Hansard Contribution By Lord Mawson (CB) On Wednesday 26 January 2022
159A: Clause 22, page 32, line 29, at end insert—
“223CZA Financial duties of NHS England: the principle of subsidiarity(1) NHS England must exercise its functions in accordance with the principle of subsidiarity, and must promote the principle throughout the integrated care system in particular by ensuring that integrated care boards observe the principle.(2) The principle of subsidiarity is that responsibility for deciding how and where to use resources is as far as possible to be delegated to local areas in order to meet local needs and to promote local groups working collaboratively.(3) In doing so, the process and timing of procurement should take account of the benefits of long-term relationships and stable partnerships in delivering sustainable integrated solutions to local health issues.”
My Lords, I have listened carefully to the debate taking place in Committee over the last few weeks with great interest and noted the growing consensus that now exists across this Chamber for transformation and change. These debates have shown the House at its best. It is clear that the Government now have before them an opportunity to transform not only the NHS, its culture and its ways of working but the public sector, much of which is not fit for purpose in this century. People inside and outside these systems know this—listen to those who are leaving for early retirement.
As well as listening, I have been talking to colleagues around the country: those inside the NHS systems; those responsible for the development of the ICSs; and those outside who seek to transform the health and care world and who wish to partner with these systems. I will share a few concerns that I have heard, because they relate to my two amendments, Amendment 159A and 210A.
First, colleagues both inside and outside NHS systems have heard fine words from Governments before about change and transformation in health and care, but they are sceptical. They know that the Civil Service and government systems and mindsets are not fully fit for purpose. The Civil Service’s culture and mindset need to transform; it needs to get interested in what is happening among young entrepreneurs in Bradford, for example. The voluntary and social enterprise sectors need the Government to go beyond fine words and deal with, for example, the situation that my colleagues at the Bromley by Bow Centre have to deal with every day as they navigate—as the noble Baroness, Lady Cumberlege, mentioned last week—41 different funding streams coming up the silos from the Treasury, at enormous cost and wastage of time, as they try to deliver integrated services. If we are to build a more integrated health and care programme, these practical issues are going to get worse—not just in east London but across the country—unless we address this now.
Many years ago, we had a secondee from the Treasury in Bromley who told us how all tax revenue was paid into one bank account. How much does it cost to then spread this out across 41 government departments and programmes, only for it all to be brought back together to address the multiple, complex and interlocking issues that somewhere like Bromley by Bow faces? How much cost does all this add? No one knows. Is it 20%, 30% or more? No wonder we have a productivity crises.
The Single Regeneration Budget programme was an early attempt, some years ago now, by the Civil Service and the Government to bring funding streams together. What lessons have been learned in government and the Treasury from it? I suspect there is no memory of this programme in the system.
There is also a danger of the NHS and public sector culture imposing itself on the voluntary and social enterprise sectors, as they try to innovate and generate new ways of working—what I call putting old men in new clothes. I have seen this in the housing association movement, which I was involved with in the very early days, and in what happened to children’s centres, which were launched in Bromley-by-Bow by a Labour Government, which then unwittingly undermined our integrated model and ways of working with local families.
My colleagues in parts of the country can already see the NHS centrally trying to impose its old processes on them as they innovate, at the very moment there needs to be a two-way street and real learning taking place. The centre needs to learn from the micro, from the innovation platforms we have created, not impose its outdated systems on them. Government needs now to show a clear resolve to transform the culture of the NHS or people will become even more cynical. The whole system and culture desperately needs change, and the way into this is via the micro and practical details.
Yes, it will take time, but first we must be clear about why we are taking these initial early steps and where we are trying to get to. There is a real danger of our Civil Service systems unwittingly deepening poor-quality outcomes and a dependency culture. The centre should see these innovation platforms as a place that can teach the centre, not the other way around. I declare my interests here. We need new behaviours from NHS England, not last-minute processes that want everything tomorrow. The macro needs to learn from the micro; the whole system needs to return to first principles and create an environment which encourages healthy communities.
Levelling up is surely about addressing the UK’s productivity gap, especially in marginalised communities, and one way of doing that is via a healthy and thriving population. It is also the only way to stop the NHS taking an ever-greater percentage of the UK’s GDP. I suggest health is now everybody’s business.
My two amendments fit within this mindset and suggest some first steps that could be taken along this road. Let me now deal with my first amendment, Amendment 159A. True subsidiarity cannot be achieved without delegation of resources and the authority to allocate in a way which will achieve the intended and agreed objectives. For example, systems may wish to ensure that discretionary local services such as community centres, community transport, struggling family support and meals on wheels should be prioritised and sustained ahead of further spend on health capacity, given their key role in supporting ongoing independence and social cohesion and preventing the need for health services.
Place systems may choose to pool delegated resources in order to commission collaborative services at scale, where they jointly agree that they are not best placed to provide such services, and such discussions are already taking place in mature systems. For example, in north-west Surrey we have agreed to jointly commission dermatology services across two place systems. The point is that delegation to place does not work against the development of services at a wider scale where that is appropriate, but the recognition of this needs to come from the place level.
