A Quiet Word:
Lobbying, Crony Capitalism
and Broken Politics in Britain

November 2013

  • Dr Martin McShane, Director, Improving the quality of life for people with long-term conditions, NHS England, thank you very much for joining us.Norman Lamb: It is a pleasure. Am I allowed to take my jacket off?Chair: Please do.Valerie Vaz: Just the jacket.Norman Lamb: Don’t worry, Valerie.Chair: Dr McShane, you are extremely welcome as well. I would like, if I may, to lead off by asking where we are in the process of preparing a policy for dealing with longterm conditions. Our understanding was that this was being followed up within the Department of Health, that there was a commitment to publish a policy for how we deliver improved services for people with longterm conditions, that has now been transferred as a responsibility from the Department of Health to NHS England. What effect has that had on the process? Is the team being transferred or is NHS England starting again? How is that transfer working?Norman Lamb: Perhaps I can start and then hand over to Martin. There are two things I would say first of all. To be honest, the work that was under way was slightly out of sync with the changing architecture of the way the system works, a conclusion was reached that it was properly the responsibility of NHS England. So all of the information that had been gathered as part of the process building up to the strategy has been passed to NHS England. None of that is lost, but it does more sensibly sit under the responsibility of NHS England to map out the way forward. Along with that, the Secretary of State has made it clear that he wants his personal focus next year to be on longterm conditions. As you will be aware, he has focused very much on the 'Vulnerable older people’s plan', which will be published before the end of the year, but he wants to turn his focus-and inevitably I will be working alongside him on all this-to longterm conditions next year.Q232 Chair: What is the difference between a vulnerable older person and an older person who suffers from longterm conditions?Norman Lamb: There is clearly an overlap, isn’t there? Chair: You have accurately predicted my thought process.Norman Lamb: Clearly, there are lots of people who live with longterm conditions who are younger than the sort of scope of the 'Vulnerable older people’s plan', which is primarily looking at people over the age of 75. But the view that the Secretary of State took was that, if you can try and get things right for frail elderly people, you can then learn important lessons for all other people who might have similar complex health needs and whose care too often at the moment fails because of-as we have discussed many times-a fragmented system where people fall through the gaps, breaking up the continuity of their care. These things will, ultimately, all move in the same direction of policy, with the idea of an accountable, named clinician and the idea of a pretty fundamental shift towards a model of care, which is joined up and integrated around the needs of the patient. Whether you are talking about longterm conditions for people of any age or frail elderly people, the policy and the care solutions are rather similar, I think.Dr McShane: Just to build on that, if I can contextualise it, there are the two big changes that we need to understand. One is that, as I would put it, we are almost a victim of our own success. We have seen huge improvements in health, life expectancy and longevity across the UK and in England. The problem that that has created is that, as people live longer, they are also developing both longterm conditions and frailty. Now we are trying to create an understanding that frailty is a diagnosis, not an adjective-that you can be frail because of your age without it necessarily being accompanied by longterm conditions. So it is a 'both and' issue. It is quite right that the definition of 'vulnerable' is both people with longterm conditions and people with frailty. The other big context change is that we have done very well on health and planned care, but the system we have created does not really address longterm conditions and these are now dominating the consumption of resources in both health and care, of which I am sure you are fully aware. From my perspective, longterm condition management needs to be integrated with everything else that we are doing. That is why, as one of the domain directors, we have started to model the way we work in the way that the system should work so that we are working as a team. If we take the proposition that the vision for NHS England is to deliver high quality care for all, we have the legacy of the Darzi definition of quality, which is safe, effective care, which gives a positive patient experience. Effective care has been divided into three components: preventing premature mortality or avoidable deaths; enhancing the quality of life for people with longterm conditions, helping people to recover from acute care or episodes of trauma. Those components are three of the five domains that lead to high-quality care for all and form the NHS Outcomes Framework. My role is to provide leadership and a narrative, to look at the system levers and enablers that will enhance the quality of life for people with longterm conditions. But I am also dependent on the work that