16
Examination of witnesses
Patricia Hewitt and James Bullion.
Q219 The Chair: Good afternoon and welcome to the Integration of Primary and Community Care Committee. We have apologies from two of our members, Lady Wyld and Lady Finlay. One of our members, Lord Watts, will be online and joining us shortly.
We are delighted to have with us the right honourable Patricia Hewitt, author of the Hewitt review, which is really why you are here. She is also chair of NHS Norfolk and Waveney and deputy chair of the Norfolk and Waveney Integrated Care Partnership. Also with us is James Bullion, chief inspector of adult social care and integrated care at the CQC. As you know, we will take it in turns to ask you questions, and my colleagues will also come in with some supplementaries as and when.
Let me start with you, Mr Bullion. This question is about whether the CQC will assess whether improvements are necessary in the extent to which primary care and community care are integrated with each other—that is the subject of this committee—and with other components of healthcare. Perhaps you could roll up in your answer ensuring the integration of your role with that of NHS England.
James Bullion: There is quite a lot in that question. I would start by saying that, as part of the way we work now with NHS providers—in primary care with GPs, and in community healthcare with community healthcare providers—we already, as part of our health assessment framework, look at the extent to which services are integrated between primary and community care. We look at people’s experience of the quality of those services, as well as the movement between services, such as how someone moves through primary and community care when they are admitted to or discharged from hospital. To some degree, our current assessment arrangements already look at how integrated services are and what the outcomes are for people.
In addition, we have new duties, which began this April, for looking at integrated care systems. There are three elements of focus—leadership, integration, and quality of service. We are now the only body looking at the whole of the integrated care system to see how the elements work and blend together at that systemic level. We take the evidence that we find in the individual assessments of providers and aggregate that to a judgment about integrated care systems.
We are at the beginning of that journey, so we are about to go into a piloting phase of looking at a couple of ICSs to see what the evidence is and what integration looks like. You may want to draw more of this out, but our role is distinct from NHS England’s, which is very focused on the integrated care board, the NHS functions and the performance of that board.
Ours is a slightly wider look at systems. We will not have regulations, in the sense that ICSs are not provider bodies. They are a partnership between the integrated care board and the integrated care partnership, so we will not be looking at the same elements as NHS England, but we will work and have worked in a co-productive way with NHS England to work out our approach against its approach. We will its evidence take into account, and I am sure that over time it will take into account what we find for ICSs as part of its own performance management. From a systems point of view, I realise that that might look complex, but it is trying to be distinctive in our respective approaches.
The Chair: We have heard that it looks complex from the outside, but it is good to hear you sounding positive about the way in which you will work with NHS England.
Q220 Baroness Redfern: My question is to you, Mrs Hewitt. In your introduction to the review, you say, “Unless we transform our model of health and care, as a nation we will not achieve the health and wellbeing we want for all our communities—or have the right care and treatment available when it is needed”.
What does this imply for the role of primary care and community care services, and their integration with the wider healthcare system? How well equipped are they currently to fulfil their roles?
Patricia Hewitt: Thank you very much indeed for inviting me to give evidence to this committee and for that question. That sentence from the review that I recently completed goes to the heart of the matter, because, as many others have said, what we have had in our country, really for 75 years, is a national illness service.
The population is getting older. We are living longer, which is often due to the wonders of medical care and technology, but we are also increasingly an unhealthy population, an increasingly unequal one, and one where many people are living with lifelong or long-term conditions and disabilities. All that requires a fundamentally different approach from a system that is focused on treating illness, often in its most acute emergency form in specialist hospitals, to one that is focused on prevention and on supporting people to be as healthy and independent as possible for as long as possible.
That, of course, has the crucial implication that primary care, community care and many other services in communities need to become the heart and the main focus of policy and of our health and care system, rather than, as is too often the case, being seen as much less important than the really important stuff that is going on in the acute hospitals. It almost needs to be the other way round, although that is probably an exaggeration as well. That is the first part of the question.
