango such as NHS England should be freely floating. But we need to recognise that it is a fundamental change in the relationship to impose that power of direction again.
My Lords, as I was about to say, the 2012 Act does provide for the ability of the Secretary of State to intervene when that is necessary for the smooth and effective running of the system. Furthermore, we should not exaggerate the extent to which this Bill modifies the 2012 provisions. As the noble Lord said, we will debate the powers of direction on a future occasion but, when we come to do so, my colleagues and I on the Government Benches will contend that the powers of direction, such as they are, are very narrow and specific in their scope. They have been deliberately framed in that way to reflect experience over recent years. I would not be in favour of reopening this piece of drafting, given its history and the effort that noble Lords from all sides of the House made to build an effective consensus in respect of the 2012 Act.
The noble Baroness, Lady Brinton, asked about dental access. The department is working closely with NHS England to increase levels of service as quickly as possible. Practices are continuing to prioritise patients based on clinical need. Dental practices are now being asked by NHS England and NHS Improvement to deliver at least 85% of contracted units of dental activity—UDAs—between January and March 2022 to provide improved access for patients. These updated figures are based on what many practices have been able to deliver to date. They take into account adherence to the latest infection prevention and control guidance. I hope that this is helpful to the noble Baroness.
I hope also that I have explained to the noble Baroness, Lady Bennett, why I cannot entertain her amendments, but also that I have reassured her that the accountability chain between health services, Ministers and Parliament, which lies at the centre of her concerns, remains intact.
My Lords, I thank the Minister for his response and thank all noble Lords who have taken part in this debate. I particularly thank the noble Baroness, Lady Brinton, for her support. She stressed how this is very much about restoring a public health system with full public accountability.
I was a little surprised, not so much by the direction as by the emphatic nature of the comments from the noble Baroness, Lady Wheeler, given that it was members of her party who moved the amendments in the other place. To address the Minister’s comments—this also picks up the point raised by the noble Lord, Lord Hunt—we are talking about a significant change in relation to power of direction; a power that we will be discussing further, at great length, and about which we have seen considerable expressions of concern. I come back to the way I framed my speech: if you have more powers, you have more responsibility. If you say, “We covered all this in the 2012 Act—it’s all fine”, once could argue that the 2012 Act did not work out fine, but we are in a new situation, creating very new structures.
Thinking about the success or otherwise of accountability, some issues where we have failed in terms of accountability—and we will see amendments on these later—are workforce planning and, as the noble Baroness, Lady Brinton, highlighted, dental provision.
This is about ensuring that people have faith, know who to look to and cannot be fobbed off, as the noble Baroness, Lady Brinton, said, by this terrible, complex diversity of funding and arrangement structures. Like other Members of your Lordships’ House, I took part in the public debate in 2012, not in this place but in the public domain, and I have given many speeches on this issue. The complexity must not be allowed to cover over the fact that what people want to know is that the healthcare is there when they need it, and if it is not that they know who to point to.
I will of course withdraw the amendment at this point, but I reserve the right to consider this and come back to it at a future point.
Amendment 46 withdrawn.