True transformation—true to the spirit of the Bill and the long-term plan and to achieving the intended benefits of integration—cannot be achieved without the freedom to invest those resources in a way which can unlock long-term benefits. This may require speculative investment in some cases, as well as investment in preventive services which do not offer rapid returns but are essential to maintaining the ongoing sustainability of services. We would not expect any of this to be done without due diligence on the capability of place-based partnerships and appropriate levels of holding to account for achievement of improvements and results. The ICS will have a key role in not only ensuring that funds are delegated appropriately but supporting place-based systems to build the capability to manage delegated funds effectively.
We need to make leaps in how health services are now delivered through integrated services and offers to populations, by thinking radically about who can support people best, and in what way, to keep them healthy, look after them at home where possible and provide services which understand people as individuals and meet their needs holistically.
This degree of change in public health, prevention and provision of services needs innovative and broad-based collaborations and partnerships between organisations—health organisations, local authority organisations, VCSE and business—tailored to fit the needs of the place. These relationships are not quick to build; they take time and effort. The work takes years and the impact can be seen only through long-term relationships and stable partnerships. For this to succeed, the ICS will need to embrace the principle of subsidiarity, delegating meaningful responsibilities and accompanying budgetary responsibility to place level. This may mean that standard procurement cycles and processes do not immediately bring the outcomes that the Bill envisages. More innovative processes and timings may be needed to ensure that the benefits brought through long-term relationships and stable partnerships are given time to be achieved.
Let me now deal with Amendment 210A. In general, NHS bodies do not currently make best use of their local voluntary community, social enterprise and faith sectors when procuring services to achieve key health outcomes, especially in prevention and early intervention services. This is all well understood but, somehow, we never seem to get beyond one-off experiments or short-term, time-limited initiatives. By contrast, the best local authorities have been procuring and partnering with their VCFS for many years, though this has become more difficult with recent funding pressures. There is an opportunity, therefore, for health colleagues to learn from their local authority colleagues in the ICS on best practice in this regard.
With NHS vacancy rates at their highest levels, together with waiting lists for treatment, now is the time to take a whole-system approach and look more collaboratively across the local community. There is also a strong value-for-money argument. Simply waiting for people to become seriously ill, which is what is happening in practice at the moment with regard to many mental health services—but not by design—and could equally be applied to services for struggling families, leads to very poor outcomes and is very expensive. Using VCFS organisations and others, with a combination of staff and local volunteers to create a coherent health-oriented rather than illness-oriented approach, will pay dividends, but only if there is real intention and focus over a sustained period of time. This is a long-term play, not a quick win, but vital none the less.
Traditional models are not working for the groups which can offer most value. Local charities and social enterprises tend to be funded on a hand-to-mouth basis using grants, so most cannot permanently invest in their services. This is despite a huge growth in charitable giving from the public, directed in the main at the NHS.
In north-west Surrey, we are looking at how we can give similar prominence to local charities supporting areas of deprivation and communities in need, but more needs to be done to enable charities and voluntary sector groups to be assured of ongoing funding to provide core services. Keeping such VCS groups active is essential to achieve insight into the needs of communities. There are innovative approaches such as Tribe, a platform developed by a technology business- person, Richard Howells, simply because he had become so frustrated by the inabilities of the NHS and care services to deal with his own mother’s care needs. Richard did not write a research paper; he created a practical solution, which is pretty impressive. When he shared this practical solution with the NHS centrally, there was a lot of interest and fine words but, in actual detail, no follow through.
We now need to allow these insights at the most granular level to inform the commissioning and targeting of services. Without this, we will not be able effectively to respond to specific areas of inequality or health risks, leading to ill health and pressure on services. The existing models of voluntary sector support need to be developed to enable and promote micro- enterprise creation on a far greater scale. This both protects the quality of services and enables individuals to gain training, support and income. It has the potential to open up a currently untapped resource of care support, which is critical in places such as north-west Surrey, where community care staff vacancies run at around 40%.
Employment and volunteering are themselves key determinants of well-being. Place-based systems will wish to use their spending power to leverage this benefit and invest directly in local employment, where it can be demonstrated to be the most effective use of resources. In north-west Surrey, we have achieved a virtuous cycle of supporting furloughed airline workers during lockdown through recruiting them into the hospital workforce, supporting the delivery of services and well-being of clinical staff, and reducing the risk of those individuals developing physical or mental health problems through inactivity and stress.
Link to the debate published on Wednesday 26 January 2022
My Lords, I thank the Minister for those helpful thoughts and reflections. First, on NHS England, we need to be very sure that a two-way street is established, because I worry that systems such as this are not learning organisations—we know this from experience—and they now need to become such if they are really to embrace an environment that is about innovation and more entrepreneurial activity. I put that on the record. We will watch what happens; I am sharing with noble Lords what is actually happening now, live, in some of these services around the country as they try to establish new ways of working.
I pass on apologies from the noble Baroness, Lady Andrews, and the noble Lord, Lord Clement-Jones. They have supported these amendments but, because of the change in the timetable, were not able to be with us today. This debate is being watched around the country, and I am aware of a very interesting dialogue going on with people both inside and outside the system. We should all be encouraged by that and should build on it.
With regard to the Report stage and to these two amendments and my earlier amendment, my colleagues and I, with others in the system, will reflect on these discussions. We will, I hope, talk further with the Minister and other colleagues and think about what the next steps might be. For now, I beg leave to withdraw my amendment.