On the second part of the question about how well primary care and community care are equipped for this, in every part of the country, certainly including Norfolk and Waveney, there is wonderful work going on in many primary care practices and in parts of community, not just in community health but in social care, mental health and work with the voluntary sector.
Statutory integrated care systems are giving us a real opportunity to reinforce and build on that, but the whole system has not been designed to maximise their potential or to work in the transformational way that I have been describing. Within the broad range of primary care, perhaps especially with GP practices, we have outstanding ones working with integrated, multi‑professional neighbourhood teams and transforming people’s lives, but many of them are doing that despite, for instance, the GP contract and other aspects of the policy framework.
For far too long, we have been managing the health and care system as a series of separate, vertical silos of GPs, dentists, community opticians, social care, community health and so on and so forth, instead of making them part of an integrated whole that is wrapped around patients and communities. That is the big shift that we need, and that requires further changes in the national policy framework as well.
Baroness Redfern: So there is not one main barrier. You are saying that there are quite a lot of barriers coming together to stop the transformation of this service.
Patricia Hewitt: There are barriers and there are opportunities. Where, for instance, GP partners and their colleagues in a practice want to work in this transformational way, it is happening.
I give the example, among many examples in my review, of Medicus, which is a big practice in north London, with five or six GP practices merging into a single group, now employing over 300 staff in many professions and providing superb care for their patients. They are reaching out to the patients who they know, from their own data and relationships, are most at risk and most vulnerable, transforming the outcomes and significantly reducing the number of emergency admissions to hospital, and so on. They wanted to work in that way. They had really good support from their local integrated care board and, before that, the CCG, but the GP contract, which is held in perpetuity by each partner in each GP practice, is a massive barrier. We might come back to that, but it certainly needs a complete rethink and reformulation, in my view.
So there are opportunities and there are barriers, but, like James Bullion, a former colleague in Norfolk, I am very optimistic about the potential that we have created with statutory integrated care systems. As I think my review showed, they are already making a difference on the ground, and we need to reinforce that direction of travel, which, after all, is very new; we came into effect as statutory organisations only a year ago.
Q221 Baroness Shephard of Northwold: May I declare my interest? My husband is a self-funding resident in a care home.
My questions are for Mr Bullion. You have been a director of adult social services in a local authority. Therefore, you must be bringing to your role a number of questions that you want to put about the role of the CQC in inspecting integration. What questions stem from your experience as a director of adult social services? You must come very well armed.
James Bullion: As you will know, and as Patricia Hewitt knows, I have been the director of adult social services in Norfolk for six years and, prior to that, in Essex, so I come with a perspective of a local authority DASS as well as now a chief inspector. I welcome, as a DASS, the reintroduction of the assurance process of local authorities as part of the CQC’s work, alongside the new assurance task of integrated care systems.
Like Patricia Hewitt, I am very optimistic that, if we can get the right balance locally of autonomy for integrated care systems and the local vision for integration, and if we can avoid overmanagement but not avoid national expectations and have an enabling national framework, integration between primary care and community care can be improved.
Crucially, to answer your question, I come with an expectation that the integration needs to have at its heart local authorities as an equal partner, both in the integrated care systems and in social work, alongside primary care, community healthcare and public health, so that local areas can take a proactive, preventive, evidence-led approach rather than a nationally dictated approach or one that does not take into account the evidence of people’s lived experience.
In the CQC, we have set great store by our new single assessment framework, which tries to put people using services at the heart of how we will judge integration in ICSs and in local authorities. I also have to say, with my old hat on, as a director alongside Patricia Hewitt in Norfolk, that it is incredibly important that the social care reform journey carries on and is reignited to clear up the issues of the social care market and to create the capacity that is needed alongside the regulation of the quality.
Q222 Baroness Shephard of Northwold: You must have observed how difficult it is for social workers to feel equal partners in a system that is dominated, frankly, by medical interests and medical professionals. In your new role, how would you inspect the effectiveness of systems that will reduce that feeling of inferiority on the part of social services?
