Health and Care Bill (Fourth sitting)

Nick Timmins: I do not want to take up a lot of time. I particularly agree with that last remark: stopping now would be worse than carrying on. A lot of this is already happening. We have been merging clinical commissioning groups ever since the new system came in in 2012. It is sort of completing a journey. You may not be entirely happy about all the arrangements around the different sorts of board and what have you, but to stop now, I think, would be not sensible.

Nick Timmins: I have nothing particular to say about capital. I do think you need to retain a tariff—not for everything, because in some areas of healthcare it just does not work, but for electives and those sorts of procedures. That has two advantages: it means you need to understand your costs to construct the tariff in the first place so it is a driver of efficiency, and, equally importantly, it gives you a benchmark price with which to negotiate with the private sector whenever you do outsource some operations and procedures. You are able to say, “This is what is costs us, so this is what we’ll pay you.” If you do not have that, you are subject to a seller’s market and can be charged what you like because you do not know what your own costs are.

Richard Murray: On the flow of money, we are expecting revenue allocation to ICSs based on the current formula, trying to reflect need, inequalities, deprivation and age. The uncertainty is then how much those ICBs will allocate down to place level on a local government footprint. The expectation is that quite a large proportion of that funding—general practice, community services, quite a lot of mental health, and some acute services, too—will go down to that level, but none of that is in the Bill. The allocation to ICSs stops at that point, and as has been said, you need a payment mechanism to get the money off what are, effectively, commissioners and over into providers.

The changes to tariff are mostly about flexibility, so it should still be transparent; you should still be able to work out what people are being paid, which I think is important, and you should be able to benchmark between different providers, but instead of paying for each operation and each widget bit by bit, you can have formulas that try to reflect fixed costs. You can do it in a different way that adds some flexibility into the system, which I think is important when you are trying to bring providers and commissioners into common alignment over where the money is going. Tariffs had the problem of setting them at each other’s throats sometimes, because every time someone was admitted to a hospital you would get another payment, so commissioners wanted to keep it down and providers wanted to keep it up. There is the chance to try to align some of those incentives, but there is still a lot of gap around what actually will go down to place and what will determine it; of course, again, the budgets need to be equitable.

Nigel Edwards: Richard, if I may, I think a very important point that ought to be made here is that because the allocations will now shift from 100-plus clinical commissioning groups to 42 ICSs, the variations between them will be evened out. There will need to be some way of recognising the fact that within an ICS, you have very different patterns of need, which at the moment are recognised by the allocation formula, but in the future will not be. The money will be received by the ICS, so I think there is a question there. I know that local authorities—and, indeed, GPs and primary care networks—will want to say, “If we are in a particularly deprived area and we have historically had higher funding to recognise that, we would expect that to continue.” There ought to be a line of sight from the national allocation formula based on need to the money that is received by our locality.

Sorry, Richard. I thought you made a really good point.

Richard Murray: That is absolutely all right. On capital, the Bill does not really change the way that capital works in this system. The only difference is the ability of the Department, through NHS England, to cap the spending of foundation trusts, which they have not been able to do in the past. There are some limits around them being able to do that, but it gives an additional lever at national level. Having said that, the way that capital is working in the system has changed fundamentally already: some capital goes through an allocation system, a bit like the revenue funding, and I am leading a review for NHS England now on how that money flows.

The bit that I think is really uncertain is how the big hospital schemes get picked. That is the bit that looks very different. Obviously, there is a manifesto commitment. There used to be a process by which it was determined whether providers could afford to repay—if they could do it through loans, or if there was a need system. That is now going off in a completely different place, and I think that is the bit that is not quite clear. How does that work within this system? Who gets to choose how those projects get picked, so to speak? That is the big change but, again, it is not actually in the Bill; it is being done under the existing rules.

Nick Timmins: Yes, and you can see that in evidence that you have already heard about the construction of the board and the partnership. It seems clear to me—you have heard from the Local Government Association—that some local authorities were happy to join a single board and others felt that that was too much of a loss of sovereignty, which is why we have ended up with this slightly complicated system of an NHS board and a partnership board. Probably, in an ideal world, it would have been better if it was one, but you have to live with what people are prepared to do.

Nigel Edwards: Can we just nuance the competition point? Actually, there were two elements to the competition regime. One was the very formal going out to tender and big, bureaucratic procurements—often resulting in the reappointment of the previous provider at significant expense. But the other component was patient choice—for diagnostics, for maternity and for elective surgery. I think that dynamic has benefits. One of the slightly worrying things in some of the plans produced by the ICSs’ predecessors—the STPs or strategic transformation partnerships—was a wish to “repatriate” work, as they called it, which meant to bring work back from providers outside their patch into their own. That was not necessarily a good thing; patients should have the opportunity to have a choice of provider and, particularly in the case of specialised services, one would be concerned about people saying, “Let’s grow our own services locally,” rather than, “Let’s use centres of excellence.”

