Health and Social Care Committee
Oral evidence: NHS Long-term Plan: legislative proposals, HC 2000
Tuesday 23 April 2019
Ordered by the House of Commons to be published on Tuesday 23 April 2019.
Members present: Dr Sarah Wollaston (Chair); Mr Ben Bradshaw; Andrew Selous; Dr Philippa Whitford; Dr Paul Williams.
Questions 98 - 188
Witnesses
I: Dr Amanda Doyle, Chief Officer, Healthier Lancashire and South Cumbria; Professor Chris Ham, Chair, Coventry and Warwickshire STP; Patricia Hewitt, Chair, Norfolk and Waveney STP; and Jon Rouse, Chief Officer, Greater Manchester Health and Social Care Partnership.
II: Julie Wood, Chief Executive, NHS Clinical Commissioners; Chris Hopson, Chief Executive, NHS Providers; Niall Dickson, Chief Executive, NHS Confederation; and Sarah Pickup, Deputy Chief Executive, Local Government Association.
Written evidence from witnesses:
- Local Government Association
Witnesses: Dr Doyle, Professor Ham, Patricia Hewitt and Jon Rouse.
In the absence of Dr Wollaston, Dr Paul Williams took the Chair.
Q98 Chair: Good afternoon, everybody. As you might have noticed, I am not Sarah Wollaston. She has been delayed; she is on a train that is going to be a little bit late. I am Paul Williams. I am your host for this part of the session.
This is the Select Committee’s second evidence session on proposed legislative changes. Thank you very much to everyone who has come today. Maybe you could begin by very briefly introducing yourselves and whom you represent for the purposes of the cameras.
Jon Rouse: I am Jon Rouse. I am chief officer of Greater Manchester Health and Social Care Partnership.
Dr Doyle: I am Amanda Doyle. I am a GP by background and chief officer at Blackpool and Fylde and Wyre CCGs, and chief officer for Lancashire and South Cumbria Integrated Care System.
Patricia Hewitt: I am Patricia Hewitt. I am the independent chair of the Norfolk and Waveney STP.
Professor Ham: I am Chris Ham, independent chair of the Coventry and Warwickshire STP.
Q99 Chair: Thank you. We have all seen the proposals from NHS England for possible changes to legislation. How much involvement have any of you had in drawing up these proposals?
Jon Rouse: A significant amount, through the integrated care system network, which is the 10 or 12 systems that are most advanced. We were engaged through the development of the proposals, particularly by Ben Dyson, who I think has already been a witness before you on behalf of both NHS Improvement and NHS England. There were some surprises when they came out, but, broadly, I recognise the proposals.
Dr Doyle: Yes, it was the same group, and a lot of what has come out in the proposals are barriers we came up against as we were trying to develop integration. A lot of the proposals developed from work we were doing in that group.
Patricia Hewitt: I have not been involved personally, although I think my executive lead has been. Certainly, when I saw the proposals, I thought generally they all addressed issues that I recognised from my experience in Norfolk and Waveney.
Professor Ham: In a previous role I was at the King’s Fund when the plan was being worked up by NHS England and others. We had a number of conversations with the officials who were working on that particular section of the plan, and indeed one of your advisers, Nick Timmins, one of my former colleagues, wrote a paper for King’s Fund setting out our suggestions on the areas of the law that would need to be changed. There is quite a lot of similarity between the ideas that the fund was putting forward and what is in the plans, so, yes, I have had similar involvement.
Q100 Chair: You mentioned, Amanda, the barriers that have been identified. Perhaps it would help the Committee if you could all identify some of the barriers to effective delivery of integrated healthcare, and then the follow‑up questions will be about whether or not the proposed legislative changes address those barriers. Maybe you could start by explaining to us what is wrong with the current system.
Dr Doyle: When we are trying to develop integrated care, we are trying to move to a more collaborative way of working across the system so that the barriers, the gaps between organisations, become less of a hurdle for patients to jump through when they are travelling through pathways.
The way we work has traditionally kept a very clear divide between commissioners and providers, and a more competitive than collaborative approach between individual providers. The changing population we have—needing a different sort of model of care, an ageing population with long‑term conditions who often move in and out between primary and secondary care, and spend quite a lot of time between primary and community services as they age—needs an approach in which we are much more collaborative, there is a much more streamlined path in and out and between individual providers, particularly between primary and secondary care.
All of that lends itself to an integrated system of working, but the way the system is currently set up makes some of that quite difficult to develop. Some of the competitive behaviours—the very transactional approach, the sometimes perverse incentives that a tariff‑based system puts in place—all work against moving quickly to an integrated system.
Q101 Chair: Can you describe for the Committee some of those perverse incentives?
Dr Doyle: A tariff‑based system works very well in a traditional model of “Refer people to a hospital, treat them, cure them, discharge them and send them out again,” but if somebody has a number of long‑term conditions whereby they may have a small part of their care in a hospital setting, but a much bigger part of their care in a community or primary care setting, if a hospital provider is incentivised to increase the number of episodes of care in the hospital because of the financial regime under which they are working, you are not necessarily using your resource in the most effective way or treating your patient in the place where it is going to be most effective for their best outcomes.
Q102 Chair: Who would like to go next in describing what is wrong and what the barriers are?
Patricia Hewitt: To build on what Amanda has been saying, I was quite shocked when I became chair of Norfolk and Waveney STP, which was in about July 2017. It is a large rural area, with a population of just over a million, an NHS budget of about £1.6 billion a year and an enormous number of organisations: five CCGs; three acute trusts; two community providers; a mental health trust; two county councils; seven district councils and an ambulance trust that covers a much bigger region. Then I started discovering various other people who hold various other contracts for other parts of the system, including children and young people’s health services, who are not included currently in the STP. That problem of fragmentation is very real.
When you add to that the competitive relationship between many of them, you can end up with very high transaction costs, lots of tedious arguments about coding and activity levels and who owes whom money and, ultimately, a great deal of money wasted on legal fees because of disputes going to arbitration or whatever, none of which adds to the total resource within the system. It just decides whose balance sheet some bit of the deficit—because we are an overspender—is actually going to sit on.
To build on Amanda’s point about the perverse incentives, particularly I think in the acute sector, while it is very helpful to have a unitary board that is responsible for what goes on inside that organisation, it is not helpful if, perfectly understandably within the current framework, the board comes to believe that the right strategy for its organisation is to maximise capacity, activity and income regardless of the fact that that is not necessarily in the best interests of patients. It may well not be affordable within the NHS budget for the area, and it does not, therefore, achieve the triple aim of the NHS. While you have strong accountability for individual organisations, you have very weak accountability for the system and the value of the system as a whole.
Professor Ham: I agree with what has been said, Chair. Given the inquiries about legislation, the 2012 Health and Social Care Act was predominantly designed to put in place arrangements to promote competition and the detail that Patricia has just spoken about—the contracting system and the focus on organisations—rather than on place and local systems.
Policy and practice have begun to change since 2012, but the law has not, so it feels increasingly uncomfortable that organisations work in the way they do, yet the policies are around place‑based working and partnership working to achieve different models of care, as Amanda rightly set out. That is not unsurmountable. We know that in some parts of the country the most advanced of the integrated care systems have found a way around some of those obstacles, and they are not all enshrined in law. You do not have to stick with a traditional payment‑by‑results funding system; you can choose to procure and tender in a way that does not require you to go out in an open competitive way.
There are workarounds, but the workarounds are a second‑best solution to the kind of practical changes that the long‑term plan has set out. While those changes are necessary, on their own they will not be sufficient, because so much will depend on building the partnerships, the relationships, and changing the behaviours that we are now being asked to leave behind that stem from the drive to promote competition rather than to promote collaboration.
Q103 Chair: I have my follow‑up question to that ready, but perhaps, Jon, you could give your view.
Jon Rouse: I would not add a lot more. I agree with everything that all three of my colleagues have said. I would make two points.
First, in this session it is very important that we recognise that not all the barriers are legislative or systemic in that way. They are often cultural, and they can be to do with other gaps and deficiencies—for example, in terms of workforce, and the education and training system that sits behind this. I think you covered a lot of that territory in your report on integrated care in the last Session. I do not want us to lose sight of the fact that legislative change is important, but it is not a panacea. There is still a lot of hard work that needs to be done at ground level in shifting those cultures, which are pretty embedded. That is the first point.
The second, which builds on Chris Ham’s point, is about the regulatory system and the lack of alignment—how the regulatory system is aligned and the way we are trying to create integrated systems at locality level. The regulatory system at present is focused on the organisation. That is how the legislation is designed, and, therefore, even an organisation that wants to maximise its system contribution will always have half an eye on the regulatory perception of that, particularly in terms of finance.
Q104 Chair: Amanda, you talked particularly around competition, or how the system does not encourage collaboration and there are perverse incentives from the tariff. Patricia, you talked about fragmentation and about there being nobody with accountability for the whole system. I think, Chris, you described what is largely the culture that is the result of the legislation, and you expanded on that—legislation focused on organisations. My question to all of you is: do these legislative changes adequately address the barriers that you have just identified?
Dr Doyle: They go a long way to enabling us to do the important parts of what we want to do. Nobody I have heard in the health service wants a huge reorganisation of the NHS at this stage, but there is a need to get on with the move to a more integrated approach—new models of care, bringing ourselves back into financial balance. These proposals address some of the key barriers to us being able to do that. Some of it we can do anyway within the current legislative framework, but only as long as everybody wants to. That makes it time‑consuming and difficult.
Q105 Chair: Will this enable a strategic shift from community‑based prevention, away from active hospital‑based activity and towards community‑based prevention?
Dr Doyle: The combination of this relatively small number of legislative changes with the proposals in the long‑term plan and the targeting of investment to primary and community care, the focus on addressing health inequalities and the move to prevention will certainly help us to do that.
Q106 Chair: Patricia—accountability?
Patricia Hewitt: I am very strongly supportive of the proposals that are being made. I think they will be very helpful, including the proposal for a joint committee of both commissioners and providers. There are two other changes that I think would be helpful, although they are not essential.
Moving beyond the idea of the joint committee, it would be well worth considering creating a legal form for an integrated care system that would not be compulsory for systems to have to use but would be available for systems that wanted to use it. It would effectively provide for the ICS—the system and its partnership board—to be accountable for system performance and the triple aim. I would also allow the system partners to decide for themselves for that local system the detail of what accountability sat with the system and what remained with the boards of the individual organisations, because you will still have multiple organisations.
A variation would be to say that the system board in its accountability for system performance also had to take account of the statutory and other duties of each of the partner organisations, and equally each partner organisation would be held accountable for system performance as well as organisational performance. Given that we do not quite know when we are going to get legislation, a legal model of that kind could be very useful to some ICSs in a couple of years’ time.
Q107 Chair: My understanding of the current proposal is that the CCGs will merge or combine in some way and, effectively, the CCGs will be the same size as the integrated care system. Is it your understanding that the CCGs will retain accountability?
Patricia Hewitt: Yes. That is what I understand the long‑term plan to say—typically one CCG per system—but I have also heard some officials in NHS England saying that really what we are doing is going back to the old days of the district health authority. I profoundly hope that that is not the case; I do not think it would be particularly helpful.
There is a danger that we inadvertently deepen the purchaser-provider split, rather than create a much more integrated and collaborative system with both commissioners and providers around the table almost all the time for almost all decisions. The joint committee proposal, which would allow commissioners and providers to form a joint committee, is certainly helpful. We might well want to take advantage of that. What I am suggesting would go one step further.
Q108 Chair: I think what I am hearing from you is that it is inevitable that at some point CCGs will no longer exist, and that the ICSs will need to be the accountable body, so we may as well legislate for that as an option now rather than have to come back in future years.
Patricia Hewitt: You could still have a single CCG, particularly for situations where, with the best will in the world, you have not been able to sort out quality and performance issues in some aspect of the system and commissioners therefore want a separate conversation, which may or may not lead to a procurement, but they need that option. You could still have a single CCG, but it would sit within an ICS partnership board that had overall accountability.
Professor Ham: I agree with that, because I think there is a risk in equating the move towards more strategic commissioners aligned with ICS boundaries with that then becoming the statutory body that is the ICS. For the reasons that Patricia set out, that feels to me to be not the case, because ICSs are commissioners and providers. I am not sure anybody has mentioned local authorities yet.
Dr Doyle: Critical.
Professor Ham: They are very important partners, in my view, as well and rather neglected in the long‑term plan, so the move towards fewer, larger strategic commissioners in most places—but not all, because there are some parts of the country where that probably will not be the right answer, but very much focused on the governance being one of partners across the NHS and local government—would take us a long way in the right direction.
Your question was about what are the practical barriers in the current system. For me, they centre on the requirements on procurement and tendering, which are either real or perceived barriers—I think they are both, depending on where you look; the CMA powers, which have been identified as one area for change; and the tariff arrangement, but actually much of what is in the tariff is not a matter of law. Places like Bolton, Leeds and others have moved away from the tariff as a principal way of paying for services towards a place‑based funding model much more aligned with what ICSs and STPs are trying to do. That is why it is important to say that we do not have to wait for the legislation. There is an awful lot we can and should be doing, and are doing in many places, to get on with this.
