Department's White Paper on health and social care

We support the proposals in the White Paper that will be included in the new Bill and welcome the direction of travel in the Government’s reform of health and social care. Provided that proper accountability mechanisms are put in place, particularly relating to the safety and quality of care, we believe that creation of Integrated Care Systems throughout England has the potential to improve the delivery of care services for patients. However, there are areas in the White Paper that require further clarity or revision—and some concerning omissions which we set out in the subsequent chapters of this Report.

We welcome the Secretary of State’s confirmation that the statutory right of a patient to choose where they receive treatment will be retained in the forthcoming legislation. We welcome the Secretary of State’s commitment to this and look forward to seeing provisions in the Bill to maintain and enhance patient outcomes and to retain the patient’s right to receive treatment outside the area served by their local ICS.

We welcome the Secretary of State’s commitment to include in the Bill, at our suggestion, provisions to enable the Care Quality Commission to undertake ratings of Integrated Care Systems. As an independent regulator it must for the CQC to decide how such inspections and ratings work but we note that the success of the system to date has been partly because the core domains (safe, effective, caring, responsiveness and governance) are largely patient-facing, so it is essential such an approach is maintained including a domain that focuses on safety and quality and is named as such. We believe within these domains it should be possible to include assessment of delivery of core NHS England and DHSC objectives so that there is alignment of objectives across the system.

We recommend that the CQC’s assessment of ICSs includes consultation with patient groups and consideration of patient outcomes, and that all relevant data is published.

We further recommend that the CQC rating includes progress ICSs make on the integration of information technology between primary care, secondary care and the social care sector.

While we accept the importance of the timely implementation of the proposed Bill, we recognise the concerns raised by our witnesses about the effect this may have on the NHS and the care sector; both of which have been put under unprecedented strain during the covid-19 pandemic. The Government must be alive to the need for flexibility in the timetable for implementation as the scale of the post-pandemic backlog becomes clearer.

Different parts of England will be further along the journey towards integration than others. In order for all areas to benefit from Integrated Care Systems, we recommend that: The Government’s White Paper proposals for the reform of Health and Social Care 39 a) The Department and NHS England ensure that processes are in place to share best practice quickly and effectively so that all areas can implement these reforms efficiently, with additional practical support mechanisms offered to ICSs that get low CQC ratings; b) The implementation period takes into account fully, the fact that parts of the country will be at different starting points on this journey; and c) Local NHS leaders have a role in setting the pace of the implementation to ensure that the establishment of ICSs will not adversely impact an area’s covid-19 response or recovery.

The success of ICSs will, in no small part, be dependent on good working relations between the NHS Body and Health and Care Partnership. While we agree with Sir Simon Stevens that the proposals provide flexibility for local decision-making, clear lines of accountability will be necessary to ensure that both component parts of an ICS can function efficiently and effectively.

We therefore recommend that the Government include in the Bill a more detailed framework that sets out the roles and responsibilities of both the NHS Body and the Health and Care Partnership and of the Chair of the ICS. NHS England should set out in guidance how the responsibilities and accountabilities of NHS trusts and foundation trusts align with these to avoid confusion, duplication or overlap.

It is vital that local populations have confidence in the boards of the NHS Body and the Health and Care Partnership and transparency in the appointment process for those boards will be a key factor in that. If NHS Bodies and Health and Care Partnerships are to be successful they must not be dominated by the views of the NHS but draw on the experience and expertise in all areas of the health and care sectors as equal partners. We therefore recommend that a duty be placed on ICS boards to ensure that: d) the composition of boards includes representatives with experience and expertise in the views and needs of patients, carers and the social care sector. e) where an ICS’s decision-making affects carers and the social care sector, that the ICS undertake formal consultation with the groups and sectors affected.

The White Paper will give the Secretary of State the ultimate responsibility for appointments to NHS boards. Given the concerns about the potential politicisation of the NHS, there will need to be full transparency in the appointment process. We therefore recommend that the Bill sets out the criteria by which the Secretary of State will use this power so that appointments and vetoes decided upon can be assessed.

