20
Examination of witnesses
Professor Claire Fuller, Dr Harpreet Sood and Adam Doyle.
Q52 The Chair: Welcome to the second evidence session this afternoon of the Integration of Primary and Community Care Committee. We are fortunate to have three witnesses with us: Professor Claire Fuller, CEO of Surrey Heartlands but much better known to us perhaps as the author of the Stocktake review; Dr Harpreet Sood, who is a GP and board member of NHS England—I am sorry if we got your designation a bit wrong in some of the stuff that we have put out; and Adam Doyle, who is CEO of Sussex Integrated Care Board. As you know, we will take it in turns to ask questions. We will be delighted to have your comments and responses.
I will start the questions, and I will come to Mr Doyle first. To what extent have integrated care systems been able thus far—we know this is very much work in progress—to deliver the aims they were set up to achieve?
Adam Doyle: Thank you and good afternoon. It is important to recognise that although we worked hard to set up our integrated care boards as part of integrated care systems, we are nine months into this endeavour and are still dealing with the back of the pandemic and a number of issues that we have dealt with across the NHS and wider public sector this year. We point to matters such as industrial action.
Each of the ICSs and ICBs was set up with four main aims. Each aim was to consider how we approach value for money; productivity; how we respond to tackling health outcomes and improving health inequalities; and how we support broader economic development. Each of the ICSs is at a different stage of maturity and some have been operating in partnership models for some time. Others are much earlier in that. We have different sizes and different scales across England currently.
We have seen that where people have been working together for quite some time, they start to see significant progress in those areas. Where integrated care systems have not been working so long together, they will take a bit longer to take forward. It depends on the starting point of each of them and, therefore, on how long those organisations have been working well together and where they achieve good outcomes currently.
The Chair: Professor Fuller, we have heard that some are working not as well as others. Could you perhaps identify what is preventing them from working as well as some other ICSs?
Professor Claire Fuller: As part of the Stocktake I did last year, I was privileged to meet and talk to each of the ICS chief executives two to three times over six months. That gave me some insight into the diversity of the leadership that we have and the wealth of experience that comes out. What shone through from all the thousands of conversations we had was the pride in each one of our 42 systems in their primary care and how well their primary care was integrating and working for and with communities, which, to be honest, surprised me. It was universal. What came through out of every conversation was this shining pride in how we deliver care close to where people live.
As for why people are at different stages, this goes to add to Adam Doyle's answer. Adam and I have both been doing these jobs, it seems, for ever. I have been leading Surrey Heartlands since 2017 with various titles. That has given me a different view of the system and an ability to run the system, because so much of this is still about relationships. If you are new and do not know people and you start with more difficulties than other systems, of course you will be in a different position than those of us who have been doing it for longer and who started with good-quality provision of care.
The Chair: What are those additional difficulties?
Professor Claire Fuller: They are the lack of availability of workforce, challenged providers, inherited financial positions and complexity of systems. I call them the unicorns. We have some beautiful systems that have one acute trust, one community trust, one local authority and one GP federation, and they work beautifully. Sam Allen in the north-east has a population of 3.2 million. I cannot even count the number of local authorities, specialist trusts, district trusts, and there is more than one ambulance trust. You can see that those are different jobs, and people will be at different points on their journeys because of that complexity as well as their longevity in role.
Dr Harpreet Sood: From a clinical perspective, we are starting to see some positive changes in how we work across the patch with multiple providers. Like Adam said, we are still in the early stages of that, but the case for change is there from a clinical perspective in how we relate with our social care colleagues, how we think about mental health and how we think about other community services. On that basis, as a GP I have seen good, positive working towards that.
On your point about things that might stop effective integration, a key thing that I have certainly been seeing as a GP is the ability to recruit and retain members of staff at that ICS level. I will come later to the digital tech front in particular later. If we look at it through that lens, it is proving to be more challenging to recruit and retain talent than might have been envisaged because of the competing priorities with the health service system and other employers. The way the clinical services are starting to align more towards the focus of what we are trying to achieve has been hugely positive.
Q53 Baroness Armstrong of Hill Top: Good afternoon. As you said, Professor Fuller, the structures are so different. I come from the north-east. It is not just the north-east; it is Cumbria as well. It is a huge part of the country and, culturally and historically, provision is different. Yet we hear from other witnesses that this is all about place, understanding place, and how to develop integrated services around place. I will not go into how we got here, because it is ludicrous. Nobody understands it in the north-east. Will the assessments of what is happening lead to more sense so that we can compare? It almost feels at the moment that they have been set up so differently that they can never be properly compared.