Jon Rouse: Starting with the question you asked right at the outset, we are broadly supportive of the proposals. We think they go a significant way to addressing some of the barriers that we have been concerned about, going back before the start of devolution in April 2016. Probably for the last five years, we have been talking about some of these things, so we welcome this package as a whole. There are three things, therefore, that I would pull out that we probably need to be watchful of and that need addressing if they are going to make the impact they are intended to have.
I will start with local government. The main problem with the proposals as a package is that they are almost entirely NHS based and focused. What we have created in Greater Manchester is a genuinely integrated model. Our governance, our executive board, has equal voting rights between local government, combined authority, NHS England, primary care trusts and CCGs. We are in there together; it is an equal relationship and we make decisions together.
Even on the commissioning side—our joint commissioning board—each locality is represented by either the leader of the council or the lead member and the CCG chair or nominated individual. It is formally constituted as a joint committee of the CCGs, but through use of delegation powers we are able to create an equivalence in terms of enabling local government and CCGs to make collective decisions. It is very powerful when you see it in action.
We want that part of the proposals to go further than they do. We would want to see the creation or the enabling of a form of governance that could be genuinely cross‑local government and NHS so that you can do proper place‑based reform that is around health improvement, not just integrating health services. It is a different paradigm. That is the first point. I will be much quicker on the second two.
The second point is that there is an inbuilt risk to some of the proposals of centralisation that we were not expecting. We thought that this was about enabling integrated care systems, devolved systems, to be able to join up, but with some of the proposals—for example, the ability to direct mergers in certain circumstances—we would at the very least want to understand what the circumstances were. Frankly, in a mature integrated care system, if you got to the point where you were having to ask a national body in order to intervene, you would have lost something in terms of the partnership itself. You need to be careful where there is a risk of centralisation.
The third point is what I call the law of unintended consequences. To give an example, I think we would all agree with the benefits of being able to make flexible use of local tariffs. Some examples have already been given. If you are a major teaching hospital, you do not want 15 or 16 different versions of a pricing mechanism for the same provision of care, the same specialty, and you are left trying to make sense of 16 different ways of paying for the same thing in different geographies. There is a bit of devil in the detail that needs to be worked through to make sure that there are no unintended consequences of what is otherwise a good proposal.
Chair: Thank you.
Q109 Mr Bradshaw: There is an awful lot of technical language and jargon in this. I wonder if we can try to cut through it in a way that makes it more intelligible to people watching and to the public at large. Most patients, I think, find the purchaser-provider and commissioner-provider split difficult to navigate and to understand, but they understand choice and the ability, if a local provider is failing or has failed, for them to be able to access an alternative. Is there a danger that they could lose that in some of this?
Dr Doyle: It is really important that we ensure that they do not. There is nothing in this that suggests losing the obligation to offer choice at the point of referral, or the obligation to re-offer choice after a lengthy delay in wait for treatment. In practice, what happens, particularly in very deprived areas, is that people overwhelmingly choose based on geography, and occasionally on waiting times. I cannot think of a patient who has ever asked me details about quality of performance at an individual trust.
We have to balance getting the local provider for a community delivering as well as it possibly can, and put a real focus on driving up quality improvement across the board, but retain the ability for patients to choose to travel if they want to, if they want to get a shorter waiting time or if they want a choice of provider within a geography. There is nothing in this that removes the obligation to offer choice, and it is quite important. At its simplest, people often want to have their hip surgery near where their daughter lives, not where they live; it is fundamentally important that we keep that.
Competition, on the other hand, often gets lumped in with choice when people are talking—the slightly inflexible. Chris mentioned perception versus reality, but what actually happens in fact is that commissioners are so scared of being challenged that they often do not risk not procuring services, even relatively small services, even services where there is an obvious local provider to work with to develop and improve a service. We absolutely need to protect choice—the use of competition—where it can add value or where we may be able to get a service that is difficult to get at the moment, but not the absolute, inflexible approach to competitive procurement that we are seeing at the moment, because that just adds costs and reduces flexibility.
Jon Rouse: To add to what Amanda said, choice comes in a variety of different forms in health and care. The first and most important choice is choice of GP and that relationship, because it is the GP who will partner the individual and the individual’s family through the decisions and choices that they are going to make, so nothing should be done that would erode that first choice that is made.
The second is around the range of needs of an individual. If you are somebody with multiple long‑term conditions who maybe has the opportunity to hold a personal budget, that might be the best way of exercising choice—actually giving you direct control over the decisions that you need to make about your long‑term care. With planned care, particularly simple planned care, it might be about who has the shortest waiting time. It might be as simple and practical as that.
What we say about choice is beware false choice. If you were in Greater Manchester five years ago and you were looking at the choice of stroke services within Greater Manchester, they were all separate, all fragmented and most of them very poor. Through a unified model, a single-service model, spreading workforce and expertise across each of our stroke centres, and having a hyperacute centre that is best in class, you may not have quite the same level of choice, but actually you can go to any one of our centres now in Greater Manchester and you will get high-quality care.
Q110 Mr Bradshaw: Does anyone else want to add anything? What about the tariff issue? Are there any potential unintended consequences of that that would concern you?
Jon Rouse: I have already given one, which is that we need to make sure that we do not create impossible situations for larger hospitals, whereby they are trying to make sense of multiple different tariff options across different geographies that would be very difficult to manage when you were providing one service.
Q111 Mr Bradshaw: There is nothing in these proposals, if I was a patient faced with a choice between a local failing hospital and an excellent hospital, that would be removed from me for my elective surgery—my elective care—or, if I was having to wait an unacceptable period of time for a hip operation, I would not be prevented from asking to go to my nearest independent treatment centre that could do it more quickly.
Jon Rouse: There are no changes foreseen in these proposals that would affect that right.
Patricia Hewitt: There is certainly nothing I can see in these proposals that would compromise the right to choose for a patient needing a hip replacement, or whatever it is. The real problem, and I have seen this in practice, both in Norfolk and Waveney and in London, is simply that waiting times for a lot of elective operations in many places are very long, and your ability to go somewhere else is pretty constrained. That can include even a reasonably nearby independent treatment centre, because they seem to be pretty full as well. I do not think any of us should run away with the idea that there is huge availability of choice at the moment.
The other point related to tariffs is that, not specifically because of these legislative proposals but because of the pressure to get the best possible value for the NHS pound, we are all being urged to move towards block contracts for the bulk of the activity in acute hospitals. That seems to me to me to make very good sense because it cuts out lots of arguments and transaction costs, and then you can have a sort of layer at the top that is more related to activity and can involve some risk sharing with the hospital that may find that it has more emergency cases turning up than the rest of the system was promising and obviously has to deal with those patients. You can adjust for that at the margins rather than running the whole system on a tariff basis.
Professor Ham: The main constraint on choice is not to do with legislation; it is to do with the funding and workforce constraints we are all very familiar with. If we do not have enough money for CCGs to buy additional waiting time capacity or enough staff to deliver the care, those waiting times are going to get longer.
Q112 Mr Bradshaw: Yes. I think the worry people have, and we experience this as constituency MPs with people writing to us, is that in effect there is no choice now; commissioners are not commissioning from alternatives that would provide that choice because the money is not there. The danger is that this would then cement that in legislation, which goes counter to the rights enshrined in the NHS constitution, but you are not worried about that.
Jon Rouse: I am not worried that the legislation would have that effect. I think there is an issue, which Chris Ham has just talked about, that funding and workforce constraints may be making it difficult to provide the level of choice that one would want to provide.
Mr Bradshaw: Thank you.
Q113 Dr Whitford: Coming back to Amanda’s point, I am not sure how much evidence there is on the percentage or number of patients who actually exercise choice, but certainly my impression would be that most people want to be done in their local hospital and want their local hospital to be good and safe. Shouldn’t that actually be the focus? Often people have said that competition drives efficiency, but clinicians will compete if you make it clinical outcomes that they have to compete on rather than not.
Dr Doyle: Absolutely. We have certainly seen from GP practices, as well as hospital clinicians, that the most effective way of driving up improvement and reducing variation is often just showing people the data about what they and their colleagues are delivering. When you get to frontline clinicians, not many of them are thinking about extra income for their trust. Using those other tools to drive improvement is much more important.
Professor Ham: Choice has primarily been about planned and elective care for 25 years. Most acute hospitals do far more in the way of unplanned emergency care, and choice does not apply in quite the same way.
Q114 Dr Whitford: It is interesting that you were saying that it is mostly geography and waiting times rather than people looking into performance, but if it wasn’t, if it was requiring more research to make your choice, would that not widen health inequalities? There will be quite a big difference between people who do a lot of homework and demand to be sent to hospital A and people who just go to their GP and go where they are sent, and we actually want to narrow health inequalities.
Dr Doyle: That is absolutely right. To be fair, all my general practice experience has been in Blackpool, which is a very deprived population who are not going to travel and are not going to do their homework, as you have described, so it is important that we focus on quality improvement across the board.
Jon Rouse: Also, we should be looking for opportunities where we can take high‑quality care and bring it close to people’s homes. One of our big innovations in Greater Manchester is taking the Christie model—the cancer model—and bringing it to local hospitals, because a lot of the procedures can be done in mobile units in people’s communities. That is much better than creating some sort of artificiality in terms of competition.
Q115 Andrew Selous: I have a brief follow‑up to Amanda about data driving clinical performance. Has that been your experience of the getting it right first time programme in the work you are doing? Maybe that is not a fair question if you have not had much personal experience of it.
Dr Doyle: There is getting it right first time around delivery but it is also about the right care—the commissioning equivalent of getting it right first time when we are looking at appropriate referral rates, the use of medicines and a whole range of indicators that are going to improve health, as well as the efficiency measures around interventions that getting it right first time will often have. What we often see is a reduction in variation, and that is reassuring; we are tending to see an improvement in quality, so, yes, absolutely.
Patricia Hewitt: What is becoming increasingly important is getting good data and intelligence across the whole system, so that you are not just looking at efficiency in an acute hospital, and you can benchmark all of that. You are actually looking at what we are doing to keep elderly people in particular as well and as safe as we can for as long as possible in their own homes, and, obviously allowing for different social and economic factors, how well different GP practices and, in future, primary care networks are performing when it comes to that range of outcomes for elderly people. Or diabetes, for instance: what is happening to prevalence of diabetes but also for the outcome? What are the amputation rates, and so on? You need to be looking at that kind of data, which will often cross organisations, and then saying that this is where we have the worst health inequalities, the worst outcomes; this is where we need to be putting additional resources and the best practice.
Andrew Selous: Thank you.
Q116 Chair: Chris, can I ask you about the tariff? At the moment, we have a uniform national tariff, and these proposals change that principle. Is there a risk that once the principle has changed there could be competition between different providers on price?
Professor Ham: There is a theoretical risk. I think it is unlikely in practice, because there is a lot of evidence, and it has been reflected in policies in the past, to show that if you have competition on price it tends to have an adverse impact on the quality of care.
Although you say, Chair, that at the moment we have a national tariff, increasingly there are divergencies—for good reasons—from that national tariff. Many areas of the country have already taken the initiative and put in place their own versions of the tariff, often not using the tariff at all, or using it very much at the margins. I see no evidence from those places that that is having an adverse impact on patient care or use of resources. In fact, I see evidence of precisely the opposite.
The message I take from that is that people locally who are commissioning and providing have a much better understanding of these issues, frankly, than those in the national bodies we have relied on in the past. If this aspect of the proposals in the plan goes forward, I hope we do not come out with an alternative national solution but that we actually give permission to STPs and ICSs to figure out locally what would work for them, and to share some of the really good innovative work that is already taking place.
Dr Doyle: The other thing about the tariff is that in a system with a deficit, which we have in Lancashire, we have to take cost out of the system and we only save a pound if none of us spends it. Using the tariff just to shift the burden from provider to commissioner and back again is not particularly helpful. We have to deliver our pathways in the most cost‑effective way and remove cost. That is why the move away from a fixed tariff across the board would be helpful to us.
Q117 Chair: Jon, the proposals suggest movement away, in certain circumstances, from compulsory procurement and use the phrase “a best value test”, which is a phrase used in local government, isn’t it?
Jon Rouse: It is.
Q118 Chair: That best value test has not yet been defined and we do not know yet whether or not it is the same test as in local government. What elements would the best value test need to consider in order to make it work?
Jon Rouse: The first thing to say is that the Greater Manchester Health and Social Care Partnership is positive and supportive of the proposals to take, effectively, NHS commissioning out of section 75 of the public contract regulations. I wanted to put that on record.
In terms of the best value test, there is a lot to learn from the local government test. The local government test has three elements: economic, social and environmental value. I get quite excited when I begin to think about importing social value properly into an NHS assessment of how best to commission or buy services. If you think about the amount that the NHS spends in a local economy and the good that could do if there was built into it both testing of how to provide, and obligations on who provides— around apprenticeships, around how goods are procured and around sustainability—the impact could be absolutely massive. We spend £6 billion a year in Greater Manchester on our health system. Imagine that being harnessed to that cause.
I hope that, in defining the best value test, the NHS will look to the experience of local government—good and bad—and draw from it the ability to take a broader view of what is value.
Q119 Chair: Are there some disadvantages?