We conclude that the Bill provides a timely vehicle to introduce reforms to the fit- and-proper persons test for appointments to NHS boards. We therefore recommend that the Bill is used to establish a UK-wide public register of people that are holding, 40 The Government’s White Paper proposals for the reform of Health and Social Care have held, or are seeking to hold a position on an NHS board. We also recommend that NHS England and the Department undertake a review of the adequacy of the training and support provided to board members.

We were concerned that the White Paper did not set out a long-term plan for social care. The absence of a fully funded plan for social care has the potential to destabilise Integrated Care Systems and undermine their success. However, we note that the Prime Minister has committed the Government to producing a 10-year plan later this year; and we would be extremely disappointed if detailed plans for this were not published before the end of the calendar year. It is vital that this plan is fully costed and funded at the levels set out in our Report, Social care: funding and workforce. Without secure, long-term funding, the problems that have bedevilled the care sector over the last two decades will not be solved.

The social care sector needs reassurance that both the structural and financial problems it faces will be tackled by the Government in a timely way. For that reason, we recommend that a duty is included in the Bill for the Secretary of State to publish a 10-year plan with detailed costings within six months of the Bill receiving Royal Assent.

Unpaid carers are partners in care and it is deeply concerning that the White Paper does not mention unpaid family carers at all. We welcome the commitment by the Secretary of State to consider what support and representation can be given to unpaid carers, and recommend that the NHS should have a responsibility to have regard to carers and to promote their health and wellbeing. This should be included in the Bill. We further recommend that provisions to protect carers’ rights on discharge also be included in the Bill.

The involvement of the CQC in Ofsted-style rating of social care provision by local authority area would create parity in accountability with the new ICSs and shine a much-needed light on local variation in the provision of social care. However, for this to be successful the social care system needs to have in place a fully funded 10- year plan to sit alongside the NHS’s own 10-year plan.

We recommend that, following consultation with local government on its implementation, the Bill gives the CQC powers to give Ofsted-style ratings for local authority social care.

We further recommend that the CQC ratings includes consideration of food standards in social care settings to better align social care and the NHS in relation to the proposals in the White Paper on food and nutrition standards in the NHS.

We recommend that the new Bill gives the CQC powers to give Ofsted-style ratings for local authority social care provision but that these are not enacted until the 10 year social care plan is published later this year and there has been full consultation with local government.

We do not believe that the duty to publish an update on the roles and responsibilities once every five years is an adequate response to workforce shortages that are endemic in the NHS. We are very sympathetic to the detailed joint proposal from the Kings Fund, Health Foundation and Nuffield Trust to place a duty in the Bill to produce annual workforce projections. Equally, we welcome similar proposals submitted by the Academy of Medical Royal Colleges and Royal College of Nursing. The detail in both proposals is key to ensuring that the Department and NHS England can develop strategies to adequately staff health and social care in the short, medium and longer term

We therefore recommend that the Government include in the Bill, provisions to require Health Education England to publish objective, transparent and independent annual reports on workforce shortages and future staffing requirements that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained. We further recommend that such workforce projections cover social care as well as the NHS given the close links between the two systems. These reports should include input from staff, NHS bodies and unions, and content on the sufficiency of training should be reviewed by independent experts prior to publication.

We further recommend that workforce reports be undertaken in consultation with the Devolved Administrations to ensure that a clear picture is given on the health and care workforce throughout the United Kingdom.

The Secretary of State for Health and Social Care is responsible to Parliament and the taxpayer for health and social care. It is therefore reasonable that the Secretary of State has the appropriate levers to ensure that Government policy is delivered. However, the White Paper does not give adequate detail on how the new powers proposed for the Secretary of State will be used. Nor does it set out the necessary safeguards to ensure that the powers do not open the door to the politicisation of the NHS.

We recommend that the Bill includes provisions that set out in detail, both the range and restrictions that will apply to each of the additional powers proposed including provisions for transparency around ministerial interventions and the operation of the public interest test.

We recommend that the Bill sets out in detail, the scope and areas of decision-making that will apply to this power. We further recommend that the Bill places a duty on the Secretary of State to publish any direction made by his office, including responses by the affected body, and that such powers are implemented in accordance with a public interest test.