Professor Claire Fuller: We used to live in Rothbury and my children were born in the north-east. I used to work in Wooler and in Felton. I know the complexities of the patch.
Baroness Armstrong of Hill Top: It is different from Teesside.
Professor Claire Fuller: Indeed. There is a rurality base with then areas of real deprivation.
Place is interesting, because it means 12 things to five people and you can spend hours debating what you mean by place. Some systems that are classified as ICSs are the equivalent of places in other ICSs. How we have arrived where we are is clearer if we go back to where people started.
When I had the conversations with the 42 Chief Executives of ICSs, I asked everybody why they are in the system they are in and why they have that footprint. There were two different reasons. One was that it makes sense from a local authority point of view. That was largely the county council. You would get Hampshire and the Isle of Wight. You would get Surrey and Kent and Medway. That would be why they had come together. Then you would get your other systems, like some of the London ones, where it was about the teaching hospital rotations. Those that had come together because of a big NHS hospital rotation piece were often in our more densely populated areas and tended to have metropolitan boroughs or boroughs. Their place-working was quite clear because it was around those smaller footprints. There is a lack of integration there between the big acute hospitals and places.
Where I am I have more small district general hospitals, because I come from a county that is more spread out. My place-working, which is around those footprints because that makes sense, is advanced. The bit that is less well advanced is the integration between the four hospitals.
All of us are going along the way of doing both horizontal and vertical integration, but where we are at the moment depends on our starting point. At the moment you may not be able to compare, but I expect that in the future, as systems mature, you should.
Q54 Baroness Tyler of Enfield: I have a quick follow-up to something that Dr Sood said. If I understood you, you made reference to social care and to mental health and the potential that the integrated care systems have to join up there. I spend quite a lot of my time working in both those areas, including talking to practitioners. I know that many of them still feel like the Cinderella of the healthcare sector. What gives you the optimism that you expressed that ICSs will be able to achieve much greater integration across social care and mental health?
Dr Harpreet Sood: A lot of this is based on my own personal experience of working where I am at the moment, south-east London. There, I see that the leadership across the patch is bringing the various key care services together in multiple ways. We see more co-ordination with services that we provide, thinking about hospital-at-home treatment teams, about the mental health services that we are about to see in the community, about more mental health psychologists coming in as part of the Additional Roles Reimbursement Scheme. We are starting to see more initiatives like that, which are giving us a greater sense of optimism.
I cannot comment for the rest of the country on the ICS variability that we might see, but if we were to go back to the exam question and ask what ICSs were set up for, that is a good example of how things are progressing in the right way, versus understanding that there is still a long way to go before it becomes fully aligned. Part of that will also be about how we think about the funding and the system allocation that is then ring-fenced for that, which needs to be a core priority for this so that it does go through primary and community care services and does not go through acute providers. That is why I welcome the work today and the discussion, because we look at this through the lens of primary and community care rather than through the lens of an acute provider.
Q55 Lord Watts: We talk about some of the differences between the different parts of the care and health service. The local authority is the only partner that has any form of democracy in it. The trusts tended to be set up in a way that was run by accountants because competition was a major issue in the way the Government of the day wanted the health service to move.
Are there any lessons to be learned from that in the new structures that need to be brought together for accountability? It seems to me that the other sectors—GPs and hospital trusts—could learn a bit about priorities and moving resources from one place to another in a way that perhaps the health service and the GPs do not do.
Professor Claire Fuller: In the structure that we have in the integrated care system, it is important that we have the two boards. The integrated care board is largely about the NHS accountability up into NHS England, which has local authorities as partner members. Then we have an integrated care partnership, which is much more about the broader partnership across health and care and very much more about addressing the wider determinants. The NHS on its own can address only 20% of health outcomes. We need to work with all partners to work differently.
The local authority has always had the democratic accountability and has always been much better than the NHS at doing the patient engagement and listening to communities. We need to do that better at a local level, particularly as we come to the agenda about how we improve our health outcomes and our health inequalities, and talk to our communities and understand what matters to them, rather than be driven by a single blanket view across the top. There is much to learn.
Adam Doyle: There is something about how we get our primary care colleagues and our acute colleagues to work differently now, because the world has changed. We were in a competitive market and now we are in a collaborative market. These things take time. Across all the systems we have seen some significant work and people working well together, but we now, together across all 42, have to write a five-year delivery plan.
How will we transform our system? One clear plank of that is building on the integrated team working of Claire's stocktaking, making sure that we integrate services where people live. That is a key part for all of us. Every part of the NHS and the wider public sector needs to pull together to make that happen.