Jon Rouse: The only potential disadvantage is if the NHS were to perceive this as an ability to be protectionist. The best value test is a true test if it is used properly. It requires that you carry out a proper market assessment of what is the best option for meeting the needs of your population. It is not a get out of jail free card. It still requires you to make a very clear set of decisions against some clear criteria for making that judgment.
Q120 Chair: What safeguards need to be there to ensure that the same provider is not commissioned every single time, regardless of the quality of what they are doing?
Jon Rouse: There are two things. First, the integrated care system construct, or, in our case, the devolved system, should do some of that self‑management in terms of the integrity of the whole system, rather than that of one organisation or one commissioner. Secondly, this is presumably where there continues to be a need for a degree of regulatory oversight, and where the role, for example, of the regional office comes in, to ensure that the new duty is not abused in some way.
Q121 Chair: Does anybody else have any thoughts about what the best value test needs to consider? We have heard of a model considering economic, social and environmental value. What else does it need to consider in order for it to work?
Dr Doyle: I agree with what Jon said. We have a wealth of data, evidence and information that suggests what delivers best outcomes, cost‑effectiveness and clinical effectiveness, and we could use that more to drive evidencing that we are achieving best value. The important thing, as Jon says, is how an ICS holds the providers in the system to account for delivering quality.
Q122 Chair: Just to play devil’s advocate, without the ultimate lever that you have of saying, “If you are not going to provide it to the standard I want, I am going to go somewhere else,” is there not a risk that patients will end up with a service that is not as good or as efficient?
Patricia Hewitt: I think that is a real risk. That is what lay behind my reference to the old district health authorities, which at their worst were shocking old monopolies where patients were expected to be grateful for what they got, and the system was organised for the benefit of the system rather than the benefit of patients. That puts it crudely, but that was very much the debate back in the days when there were district health authorities.
It is important for best value to include a very explicit focus on health outcomes—one of the three elements of the triple gain—but also to look at both outcomes and costs across the whole system and the whole pathway. If you, for instance, simply look at things from an acute hospital perspective, which is where the bulk of the costs sit, or at least about half the costs, you might look at some quite small changes to make your outpatient service more efficient. If you look across the entire pathway, you can see that an enormous amount of consultants’ time, patients’ time and their families’ time is wasted with wholly unnecessary out-patient appointments.
There are all kinds of ways, demonstrated in different geographies, of stripping out quite significant amounts of cost there and actually getting better outcomes and more satisfied GPs who get faster access to advice from consultants and so on and so forth, and saving the consultants, who are a very precious resource, for the smaller number of patients who really need to be seen in person by those consultants. Again, you need to look at that across the whole system and you need some levers that the system can exercise to get the resources where they are needed.
Coming back to the point, if I may, about local government, we have very strong relationships, particularly with Norfolk County Council, which covers the bulk of the Norfolk and Waveney STP. It is a very helpful bit of grit in the oyster, if you like, to have very senior local government colleagues coming from a completely different financial regime, where they are not allowed to overspend, contributing to the debate about health outcomes and about the NHS. Obviously, the NHS has a different regime, but learning from each other is part of the benefit of creating an integrated care system.
Professor Ham: You still have to have what you were indicating, Chair, within the future system: the possibility of the funders—the commissioners—moving a service from A to B. That might be, to take the example of out-patient services, the primary care networks of the future working closely with community health services who might be able to deliver better care to patients in an alternative way than hospitals are in the traditional old‑fashioned patient model we are used to. There could be an element almost of contestability within the NHS family.
Dr Doyle: It is worth saying, to your point, that the services we often struggle most with around performance, delivery and quality are not necessarily the services that lend themselves to going out to procurement anyway—A&E services and those sorts of services. It is very difficult meaningfully to use that lever at the moment. There are other ways that we need to assure ourselves and drive up improvement.
Q123 Mr Bradshaw: Patricia, you just mentioned the huge difference in the way that local government and the NHS have traditionally viewed deficits or have to view deficits. Is this not an unsurmountable problem? The opposition on integrated systems that we picked up from local government as we toured the country is the fear of having to take responsibility for horrendous NHS deficits. What is the way round that, and do the legislative proposals address it?
Jon Rouse: We have had mixed experience on this, and I think the legislative proposals could help in a number of ways. In some of our local systems, they have fully pooled their resources, they have shared risk to a significant degree, and they have lent money to each other in order to generate the best position they can collectively. I have been very impressed with the maturity with which they have operated. That has been between NHS organisations but also between NHS and local government. That has not been the pattern everywhere—I am not going to pretend it has—but in some parts of Greater Manchester that is now quite mature.
One of the proposals that potentially could help with that is the opportunity to create a new type of trust, a new type of integrated care provider, as an option among other options. I do not know whether any of our 10 areas in Greater Manchester would choose that option, and in order to choose it a number of them would want local government to be part of it in their social care provider role, and possibly the voluntary and community sector as well. If you could get that construct right, it might create a mechanism for moving some risk from the commissioner side to the provider side and managing it in a single NHS organisation where there is equality of ownership in the governance of that organisation.
Q124 Chair: On mergers, Jon, you have already talked about the role that NHS England would have to force provider organisations to merge. I think it was you who said that, if they have to use that power, it probably means that the relationships have broken down, have failed, because it is something that should be happening anyway. Does anyone else have any views on the proposals around the ability to have compulsory merger and whether or not it is a good thing, whether it is a necessary element?
Professor Ham: It feels to me that surely this is what we should be looking to the systems to take responsibility for, not forcing mergers, but to say that in our system there is an issue about the sustainability of local specialised services and we, as a system, because we are being given more responsibility for money, performance and planning, see it as part of our role to grasp these difficult nettles and come forward with proposals on how the sustainability of specialist services can best be addressed. The knowledge will rest, I think, in most places, within those systems, more so than at a national body or indeed in the regional office.
Q125 Chair: Can’t you see, though, that these are institutions that have existed for years, and people have a strong emotional attachment? Despite the evidence that mergers are the right thing, people still feel loyalty to their organisations.
Professor Ham: They do, but it is a sign of the maturity of systems whether that view prevails—
Q126 Chair: If it does not, should not NHS England have the power to say—
Professor Ham: There needs to be some kind of check and balance in the system. Jon can speak about what has happened in Greater Manchester far better than I can. The work that was done around Pennine Acute Hospitals, for example, was Greater Manchester, as a system, saying, “We have a challenge collectively. With the support of the regulators, we are going to put in place arrangements for looking at how we can sustain and indeed improve services through bringing in our other trusts that are performing well and ending up with a different configuration of services,” which probably would be a demerger, rather than a merger.
Q127 Chair: You do not think it is necessary.
Professor Ham: I think the first responsibility should be at the system level by the leaders who have collective responsibility for the performance of their system. They should be intervening before there is a need for the national bodies or the regional bodies to do so.
Q128 Chair: You phrased it as “the first responsibility”. By implication, there should be an insurance policy as well.
Professor Ham: There should, but that should not be the first resort.
Patricia Hewitt: No. The first, second and even possibly the third resort should be with the system. I can imagine a very small set of circumstances—I do not envisage them in Norfolk and Waveney, I should make clear—as backstop power would be fine.
Q129 Chair: Is that a general view?
Jon Rouse: I hope it is not necessary; I have to be honest. At the end of the day, the difference is this. In the transactions we have done—we are now on our fourth and fifth significant set of organisational changes in order to make sense of the GM system at this time—I can be called at any time to go in front of a scrutiny and overview committee in any of those geographies, or the Greater Manchester level, and explain myself. I work in that patch, and I have to give account, and other leaders have to give account, for the judgments and decisions that we take through our governance. I find it difficult to envisage the equivalence in terms of that being done by a national organisation at that distance. If that had to happen, I would see it as a failure of that local system, basically.
Chair: Thank you. We will move on to Philippa talking about new integrated care organisations and systems.
Q130 Dr Whitford: Jon, you talked about the benefits of integrated care partnerships and integrated care trusts, looking at taking a broader view—secondary, primary and community. What benefits do you think that will have for patient care?
Jon Rouse: First, I want to reiterate what I said previously. It is only one of several options. It should be available as an option, and I do not think it is envisaged as anything other than that. It will add to the suite of options we have at local level.
I think why some localities may choose it and find it beneficial, and why it therefore may impact positively on patient care, is that it provides the opportunity for a single workforce to work for one organisation, which seems to make a difference in joining up care around the patient. It seems to reduce the sort of frictional and transactional costs and the gaps that can be created within care pathways if you have that within one organisation.
The key to it, though, and why we do not have an equivalent mechanism at the present time, is that all the individual providers have to feel that they have an equal stake in that trust. At the present time, we have some very successful prime provider models in both Salford and Tameside, and those organisations work hard to make them feel like they are a collation of equal providers, but the reality is that they are run by the foundation trust—by the acute trust—which has turned itself into a much more integrated care provider. This option may bring something that is genuinely, in a more equal way, primary care, community health and so on, and feels that equivalence within the ownership of the trust.
Q131 Dr Whitford: One of the concerns around the changes that came after 2012 was fragmentation, which you talked about, Patricia, and therefore pathways not actually being pathways but having to leap from one atoll to the next. If outsourcing is still going to be part of this, and therefore that might change every year or few years, how will that partnership or trust stay together if bits of it can still be hived off?
Jon Rouse: I do not want to hog this—I will hand over to others—but I will give you the example of the city of Manchester, which has basically come up with a hybrid form of provider organisation, partly because of some of the limitations of the legislation and some of the rules around taxation. What they were pursuing was a 10‑year contract to give longevity in the relationship so that trust could be built up, significant service redesigns and changes could happen and there could be deep engagement in neighbourhoods with local communities. Some of it is about the length of the relationship that is on offer.
Q132 Dr Whitford: I do not mind who wants to come back on this. Is there not still an issue, if you are outsourcing to a private company or provider, that some of their motivation at least is that they obviously have a profit imperative that rests on the chief executive, whereas other bits of the service may have a service or quality outcome imperative? How do you bring that together when it is clear so far that the business of procuring outside will still be there as part of these systems?
Dr Doyle: The option to procure outside will still be there, but largely these are about integrating secondary provision for a community, with its community services and primary care services working with the voluntary sector locally. The long contracts that Jon described, as these largely would be intended to be, enable you to allocate a single large contract—a financial allocation for a place with a contract that asks for delivery of improved health outcomes, as well as clinical care—so it incentivises service redesign, the models of care that invest up front and focus on tackling primary and secondary prevention, working with public health and social care in a place. It does not remove the option of contracting separately for some parts of that service, but the responsibility for delivery of the outcomes required and management of the allocation would be with the integrated care provider or partnership.
Professor Ham: The integrated care trust idea may work in a few places but other alternatives are emerging. Not far from here, it is worth looking at what is going on in Croydon, where an acute community combined trust is very actively working with the local CCG to try to bring together both of their functions as a combined commissioner and provider, in so far as they can within the constraints of the law, as a step towards further integration with Croydon Council’s services. An integrated care trust for me is a combined provider organisation. This goes beyond that, and it might work well not just in Croydon but in a few other places too.
Patricia Hewitt: This is where local knowledge and local circumstances are what it is all about. In Suffolk, which is our neighbouring STP, they are building two alliances, each centred around a district general hospital but including their network of primary care—the PCNs—their community providers, and they will have community‑facing mental health and council social services. That will be done, I think, with an alliance agreement, and they are very pleased with the progress they are making.
For Norfolk and Waveney, that does not feel like the right model. We have three hospitals, of which two are DGHs and one is the teaching hospital providing tertiary services for the whole area. We need our three hospitals to be working even more closely together across the whole system, as well as getting the integration into primary, community, social care and mental health services at community level. We need to take a different model. We will design that for Norfolk and Waveney.
Q133 Dr Whitford: One of the very welcome things is coming back from the compulsion towards tendering and outsourcing that was section 75. Many people objected to it and campaigned, me included. Moving to the integrated care systems, which is looking at the bigger geographies, do you think that just bringing joint committees together—if I could start with you, Patricia, because you mentioned it earlier—will make a significant contribution to integrated care? Or do you think that the problem is that it might work in the good times, when everybody is happy to go along—both Amanda and Patricia mentioned that you are in deficit areas—but who is going to volunteer to be the balance sheet that takes the hit? Therefore, without some sort of underpinning, this may hit the buffers at some point.
Patricia Hewitt: That is exactly the problem, because at the moment we have an STP with no statutory underpinning at all, and good relationships and a lot of effort put into building them and continuing to build them. The important step that we have just taken is that our five CCGs have created a joint strategic commissioning committee, which is already getting rid of some of the variations in clinical care standards. They have now appointed a joint accountable officer who is also the substantive executive lead for the system—for the STP. They will now move to appoint a single management team for the five CCGs, but, effectively, alongside that we will have some system‑wide posts, so we will have a team that is working effectively for the system as a whole. A joint committee, provided that it includes local government, which is the point both Chris and Jon rightly stressed and I should have made initially as well, could be very helpful in giving the system, and the embryonic integrated care system, a bit more governance and clarity about what we are accountable for.