is being done in Domain 1 on reducing premature mortality and working closely with Keith Willett-I am sure you are aware that there is an 'urgent care' review going on-because everything that happens in longterm conditions has an impact on emergency care as well. We have to try and create a system that looks at a system, not just its different components. We have had a system that has focused very much on hospitals and we have had this mantra about moving care out of the hospital. I do not think it is about moving care out of the hospital. It is about creating the right care in the community so that people do not need to go into hospital. That is the agenda we are facing and which we need to tackle. To do that requires a huge cultural change, which is the biggest change. Q233 Chair: Can I bring you back to my original question, which was a relatively narrow process question? Are you supported by a team that was previously in the Department? Are you starting again? We have been talking about the need to remodel services for people with longterm conditions since I was Secretary of State and that is a very long time ago.Dr McShane: We have taken a very different approach. When I came into this job I discovered there were three different teams in the Department of Health addressing longterm conditions. We have set up the five domains and we have created crosscutting programmes across each of the domains to support improving quality of care for people across the whole context, as I have described. If you like, my team is very small but my resources are very large. So I work in a crosscutting way with all the other directorates in NHS England-patients and information, finance, commissioning development and operations-to make sure we have a clarity of purpose, a clarity of direction and we are focused on making those system changes.Q234 Chair: I will have one more go. When are you going to publish an outcome from this process?Dr McShane: We already have published a number of documents. On the NHS England website there is the narrative around quality. We have published the narratives for each of the domains and have already started to publish some of the tools. But the traditional 'Let’s publish one strategy which says how we are going to deliver longterm condition management' is not our approach. It is about how we move the whole system to ensure that people with longterm conditions get high-quality care as well as delivering changes to premature mortality and hospital care.Q235 Charlotte Leslie: Dr McShane, the overarching objective in Domain 2 of the mandate, for which you are responsible, is that the NHS should 'make measurable progress towards making the NHS among the best in Europe at supporting people with ongoing health problems to live healthily and independently, with much better control over the care they receive.' What is your assessment of progress against that and how on earth are you measuring it?Dr McShane: First of all, I think we have made good progress, let me give you one example of where the new system might differ from the old system. We have recently had the national audit report for diabetes published, which says that, in terms of care processes, we could do better. The 'Global burden of disease', which was published in the autumn last year, with followup articles in The Lancet and a Canadian study, show that, benchmarked against the rest of Europe, we deliver the best outcomes for people with diabetes. When we look at the change in premature mortality for people with diabetes, only one country has done better than us, that is Canada. So process is really important, but for too long we have completely disconnected it from purpose. We have not understood what the outcomes we are trying to deliver are and the measures of progress we are making. That is a huge step forward and we are probably the first country in the world to make that step. Other countries are looking at us to see how we do with it. There is a great deal of interest around it. We are now working with the analysts to look at a whole range of new analytical measures. For instance, in the survey that is done annually for GP practices on patient experience, we have the EQ5D. Don’t ask me to explain it. It is a measure of what quality of life people have and I think it goes from 0 to 5. The 0 means dead, but I discovered that there is a negative measure as well.Dr Wollaston: Worse than dead?Dr McShane: Yes, working for the-no. Charlotte Leslie: Being on a Select Committee. Dr McShane: Anyway, measuring that, we are starting to understand what those factors are that correlate with improved quality of life for people with longterm conditions, because 52% of the people who responded to that survey selfdeclared that they have a longterm condition or conditions, which is becoming more prevalent. We are now starting to tease out what the measures are that we can put in place that show that doing this improves someone’s health and care.Q236 Charlotte Leslie: So it is a sort of 'work begun but very much a work in progress'.Dr McShane: It is absolutely a work in progress because it is a fundamental change in the way that we tackle improving health, given that the nature of the challenge to health care has so fundamentally changed itself.Q237 Charlotte Leslie: Moving on, the mandate also requires particular