James Bullion: I am optimistic, because the one group of people who tend to understand social work and what it is trying to achieve are GPs, because they have a very similar outlook on and notion of taking care of people in their local community, anticipating risk and really understanding the wider determinants of people’s ill health. There is a natural affinity between social work, primary care and community nursing. As Patricia Hewitt has outlined, the emphasis of a system is often at the other end. In particular, the experience that we had in the previous winter of acute services has meant that that proactive work has not been able to be done.
In the way the CQC approaches this, we, in our work with ICS systems, will go looking for the evidence, as Patricia Hewitt has outlined, of multidisciplinary working, data sharing between local systems, and relationships. Crucially, is the relationship between local authority services and local health services equal, and do they have agreements in place like the better care fund or the use of joint approaches? That is the kind of evidence we will look for to see whether that equality of broader well-being and needs is being taken into account alongside the healthcare needs.
I am optimistic that we will find evidence of that. The key will be dragging and dropping the best practice from here to there, as it were.
Q223 Baroness Shephard of Northwold: That was going to be my next question. How would you enable the various players to put into practice what you have observed but which is not happening in their patch?
James Bullion: We have the opportunity in our assurance work to publish a report about a local area, so that can serve to highlight what is good and what needs improving there. In our State of Care report each year, we can report on what we see as the national trends and good practice. In partnership with NHS England, and indeed with the Local Government Association, we are able to have an improvement relationship that can amplify a really good idea in Norfolk and Waveney, or in Devon, and say to colleagues elsewhere, “This is best practice. You ought to think about doing that”.
Baroness Shephard of Northwold: So you do share good practice.
James Bullion: Yes, indeed.
Q224 Baroness Tyler of Enfield: Could I first mention my interest as a non-executive director of the Royal Free London NHS Foundation Trust?
My question is primarily to Ms Hewitt. I was very pleased to have the opportunity a few months ago to hear you outline the findings of your work at the Health Devolution Commission, which was an excellent session.
In your review, you say that ICSs bring together all the main partners—local government, the voluntary sector, social enterprise, social care providers, the NHS—in a common purpose expressed in four main aims. That sounds very good from the perspective of integration, but we have received a lot of evidence saying that not all partners feel they have been able to engage sufficiently with their ICSs so far. That is particularly the case for some primary and community care services. Do you recognise this problem, and could any practical steps be taken to address it?
Patricia Hewitt: Thank you very much for that question. It very much depends on the individual system. As Sir Chris Ham once said—he is very wise in these matters—“If you’ve seen one integrated care system, you’ve seen one integrated care system”. They vary hugely. In my review, I received evidence similar to the evidence you have described, but I also heard from other people that, in some systems, social care providers felt excluded, local government as a whole did not feel like an equal partner, or public health was not getting a strong enough voice.
It very much depends on the individual system. The truth is that we are all work in progress. Some systems are more mature because they have been working in these close partnerships for years, going back well before even the creation of the sustainability and transformation partnerships six years ago, which were the first shot at an integrated care system.
In parts of the country, the relationships are strong and pretty mature, but others are less so. In some cases, you may well have systems where the integrated care partnership convening the whole system and the integrated care board are really keen to have a strong voice and presence from, for instance, primary care, but are simply finding it very difficult to find GPs and other colleagues who are willing and able, given all the other pressures on them, to play that role in the system.
You need to understand the specific problem in different systems. I would caution against any idea that there is a single fix to this or to any other issue. Building on what James Bullion was just saying, the CQC has a really important role to play in all this. If it finds in a particular system that primary care or community health is in a weak position—for instance, because acute hospital trusts are dominating the system, the allocation of money or whatever—it is really important for the CQC to call that out in order that all the local mechanisms of accountability can kick in and help to solve that problem.
Mandating a particular approach for all systems is doomed to fail and, indeed, could be very destructive, because you might find a really good idea or a real problem in one place, mandate something to either spread the best practice or fix the problem, and create a whole bunch of other problems in systems that are completely different from the ones where the good or bad practice was showing itself.