Increasingly, I find that we are being held accountable by NHSE and NHSI for performance, for money and for everything at the system level, but we are a bit short of people to deliver on that. We have to persuade provider trusts, on occasion, to let us see the details of their cost base, which we have to be able to look at in order to understand the system finances as a whole and collectively work out the best way of dealing with the overspend.
Q134 Dr Whitford: You mentioned “statutory”, and that was a recommendation in the Committee’s report but is not currently included in the legislative proposal. Mentioning accountability without responsibility or control, do you think that these systems require to be underpinned as a statutory body—to have both the governance and the control?
Patricia Hewitt: I think we can make enormous progress. Even with the law as it stands at the moment, the proposals we have will make it easier, and we could strengthen those proposals to make it even easier.
I just throw in that I do not think there is any reference to the CQC in the proposals, and, when they come in and look at an individual organisation, they should also be thinking about what that organisation is contributing to, how it is contributing to the wider system and how the wider system is perhaps causing the problems that are showing up in an overcrowded A&E, for instance. It works both ways. There needs to be something in relation to the CQC in the proposals as well.
Q135 Dr Whitford: Thinking about accountability and answerability to the public in this place‑based system, do you think that there is a need for ICSs, or whatever they are finally called, to literally have a board, to have public board meetings and publish papers in the way our health boards do in Scotland? The worry is that everything is so informal and organic that it is not going to be clear where accountability lies.
Professor Ham: Yes is the answer. The difficulty in creating ICSs now as statutory bodies is that you would have to rip up not just the 2012 Act but all the prior legislation, and start again. That would amount effectively to another major top‑town reorganisation of structures, which I do not think anybody wants. It is perhaps better to live with some of the complexities and ambiguities we have, with the transparency you are talking about.
Q136 Dr Whitford: You envisage the transparency even in an informal stage.
Professor Ham: Especially in an informal stage, yes.
Dr Doyle: You can do that, and we do it now—increasingly so. It is important to remember that once we start to talk about these constructs—these ICSs—that is who the public will look to as responsible for their health and healthcare in their place. They now do not really start to think about several individual organisations all being responsible for a little bit of their pathway, so we have a responsibility as an ICS, even if we are not a statutory body; we have a lot of influence and a lot of levers, and we have to be able to front up the system.
Q137 Dr Whitford: Obviously that is what the patients want to see; they want to see the right and left hand knowing what they are doing.
Dr Doyle: Absolutely.
Q138 Chair: Jon?
Jon Rouse: I want to issue an invitation. If it would be helpful for any members of the Committee, or indeed your support team, to come to one of our health and care board meetings, which are in public, are webcast and all the papers are published, you would be very welcome to see that in action. It is politically chaired, and the Mayor of Greater Manchester always comes. We get quite a few leaders of councils as well as NHS organisations at those meetings. That might be helpful to you.
The key for us of this proposal is that it allows breadth. It cannot be just an NHS construct, certainly somewhere like Greater Manchester where we are aiming for a unified public service model and we are interested in tackling the social determinants of health. It has to be broader in terms of its representation. If we can get that right, and it enables responsibilities to be delegated to that committee in return for accountability, we are empowering the integrated care systems and the devolved systems in a different way. At the present time in Greater Manchester, the devolution or delegation is actually to me; I have to be an NHS England employee and then I render myself accountable to the health and care board. It would be a lot stronger if that delegation was to the committee itself.
Dr Doyle: You need to recognise that Greater Manchester in many ways is lucky, in that its local authority configuration matches its health configuration, so it is possible to construct it in that way. In Lancashire and South Cumbria, we would have no chance. There is no coterminosity between any combination.
Chair: Thank you. Our final two questions for this panel are from Sarah and then Andrew.
Q139 Dr Wollaston: To follow on from that point, it is all very well when it works well—
Jon Rouse: It does not always work well.
Dr Wollaston: —people can see who they can hold to account when things go wrong, but where you have very complicated geographies, do you think that unless we formally set up some clear accountability, when things go wrong people will not know who they can hold to account? Do you think that is a possibility, Amanda?
Dr Doyle: It is doable without it, but it would strengthen it if there was formal accountability.
Patricia Hewitt: But with the qualification that one size does not fit all. That is why earlier on I was suggesting that it would be useful, in my view, to have a statutory organisational form that an ICS could adopt if it wanted to, just as, if it wants to, it can use an integrated care partnership contract, or it might decide to set up a new trust if these proposals go through. It is really important that there is no single, “This is what an ICS must look like,” written into law. That would be disastrous.
Q140 Dr Wollaston: You would have a range of options that they can choose from that are appropriate for the local systems.
Patricia Hewitt: Yes.
Q141 Dr Wollaston: Thank you for that. There is always going to be a tension between centralisation and local decision making, and you touched on that, Jon, in one of your earlier answers. Do you think there are sufficient safeguards in these proposals to make sure that decisions can be taken at local level and are not simply overruled?
Dr Doyle: I think this strengthens the ability to take decisions at local level. At the moment, we have CCG local level, which for a lot of the decisions we need to take is too small, whereas the ICS configuration makes much more sense and you should be able to take the vast majority of decisions at that level. It is important to retain some of the principles around the clinical commissioning group, local clinical engagement, local community engagement and working with local authorities, strengthening the relationship around the local authority and the democratic leadership there.
Professor Ham: One really positive thing in the last two or three years is that there has been no national blueprint for any of the stuff we are talking about. If you go back to all the official documents, you have to search for references that help to inform what we have been talking about today. Some people find that a bit scary, because the NHS for 70‑odd years has been based on waiting for the centre to tell us what to do and then we follow the blueprint. The stuff around STPs and ICSs has been much more permissive and has resulted in a variety of different arrangements. I think that is all to the good.
Dr Wollaston: Thank you.
Jon Rouse: I agree. At this stage, you have to trust that NHS England and Improvement really mean it in terms of directing the system to support the integrated care systems. That intent is writ large in the long‑term plan; it is reflected in these legislative proposals that have been published and the regional officers have been given a clear mandate that their principal role is to support the development of the integrated care systems across the country. If you combine that with the embracing of heterogeneity that we have talked about in the last few minutes, it is quite an exciting prospect.
Patricia Hewitt: It is genuinely very exciting, and it is really healthy that NHS England recognises that for some things you need the smaller entity, which might be a primary care network or at the place level, CCG level or district council level, but you also need the larger, the system‑wide level, and you need to work out which decisions you are going to be making at which level for your particular area. You have to build the ability to have very honest and sometimes quite challenging conversations within the system so that you do not tolerate a kind of cosy mediocrity, which could happen because everyone is too busy being nice to each other.
You have to be able to have difficult conversations that say, “Do you know, if we look at the data here, we are not doing well enough on” whatever it is, and, “We have to do something together to improve that.” In order to make sure that happens, you also have to have NHSE, NHSI, and indeed the CQC, at a remove, saying, “Hang on a minute, your performance on X is really not up to scratch. What are you doing about it? If you are not doing anything decisively enough, we will come along and help you.” That tension has to be there in the system as well.
Professor Ham: We should not underestimate, sparing the blushes of Amanda and Jon, the influence that the leaders of ICSs have had in the shaping of national policy. Sometimes the national leaders have come forward with proposals that have not gone down well, and the leaders of ICSs and STPs have pushed back and made that very point very clearly. That is a healthy sign that there is willingness to listen and also willingness to express contrary views and to know that they will be heard.
Chair: Thank you. The final question is from Andrew.
Q142 Andrew Selous: We have covered a little bit of this, but I would like your response, if I may, on two points made in the evidence given to us by the Local Government Association, who we are going to hear from in the next panel. One point that was made to us is that there is a danger that, in making the legal changes necessary to have greater collaboration between NHS organisations, we could end up with a sort of two‑tier system that inadvertently brings in barriers to collaboration between the NHS and local councils. You talked about that, Jon, in Manchester, and you gave us an example of how you dealt with it. What would your response be to the LGA’s point on that?
Jon Rouse: I have already indicated to the LGA that there is much in their submission that I would agree with, and there are real dangers. To be fair to NHS England and NHS Improvement, there is only so far they can go in terms of these proposals as NHS national bodies, and there is a role for the Department of Health and Social Care potentially to broaden them to give them the scope they require to ensure that this can be genuinely an equal partnership.
Q143 Andrew Selous: Do you see the Manchester model, which you outlined at the beginning of the session, of having equal voting rights for local government as a blueprint?
Jon Rouse: I do not think it is a blueprint. Something that the witnesses this afternoon have been consistent about is that there is not a one-size-fits-all shape, but my personal view is that any local partnership is strengthened if local government has a strong voice and a representative role within the governance.
Q144 Andrew Selous: My second question is around the issue of health and wellbeing boards, which we have at the moment. That is the sort of governance structure we have at the moment within local authorities, to try to get health and social care and the role of local government working well together. The LGA made the point that health and wellbeing boards can strengthen the shared narrative and share the democratic leadership needed to drive forward change, but I note that there is actually some research, both from the LGA itself and from the King’s Fund, Chris, that health and wellbeing boards have sometimes been a bit of a disappointment and have not always delivered what we would have hoped. How do we square that one?
Professor Ham: Speaking from a Coventry and Warwickshire point of view, one of the great delights for me going in there was to see the very important role that both the Coventry and the Warwickshire health and wellbeing boards were playing and working together to create a Coventry and Warwickshire-wide place forum, as they call it. It is like a joint health and wellbeing board.
Q145 Andrew Selous: They were an exception to the King’s Fund research in this area.
Professor Ham: Yes, because that is not the model you see everywhere. It is not isolated; it is not the only example, but it is one of the best examples I have come across. We are still working to achieve more effective alignment between what the health and wellbeing boards are doing, particularly on population health and tackling health inequalities, and what the STPs are doing on prevention and population health, but all the ingredients are there. It was disappointing that the long‑term plan made, I think, only one reference to the role of health and wellbeing boards.
Q146 Andrew Selous: Whose job is it to spread best practice in how health and wellbeing boards behave? Is that the LGA or does the NHS have a role in doing that as well?
Jon Rouse: Hopefully together. It is an opportunity for them to promote best practice. In Greater Manchester, we think you need three key elements for a well-functioning, local integrated system. The first is the health and wellbeing board, because that is where strategy should be set collectively, and it is very important that providers have a seat at that table, and the voluntary and community sector, as well as commissioners. They should be deriving strategy from the best evidence from their public health function.
The second thing you need is a good integrated commissioning function, with local government and CCGs making decisions together, hopefully with a pooled budget, and single governance around how they want to shape their system, and that should obviously derive from the strategy.
The third thing, on the provider side, is that you need an integrated care organisation of some form or an alliance that manages the health of the population with the resources it has been given. You need all three ingredients for a well-functioning system.
Andrew Selous: That is very helpful. Thank you.
Chair: Thank you very much. Thank you to everybody on our first panel for your contributions.
Witnesses: Sarah Pickup, Julie Wood, Chris Hopson and Niall Dickson.
Q147 Chair: Good afternoon. Welcome. I think you all heard much of what the first panel said. What we will try to do with the second panel is get you to add to what has already been said, to give a slightly different perspective on some of the points. We are going to go through the same topics, giving you the chance to give your views. Can you start by introducing yourselves and the organisations that you represent?
Chris Hopson: I am Chris Hopson. I am the chief executive of NHS Providers. We represent the 226 community, mental health and ambulance trusts and foundation trusts.
Julie Wood: My name is Julie Wood. I am the chief executive of NHS Clinical Commissioners. Like Chris, we represent the commissioning end of the NHS system—CCGs in England.
Sarah Pickup: I am Sarah Pickup, deputy chief executive of the Local Government Association. We represent councils and health and wellbeing boards, and the social care side of the equation.
Niall Dickson: I am Niall Dickson, chief executive of the NHS Confederation, which represents a wide range of organisations across the health and care system.
Q148 Andrew Selous: I want to start by finding out whether you feel that you have had sufficient involvement and been sufficiently consulted by the NHS in drawing up the legislative proposals that are currently before us. Have you had good input into that process?
Chris Hopson: Our view would be that you have to start somewhere. NHS England and NHS Improvement developed some proposals, and we are in the middle of a very extensive dialogue with them. For example, we are having a very detailed conversation with them about the two proposals that our members are most concerned about—the ones on mergers and acquisitions, and the power to direct FTs on their capital limits. They came up with the proposals, and we are in the middle of talking to them about them.
Q149 Andrew Selous: Sorry, I did not quite get that—the power to direct, you said.
Chris Hopson: The plan to direct foundation trusts on how much capital they can spend.
Andrew Selous: Thanks.
Julie Wood: Our involvement is earlier than Chris’s, in that we were talking to our members last year about the barriers to integration. You heard about some of those barriers from Jon and Amanda, when they explained them to you. Very early on, we went to NHS England and NHS Improvement to talk to them about those barriers. Pleasingly, we came up with five key asks, and all of them are included in the scope of the legislative proposals. Yes, we have been involved, and we are still involved in some of the detail, and there is more detail that we need to work on—things like the best value test, as you heard before, and those sorts of areas. The devil will be in the detail, and we need to be involved in the detail as well as in the principle.
Sarah Pickup: In the Local Government Association we were involved in the development of the long-term plan to an extent, and obviously some of that flows through into the legislative proposals. We were not specifically involved in work on this, although we have had NHS England along to a group of CCG and local authority colleagues to talk about it since the publication of the proposals, and we have had a chance to have our say.