What levers do we have to make that happen? Claire has been clear about the integrated care partnerships, but we also have two other levers to be used at place. First, we build our strategies all on our health and well-being plans that happen at a local authority level and tell us the health needs of the population over the next five to 10 years. We can look at those and ask, "If we see a change in demography of X, what response to Y that would make that happen?" The other key part that we do and we work closely on is making sure that all our health partners tie into those health and well-being plans. The 2022 Act also asks each of our trusts to have a duty to collaborate. We can use that lever, should we need to, if we feel that organisations are not coming together.
The other key part that we still use locally at a democratic level is the role of the health overview and scrutiny committee. We work closely with our local government partners to scrutinise what the NHS does locally to make sure that we collaborate and challenge going forward.
In summary, the key part is for the 42 integrated care systems to write a five-year delivery plan that truly integrates services. It is a huge opportunity for all the public sector at each of those levels to respond to that challenge.
Q56 Baroness Finlay of Llandaff: Dr Sood, you described the integration of the services. It sounded to me that those react to the demands on them and the things that are presented. Where do you see the levers in prevention—improving housing, improving playgrounds at schools, improving children's diets and so on—to manage the big problems that are coming down the track and that will overwhelm the NHS and care systems unless they are tackled early?
Dr Harpreet Sood: You are absolutely right. It is a huge opportunity and needs to be considered. If I look at the clinical caseload that I am seeing in my practice, there are some clinical presentations but a lot of it is about the social issues, whether financial, social, related to mental health, domestic violence or safeguarding. A lot of this is built on the fact that it is not just about looking at this through the lens of being a GP anymore. We have to collaborate and work a lot more closely with all the different sectors that you outlined. Housing, schools and so on will be critical components of that.
If we look at the mandate and why ICSs have been set up, bringing that together is a core priority for them. Again, alignment on incentives, how we think about the system allocation of funding and the population needs that are driven through a data-led approach will be critical to success here. That is a big side of the prize.
Professor Claire Fuller: In the Stocktake, the model of care that we recommend and the vision that was signed up to by all 42 talked about three different lenses. The first is how we improve access and integrate urgent care for on-the-day access. The second is how we look after our most complex and vulnerable people. The third, which speaks to your point, is how we improve health inequalities by working with our communities. We have a letter signed by all 42 ICS chief executives saying that they accept the recommendations of the Stocktake, but this is about how we then start to work with our communities to address those longer-term, wider determinants of health to make sure that, instead of mopping the floor, as the NHS can do, we start to turn that tap off and address demand rather than react to it.
Baroness Finlay of Llandaff: I wanted to dig down into where your levers are to bring about change. That is high-level intention, but where can you make things work differently?
Professor Claire Fuller: There are things that we can do. The fact that all 42 have signed up to the model of care and we are now committed to implementing is a huge lever. It is building on the work that we started during the pandemic, particularly on the vaccines. If you think about the work we did there, which was absolutely about the health inequalities and targeting communities that would not otherwise have come forward for vaccination—locally, our Gypsy, Roma and Traveller population—we vaccinated against Covid and against other immunisable diseases, because we built those relationships and we worked with those communities.
A lot of our levers are about influence and relationships but also about this real understanding of the importance of doing the prevention work, and, in the set-up of the ICSs, one of our main aims being about tackling health outcomes, there is direct accountability to make sure that we do that as systems.
Q57 Baroness Shephard of Northwold: I want to pursue the theme of the imbalance of resources between local authorities and the NHS. I am beginning to sound like Cassandra, because you have all been so positive. On the ground, a local authority could enter into partnerships on essential schemes with a health authority in total good faith. Then the particular local authority could, in one particular year, find itself poleaxed by having a bad winter. It will have nothing left in its budget because it spent it all on gritting. That is the reality on the ground, as I see it. There is this imbalance that is not helping me to be as positive as you are. The whole thing is new. It is growing. Ways will develop. There will be understanding and so on. But do you have any comment on this doom scenario that I have given you? What would happen, apart from, "We’ll sort it out as best we can"?
Professor Claire Fuller: I come from Surrey. We are fortunate in that we are nearly coterminous with one local authority, which is quite unusual. Because of that, we have close relationships and a number of joint posts. This is all about how you work it through local relationships, understanding the long-term good for the population, being clear on what matters and doing the right thing. I completely recognise what you say about the different ways in which funding flows, but you can still make it work through positive relationships, understanding what is important and having a strategy that focuses on the longer term so that we do not all keep getting blown off by operational pressures.