Baroness Tyler of Enfield: I would like to pursue that a little further, going back to something that James has already alluded to. I quite take the point that all these systems will be different and you do not want a one-size-fits-all solution, but it is really about whether, as James said, the partners, particularly those from the community sector or local government, feel like they are equal partners round the table.
More than one of our witnesses has said to us that, in systems that would like to go in this direction, where all partners signed up to it, they felt that it should be possible for perhaps a local government leader or the lead member with the health portfolio to chair the ICS, if that is what everyone wanted locally. At the moment, my understanding is that it has to be an NHS person chairing it. What do you think about that degree of flexibility?
Patricia Hewitt: It is already happening. In Norfolk and Waveney, the senior councillor from Norfolk County Council, who has chaired the health and well-being board for many years, chairs the integrated care partnership, which is the statutory committee that convenes the entire system and all partners in it. I am the chair of the integrated care board for Norfolk and Waveney. The statute requires all ICB chairs to be independent, which I am. I am also the deputy chair of the integrated care partnership, but Councillor Borrett, who chairs the partnership, is also a partner member—in other words, a non-executive director—of the integrated care board, which I chair. So you will find different arrangements in different systems.
It is really important to recognise that some systems are very large. There is one system with over 3 million people and 13 upper‑tier local authorities, at least 12 of them with their own health and well-being boards. Then they have one overarching integrated care partnership and integrated care board. That is a very different set-up from a system like Gloucester, which has 750,000 people, one upper-tier local authority, one health and well-being board, and one integrated care board.
So a lot of what you are talking about already happens. There is flexibility in the legislation. Ironically, if I may say so, an amendment to last year’s Bill that was introduced and passed by the House of Lords made it impossible for any provider from a social enterprise to nominate or, in the case of its chief executive, to become a partner member on an integrated care board. In many parts of the country, including Norfolk and Waveney, there are social enterprises that provide NHS community health services through a contract with the NHS, so that amendment, which was also aimed at the for-profit, shareholder-owned private sector more widely, has had some unintended consequences that perhaps are not so helpful.
I would just caution against trying to change what is already a flexible framework. It is only a year old. We are all doing governance reviews designed to answer challenges that we have found in our operation. As that work and the CQC assessments develop, we will be in a much better position in a year or two to see whether any, I hope, minor changes are required to the legislation, but I would really caution against changes to the statutory framework. We are only a year old, as I said, and we need policy stability and no more reorganisations for at least five and preferably 10 years, so that we can make this work.
Baroness Tyler of Enfield: James, do you want to add anything on this issue of local authorities and others feeling equal partners at the ICSs?
James Bullion: As Patricia Hewitt has outlined, what is crucial is that councils feel confident that ICSs are it and that this will be the process of working in partnership. That will bring them around the table. From our point of view as a regulator with an independent assessment of them, we need to give them the message that we will be looking for a serious and medium-term approach. We will spend a year baselining with ICSs, so I would echo Patricia Hewitt’s message that the medium-term view here is crucial to get partners around the table, and for the CQC and others to do the learning about what works. That should lead to further improvement.
The Chair: We hear your caution and your warnings.
Q225 Lord Watts: How far will the regulatory framework for ICCs recognise the need for ICCs to navigate the tensions between local needs? Will there be changes to local needs and essential standards that have to be navigated between the two bodies? How will that work?
The Chair: Did you manage to hear that question, Mr Bullion? I think it was for you.
James Bullion: I think I get the sense of the question about how the tension will work out between local and national and between health and wider needs. From a CQC perspective, our independent assurance is of the ambitions of the area. We will begin with the integrated care strategy agreed by the integrated care partnership, and we will look at what needs are identified locally, whether they are being met, and what the outcomes are for people. We will not be concentrating on the elements that NHS England would concentrate on, which are the national requirements for the delivery of certain health services, although we will take into account evidence of whether they have been achieved.
We recognise a real tension between allowing local autonomy and working up from needs for a local area against national targets. We do not have any independent regulations for integrated care systems. We will be looking at the combination of what we found in our provider inspections, what the ambition says in the local strategy about the needs of an area, the impact on outcomes and, crucially, as part of that, what people in an area say about good or preventive outcomes based on lived experience.