A lot of things that we would have said in relation to legislation or changes that would support things are not necessarily in here, partly because the proposals were drafted by the NHS, which is looking at the proposals from an NHS perspective and, I suppose, is not as able to suggest things that would impact on local government. I hope that will be addressed as we go forward.
Niall Dickson: Like Julie and Chris, we have been involved from a fairly early stage; when they were first identifying the areas they wanted to cover, we had an involvement at that stage. It would be fair to say that we still have significant concerns about aspects of the proposals, although we think each of the proposals has merit, and we are currently consulting our members in the consultation exercise.
We welcome the fact, first of all, that there is recognition that these will require further scrutiny. I think that is absolutely acknowledged by NHS England and NHS Improvement. They will require widespread support from across the system, as well as in this place, if they are actually to have traction going forward. I think that there is recognition that whatever emerges at the end of the day may look similar in some ways to what is here, but significant changes will need to be made as well.
Q150 Andrew Selous: We have talked about the barriers at the moment, which we are trying to deal with. Are the proposals fit for purpose in dealing with those barriers, in broad terms, in your view?
Niall Dickson: On the first point, certainly on the reaction from our members, we would say that each of these proposals has some merit. That is the first point. We would not want to be curmudgeonly, because there is certainly a great deal of merit, but they will each require, as I have already touched on, more scrutiny than we have been able to give at this point, to understand their individual impact but also the question of their cumulative impact—for example, in the relationship between the centre and locality. People are really feeling their way around this.
One way of interpreting these proposals is as a sort of grab for power from the centre, but we need to be absolutely wary about moving towards a system in which there is a greater degree of central control. I know that that is not the intent, or certainly not the stated intent—I do not think it is even the intent—but of course there are unintended consequences in making these kinds of legal changes.
This is an attempt to try to reflect the fact that we had a reorganisation of 2012 that nobody liked and an absolute determination by everybody that we do not want another major top-down reorganisation. It is an attempt to try to weave us through that, and quite a brave attempt, I have to say. Interestingly, the response was that the Government asked the NHS to come up with something and then said they would deal with it, which is a fairly unique way of seeking to bring about legislative change. Your expertise and the wider expertise of the system will also be needed to scrutinise these legislative proposals and make sure that they achieve what we all want to achieve, which is greater local autonomy, not less local autonomy, and a system that fosters integration and, from our perspective, does not lead to monopolies at local level that then become self-satisfied or mediocre, to use Patricia’s words.
Sarah Pickup: Like Niall, we support the intent. Of course, our worry is the lack of reference to local government and, particularly, to health and wellbeing boards. We absolutely support the intent to remove some of the barriers in the current system and the sorts of things that require you to go to tender when you have a good service in place already. We see merit in that, and we believe that better collaboration within the NHS is essential.
There are some opportunities in the current system, also sourced from the 2012 Act, such as the existence of health and wellbeing boards and the requirement for them to produce joint strategic needs assessments and health and wellbeing strategies, to which Jon referred in the previous evidence, which actually formed the basis of a change note in Manchester. The opportunities to exploit those existing structures are missing. They may not be perfect, and they were not set up to succeed, in the sense that they were not given any powers, but you could build on what is there, rather than creating new structures. Yes, there are some barriers, but we think that there are probably some more opportunities that could be exploited to overcome those barriers rather than creating parallel processes.
Julie Wood: To build on what Sarah said, we need to make sure that in working with these proposals we do not inadvertently change or make worse the relationship between local commissioners, local providers and local government. We have talked a lot about systems, and a lot of the panel discussion has been about system working. From a clinical commissioning group perspective, the need to retain local working at place level, and the critical link between health and care at place level, must not be undermined by these proposals. I think Jon Rouse talked about the law of unintended consequences; we must make sure that we do not fall foul of that and actually undo a lot of the good that has happened at local place level.
It is about what Patricia Hewitt was saying about being clear within your system what functions you need, what actions and decisions you need to take at a system-wide level and what you need to take at place level, and then getting your governance and accountability right at both those levels and, indeed, neighbourhood level, to ensure that you keep the right level of decision making at the right place, with the right outcome, and you are held to account for it.
Chris Hopson: There is one piece of evidence that should give us cause for reflection, which is the fact that there are a number of local systems that are actually going full pelt and effectively, without these changes. It is not necessarily the case that you need the changes to get the degree of progress that is needed. I thought Jon had it absolutely right in the previous panel, when he said that we must not fall into the trap of believing that legislation and organisational structures are what drive effective health and care integration. It is actually a whole bunch of stuff about how you get staff working together, how you redesign patient pathways and how the money flows. Our suspicion is that this will probably help, but it is not in any sense of the word a magic key that will somehow make all of this work effectively. We need to be really clear about that.
Q151 Andrew Selous: I want to move on to the local government area, focusing primarily on Sarah, although others should feel free to chip in if they want to add something. Perhaps just to focus on one of the last points made by Chris, we had evidence in our last session from Richard Murray, drawing attention to the fact that there are parts of the country where local authorities are very well engaged in this process and others where it is just not happening to that degree, or there is a bit of resistance. What do we do about that, Sarah, to make sure that all local authorities are properly engaged in this process, in due course?
Sarah Pickup: The first thing is to make sure that it is expected. The NHS is a very requirement-delivered system. The thing that is required is the thing that gets done. If it is seen to be optional to engage with councils, it is treated as optional. I do not think that is the intention here; I think that the intention is to engage with councils, and we know that in many places that is working well. Even in areas where it is not necessarily working well at ICS or STP level, it could well be working well at place or local level. In a session that we had last week with CCGs and council leads in this area, we had one CCG saying that the ICS must be the servant of the place, and we had one council representative saying that the council is not necessarily the place. So that is people recognising that there are different footprints on which you need to do things.
In engaging councils, one test that we put in our written evidence to you is that we must make sure that we do not create a two-tier system. I think that it was mentioned in the previous evidence that we should not create lots of parity between all the health partners in the system with it being kind of optional to have local government engagement at the table, losing some of the partnership tools that we had. I set up a joint commissioning partnership board in Hertfordshire in 2001 jointly to commission health and care services for mental health and learning disabilities. We do not want to lose those kinds of things by creating the opportunities for health partners to work more closely together, particularly where there are contractual arrangements around some of the trust arrangements. It could prove more difficult for councils to engage in the kind of system in the way that Jon described than at present.
The way in which to engage councils is to make sure that you look at what is there already, which is working. Don’t throw it out of the window, because they are not going to be very engaged if all their hard work is in vain. Every area has a health and wellbeing strategy, which is not a council strategy but a joint strategy. So there are joint things in every area. With some it may be like pulling teeth to get them, but quite a lot of them are quite well established. But the ICS and STP put another footprint on it, and it is complicated, which is why the council rep said that the council was not necessarily the place. He recognised that in his area.
Q152 Andrew Selous: Okay. So, in terms of the legislative changes, which is what we are looking at in this inquiry, what do we need to make sure happens that gives the best chance for good local government and health collaboration?
Sarah Pickup: I think it is about parity of treatment. If there are going to be duties to collaborate or work together, they should be equally played into local government, and, if you are going to have a joint committee, it has to have local government on it. But we should think whether it should be a joint committee or whether we could use the health and wellbeing boards. We may need a joint committee in some areas where there are multiple health and wellbeing boards underneath, but, in some areas, they are actually coterminous; so don’t create parallel structures.
The key thing that we put in our test is to make sure that we do not create a two-tier system where NHS people have some rights and local government has different rights. Local government can be really helpful in delivering change, if it is on board with difficult things that you want to do. If it is not on board, it can be really difficult, because, obviously, these are political people, like yourselves, who have been elected and want to represent their constituents. If they can explain to their constituents why this merger or change is happening, they can help the health system. So parity of esteem is important—and in law.
Q153 Andrew Selous: What were the main recommendations of the Local Government Association’s own research on how to improve those health and wellbeing boards that are not doing as well as some of the best? I believe that you, in common with the King’s Fund, published some research saying that they have not been as effective as they could have been. What is the LGA take on what health and wellbeing boards need to do to be exemplar organisations?
Sarah Pickup: The key thing for health and wellbeing boards in the new system, with the intention of integration across the system, is to make sure that they are inclusive of different partners, as Jon described. They were set up in a different time; many of them were only commissioners to start with, because that was the intention when they were set up; it was a partnership of commissioners coming together. The statutory attendees represent that, the directors and so on. So they could be built on, and you could talk about them in the same way as a joint committee, as a coming together of providers and commissioners, which would be helpful.
I also think that there is a tendency—I have used this terminology and I think that members of the Committee have as well—to talk about them as local government bodies, and they are not. They are set up within local government for convenience, but they are joint bodies; in fact, they are the only joint statutory body. The thing to do, to make them work better, is to empower them. They are not going to be effective if they are left on the sidelines and scarcely mentioned; they need to be told that they are at the heart of the system and need to pull their socks up, make this work and engage people in the system. But it is there to use. Patricia and Chris were saying that, in their systems, these things are working, and we heard examples last week of how they are working.
We hear that in Greater Manchester it is really successful, but, if you listen to Jon talking, he is talking about 10 health and wellbeing boards coming together, which are not all doing the same thing at the same time; they are the building bricks within which that overall system works. Greater Manchester has an advantage in that it has formal delegated power to do some of this.
Q154 Andrew Selous: Is there more cash, as well?
Sarah Pickup: Yes, more cash and formal delegated power, which has helped Greater Manchester to build on what was already working well, due to coterminosity and historic relationships. Give some others some of those advantages and say, “These are the vehicles we are going to use.” Then you are on the road to success.
Andrew Selous: Thank you very much.
Q155 Chair: Before we move on, does anyone else have any other perspective on how local government is at the heart of this?
Julie Wood: Sarah, myself and others were at a roundtable convened by NHS England and NHS Improvement about the best value test. We were talking about whether you could use health and wellbeing boards and scrutiny committees in that process. That, again, legitimises and supports the role that they can play in supporting the right sort of service change.
Chris Hopson: I have just one quick comment to make. The consistent feedback that we have had from our members is that a number of them feel that they are currently inadequately involved in the health and wellbeing boards. So, if there was a desire effectively to make that the crucible in which key decisions were made around integrated health and care systems—as, I think to be fair, Jon was saying—it is vital that the key providers in the area feel that they are equal partners. We can point to a number of our members who are saying that that is not how it feels at the moment.
Niall Dickson: We would all acknowledge that this stuff is not easy. Some of the messages from the centre are also important. One reason why STPs did not go off in the right way was that they were too NHS focused; they sounded like NHS plans, and lots of local government did not feel that it was involved at that stage. As Chris says, it works both ways. You have heard some fantastic examples, but, obviously, there are lots of other areas that are considerably well behind, and we cannot afford the pace and scale of this to be slow; it needs to move fairly quickly so that people start to come together.
The message from the centre is really important: it is about involving local government, but it is also about involving other providers as well, including the voluntary sector, which is again not really reflected enough. If you have an integrated care system, you have to recognise the wide range of organisations that have to be involved at all levels. I also think that much greater movement towards joint local government and health commissioning will be a really important driver in taking that forward.
Sarah Pickup: I just wanted to mention social care providers. Of course, when Chris is speaking, he is talking about NHS Providers being at the table, and Niall and Jon referenced the voluntary and community sectors. There is a whole array of social care providers, and you have to work out how to have that representation at the table. It is not as easy, but it is really important. If we do not work with that sector, we will not succeed.
Q156 Mr Bradshaw: Sarah, in the previous panel, when I asked Jon about the different financial, legal and cultural environment that you operate in in local government compared with the NHS, he was quite confident that, by drawing on the Manchester model or some of the provisions included in these proposals, there is a way through that. Do you share his confidence?
Sarah Pickup: I am usually optimistic that there is a way through things, because I think there is, but there are areas where there are deficits in either part of the system. It could be where a council is struggling—in a different way; it will not have a deficit, because it cannot have a deficit. But if a local government is cash strapped and has to cut back its social care services, the health service might worry about bringing it into a formal partnership or pooling. Also, I know that some areas are holding back from formally pooling resources because of deficits in the local health system, so it is a barrier, but, where areas genuinely want to move forward and find these barriers to formal pooling, they find ways in which to align budgets. That does not stop you joint commissioning, but you have to have clear rules.
In 2001, I talked about setting up joint commissioning arrangements. The really important thing for me was to have a clear agreement about what happened in different circumstances. We changed that agreement many times over the years, but the key thing was that you knew what would happen if one organisation had to cut its budget. The answer was that that organisation had to say what it did not want to buy through these joint arrangements as a result of cutting its budget, and it was not everybody else’s problem. That is a long time ago now, but you have to have some arrangement, so you know what happens in circumstances when you get into difficulty. That is key.
Q157 Mr Bradshaw: The example that comes to mind for me is Cornwall, where I remember, when the talk of integration was first mooted, in spite of the good will among the local government folk, that there was real nervousness over the long-standing and long-running problems with the main hospital in Truro, which has had massive deficits going back ages now, and the risk that they would be taking on. But you do not think that they have anything to worry about.