The maintenance of patient choice, and ensuring that ICSs do not act to limit patient choice, particularly for those patients living on their margins, is quite an important dynamic; almost all ICSs have borders with someone else, and patients naturally flow across them. People want to be able to make choices, because they have an existing relationship with a provider or because they have a relative who lives nearby and could care for them while they are there. There is international evidence that that dynamic has a beneficial effect on providers’ behaviour.

Louise Patten: From my point of view, having experienced health overview and scrutiny committees as an accountable officer, the patients and public certainly feel that there is the voice of that local place. It is important to NHS leaders that that continues—that ability to have local scrutiny at local level, which is very much where patients and service users feel is the right place to do it.

At the strategic level, we must not forget that ICSs comprise both the integrated care board and the partnership. This is a real opportunity to tether the NHS to always thinking about the wider determinants of health, social value, public health and, again, patient experience.

A lot of our effort—in particular around covid and some of the successes—has been in getting that synergy, with clinicians in the transformation box feeling that they can not only write on what the hospital does, but define what the community does and what the GPs do, because they are all working collectively. That has been transformational. Certainly, we would not have managed covid as effectively as we have without those sorts of relationships running all the way through the system as a thread.

Louise Patten: The clinical leadership has to be multi-layered, right the way through from the strategic level to place. We have to have clinical advice and we must heed it when we are talking about planning clinical services. That is fundamental. I think it will involve different groups of people. If it is a care pathway about cardio-vascular disease or a professional pathway about social care, we must heed clinical and professional advice when we are planning these services, so it is multi-layered.

Louise Patten: Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.

Louise Patten: On balance, it is about the Secretary of State’s powers of reconfiguration, and NHS leaders in general are concerned about that. It is not so much about the Secretary of State having an early understanding of the reconfigurations or the intent, but about the fact that that decision could be taken at a point where all the evidence is not ready to be properly considered.

Building on Gill’s point, patients and the public would be very frustrated if they felt that they had not had an opportunity to be answered, so we are asking, if not for the clause to be removed, for at least the clinical case for change to be considered from the ICB. Coming back to clinical decisions about clinical services, we want that accountability to local communities, not just up to Whitehall, and some transparency about why the decision was made, and on what basis and information it was taken.

At the heart of this, every ICB and every partnership board will have to define, “What’s my purpose? What’s your purpose? What’s our shared purpose?” That managerial trust-developing, partnership-developing work is what will make this a success. I started, and I was rapped across my knuckles by Mr McCabe for saying too much—quite appropriately. At the end of the day, you are not going to get that through legislation. You are going to get it by creating an environment and properly holding us to account for what we are doing in these boxes.

For me, the risk of these new arrangements is that, first, the removal of the power of referral to the Secretary of State by health overview and scrutiny committees on matters of concern relating to substantial variation of local health services is a worry for us, as it is for NHS colleagues. Also, the focus on system-level decision making will, by definition, make it more challenging for local health overview and scrutiny committees to co-ordinate to form, where necessary, joint committees to effectively oversee, scrutinise and hold to account ICS, ICB and ICP activity at system level.

I think this can all be made to work if there is sufficient transparency in the system, so that those within and those outside it understand how decisions are being made, on what subjects, and by whom. When you have that clarity, it becomes easier to unpick what is happening at place level. Are decisions being made at system level that would be more appropriately made at a lower level? Is there consistency across the entire system? What does the geography mean for decision making and commissioning, and these kinds of things? It provides assurance, and it provides everybody with more confidence that decisions are being made properly in the interests of local people.

Going back to the point I made before, that is also why some external local accountability is so important, because effective local external accountability can challenge the system on whether the right decisions are being made at the right level, and whether they reflect and are responsive to what the local needs are. Local scrutiny committees are, at the moment, anchored at place level within local authorities. They are well able to publicly draw in the voice and concerns of the public about those kinds of issues, and transmit them to health and care partners so that there is a clear way for those concerns and issues to be responded to.

We very much welcomed the promotion and prevention fund set up recently by the Government, which gave funding to local authorities in the 40 most deprived local areas in England for mental health promotion activities. We are really looking forward to seeing what that money is used for, and we very much hope that it will be the beginning of something much bigger. Our worry, in relation to the Bill in particular, is the understanding of prevention, and indeed the understanding of prevention that I read in yesterday’s Command Paper on the health and social care plan. It is still based on physical health, and the idea that public health is about telling people how to live their lives and how they should behave, rather than what really determines our mental health: how much money we have coming into our home, how safe we feel, and our position in society. It is really clear that very often the way that economic and social inequalities affect our mental health also affects our physical health. Very often it is poor psychological wellbeing that leads to later physical health problems, so we really have to start taking public mental health as seriously as any other part of public health.