Lord Watts: There is still the problem that you have two bodies possibly working in different directions, with local partners wanting to know how they best achieve what they are being asked to achieve. When those tensions come forward, how will national standards comply with local needs? How will those tensions be ironed out? It has the potential to be very confusing for the partners back at the ranch and down at the coalface who will be trying to navigate two things.
James Bullion: I certainly recognise the dilemma of the need for the Care Quality Commission and NHS England to align our approaches. Our co-production approach so far with NHS England is to make sure that there is a clear understanding of what we are looking at through our single assessment framework and what NHS England is overseeing through its performance and oversight arrangements.
I do not think we can entirely take away the need for systems to look at both those approaches in order to give independent assurance on what the outcomes will be. We are currently on a journey of working with a couple of integrated care systems as pilots for our approach to assurance. As part of that process, we will look at how this feels and looks to the local system and what it is experiencing in the way we and NHS England are working together.
One practical example of that is the question of information sharing. How much will we, as the regulator, ask the local system to collect information, to survey or to talk to people? How much can we already collect from NHS England—that is already in its framework of performance—and so not ask the system to do that task twice? That is a practical example of us trying out, in the piloting approach, whether we can minimise the bureaucracy.
I go back to my earlier point that we are trying to look at two distinct things. Rather than performance, what are the outcomes? What is integration like? What are relationships and leadership like? What is the quality of service? We are not counting how much of this, that or the other has been met through the NHS England national performance framework.
The Chair: You are also looking at how it is for the patient, presumably.
James Bullion: Indeed. A good third of our work now is on what people say about their experience in an area. That will form part of any rating or outcome that we would have from our assurance process.
Lord Watts: Is there a mechanism for those two bodies to meet and discuss any tensions that arise? Will there be an ongoing dialogue between the two bodies to say, “This is what’s happening down at the coalface These are the problems and these are the potential solutions, but it will need one of us to change our policies or our direction to help partners locally”?
James Bullion: As part of the way the CQC is going to operate the piloting process, we will have an outcome and evaluation of that. Part of that will include conversations and discussions with NHS England, and part will include signing off the process with the department. At that point, we could take into account whether any changes need to be made to our single assessment framework or our approach and, indeed, whether there will be rating or scoring of systems.
So there is plenty of opportunity for further dialogue. Even after the end of the pilots, we will spend at least a year baselining ICSs, which I think will offer a further opportunity to take stock.
Q226 Lord Kakkar: I should remind noble Lords of my interest as chairman of King’s Health Partners and chairman of the King’s Fund.
Mrs Hewitt, you probably have the best understanding of the distribution across the continuum of national, ICS and place-based commissioning and, indeed, financial decision-making to determine how best it is distributed across that continuum and how it varies across the country. As a committee, we have heard that there needs to be a greater emphasis on financial decision-making at place, rather than higher up the continuum, to drive the integration of primary and community care services. Is that your view? How can we ensure that appropriate decisions are taken about the skill sets that are necessary to drive it across those different environments? How might they be developed?
Patricia Hewitt: This is a really important question and one that we spent quite a lot of time on during my review. I would start by making the same point that I made in answer to an earlier question. This varies radically across different parts of the country and different systems. If you are looking at one of the big northern systems—Greater Manchester or Birmingham, for instance—or at what is happening in London, you are looking at large integrated care systems generally covering 2 million or more people and including several unitary or upper-tier county council local authorities.
All those local authorities are responsible for social care and adult services generally. They are responsible for children’s services, which are crucial when it comes to prevention in particular. They are responsible for public health and many other things that bear directly upon the wider determinants of health. In those large systems, place with a capital P, based usually on that upper-tier local authority footprint, is crucial.