Baroness Shephard of Northwold: I quite see that, but you cannot foresee an enormous, unexpected and protracted period of snow. I take your point about relationships. Indeed, they are essential. They must be the basis of it all. But there will be years when the local government side of the bargain will not be able to deliver. Of course, if that situation pertains, it can be improved only by having good relationships already in place, which is what you have said and maybe what Mr Doyle is about to say.
Adam Doyle: In reality, Claire and I are responsible for an NHS budget and we work closely with our local government partners to do the best we possibly can. We have to recognise some of the funding constraints that local government has. That is clear. But when we look at what would happen to a community on any given day, we have to recognise that the NHS can still do better with its integration, and we can do better with how we integrate with our social care colleagues. We still hear stories today in my own system about where we can do better in getting that right. It is important to recognise that there is a realism about what we can do in terms of what the local government funding settlement looks like.
We do, however, have a number of levers that we use. We have a better care fund where we have to pool our resources with a local authority and therefore take a view about how we best invest that money for the needs of our local population. In my system, I have West Sussex, Brighton and Hove, and East Sussex. They are completely different areas. When we look at a local level, how people live their lives in those areas is different. Our job is to work closely with the local authority to find the best solution for these communities. In my experience, I have learned that working closely with local government has brought the NHS much closer to the community and voluntary sector and the charity sector. We learn things every day from working more closely with them.
Will it solve the long-term funding position for the public sector? No. But our challenge together is to be as productive and as positive as we can be with a sense of realism.
Lord Kakkar: Coming back to the point about the disparate nature of these different integrated care systems, some have a single acute provider, a single primary care system, a single local authority and so on. Those are coming together well and at some pace. But how will those that are more complicated be brought together? How do you deal with this rather complex ecosystem in many parts of the country that ultimately may stifle the kind of delivery that we all hope for?
Professor Claire Fuller: We have used the word "place" already a lot today, but it comes back down to understanding the footprints in that broader system that make sense to local authorities, to NHS flows and to local communities. You build the integration around that place-working which you can then build up into system working. The unicorns that I described in many places are the equivalent of a place in a much bigger system, but our unit of integration that works particularly well is where we bring together the NHS and the local authority at whatever footprint works within the geography.
Lord Kakkar: How long will it be before we can be confident that this particular change is working? It is only nine months old. First, what is the correct moment in time to start asking whether this was a sensible move or not? Ultimately, what metrics should be used to determine the answer to that question?
Adam Doyle: Recognising the starting position, there are a number of factors to check how the system is performing.
The first for us in an NHS context is that there is an operating plan for the NHS to improve waiting times for people waiting for elective care, the length of time people wait for an ambulance, and the urgent and emergency care performance. The first key challenge of the NHS is what we will deliver this year. In our first reset year after the pandemic, what do we need to achieve?
The other key part is that every integrated care system has to now complete a five-year delivery plan that seeks to deliver the integrated neighbourhoods that are part of Claire's Stocktake. In those will be a KPI framework about outcomes for the community. Each of those areas will be different. In East Sussex I have Hastings, for example, which is one of the most deprived parts of the country. I also have Wealden, which is one of the most affluent parts of the country. They are in the same local authority footprint. The outcomes for the community in Hastings will be focused on drugs and alcohol, homelessness and getting people into work to have a better chance at better health outcomes, whereas in Wealden I have a much more aged population and my responsibility there is to make sure that we have the right integrated services for people as they enter their later years.
In each of our neighbourhoods, we will look for a set of measures to measure how we are improving. We need to aggregate those for each integrated system and report progress at each of those layers. In terms of timeframe, we will look to see those starting to bite in years three to four of that strategy. That is when we will start to see the return on this way of working.
The Chair: Thank you for putting a number on that. It is helpful.
Q58 Lord Altrincham: Going back to the levers question, we regularly come back to primary care, as you can imagine. We have two important questions on primary care. We would love to hear from all of you. Could changes be made to the way the primary care estate is managed that would help to deliver better integration and improved services for patients? Also, to what extent is the ownership structure of GP practices a barrier to further integration?
Professor Claire Fuller: I have been a GP for 28 years, which is longer than I have not been a GP. For all my career, the primary care estate has been neglected. I will work through talking specifically about general practice rather than primary care in the round. To give you a few numbers, there are 9,000 general practice premises in England. About half of those are owned by GP partners. About a third of them are owned by a third party. The remainder are owned either by NHS Property Services or by community health partners. There are mixed models of who owns the actual sites. Some 80% of those premises are not fit for the future.