progress in four key areas for longterm conditions. They are involving people in their own care, better use of technology, better integration of services and better diagnosis, treatment and care of dementia by March 2015. What is your assessment of progress in those specific areas and what do you think they will have delivered by March 2015?Dr McShane: If I take those in reverse order-so I do not forget them-with dementia, the issue is that we have a national clinical director for dementia, Alistair Burns, who has provided continuity of care through the transition. We have, I think, first of all changed the nature of the debate. We have put measures in place. We are working assiduously on better measures to track quality improvement. We have, over the last two to three years, vastly increased the number of people who receive a timely diagnosis. It is a bit of an uphill struggle because the more people we diagnose, the more our estimated prevalence goes up at the same time. The denominator is changing almost as fast as the numerator. If we look at absolute percentage changes, we are seeing 10% or 8% changes year on year in absolute numbers diagnosed, but that is not being reflected in the ratio because of the change in prevalence. Also, we are now working with the Alzheimer’s Society on what is critically important for longterm condition management-all four components. Traditionally, we have just looked at the person and the professional. It is critical that we also look at the carers because the carers suffer a huge burden where people have longterm conditions, yet the culture-and, as a medic, I can say it-is kind of, 'Oh, well, we exclude the carers from being involved.' That culture has to change. The fourth component is community. The work that the Alzheimer’s Society and the Prime Minister’s Challenge on Dementia are leading on dementiafriendly communities is incredibly important-that we change the stigma and perception relating to that. So in dementia we have made good progress. On personalisation I would warmly commend-and, if it has not been submitted as evidence, perhaps we can have a late submission-'Transforming Participation in Health and Care', the document published by NHS England a few weeks ago. One of my ambitions is to make sure that people have much more control of their own care and ownership of it. That is not abandoning people but giving them authority to inform and influence their care. There were four things, but I can only remember three now. The other one was integration and the Minister has led the push, which I am quite willing to surf, on integration and integrated pioneers.Q238 Charlotte Leslie: Great. I have another quick one and you have semianswered some of it. Have you set out any other measures of progress against other indicators in Domain 2 of the mandate-the proportion of people, for example, feeling supported to manage their own care? Dr McShane: Yes. Fortuitously, I was able to influence the GP Survey this year.Chair: It was more than fortuitous.Dr McShane: They had dropped the question on care planning and we went back round and said, 'Actually, we need to have this reinstated, ' because I truly believe that people being involved in the decision making about their care is incredibly important.Norman Lamb: Can I quickly add, in terms of measurement, that you will be aware as part of the Prime Minister’s Challenge on Dementia that one of the focuses is on the health and care system, part of that is about diagnosis, as Martin has said? The overall position is still under 50%. So we have made progress, but we are still massively behind. By going to all parts of the country, all CCGs, getting them to determine what they want to achieve by 2015, we have come up with an objective to get to two thirds of people with dementia diagnosed by 2015. There is a very clear measurable objective there. Progress is being made, but there is a long way to go still on it.Q239 Rosie Cooper: Can I make some general observations, Dr McShane, on that which you have talked about? As somebody who is close to this currently, you talked about operating as a team, yet out on the front line the NHS is fragmented and nobody knows who their boss is. I used to work for Littlewoods and we started off with a hierarchical system that everybody understood and we did very well. Then a managing director came in who believed in matrix management, which is a little bit like what you have just reflected, in that everybody worked up and down as well as across. The organisation froze and nobody knew whose boss was who and who did what. I have to say that that is how the health service feels to me today. A lot of people in the health and social care system talk often about care in the community-and I noted you used different words 'the right care in the community'-but the truth is that, when you are out there and that system is fragmented, what you are actually saying is, 'You are on your own.' You get somebody who will dip in every now and again, but the reality is that you and your family are on your own. Of course, that is so tragic. To make an observation, in terms of cost, the cheapest patient is a dead patient, talk is even cheaper. All I hear so often is people in senior positions talking. The Chairman talked about integration, I hear it; I hear it; I hear it. The people out there