The Secretary of State already has the power to intervene in reconfigurations and therefore the proposal is an extension of that power in relation to the timing of an intervention. However, the White Paper is not clear on the criteria for intervention, 42 The Government’s White Paper proposals for the reform of Health and Social Care nor is it clear on the role or replacement of the Independent Review Panel. This lack of clarity needs to be addressed if there is to be confidence in the process of Ministerial intervention in reconfigurations.

We recommend that provisions be included in the Bill that set out the criteria under which the Secretary of State may intervene in reconfigurations. We further recommend that a duty be placed on the Secretary of State to lay before Parliament all information and advice in relation to an intervention in a reconfiguration.

The additional powers proposed for the Secretary of State have the potential to provide a more agile response to the changing health and care landscape. However, that power requires a commensurate level of Ministerial accountability and Parliamentary scrutiny. We believe that the Bill should set out in detail the extent of this power and the restrictions on its use - including bodies that would be outwith the scope of the power—so that it does not become an unfettered power to chop and change the ability of arms’ length bodies to carry out their important roles.

We recommend that the Bill includes schedules setting out the use and restrictions of the power to transfer responsibilities of Arm’s Length Bodies -including a list of bodies outwith the scope of the power. We further recommend that the affirmative procedure for secondary legislation is used in the transfer of functions and responsibilities of Arm’s Length Bodies to ensure that Parliament has the ability to approve or reject such changes.

We are broadly supportive of the proposals in the White Paper on public health although did not consider them in detail. Therefore, we do not make detailed recommendations on the potential merits of the individual proposals. However, we conclude that there are wider health benefits to including in the Bill a duty to be placed on ICSs to have specific regard to public health, mental health and well-being and the prevention of ill-health.

We recommend that the Bill include provisions to place a core duty on ICSs to have regard to public health and mental health; and to include in ICSs’ public health duties, a requirement to develop strategies to ensure the prevention of ill-health through the delivery of programmes to support the wellbeing of the local community, health and care staff and voluntary organisations that support the health and care sector.

We welcome the direction of travel in the White Paper’s proposals to tackle obesity. If this is to be successful, the proposals on food advertising should reflect the fact that the viewing habits of children and young people are not restricted to television but extend to social media and online providers of content.

We did not consider the fluoridation proposals during our evidence session. That said, it was covered by a number of submissions from both individuals and organisations that were opposed to the proposal and several clinical bodies that were in favour of it; and we draw the Department’s attention to that evidence. The The Government’s White Paper proposals for the reform of Health and Social Care 43 Secretary of State will recognise the long-standing debate on fluoridation, and we look to him to set out a balanced response to both sides of the argument during the debates on the Bill.

We welcome the proposals to reduce bureaucracy in NHS procurement, which have been broadly well received by stakeholders. If they are implemented in a clear and transparent way, they have the potential to both streamline Trusts’ procurement practices and reduce their financial and administrative burdens. That said, a framework of clear guidance and monitoring will need to be put in place to ensure that a lighter touch regime does not inadvertently establish practices that favour incumbents and excludes innovators. We note that implementation of the Health and Social Care Act 2012 led to unintended consequences in terms of bureaucracy and procurement and therefore for this set of changes it is extremely important to make sure implementation is well executed.

We recommend that alongside the proposals to remove competition regulation, the Department establishes a framework that formally monitors and makes public annually: f) the proportion of contracts which change from year to year and the companies that were awarded contracts or had contracts renewed in each year; g) the proportion of contracts awarded to small and medium-sized enterprises; h) value for money of those contracts; and i) the patient experience. That framework should also ensure that innovation and diversity of provision from voluntary sector, social enterprise, and NHS organisations is encouraged and supported.

Because of the importance of implementation, the Committee puts the Government on notice that we will return to these issues before the end of the Parliament in time to assess how effectively the plans have been put in place. We will also ask the Secretary of State, NHS representatives and patient groups to return to the Committee on a regular basis to brief us on progress in implementation.