Collaboration is incredibly important too. One thing we really welcome about the Bill is that it is moving us away from a system of competing providers to providers working collaboratively—literally, in providing collaboratives. There is a slight risk that all the power will be vested in one organisation and there will not be that check and balance between commissioner and provider. But some of the early provider collaboratives working in children’s mental health services that we have looked at have made really huge strides really quickly to reduce, for example, the number of children forced to go to hospital outside their local area in a mental health crisis. They have come together, looked at what support is needed for children in a crisis and put community services, in particular, in place to achieve that.

One further thing that will be important is that there is some positive provision in the Bill to ensure that ICBs—I think it is ICBs, yes, it is—have to take into account inequalities in access and outcomes. That is great, but there is not that requirement to pay attention to inequalities in health and to go out and identify which groups of people are experiencing health inequalities and what the system can do to deal with that upstream rather than waiting for people to need formal healthcare. That would be the other part that would really help in the Bill—to build on some of the positive noises and moves in the right direction in collaborating at the level of prevention and on the things that determine our health as well as in the provision of services when things have reached a point where people need care.

We are talking about continuing to build on some really good relationships and experiences that have existed but, rather than allowing them to evolve because individuals—either at a system level or a personal level—believe it is the right thing, it becomes policy and direction. I think that the success for us has to be looking at where systems have been able to resolve some of those challenges. I am still working with my CCG colleagues in Oxfordshire around what we believe the better care fund will look like, having signed the agreement at the beginning of the year. That is about us becoming much more involved and therefore much more confident in each other.

You will appreciate that ADASS members are constantly providing reassurance and at times caution to our elected members on how far we could and should go in relation to sharing and using our resources. Some of the developments in the Bill around the establishment of integrated care partnerships fully provide a vehicle for some of that greater transparency and greater opportunity to look at the problem, the challenge and the opportunity from a place, and then from a system, point of view.

I personally believe that discharge to assess is a robust and positive model, and I am hearing nothing to the contrary from director colleagues. What I am hearing from director colleagues, though, is real anxiety about conclusions that might be being drawn from the very point you made, which is that we have tried to evaluate discharge to assess in a very short period of time, and at a time when demand and pressure on the service has been at its most acute. Remember that it is not just the physical demand on those services that we have been experiencing; we have been working on an assumption that there is likely, at any point, to be an immediate surge in the demand for acute services, so we have been working to try to ensure that there is always capacity behind us should a further wave—either a local or a national wave—occur. We have been, up and down the country, operating systems at a pace that I have never seen before, as a result of covid. I would be cautious about drawing out any strong opinions around discharge to assess from an evaluation that was done during that covid period. For me, it is the only model that really helps people leave hospital in a timely manner.

I do not know about any of you, but as I get older and hospital admission becomes more likely, I want that hospital admission to deal with the acute need that requires it, but I want to go back home as quickly as I possibly can and to be able to continue to regain the independence I had. I do not want to become reliant on the local authority for all my support, which is why that reablement support at discharge is so critical.

Gerry probably wants to add to this, but the multidisciplinary approach that has a social worker and the local authority at its heart, building upon not just the professional expertise we bring but the relationships with our communities, our voluntary sector and our social care providers, is critical to that success.

The Bill is helpful, but it will be interesting to see how it works where, perhaps, systems have not had positive relationships or have had a more adversarial approach. I was really lucky in Somerset, because the emerging ICS there was coterminous with the local authority. It was a single provider. It was perfect in a way. I am in an ICS now where there are three different population groups. We know some ICSs have significantly more.

The opportunity is there to be grasped. This provides a fantastic focus if it can be ensured. In fairness to colleagues, the focus seems to be “start at place and work upwards”, rather than “start at system and work downwards”, in order to make really good differences to people, particularly around hospital admission avoidance. It also gives me, from a local authority point of view, greater leverage to challenge my NHS colleagues around their investment in secondary care and community care resources, because that area has, unfortunately, seen significant reductions over the years.

You have not gone into the area of assurance, but for me it is really important that when assurance looks at a system, it looks at the leadership and how that leadership translates the freedom, the permissiveness, but also the accountability, clearly. The feedback I am hearing from our members is, “We favour the permissive approach that is taken in this.” We would not say that the tolerance should be changed one way or the other.