want it if it delivers, but you actually do not see much change. If I might give you an example-and I will put it to the Minister as well-for me, what is going on is that we are all being kept busy talking while, using figures the Treasury have issued, the NHS will be bust in three or four years. It is just not affordable. On those Treasury figures we are bust. Last week Sir David Nicholson was here and he agreed. He told us that the Integration Transformation Fund, using existing money stripped out from the health service and from social care, would be the cliff edge to reform. How is all that going on, when you are redesigning and you have got domains everywhere? On the front line, let me tell you, my father has just been diagnosed as terminally ill and I am told that nurses will come and see him every fortnight, but they cannot possibly tell me when they are going to come other than 'sometime on Thursday'. What am I to do-sit around? What are all these families supposed to do? Are we to sit around waiting for somebody to come today? It is all talk. You are not delivering on the front line. How do you change? All this is grand and keeping us busy, but I still do not know what integration is. I absolutely do not know what it is because I cannot see it. As hard as I look for it, I cannot find it. How do you make it different for the people who really matter-the patients?Dr McShane: Okay, I think that sums up the problem and the challenges we face, so let me tell you how people are doing that in places. We need to learn from them and make sure we spread it and create the right infrastructure and national levers to give people permission to do that, because too often we have tried to direct the solution from the centre with a onesizefitsall approach, which does not recognise that Barnsley, Basingstoke and Birmingham are completely different places and require different solutions depending on their populations, health needs and also the type of infrastructure that they have. If I talk about accountability, one of the things that are absolutely right is having a buck stop. When I was a practising clinician working in the field-and I have worked for over two decades as both a surgeon and a GP-I felt that accountability for my patients. There has been some sense of dilution of that, the current proposals to create accountability-a named person who is responsible for ensuring that care is co-ordinated and planned well-is a step in the right direction. On the second point and your statement about matrix management, what I described, I hope, or intended to describe, was programme and project management. My insight and understanding of that is that, if you want to make change happen, if you have good programme and project management in place, then it happens. That is what we have set up. We have set up these programmes of work and they have clear accountability. For instance, we have just established the parity of esteem programme board within NHS England. Lord Victor Adebowale has kindly agreed to chair that, I, as the domain director, am responsible and have a clearfelt responsibility for making sure we deliver in that area. One of the things to recognise is what Chris Ham described in the health system as the inverted pyramid of power in that we are dealing with a professional system. It is the professionals on the front line who make the decisions on a daytoday basis. We have tried to overprescribe how they should do things, rather than trusting to their professional experience, knowledge and skills, focusing on outcomes. I will give examples of places I have visited in the last seven months since this organisation was established-and we have been going for only seven months, I would like to point out. Tower Hamlets a few years ago introduced a model, which I have nicked from them, called the House of Care, which took them from being the worst performing in terms of longterm condition management to the best, audited, in the UK within three to five years. I have been to Liverpool where the CCG there set out a new form of GP specification which meant that, in terms of being benchmarked against other areas, they are seeing reduced emergency admissions. I have been to Newark and Sherwood where the integration between general practice and the community and mental health team, end-of-life care, social care and the third sector is there. I spoke to a GP and asked, 'What difference does this make to you?' and she said, 'It means that when I go in and see someone in their house I do not say, ‘I am sending in a social worker and a district nurse to see you some time in the future, ’ but rather, ‘I have rung Jane and Jack and they are coming to see you this afternoon, ’' because they work as a team. So, yes, we are not there, but that is the direction of travel. That is why we need to make the changes that are being proposed and included in all the levers that we have.Q240 Rosie Cooper: Okay, I hear that. You mentioned Liverpool. That is where my dad is. Let me tell you-I will truncate this dramatically-that he is falling; he is taken to hospital; he goes in to ward 2A, which is the community ward, falls in the hospital. Useless. And I say, 'Why is he falling? I need to speak to a doctor, ' and they say, 'No, this is a community ward. You do not get it in a community ward.' I say, 'No. Why is he