Every GP will have a story. My current story is that when I go to the practice on a Friday, if everybody is in and nobody is on holiday, I work in a cupboard. We call it the cupboard because there is no couch in it, which means that I have to wait for my friend over the corridor to finish seeing whomever she is seeing if I need to examine someone. Then I will come out and we will swap. Everyone has a story about having consulting rooms upstairs without a lift or having disabled access through the bins. Every GP will come out with half a dozen stories.
We have mixed message of ownership and mixed rent reimbursements. Whoever holds the GP contract is accountable for the reimbursement of the rent. That can be through cost rent, notional rent or rent reimbursement. The amount varies: £20 million goes on cost rent, which is for GPs who own their own premises and are paying back the loans; and £200 million currently goes on notional rent, which is a district valuer’s assessment of how much the rent of the building is actually worth. It is complicated and it is complex, but, clearly, because only 50% are owned by GP partners, it is more complicated than being just about the partnership model of how that goes.
In the Stocktake, we spent a long time looking at estates and the blocks. One of our recommendations was that each system should produce an estates plan. Currently, NHS estates and capital often comes down on a one-year plan, which means that we are unable to plan longer term. In our recommendation we asked for the estates plan to be signed off by the integrated care partnership and not the integrated care board to make sure that, as systems, we did not just focus on the NHS but focused on one public estate and started to look more with commercial partners at how we could deliver care in places that worked for communities and worked for people.
Dr Harpreet Sood: I want to give a perspective from the other side of the telescope, looking at someone who has recently come into the workforce as a GP. Claire mentioned that in her career so far she has not seen an estates plan, but I look at this through this lens.
If we want to recruit and retain the talent coming through in the new generation, we need to create an environment to allow a team-based approach and to create estates that not only are fit for purpose for patient needs but that allow us to work in that multidisciplinary team environment. That becomes a critical part of it as we think about the clinical, digital and workforce strategies that we have been talking about. Ultimately, if the estates are not fit for purpose, as Professor Fuller has highlighted, it becomes even more challenging. All millennials, Generation Z or whatever you may want to call them are thinking about what this means for their work and how they do an effective job. That needs to be factored into this.
Lord Altrincham: Can you help us to understand specifically the link to integration. The unsatisfactory estate issues are well-trodden ground. Bear in mind that we also have a question on the structure of the GP practices. Do aspects of this affect the integration directly of what you have been looking at?
Professor Claire Fuller: One of the problems we have as systems is that if you deliver just general practice activity on a site, it has different capital rules. The minute you start to deliver integrated care that involves integrating general practice with any other bit—with secondary or with community care—the capital costs then fall in the system capital envelope. As you have the annual capital envelope that comes down, you then have to increase the prioritisation, which will also include the estates upkeep of the hospitals and lift maintenance. Those envelopes are limited and short term. We need a longer-term estates settlement to enable us to plan more effectively for premises that are able to deliver integrated working.
The Chair: That is a specific proposal, which is helpful. Thank you.
Q59 Baroness Armstrong of Hill Top: I am tempted to come back to what I wanted to ask before but I will not. With a bit of luck, I can come back to it later, because this question is about another area that is important. You addressed it, Professor Fuller, in your Stocktake: the use of health technologies and the capacity of the systems to begin to move that way more effectively because they are able to share information and data. We all have horror stories of patients who have been seen by one clinician and then by another clinician. They will have several conditions and those different clinicians cannot communicate with each other. The individual patient ends up not being treated as a person but with a particular issue or a particular condition on this day and on another day with a different condition and nobody is working together.
What are the main barriers to the sharing of information in a more effective way? Some means were used during the Covid-19 pandemic that have now begun to disappear. This, surely, is at the base of any integrated approach. What will we do about it?
Professor Claire Fuller: I will ask Harpreet to answer that. He led the workstream for us and did some great work.
Dr Harpreet Sood: Thank you for that question. It is hugely important for multiple reasons.
First, to set the context, we see a blurring of boundaries between primary, community, social care and the like. That is an important context for saying where the system is going and how that then plays into what we are thinking. Ultimately, it is clear through other industries and other work that we have that digital technologies can play an increasingly important role in how we transform and do exactly what you are saying. However, it is also important that we do not look at this just through the lens of what technology can do but how we think about what the future operating model might well be and where we go with primary and community care. Again, if we look at it just through the lens of technology, we will miss the big picture.