Sarah Pickup: No, I do think that they have things to worry about. It depends on the nature of agreements, does it not? It would be very difficult for a council to enter into a risk-sharing agreement in an area where there was a really big risk that it was taking on part of an NHS deficit. I know areas that have suffered as a result of entering such agreements. I also know from sitting through BCF assurance processes, where agreements have not been reached—and this was perhaps two years ago—that part of that has been to do with an insistence that risk-sharing agreements should be in place, and councils saying that they were not willing to do that, or agreements that had previously been put in place being undone because a health organisation has fallen into deficit. It has previously agreed something with a council, on what the council understood to be an ongoing basis, and it has come undone because someone higher up the national and regional layers of the NHS has said that they could not do that CCG any more because they were in deficit. That has been very difficult. So there is a risk.
Q158 Mr Bradshaw: So, to Sarah and the rest of the panel, what is the solution to this?
Chris Hopson: I was going to interject with a note of optimism here. We are rather struck by the number of trusts that have said to us—because of the slightly weird way in which NHS finances work at the moment, if you are a provider organisation, whereby you need to hit a control total to trigger access to extra funding—that they have come to all kinds of weird and wonderful arrangements with local authorities to ensure that the provider hits the required control total, even if it is in deficit. That then triggers, effectively, an influx of extra money into the local system. If you build incentives in the right way, you will find that good behaviours will follow. Just to make the point, it is not always about setting formal legislative structures; it is actually about having the right behaviours and relationships.
Julie Wood: It may not be a solution, but an ingredient has to be openness and transparency on all sides. When you go into a bipartite or tripartite arrangement, you should be absolutely clear about the state of the finances on all the areas. As Sarah says, you should be really clear, if you hit trouble and get into difficult situations, what you are going to do about it, which does not involve walking away from the table. For me, if you have set up a joint committee and you are clear about the decisions and state of the relevant finances, you should jointly own the solution, be it very painful on a particular side. But you have to get that ownership across to the players in the place, which will help.
The other point that I would just add is that we need to remember that the examples that you saw in the previous panel, such as Greater Manchester, were built on years and years of good relationships and, as you said, additional money—and there are the 40 front-running ICSs. But we are now talking about moving the whole population to be part of an ICS by April 2021, so we must not underestimate the amount of development support that some of those systems and places will need to deliver all of that.
Furthermore, we are not yet clear about the footprints of our ICSs. We have sort of jumped into an assumption that the 42 STPs are the number of ICSs, but that has not been specified. They range in population from 300,000 to, in Greater Manchester, 2.8 million. What works for one may not work for another, and we should not assume that the answer in terms of the number of ICSs is the same number. We also have to look at how we get it to work with, typically, one CCG per ICS, and what atypicality looks like. There are lots of models and lots of details that we have to work through, which will help to deliver all of this.
Sarah Pickup: I shall just add a couple of points, although I know that I have said a lot already. There are ways in which this can be made to work, but it links back to how the overall system works. If it genuinely is devolved locally and it is the lowest possible point where decisions are made, some of them at system level and some at place level, depending on what it is, and if you can come to a local agreement that holds into the next year and year after, you will get the Manchester-style arrangements, whereby a council might borrow money to help to build a hospital.
You might do the creative things that Chris is talking about to make sure that the system as a whole succeeds. But, to do that, local government has to have as much skin in the game as the NHS, and it has to be genuinely showing that we are trying to move down that preventive pushback to communities, supporting people to prevent illness. If you are not doing that, you are not going to achieve the ultimate objective. So the financial bit is part of it, but it sits within whether you are an equal player at the table, and then you can achieve great things and overcome things.
Niall Dickson: At the risk of repeating what has been said, first, the principle of subsidiarity that has come through everything that everybody has said so far applies here. If you devolve decision making down as far as possible, that is where you will get—and you can create—genuine partnerships. However, the funding question particularly around local government and social care could be critical here. Although local government has to balance its books, the reality is that its ability to enter into constructive partnerships is severely limited by the fact that a lot of its funding has been very severely cut, while its demand has increased. So, while the NHS cannot be in any way complacent about the level of funding that it is getting, it has done much better, obviously. Unless we solve the social care issue and solve the wider issue of funding of local services, that always puts a strain at local level, because people are unable to deliver, however much they might want to.
Q159 Chair: Let us move on to the best value test, which has been mentioned. Julie, I think you commented on that. We have heard from the previous panel a bit about focusing on outcomes as well as on social value, and the economic and environmental. Is there anything else that you would like to add?
Julie Wood: I guess current performance. Obviously, the CQC will inspect organisations that deliver NHS services, so it will be about understanding how they are doing, against outcomes and measures that the CQC assesses against. We were very much struck in the roundtable that we had last week about local government’s experience of best value and learning from it—when it has worked well and when it has worked less well. We need to do more to unpick that to ensure that it works for the NHS.
The key thing for me is that we do not inadvertently end up putting lots of hurdles in the best value test that are as clunky and time-consuming, and expensive in time, as what we are trying to get rid of. We have to make sure that it adds value and that we get the right level of scrutiny needed and the right outcome.
Some of the comments made in the previous panel about the need to keep the grit in the system are really important. If across the system, for whatever reason, it is unable to reach the right outcome, you still need the commissioner to be able to say that we need to test some of this. It may not be testing the whole of a hospital or community health service. It may be about a particular pathway of care, for the elderly, or whatever it is; it could be anything, really. So we need to be able to test pathways as well as particular services.
Q160 Chair: Do you think that these proposals will still allow that to happen?
Julie Wood: I do not think that they say enough yet. They talk about the need for a best value test, but we have to work with NHS England and NHS Improvement on defining just what that looks like.
Chris Hopson: I have just two more thoughts to add. One would be that there are interesting debates to be had about whether there should be a presumption of the use of NHS as opposed to private providers.
Q161 Chair: Like an NHS preferred provider.
Chris Hopson: Yes; so that is a debate that we need.
Q162 Chair: Do you have a view on that?
Chris Hopson: Well, I am here as the trade union for NHS Providers, so it would be odd, wouldn’t it, if I did not argue for the view that we think NHS Providers provide a fantastic quality of care?
Julie referred in a couple of instances to the roundtable with NHS England and NHS Improvement. You picked up a bit of this in the debate that you had with the previous panel. It is very clear, is it not, that there are certain areas where it is easier to have a genuine procurement and tender process? You are probably not going to be doing that for accident and emergency services, but, at that roundtable, what began to emerge was the idea that, effectively, we might take different approaches in different sectors, dependent on their contestability.
The key point that we would want to reinforce is that one problem that we have with the current regime is that, in areas such as community services in particular, we are currently trapped in a really very unhelpful and unnecessary system where contracts are being constantly re-tendered far too frequently for the management teams of those organisations, with staff constantly being rebadged every two or three years, and huge amounts of time, effort and money being used up in that process.
It would be unfortunate if, as a result of this process, effectively, we confirm the existing position that, in the end, A&Es probably are not going to be re-tendered with anything like the frequency, but with a different sectoral approach we still end up with the same sort of problems. Particularly since we are trying to put community services right at the centre of what we are trying to do in integrating primary, social and community care at a neighbourhood level, we must get to a more sensible system for community services going forward.
Q163 Chair: Some community services are possibly best provided by the voluntary and community sector.
Chris Hopson: Yes, and that is why you detected a small pause when I answered your first question. We would be the first to acknowledge that there are a number of areas where, to be frank, that would be quite right. The obvious one is palliative care, where there is a fantastic and really brilliant, primarily voluntary sector-led set of hospices, and NHS services would not seek to argue that they are better. Julie is right that it is too early to tell yet, but it is important that, whatever best value test we develop here, we get to a more streamlined system. Community services chief execs are tearing their hair out about the amount of time they are spending going through completely unnecessary tender processes. Partly, to be frank, because the rules are unclear, CCGs are being pressurised by private providers to undertake tendering processes when they would not need to if the rules were clear.
Niall Dickson: We represent NHS but also voluntary and independent sector providers as well. In a way to support Chris, it is fair to say that there is real frustration among some of our members around procurement, particularly in the community and mental health sectors, who feel that this is a treadmill process, which does not deliver value. There is a question about what signals could be sent from the centre about that system now, irrespective of a change of law. We need to explore more clearly where there are flexibilities, both under section 75 of the Health and Social Care Act and the EU public contract regulations.
Q164 Chair: There is in excess of £100 million-worth of NHS contracts currently outstanding, I believe.
Niall Dickson: Yes. The question is, as I understand it, that there could well be fewer contracts going out, even under the current system, before you introduce this. But we do concept back the idea of best value. As has been mentioned, it has been used in local government. The question is how objective the test is. If it is simply people marking their own homework and saying, “Oh, yes, we’ll just hand it out,” that obviously does not work. It has to be transparent, give quality and value to patients and taxpayers, and it should be fair to all providers so that they are treated equally and judged on their ability to deliver.
In the current outline, as Julie has said, there is not enough detail to understand. We would be keen to agree a set of principles around that transparency and flexibility, allowing joint commissioning between the NHS and local authorities. The key point is that the tests should give greater discretion to commissioners to enable them to do that at the right moment when they would want to do it, reducing the burden. One test of that is whether you have reduced the burden of tendering for contracts. The test should be focused around securing the best provider regardless of ownership. Patients should be able to continue to choose from a range of providers, and there should be a mechanism by which they could seek redress if that recourse is not given. But it is eminently practical and possible to move away from the current overuse of the tender process.
Sarah Pickup: We come from a local government perspective, so we have been through a big cycle of best value, starting with compulsory competitive tendering and moving through a very rigid best value regime to something that is now more as Jon described earlier. Best value does not of course preclude competition. It is really about options appraisals and what the best option is to deliver the service. Some councils have ended up re-insourcing services, because they can prove that they will now get better value. Sometimes, perhaps, they had to go through the outsourcing to get to the point of bringing it back in and it now delivers them better value.
Also, councils still have to comply with the European directives, so they are required to procure some services, but, even then, there are ways of entering into longer-term contracts and partnerships and setting up social enterprises. There are different ways in which to do things, without going through a treadmill of just going to the market when you have something perfectly good there. Sometimes you cannot avoid it, but there are ways and means of doing things.
It is really important to focus on the outcomes that you want to achieve. Perhaps in the early days of best value, we focused too much on getting the specification right and going out to the market. Actually, it is about how you manage contracts and arrangements—whether it is an internal NHS CCG-to-provider contract or a council to social care provider, or to the voluntary sector. It is about how you monitor and engage with people on an ongoing basis. Don’t just let the contract; let it go. So all that is about how you get value; it is about ongoing value and not just what it says at the outset.
If you have a vision of what you want to achieve through a partnership set-up, it is also really important to allow the time to invest and get that right, without, suddenly halfway through, just when you are getting there, having to go to the market. That does not mean that you have forever and that you can faff along being inefficient and ineffective. That is particularly the case with community services, which have been underinvested in. I mean NHS community services, although they all underinvested in. They are very much the poor relation in relation to acute trusts and probably need quite a lot of TLC to get them where they need to be at the heart of the system, alongside primary care. I say that respecting absolutely the very important roles of acute and specialist providers, but we have to shift it, haven’t we? Best value can play a role in that, I think.
Q165 Chair: Chris, moving on to being able to direct mergers, do you have a view on that?
Chris Hopson: Yes, I do, as you would expect me to. We and our members are currently strongly opposed to that power, for two reasons. First, we think that it is fundamentally wrong to instruct a board from above to undertake a major strategically transformational activity that the board disagrees with. A fundamental point of good governance is that you cannot hold somebody to account and tell them what to do, because what will happen is that it will go wrong and the board will quite rightly turn round and say, “We told you that it wouldn’t work, and it hasn’t worked.” Our view is that it is very difficult to hold people to account.
Secondly, we think it is a dangerous shift of power away from local organisations to a central body. Much as Jon and the others were arguing, we do not think that it is right to say that a national-level body, even a regional outpost of a national-level body, will have better judgment on what should happen in local circumstances.
I completely agree with what the panel said earlier. If we think there is a problem, we should ask local systems to do their best to resolve it. I disagree with the panel that giving NHS Improvement and NHS England a power to direct the merger is the right answer. We think that there are other answers. We are in the process of having a very detailed dialogue with NHS England and NHS Improvement on this; those discussions are likely to carry on going for at least the next two or three weeks.
Q166 Chair: Can you give us an insight into your views? Clearly, sometimes, there are areas where there are two or three trusts serving a fairly small population and all trying to do the same thing, which dilutes quality. Sometimes it is just obvious that those organisations need to put their organisational interests to one side and come together.
Chris Hopson: Absolutely. Effectively, what we are saying—and I thought that Jon had it absolutely right to start with—is that you ask the local system, if you think there is a problem, to address it and come up with an appropriate solution. If you do not think the right solution is emerging, we think there are other ways in which you can intervene. For example, there are duties to collaborate, potentially, sitting on individual providers. You can start to use that regular oversight relationship that you have with the trust to say that you do not think that it is the right answer.
In the end—and you may find this slightly surprising—our view is that the better in extremis power is actually for NHS Improvement to exercise its section 111 power to remove the board. We think that is a better way of approaching this problem, for three reasons. First, we think that it is just wrong and poor governance to tell a board what to do if it thinks that that course of action is wrong, and, as I explained, you cannot hold them to account.