I mentioned smaller systems such as Gloucester, or Norfolk and Waveney. We cover 1.1 million people. We have the whole of Norfolk County Council and part of Suffolk County Council. We work very closely with both, but we are a two-tier local government system, so place means something rather different in a system like ours, where we have five place boards based on an NHS footprint—the old CCG footprint of primary care networks and GP practices—but eight health and well-being partnerships based on the footprint of our district councils. They are working much more around communities where there are particular disadvantages and we really need to be focusing on health inequalities.
Again, the answer will vary from place to place. It is not a one-size-fits-all answer, but, especially in those larger systems, having strong partnerships at place level, with a significant degree of financial decision-making and commissioning going on at that level is really important.
It is not only at place. It also at the neighbourhood level, working very closely with communities, particularly the more disadvantaged ones, and being able to take advantage of the local community assets, the strong small community groups and so on, that can play such a critical role in supporting people to be as healthy and well supported as possible for as long as possible.
Lord Kakkar: That is very interesting. Is it properly understood at national level that there is a plurality of environments and relationships, based upon the determinants that you describe, and capacity for a pragmatic and flexible approach to be taken to derive the best from what you describe as local, place-based and regional opportunities?
Patricia Hewitt: It is understood in theory, but not always in practice. This partly relates to the very interesting questions from Lord Watts. There are real tensions between national direction and local needs, and ensuring that we have integrated care systems that, in the words of the Health Secretary, enable local leaders who know their communities to make the best local decisions with local people. That is a roughly accurate quote.
There is sometimes a real conflict between Ministers, not only in the Department of Health and Social Care, and NHS England. Everybody wants integrated care systems to succeed, and that “everybody” goes across parties as well, which is very important for our long-term success and sustainability. There is a real commitment and understanding that local integrated care systems, including the NHS integrated care boards, need space to understand what the data and the local intelligence and relationships are telling us about where our priorities are, where our most disadvantaged communities are and what will work best to solve particular problems.
On the other hand, we have national bodies often giving very detailed instructions. Not only Ministers or NHS England but we the public want to see ambulance handover, discharge problems and all those issues with acute hospitals sorted out. Everybody wants to see that.
If you get into detailed instructions about exactly what to do to try to solve those problems, that gets in the way of the local autonomy you need in order to say, “Actually, the cause of those problems in our system is”—whatever—“and we can be most effective in reducing those appalling ambulance queues, where people are waiting hours for the ambulance that they desperately need, by making this big shift towards integrated neighbourhood teams with primary and community care, acute hospital specialists, social care, the voluntary sector and mental health trusts all playing their part”.
The more we keep especially older people out of hospital in the first place, the better it is for them, but it also frees up the resources in our hospitals to do the things that only they can do for the people who really need it.
Q227 Lord Altrincham: Mr Bullion, you have spoken very clearly about how the CQC is the only body looking at the whole of the integrated care system. Very specifically, how do you observe integration, and how does the CQC appraise integration? Secondly, could the role of the CQC be enhanced to increase its role in assessing and encouraging integration?
James Bullion: Thank you for the question. To go back to the uniqueness point, we are the only organisation that takes a view across the whole system. We will do our assessments in a very formal way. Our assessment framework carries within it five areas where we will look at whether things are well led, or whether they are effective and safe, for example. We will have a series of seventeen quality statements, where we will look for evidence. We will, in a very methodical way, look through what is happening in a system.
If I had to summarise all of that, it would be a combination of looking for specific model ways of working, like multidisciplinary teams, particular approaches to relationships or integrated working, and looking at what key pathways are having an impact on people’s outcomes. Particularly in primary and community care, there is a focus on frailty, on admission avoidance and discharge, or on virtual wards and health checks for people. We will be taking a detailed approach and asking, “Is the following evidence in place?” If it is, that is good evidence of integration and, if not, there are findings for improvement.
In terms of our role, we are at an early stage of this. ICSs are just a year old. Our functions are new from April, so we have to go through a piloting and baselining process before we get to making any observations about our particular role. We need further time to develop whether we would be the only body to give a judgment about performance in an area. That relationship between us and NHS England about a single rating or a rating for sectors still needs to be worked through. That is the remaining area where, working with the department, we need to get further clarity on what the Secretary of State would want from us.