On that basis, we are starting at a good point. GP practices in particular all have electronic records. Many of them use multiple tools to do various things. But we still live in a world where we have a patchwork of IT systems that do not talk to each other. Much of the administrative and clinical time is spent on triaging, booking appointments, processing documents, thinking about recalling patients and repeating the same information over and over again, as you have highlighted. A lot of this time could be saved if we thought about how we bring various levels of technology into this, how we can protocolise a lot of the care pathways that we have, how we can think about automation, how we think about using those digital tools today that are available in the system in the industry that we need to think about bringing in.
I want to put this into three key buckets that we have to think about. The first is the patient interface. How do we engage with the patient with that single front door? We have seen a greater uptake of the NHS app. That has big potential for us. How do we utilise that to get people to engage more with their healthcare, access their records, access to their blood results, and give them the ability to complete questionnaires and help with their annual long-term care management? There is that big bucket.
The second key bucket is to think about it as a clinical focus: how do we develop an infrastructure for multidisciplinary teams to communicate and interact and between primary and secondary care and that interface? A lot of that is based on our communication platforms because a lot of the time I spend as a GP is about whether I have access to that document, what the consultant thinks, how I engage with that consultant in real time to help me provide a better level of care for my patient. We could do much better work on that in terms of creating better data flows and a more structured way of capturing that data through templates and thinking about the advancements we see with artificial intelligence and the advancements we see in terms of clinical decision support tools.
The third key bucket for us to think about, which again we see some progress in but we could do more in, is how we design primary care around that structure, looking at it through the enterprise lens. How do we think about automation when we think about coding letters? How do we think about automation with digital telephony? How do we think about e-rostering solutions? All these kinds of things are important and we could be using them very much.
Going back to your point about what some of the barriers are, I would like to touch on a few that are by no means the only barriers. We see limited expertise, understanding and skills in the primary care space. We could do a much greater job on that with a greater amount of investment.
Linked to that is always the issue of trust and governance. The pandemic bypassed that. With Covid, we created legislation that allowed us to get over it, but it feels like we have gone backwards on that. We, again, need to bypass that and think about how we solve that problem of the data-sharing liability and feel like we will not be blamed for it. There is a lot of fear there but GPs often find it difficult to share information.
The third key element or barrier that plays out into this is the small practices that we have and the fragmentation that we have seen across primary care. Again, there are still pros and cons about scaling up primary care and larger providers, but one of the key benefits of larger providers is that we are able to create this digital data ecosystem that allows sharing of data in a much more effective way.
Those are some of the things that we could think about as we push this agenda further.
Q60 Baroness Armstrong of Hill Top: In the block grant system that it seems we are moving to, how do you make sure that in every ICS or partnership, or whichever bit, there are clear financial flows that show that that work will be done in this ICS? I also think that about other priorities. At the moment, we do not know how much money is being spent on anything. We know what the Government pay out, but we do not know how, at local level, financial flows are working, and whether they are or not. We need a bit of reassurance about data and the improvement of the admin and training on data.
Adam Doyle: On the last point, what we are embarking on is cultural. We will digitise the health and care system; we do not have it digitised completely yet. It is important to recognise that there is a public campaign with that, and getting all the people who will have to use that trained and working in that way. Let us recognise that we have some way to go to get that in place.
On your question regarding the financial architecture of the system, that can be accounted for in a number of ways. We have to account for any programme spending that we have in any integrated care system. If I get money for digital, I have to be able to demonstrate that I have spent that for the reason it was given to me. That is important. But there is a challenge to us about how we make sure publicly that we are clear on that. If Sussex got X per cent of its funding for digital, did it spend it all, versus Surrey Heartlands, for example?
Baroness Armstrong of Hill Top: And what did it deliver?
Adam Doyle: And what was the outcome for that? There is definitely a piece of work for us to take forward.
Each of the five-year plans for all integrated care systems need to cover three things: the integration model that Claire’s Stocktake has been quite clear about; our response to digitising health and care; and how we have a workforce model around that. As we start to demonstrate our plans, we also need to be clear that they work financially. As we publish our delivery plans, we should be challenged on how we also make the funding work and how we have allocated the funding to make it happen.
Q61 Baroness Redfern: Should the budget be based on population if integrated care systems, say, want to have national and local priorities?
Adam Doyle: Our current funding allocation is a capitative formula that takes into account the make-up of the population that we serve. You can look at many models for how to hypothecate funding to health and care systems, but the one we currently have tends to give a relatively fair amount to each of the systems for the demography of their system.