Q167 Chair: But the board has duties only to that individual organisation; it does not have the wider duties to the system.
Chris Hopson: I recognise that. Clearly, what we are seeking to do through some of these changes is to give that organisation a wider duty to take account of the local system requirements, which immediately then gives NHS Improvement and NHS England a lever to say to that organisation, “We don’t think that you are exercising that duty effectively,” and then, as part of that regular relationship, to try to get that organisation into the place that it believes it needs to get to.
You are also right to identity that, particularly if you are in a place where the whole of the rest of the local system is saying that, clearly that adds to the pressure. But I am deliberately just addressing, very tightly, that in extremis position where, after doing all of that, you are still in the same place and the trust board refuses to move.
Our view is that you remove the board, for three reasons. First, we think that it is poor governance and just cuts across all governance principles to instruct from above a board to do something that it believes is wrong, because you cannot then hold it to account.
Secondly, we think that deliberately it sets a very high bar, because NHS Improvement would have to justify very clearly why it was using the power. Our view would be that it is a suitably high bar, which forces NHS Improvement to put an appropriate argument into the public domain.
The third reason is that NHS Improvement would need to be absolutely certain that it could find an alternative board that would be prepared to undertake the required merger and acquisition activity. Our view would be that that is a better power to use than to try to force people to do things that they do not want to do.
We are having an interesting debate with NHS Improvement. We discussed it with a number of our members, and NHS Improvement was quite taken aback when we came forward with that. It was a very blunt instrument. To reinforce this, Jon is absolutely right. I don’t think we want to get anywhere near any of this; we are solely talking about the in extremis backstop power. But our view is that it is a more appropriate power than directing an organisation to undertake a merger and acquisition activity from above.
Q168 Chair: Niall, do you have a view on this? Do you think that this is just providers defending their own institutions at the expense of what is best for patients?
Niall Dickson: No, I do not. There is a lot of evidence that good mergers work when the individuals concerned in the various organisations want them to work, rather than that they are imposed from the centre. Our view is that this is not a helpful suggestion.
The second point is that there is now potential under this for NHSE and NHSI both to direct mergers and then judge whether mergers are a good decision or not, without trusts having any recourse to an independent arbitrator. So I think we need some clarity about what NHSE and NHSI mean when they say that they will give proper consideration to any objectors, as it were.
The bottom line—and this comes back to the discussion with the earlier panel—is that you are much better off enabling local organisations to come together once they recognise the advantage of that within their local circumstances. If you have one particular organisation that is being very difficult, there are ways of managing that, and I believe that the region could have a role in that. I hope that they would not need the kind of powers to which Chris refers to get them to recognise that, but, ultimately, they may if they were obstinate enough. I can think of examples where an organisation is isolated and choosing to do its own thing in its own way. How I have seen that work in practice is that, over a period of time, either somebody within that organisation changes or the reality of what is happening in the wider system suddenly dawns on people and collaboration starts to work.
I just do not think that this is a very helpful signal from the centre. If the centre is saying, “We do not want to exercise more control; we want to see more local autonomy and we want to build up local systems,” issuing this, which is another fundamental undoing of foundation trust autonomy, is not a helpful solution.
Q169 Mr Bradshaw: But this could drag on for years. I am sorry to go back to our own real-life examples, but we had the case of North Devon, which should have come into the RD&E’s orbit years ago. Good people tried to make it happen for 20 years, and I think it is just happening now. The centre has a responsibility to the public. The Department and the NHS have a responsibility to the public, which funds the NHS, to make sure that sensible things are not being resisted by people fighting their own turf wars or wanting to defend their own bailiwicks, don’t they?
Niall Dickson: But the difference, as I hope you heard in the last panel, along with anything else, is that, once you have more effective systems operating, you will identify outliers choosing not to operate, and they will have a stronger duty to co-operate with one another than they had in the past. I would much rather rely on that power than start handing power to the centre both to dictate what would happen and then make a judgment about whether it is a good idea.
Chris Hopson: We should also be clear about some of the motivations for a development of this proposal. We have been discussing this proposal for quite a long time with NHS Improvement, for about six to eight months, and it was very clear that there is a band of opinion inside NHS Improvement and NHS England that would effectively like to play the generals, sitting in the central office and effectively moving around the pins on the map. They want to be the people who say, “Those two aren’t sustainable. Join them. That’s no longer viable; that needs to go there; that shouldn’t exist at all; and those three should come together as a group.” Our clear view is that the people who are best placed to make those judgments are local systems.
You are absolutely right that there is this problem of some very isolated incidents—although in our view there are a lot fewer than people pretend—of organisations holding on to their independence when the entire rest of the system is basically saying, “Look, it just doesn’t make sense.” We need to be careful. For example, the smallest organisation on the mental health side, which everybody has been arguing for a very long time is no longer viable, has just received an outstanding rating from the CQC. So we need to be careful about automatically assuming that big is better.
We recognise that there has to be some kind of potential for the central system to intervene, if we are in a place where an organisation is unreasonably holding out. Our view is that a power to direct a board to do something that it does not want to do fundamentally breaches the principles of good governance, and we would rather that what NHS Improvement did at that point is say, “This board is not doing what it should be doing; it is breaching its duty to collaborate. Let’s get a new board.” I think that is a better power, and one that does not require new legislation, than saying, “We’re going to force that board to do something that it does not want to do,” and then, to be frank, you would have no hope, in our view, of holding that board to account.
Julie Wood: Our members have not said a lot about this, but of course commissioners are interested in the configuration of providers from which they commission services. Clearly, it is a failure of the system to have got to that position, but there does need to be an in extremis backstop position that can be grabbed and executed within a reasonably short period of time. I just reflect on the fact that NHS England, for CCGs, has quite expansive roles of direction to get CCGs to do things that they might not want to do, which includes dissolution and removing the governing body. There are powers on that side of the system.
So there needs to be something. If a duty to force mergers is not the right answer, and if good will does not prevail and people have tried to get a solution for years and years and never got there, and if, as Chris suggested, there is an alternative one that will do the same thing, then okay. But we cannot be in a position where nothing happens and we have the status quo.
Chris Hopson: These conversations are ongoing between us and NHS England. Would it be helpful if we sent you a note when, effectively, those conversations have come to a conclusion?
Chair: It would be extremely helpful.
Chris Hopson: As you come together to create your report, if we get the timing right, we can hopefully help you by saying where we have got to. This is a live discussion.
Q170 Chair: Just out of interest, you said that NHS England had the power to dissolve mergers of CCGs. Does it usually use that for reasons of improving quality for patients or for reasons of improving financial sustainability?
Julie Wood: It is not a single power; it is almost an incremental set of powers.
Q171 Chair: What is the driver?
Julie Wood: It can absolutely be both. As the financial situation has got worse and worse, that is the reason why it has been used more often than improving quality, but improving quality is equally important. We have had situations where governing bodies of CCGs in some parts of the country— the equivalents of a provider board—have chosen not to collaborate with each other, and they have been forced to do so by moving officers and getting to the desired endpoint in various different ways. So there are a whole set of powers in the legislation for commissioners.
Q172 Chair: We have been on this point a long time, but can we have a final word from Sarah?
Sarah Pickup: I have a really quick point to make. It seems to me better to offer incentives and to make sure that organisations have system obligations as well as organisational obligations. However, whichever way it goes, can I make a plea for local scrutiny of such changes and consultation? If it is not a significant variation in service it does not require consultation, and if it is a back-office change that might be the case, but, if that then leads to others, perhaps consultation would be better. Actually, best value requires consultation, so that leads back to the previous point.
Q173 Dr Whitford: We see that the Local Government Association has concerns about the idea of integrated care partnerships or integrated care trusts. Would you like to expand on its particular concerns?
Sarah Pickup: Our concern is about the ability of councils to engage in them, and not setting up a provider that is too big to fail. Even in the social care world, councils that have gone down the route of having very few providers of home care, for example, have sometimes got into difficulty, because they have tried to rationalise their contracts and ended up with an insufficiency of supply.
Our worry has been particularly in relation to the contracts that have been put together for some of these organisations, which preclude councils from being lead commissioners or lead providers, partly because they do both things. The response that we have had is that there would be an expectation that arrangements would facilitate that, but our worry of course is that they might not be forthcoming.
We are not opposed to integrated provider organisations, and we are very much in favour of integrated commissioning, and some councils are engaged in both at the moment, but we need to make sure that we do not have NHS-imposed forms of things that do not fit local government models.
To go back again to my former experience, the council was the lead provider of the commissioning of the joint health and social care services, and, when the mental health NHS contract came along, we had to go through a really big negotiation to make it fit for purpose to commission social care services as well. It did not fit the blueprint. So blueprints have to take into account all the partners, not just the NHS.
Q174 Dr Whitford: This comes back to what you were talking about before—its being very much an NHS project that it has been presumed local government will co-operate with, but that local government is a little bit sitting to the side of.
Sarah Pickup: Yes. “Here is our bit and something needs to join on to it.” The something needs to be added before it gets pushed through in legislation.
Q175 Dr Whitford: Obviously, local government is critical for wider public health, as in determinants of health, and at the social care end, whereas this is looking at community, primary and secondary, and you feel that it is really important to get the whole pack.
Sarah Pickup: Yes, it is a spectrum. If you link into local government effectively through social care and public health, you access housing, leisure and the other services. The health and wellbeing boards encompass all of that, if they are working well and are empowered to do so.
Q176 Dr Whitford: Does anyone have any comment as to what they think these proposals will deliver as an advantage that was not mentioned in the earlier panel?
Niall Dickson: It is the involvement of primary care, social care, community care and the acute sector. But alongside that—I think Jon made the point—I have to say that one organisation can help to drive integration, but there are dangers in creating something too big and monopolistic. Also there is a danger that if you create single, large organisations, elements in them can feel suppressed. Mental health community services can feel dominated by the acute sector, for example.
They are not a panacea. It is absolutely vital that, when they are designed, they are not seen as, “This is the NHS with let’s have a bit of this or that attached,” but that they are seen as something that brings together all the parties. Again, it has to be 1,000 flowers bloom. Let’s see how they work in practice.
It is fair to say that, at the moment, as I think Jon mentioned too, acute providers do quite a lot of this stuff already, including taking over GP practices and doing this process. There are models even under the current FT model where it works in that way. Creating something that encourages that has to be decided locally; people locally have to want to come together and do it, rather than its being imposed by the centre. If it is another lever to help to encourage integration, we should welcome it.
Q177 Dr Whitford: Do you think there will be issues with primary care, in that the model of independent contractor may be changed in something like this?
Niall Dickson: That is possible. One of the reasons perhaps why primary care may sometimes be reluctant to go into the acute sector—although it is not always; sometimes it is quite happy to go there, because that is protection—is fear of the dominance of the acute sector. This may be a model where there appears to be, and there should be, greater equality between the different sectors coming together. Again, it is a question of local decision making about what works and fits in each place.
Julie Wood: With the emergence of primary care networks, again, you have developing general practice at scale, and it will be an important player in this, so that we have parity across all the organisations coming into it.
Chris Hopson: We would argue that you have a particularly important role to flag where the centre appears to be taking potentially quite wide-ranging powers that could have unintended consequences. Giving the Secretary of State a power to set up a new NHS trust that could in theory completely cut across the existing pattern of provision, and do so in a way that does not actually accord with local system wishes, seems to us potentially a very wide-ranging power. We would want to ensure that there were appropriate protections.
The phraseology used in the paper is “where there has been appropriate local engagement”. Niall has been talking about the importance of local decision making; that is not the same as “appropriate local engagement”. It is another example of something that is potentially slightly more insidious as opposed to what is actually on the face of the proposal, which is what we would argue the capital merger and acquisition stuff is. You can see why, if you had a Secretary of State encouraged by arm’s length bodies, with a particular intent effectively to want to increase their power, this would be a really easy way of doing it. Again this is a conversation that we are in the middle of with NHS England and NHS Improvement; we want to see specific protections around how that power can be exercised. It cannot just be the Secretary of State and the arm’s length bodies saying, “We’re going to do something completely different even if you don’t want it.” In our view, that is inappropriate.
Niall Dickson: I agree with Chris, although I do not think that is their intention.
Chris Hopson: No, I do not think it is.
Niall Dickson: You could tighten up the wording to make it absolutely clear that this is not about the Secretary of State imposing particular models of care, which would be totally contrary to the whole thrust of the proposals.
Q178 Chair: To be fair, I shall quote from the paper: “These ‘integrated care trusts’ would only be established where local commissioners wish to bring services together under a single contract.”
Julie Wood: And it goes on, “where it is necessary to establish a new organisational vehicle for these purposes.” It is almost that there is a failure to sort it out beforehand.
Chris Hopson: Indeed, we might argue to you that, interestingly, that is a power that is given to local commissioners. There are no similar levels of commitment to listen carefully to providers. Again, you might regard that as appropriate, because that may be the commissioners’ job, but would we really want to be in a position where, effectively, a local commissioner, the arm’s length bodies and the Secretary of State decided that they wanted to punish a provider by setting up a completely different structure without appropriate involvement and input from those providers? My view would be that no, we would not.