Lord Altrincham: So it is too soon to enhance your role.
James Bullion: Indeed.
Q228 Baroness Armstrong of Hill Top: Hello, Patricia. I cannot possibly call you Mrs Hewitt.
In your report, you have made significant recommendations with the aim of unlocking the potential of primary and social care and its workforce. We have now had the workforce report, but it deals only with the health workforce and not with social care. You were looking at how, through this, you could address the obstacles associated with training and national contracts, which you have already mentioned in relation to GPs, and the need for complementary workforce strategies between the sectors. Where are we at now, now that we have the workforce plan? How do you see this being taken forward, particularly given the reductions in the number of staff that people such as you are having to make in ICSs?
Patricia Hewitt: Thank you for that question, which raises several different questions. The NHS workforce plan is very welcome, but we very badly need a social care plan, not only a workforce plan but a wider conversation about how much as a society we are willing to spend on a decent quality and level of social care for ourselves as we grow older and for the people we love.
You make the point about the very large and very rapid reduction in integrated care board staff that is taking place at the moment. As I said in my review, it is too large a reduction being imposed far too quickly, and the speed and the scale of the change are undoubtedly making it more difficult to focus on what we are really here to do, which is this process of integration in order to get better outcomes for our residents.
As you have reflected in your question, this is not simply about NHS primary care or NHS community care, but about the whole of the workforce that we can mobilise here. I would make a couple of points. First, over the last four years, compared with the year immediately before the pandemic, there has been a very large increase in the NHS clinical workforce—overall, roughly a one-third increase in the number of doctors and nurses. By far the biggest increase has been in A&E and other hospital consultants, which is where the drop in activity levels has been most marked. There has been no increase at all in the number of full-time equivalent GPs, yet they and their teams are doing far more work than they were doing before the pandemic and far more appointments. In between, we have seen an increase in the number of hospital nurses, but a lower increase in the number of community nurses. Roughly speaking, that is exactly the opposite of what we need as a country and a population.
One specific thing that I very much hope your committee will draw attention to is the GP contract, which is simply not fit for purpose. It makes it very difficult for the many GP partners and partnership practices that really want to work in a transformational way and change the outcomes for the population they are serving. It also makes it very difficult for small practices, possibly in very disadvantaged areas, in premises that are now in negative equity thanks to interest rates and what is happening to property prices, where the partners simply cannot afford to invest in the premises, the digital systems, or the staff and services that they need.
We need an entirely different approach to the GP contract, which supports and encourages the GPs who want to work as partners in traditional practices to work in these transformational ways, but equally gives those who do not want to take on the financial and other responsibilities of running a business to have a rapid route into being salaried GPs where they can care for patients and use the skills they have but be taken out of the problems they have in running their premises.
Alongside that, we badly need to look at the ARRS roles, for community pharmacists and so on, which are getting in the way of integrated care boards being able to manage the limited workforce they have in their particular system or place in the way that will get the best results for patients and residents. That is what we have to keep coming back to.
Q229 Lord Watts: Patricia, will the announcements on the NHS staffing strategy help or hinder the transformation that you are looking for, given that it is likely that people will move out of the care system into the NHS, leaving a void that cannot be filled?
Patricia Hewitt: I hope it will not have that effect. I hope it will be helpful. I particularly welcome the emphasis on really tackling the retention of staff, because in many of our trusts it is not recruitment that is the problem, but retention. Many of us in integrated care systems and their integrated care boards are already doing really useful work to build and retain the social care workforce as well as the health workforce, and to make it easier for people to have careers that cross both, but we need a national framework to support that, rather than risking, as you correctly suggest, perverse incentives and the wrong consequences.
The Chair: On behalf of the committee, can I thank both of you for the richness of your answers? They have been very useful to us indeed, and we are extremely grateful to you for sparing the time in your very busy schedules. As you know, this is publicly broadcasted and you will see a transcript, which you will be able to correct for errors. In the meantime, thank you very much, Patricia and James.