The challenge we will have over the next 10 years in health policy is that, as the population ages at different rates across England and we see lots of people with further housing developments and increasing population sizes, we need to make sure that our future funding arrangements are alive and agile to respond to those changes in real time so that we do not have lag funding that we therefore cannot implement for the communities that we serve. By and large, although the NHS may feel that we could always have further funding to do more with our services and we could argue the rights and merits of the allocation formula, it seems from my perspective relatively fair for different parts of England.
Dr Harpreet Sood: I agree that it needs to consider population needs and deprivation, as you have outlined, and that is where some of this needs to go. We have seen some good examples of that being played out across the service.
Q62 Baroness Barker: I wonder if I can slightly rephrase the question I was going to ask. How do patients navigate community care and primary care?
Professor Claire Fuller: This a question is about how we organise our services better to make sure that people have access to the services when they need them at the right time. In the Stocktake, the two problems that people across the public and across the professionals wanted to solve were how we improve access and continuity. They are two sides of the same coin.
If you take the comparison between my children and my parents, my children do not care who they see or when they are seen or what mode they are seen in, whether it is on a screen or on a phone. They want to be seen. They will probably have something that is quite transactional and that will go away. My parents, however, are much more complex and will wait to be seen by somebody who knows them and understands the context of their lives, which may be the wrong thing. At the moment, we are not set up in a way that can prioritise the needs of our most complex so that they can navigate our system as easily as my children can because they do not care who they see.
The bit I will come back to is how we do the access better. It is almost by redefining what we mean by primary care. At the moment when we talk about primary care, we mean general practice, pharmacy, optometry and dentistry. I always put in a case for audiology being included within that family. If you have your eyes and your teeth, why would you not include your ears? But I would like to slightly reframe it as primary care being care that you can access from your home without a referral, because it opens it out into a much broader set of services that we then need to co-ordinate for people. That is why it is important. It should not be up to my parents or my children to work out where they should present. It should be up to them to go where they think and, if that is the wrong place, it should be up to us to connect under the bonnet the right services and the right mechanisms so that if that place cannot help them, the next place can. The person they see should take responsibility to make sure that next contact works.
If you enlarge that definition, you include not only the traditional primary care plus audiology. You will also include 111, 999, sexual health services, school nurses and any other number of services, probably in care homes, that are available to people without referrals. To join all those points of access up would dramatically increase our capacity to see people quickly and will increase the different ways in which people can access. Not only will we have all those as face-to-face or walk-ins on the high street or in surgeries, but that would also put on to it the online and remote access to better improve navigation.
How do we improve navigation? It is not good enough at the moment and we need to commit to us getting it right under the bonnet rather than necessarily assuming that people understand the vagaries of where you should go between the hours of 8 am and 6 pm versus where you should go on a weekend, on a Tuesday or on a Thursday.
Baroness Barker: Yes. What is preventing it from happening?
Professor Claire Fuller: It will come back to the wiring and the connectivity. That is the joy of working in that smaller footprint in that neighbourhood. Where I work in my practice, I know which pharmacies are open and what other services are available for my population. But we need to make that information more accessible to the public. That will be through various digital routes, websites, the use of search engines, and whatever else it might be. We need to better identify the whole directory of services that our ambulance services and our 111 services currently have access to, but it is not detailed.
We have done a piece of work looking at the number of voluntary sector services that are available in a community and—I know you will all know this—it is hundreds and thousands. The statistic we have in Surrey for the number of voluntary services is between two and 9,000, depending on which bit you look at and where the mapping has been done. We can properly describe through that close neighbourhood working all the services that are available and then start to connect them up.
If you do not have a single record that can be accessed by everybody who sees someone, it does not work. To me, it all comes down to the importance of that single digital record to join all this up and make it easier for people.
Dr Harpreet Sood: It is important to take into consideration the great work that has been done by social prescribers, care co-ordinators and linked workers. I have certainly seen in my practice that they play an important role in helping patients navigate various elements of what might be available to them and the resources that are available to them. A critical component of a lot of this is that digital is one arm of it, and an important arm, but also those who are doing this work are proving to have a positive impact on how patients work with us.
Baroness Barker: I come from a voluntary sector background. I wish we were not needed. I am not denigrating what people do, but if we have a system that relies on that, there is something wrong. I am concerned about that.
Professor Claire Fuller: There is something special about how the voluntary sector works in that local way and works with local people. Often people who work in the voluntary sector are in and of a community and understand that community in a way that services will not always do. There will always be a role and a need for making sure that we deliver care in the right way and to people in the way that works for them.
The Chair: They also always start with the patient and the user, which sometimes we are guilty of not doing.