Q179 Chair: We need scrutiny of that power.
Chris Hopson: Yes, we need scrutiny, and, as I said, appropriate local engagement is not sufficient for me.
Niall Dickson: The role of systems is absolutely crucial.
Q180 Dr Whitford: Yes, we are moving on to systems. We heard in the earlier panel, and we hear it over and over, that no one wants a major reorganisation, but actually both staff and patients live on the ground close to the frontline and, in the current system, frontlines are changing all the time. Every time a service is outsourced, terms and conditions for staff change and the service to patients changes. There will be a lot of change that goes quite close to what will happen to patients. It sounds to me as if that is all being diminished. It is said that we are doing this instead of doing major change, but surely this is going to be quite major change, the closer you get to the frontline.
Niall Dickson: But major change is required. We absolutely need to change the way we organise. It is not so much the structural change at the top that matters; it is the way services are delivered that needs to change, and the rest of it makes no difference at all. It is about whether we can create new and different styles of service that are much more seamless and integrated. That is the ultimate goal.
Q181 Dr Whitford: We are going to move on to integrated care systems, so you can talk about both. Do you think that creating joint bodies is going to be sufficient? We touched on the lack of statutory underpinning as proposed by the report. This is not about the trusts; it is looking at a whole geography. It comes back to the comments made by both panels about pathways, because that is what a patient will have, from a GP to a diagnostic, maybe to cancer or to tertiary care and back. Those have got very broken up.
Chris Hopson: It is really important to think carefully about this debate. What worries me is that at the moment, in 1984-esque language, we have got to the position where we are sort of implying “Local health and social care system, good,” and “Individual organisation, bad.” There is a sense that the 2012 Act created this rather Lansleyite lunatic vision of individual providers competing against each other, and that is dreadful. But we should remember—going back before then—that we deliberately created those statutory organisations for a good reason, which is that they carry huge amounts of risk. They manage very large numbers of people and very significant amounts of budget.
I am nervous that we are going on an inexorable journey to where, effectively, we will have STPs and ICSs as statutory organisations, and that is obviously where we should go, when it does not seem to me to be quite as simple as people are pretending. My view would be that we need to be really careful about cutting across the fact that we established those units of delivery with their statutory underpinning for very good reason.
To give you an example, I shall take Devon. As two members of the Committee know, in Devon there are two or three acute care organisations, depending on how you define it. There is North Devon, South Devon and Torbay, and the Royal Devon and Exeter. You also have a separate mental health trust, and a number of councils potentially providing social care. Are we saying that we are going to get rid of all that statutory layer and effectively have an integrated health and care system that looks after all those services? I can immediately see the benefits of that for creating an integrated health and care system, but are we really saying that the 8,000 people who work in the Royal Devon and Exeter are appropriately governed on a statutory basis at that level, when that level feels incredibly distant from those staff? Are we saying that it is right that the staff of Devon Partnership, who effectively need specialist leadership on mental health, should be governed at that level?
The only person I have heard so far who I thought began to get into this was Patricia, when she said that it probably does not make sense to replace individual institution governance with STP governance, and that probably STP and ICS level governance needs to be additional. As soon as you start creating a second tier of statutory organisations below national, which would be one extra layer compared with what we already have, you start getting into some difficult issues about what accountabilities you have at each layer.
My argument is that I am really nervous about the idea that we are on an inexorable journey where the simple answer to everything is to create STPs and ICSs as the only statutory layer. I do not think that that works for the management of the risk, assurance and scrutiny of complex services, 8,000 staff and £600 million turnover in the Royal Devon and Exeter. My sense is that we will probably have to go to a system whereby that kind of governance is kept at a statutory layer, in which case you have to be really careful about what you are saying you want the STP and the ICS to do.
It is interesting that, when things went wrong, as they did in Mid Staffs and the Liverpool Community Trust, the Kirkham and Francis reports were both able to say incredibly clearly that everything that happened inside the trust was the responsibility of the trust board. There is a real clarity there. When they say, “Let’s see who’s responsible and accountable in terms of overseeing that trust board,” they say, “Well, there’s probably a bit of the CQC, a bit of the CCG, a bit of NHS England and a bit of NHS Improvement.” Our view is clear: if you start cutting across the responsibility of the statutory unitary board to be responsible for everything that happens inside the trust, you start to risk causing confusion.
We need to be careful about the argument that we are all inexorably on this journey to STPs and ICSs being a statutory layer. I cannot see how you can take away the fact that the RD&E board, the North Tees and Hartlepool board or the James Cook board should rightly be responsible for what goes on in that very large complex organisation.
Q182 Dr Whitford: But how do you have accountability and answerability for a system? We have sat here all afternoon talking, in essence, about different bits of moving to these integrated systems, and that this is about pathways for patients. It is not really any good if each bit of an atoll that a patient stands on is okay, but the patient cannot get over the gap.
Chair: Can we bring in Sarah and Julie to talk about that?
Sarah Pickup: There are different levels of statutory responsibility, aren’t there? It does not mean that you take over everything if you become a statutory body. I do not think that we are on an inexorable road to statutory provision of an ICS. I see the ICS needing always to be formed from a number of building blocks of other statutory providers. Councils are not going to abolish themselves and be taken over by ICSs.
Dr Whitford: I don’t think anyone suggested that they would.
Sarah Pickup: There could potentially be a statutory function for an ICS, and there could be statutory obligations on organisations within it to co-operate, collaborate and have system responsibilities as well as organisational responsibilities. I do not think they are mutually exclusive. Patients and the public should notice the change, because it needs to change; it needs to be better and different.
We need to be careful about pathways, because most people, certainly older people, are not on a pathway; they have a set of requirements, and the danger is that they get on several pathways. What we need to come back to is a person-centred, population-focused, place-based way of working, which has to build on the primary care networks, working with social care to look at prevention, primary, social and community services, and, yes, the acute service and specialist services in their right place, but trying to prevent the need for them further down the system. We need to create a system where someone goes to their GP and they do not just get 10 minutes about their condition; they get a referral to someone who can talk to them for a bit longer about the set of issues they have and look at an integrated plan for them to meet their needs. That is what should be different.
On your point about outsourcing and changing name badges and so on, there are ways around that as well. In the world of social care, where people have had to tender home care, sometimes people go with that when there is a different agency. But I have been in a service where a number of providers were co-badged with the council, and it was just the Hertfordshire care service. Whether you were Serco, Allied Healthcare or the council, you had the same badge, so for the person receiving the care it was all the same. If you re-tender, it is usually the same staff; they have all been TUPE transferred and you do not need to make a big song and dance about it, if everything is going well. If there are lots of things to be corrected, you might want to make a song and dance about it, because you are trying to improve things. But there are ways around it.
Julie Wood: We do not think that you should establish ICSs on a statutory footing. It would be a massive distraction and people would just focus on that, or they would say, given that the 2022 legislation goes through, “That is going to happen, and we won’t take the decisions now that we need to,” and we will waste the opportunity of two years of significant additional funding and significant pressure on the system to transform. However, that does not mean that you are not clear about who is responsible for what at what level. You have to do it through the existing accountabilities.
You heard earlier about needing to have skin in the game. If we just said, “Oh, it’s them up there—it’s the ICS—and we are not responsible for it,” that would be a disaster. We need to make sure that it builds on the existing statutory accountability of trusts and CCGs to deliver for their population. That goes with having shared responsibility for health, so you are responsible for what happens in your institution but also responsible for what happens outside it.
Q183 Dr Whitford: Is that not the thing though—that an ICS should actually be at the same level as organisations that already exist? I thought it was an integrated care system rather than something higher up.
Chris Hopson: Far be it from me to comment on local government, but one of the things we have been going through in local government is effectively to try to eliminate overlapping and duplicative authorities to get to unitary authorities, so that we clearly have one tier where the powers are clear. I start to worry when I hear STP chairs saying, “We’re going to be responsible for system performance and system finance,” and I have NHS England and NHS Improvement trying to hold us to account for system performance and system finance, when in reality the trust is responsible for its performance and its finances. We are in danger of heading to creating layers where we ask people to do duplicative things.
I could be persuaded of the need to have a statutory underpinning of ICSs, but it would need to be incredibly clear about what that underpinning is there to do and what the powers of the STP and ICS are there to do, and we must be incredibly clear that they do not overlap or cut across the responsibilities of the individual institution. In our view, there is a lot of dangerously sloppy thinking about trying to create that level of institution without being clear that, if you start to blur what the individual institution is responsible for, you risk a whole bunch of really important stuff, such as clarity of governance of clinical risk, which seems to us to be absolutely fundamental in what those organisations do.
Q184 Dr Whitford: But people are concerned about it not having a statutory duty to publish or to be transparent, accountable or responsible. As we talked about earlier, when everything is going well, everybody is pals, but if they hit the buffers, it falls apart. It is not talking about another layer; it is surely talking about turning a bunch of individual bodies into a system.
Julie Wood: Giving them system-wide responsibility and accountability to tie it all together is going to be needed, but that does not mean creating something called an integrated care system as an institution.
Chris Hopson: But I worry—tell me if I am getting this wrong—that I do not see that complexity and nuance coming out in the debate at the moment. I do not think that anybody is suggesting that we should put ICSs on a statutory basis now. Sorry, some people are; let’s be clear about that.
What I hear is the sort of inexorability that, in three to five years’ time, when we have the chance to do it, that is what we should do. All I am saying is that I think the debate is much more complex and nuanced than most people are pretending at the moment, because of the importance and centrality of the unitary trust board being held to account for everything that happens inside a trust. If we lose that anchor, which is a real anchor in the whole NHS—
Q185 Mr Bradshaw: You only need to say something once for the Committee to hear it, okay? It is getting very repetitive and we are running over time.
Chris Hopson: Sorry.
Dr Whitford: I think Niall wanted to finish on this.
Niall Dickson: I understand and share Chris’s fear about the undermining of FTs, and there is an element of that within some of these proposals, but I do not think anybody is in the business of wanting to abolish foundation trusts, and nor should they, because their governance arrangements and their links through their governors are actually a strength in the system. Nor do I think that at this moment anybody is arguing that with STPs or ICSs we should create a Scottish-style system where you have a board and subservient providers underneath it.
We are engaged in what is frankly quite a brave experiment, which is about retaining the provider model and bringing in new forms of provider through PCNs and so forth, or new collaborations, and saying to them collectively that they are still individually responsible for their organisation, but they now have a different and separate set of responsibilities around working in the system as a whole. That is brave, because I am not sure that you can look around the world and see lots of other examples. It is true in lots of other industries that providers manage to create seamless supply chains, working out where they are co-operating with one another, so this is not entirely unique. But we need to take steps at a time.
These proposals genuinely cause fear, certainly among our members and I am sure among Chris’s as well, around what they say about the degree to which the centre wants control. We need to be very careful about that.
Chair: Can we have the final questions?
Q186 Dr Wollaston: Sarah, you said that you were interested in us hearing your views, because you said that the local government system had been largely left out of this. It would be really interesting for us to hear what you want to see within it, and what is missing from your point of view, and being very clear about that.
Sarah Pickup: There is a missing piece in the proposals, because they were drawn up by the NHS. There is a risk of unintended consequences or an impact assessment that looks narrowly and does not look out to the partners that also need to be there to make this succeed. Wherever there is a proposal, you have to think about the impact on local government and whether it is at the table. An ICS is the sum of its parts, and, if the parts do not include councils, it is not going to succeed. There are all sorts of knock-on issues, as Niall said, about properly funding social care in councils, but that is an argument for another day.
Within this, the critical thing is that it is not an integrated care system if it does not have councils in it. The proposals need to address that, and they need to address the issues of subsidiarity and proper local scrutiny, using overview and scrutiny and health and wellbeing boards where appropriate, and not reinventing the wheel. The key is to paint local government into the picture and paint back the things that already exist, which are kind of ignored.
Q187 Dr Wollaston: Well, of course the people we need to paint back into the picture very firmly are service users and their families. The whole point of this exercise was to make it feel much more seamless for patients and their families and service users. Unless we include local government in that, it is not going to happen.
Sarah Pickup: To go back to the place-based, population-focused, person-centred thing, that is fundamental to this. I do not think that the public will start looking to ICSs for their care; they will carry on going to their GP, and the GP needs to have other places to send them that are not just up a line or nothing. Social prescription is all very well, but you need things to prescribe, and it is not all about that anyway. It is about education and all sorts of things. Social care is critical, but it is about the wider link, the public health link and the wider determinants link. As I said, we started, like others, by saying that there were things that we supported and we believe that some things need to be changed, but we need to make sure that there are no unintended consequences.
Q188 Dr Wollaston: I have one final question. We have heard that Simon Stevens is talking to Chris Hopson, but is he talking to you about those final tweaks?
Sarah Pickup: We have had one discussion so far with NHSE, with Ian Dodge, jointly in a meeting about some of this, and we will be following up.
Chris Hopson: Could we provide you with a note on the capital proposals, which we have not talked about at all?
Chair: That would be very helpful.
Dr Wollaston: Yes, we ran out of time.
Chris Hopson: That’s fine—I obviously spoke too long. But it is a really important issue.
Chair: Please send us a note. Thank you very much to all members of the panel for your contributions today.