Q63 Baroness Finlay of Llandaff: I will ask the question that I am designated to ask you, but I also want to ask you something else, so forgive me. I will go to the second one first, because it follows on from what you were saying.
You spoke about a single record. Should the patient be the person who has control and holds that single record rather than the current system where they may have to apply to get access to that whole record? The reason behind that question is also that you talk about services as if they are available 24/7, but we know that for three-quarters of the hours in the week they are not. Yet we also know that major crises arise often out of hours, particularly on bank holiday weekends. It seems that this integrated model completely collapses when we get out of hours.
Professor Claire Fuller: I could not agree more. I will take that bit first. One of my real issues is how we talk about general practice but spend far less time talking about the out-of-hours and the use of extended access and then the links into 111 and 999, which is most people's experience of health and care. It is important to join it up. It should not behove us as individuals to know whether we are in or out of hours. We should make it work so that you dial the phone number and either it gets flipped up into somebody who can help you, which is the joy of cloud telephony, or you are signposted to a place that can help you. Unless we pay as much attention to the full cycle, we will not get this right.
Baroness Finlay of Llandaff: How do you get the workforce to change the work pattern? If you do not have the workforce there, the services will not be there out of hours.
Professor Claire Fuller: If you look at the demand for services over those 24 hours, when people engage and when people use services is quite predictable. Some bits of our workforce choose and would want to work in different ways if we made flexible working easier. When my children were little, I wanted to work between the hours of 10 am and 2 pm in term time only. I would have been interested in doing the odd evening.
This is to your point about e-rostering. At the moment, it is hard. A lot of people are not able to do that, so we do not have the technology to roster people in until we can catch up with making the job plans work and making the capacity meet the demand. The demand needs to be shown by the data that we have about what is going on in our services. We do not have all that information yet.
Q64 Baroness Finlay of Llandaff: We could go on for ages, but I will not because I have slightly more alternative views over the seven days from the experience that we have.
The other thing is the health promotion strategies that you need to deliver in the current structure and services. How does integration help and make a major difference to those strategies? We spoke earlier about preventing problems.
Adam Doyle: I trained as a physiotherapist and worked mainly in deprived communities for many years. The clear things that I saw in my practice were children who were not meeting their educational attainment, mothers who were smoking while delivering their children, and significant and profound mental health problems in the community. Although as a physiotherapist I could do things to treat the presentation that came through the door, often I was looking at the patient and thinking, “If there were wider things that we as a system had done to help those individuals, they wouldn’t have presented in such a severe form as they presented at my clinic”.
The first piece is that each of the systems needs to tackle health promotion in a clear and targeted way, but the data is evidence of where we should focus. We have joint strategic needs assessments about what our population experiences every day. I will use an example in Sussex. We are implementing the Stocktake and using three areas to do that. One is Crawley, one is East Brighton and one is Hastings. They all have relative areas of deprivation, but they are different. Each of the particular things we do for each of them, whether it is smoking cessation, sexual health, drugs and alcohol, helping people to navigate a complicated life, are different. By bringing the partners together, discussing things at a neighbourhood level and bringing everyone around Crawley together we have heard from the community that the biggest thing that will help that community with their health outcomes is working on an employment strategy. That is fundamentally different to what we have done thus far. Doing those interventions starts to bring this into a health promotion perspective.
Lastly, we often think as health clinicians, “If only we could fix this one thing”, which can often be about people saying, “If my benefits were sorted out, I could discuss my weight with you”. Sometimes we need to work on those things. What greater opportunity is there to integrate the public sector around that vision? That is why we are positive, but we recognise that there is a significant challenge to pull it off.
Q65 Lord Kakkar: I seek from each member of this interesting panel one recommendation or view on change that you would strongly recommend we look at to drive the most efficient and effective integration of primary and community care.
The Chair: In the interests of time, we will limit you to one.
Adam Doyle: I will go first with a fully costed and funded workforce strategy for health and care.
Professor Claire Fuller: I recommend a single digital record that everybody including the public can access.
Dr Harpreet Sood: For me, it would be aligning the incentives and funding around the need and deprivations rather than activity. That would be critical.
Lord Kakkar: Perfect. Very clear. Thank you very much.
The Chair: That was beautifully concise. Thank you very much. On behalf of the committee, I thank you all very much for your testimony today and for answering our questions. As always, if you have any further information that you think would be of use to us, please feel free to communicate with our colleagues and send it in. Also, you will of course get a transcript of today's event for you to have a look at. Thank you very much.