falling down? Is he in the appropriate place?' Then they say, 'This is a community ward, ' and then I say, 'The Secretary of State says there must be a named doctor.' The response from those professionals you have just talked about was, 'Even in the community?' If Liverpool is somewhere you are proud of, you need to get back there pretty darned quick and stay there because it is useless.Norman Lamb: First of all, the example you give from your own family is an example of very poor care. We have to be very open about that and there is too much of it. We have ended up with a completely fragmented system, as you describe. Over the years, I made the point, we have managed to institutionally fragment mental health from physical health, which, from the patient’s point of view, often makes no sense at all. Primary care is separated institutionally from secondary care-and health care from social care. So it is a horribly fragmented system and the principle of integrated care does not have to involve organisational change. It is about the model of care. It is about meeting the needs of the patient and shaping the care and the needs of that patient. I was in Barnsley last Thursday and I would encourage you to go to somewhere like that just to see it on the ground if you say, 'Where is it?', 'I do not understand it, ' and so forth. There are these places where they have really got it. I met with the chair of the CCG, together with the leader of the council, the chief executive of the acute trust and someone from the mental health trust, all working together achieving a sort of systemwide, joinedup approach to patient care. It is quite inspiring when you see it, but it is the exception, not the rule. We have identified-we may well come on to it-and announced two weeks ago 14 pioneers around the country who will push the boundaries of what is possible. I think everyone recognises that there are too many failures of care, the way the health system is designed does not meet well the needs of people with longterm chronic conditions-often quite complex, often a mix of mental and physical health-and it has to change.Chair: I think that is it.Q241 Rosie Cooper: I very much welcome that but we have to do less talking and more doing.Norman Lamb: That is why, in a sense, I got on and did. The interesting thing is that, when I invited expressions of interest for the pioneer programme, 99 local health systems came forward wanting to be part of it. We have identified 14, which I think are the real exemplars. They have been through quite an exhaustive process with an international panel, but they are getting on with it and doing it. I want these people to be leaders of change, not for the rest of the system to stand back and wait for five years to see what the result of a pilot is. We are going to constantly evaluate this. There is going to be a proper scientific evaluation from the start so that we can learn lessons all the way through the programme.Q242 Andrew Percy: That segues nicely into my questions that relate to these pioneers, who the Department says are going to be 'exemplars to support the rapid dissemination and uptake of lessons learned across the country, ' which, in English, I think means we are going to see how they do it and then try and copy them and do it quickly. What is the ambition of the Department in terms of the scale and pace of learning from these pioneers? By 2015, what percentage of the public, of patients, do we expect to be in receipt of proper integrated services?Norman Lamb: The first thing I would say is that there is now very much a shared vision across the health and care system, the Department and NHS England-all of the players. Everyone recognises that we have to change this model of care to meet this particular growing need of people with chronic conditions. It is happening internationally; this is not something that is unique to the UK. I went to the States and saw some brilliant integrated care organisations at the end of May. There are great leaders all over the world changing and adapting the way their health systems work to meet this 21st century challenge. There is a momentum now to make things happen quite fast. So you have the pioneers out in front, but at the same time we have announced this £3.8 billion transformation fund, which Rosie-what am I supposed to-Rosie Cooper: 'Rosie' will do fine.Norman Lamb: -has referred to. That comes into effect in 201516, but we are asking every area-the local NHS, the CCG and the local authority through the health and wellbeing board-to draw up their plans now. The plans will have to be finalised by, I think, February next year, the idea then is that they start to implement this new approach ideally now, but we want it really in place by 201415. Then the transformation fund applies from 201516. This is a sort of wholesystem change, it will require every area to draw up a plan of how they will use their share of the £3.8 billion fund. The interesting thing is that, when I met with some directors of adult social care a couple of weeks ago, they were all saying, 'We are looking at pooling the whole of our budget, not just that 3% element that the £3.8 billion represents.' You need to have the CCG to share that ambition, but it was fascinating that that is what they were thinking about-that the sort of catalyst appears to be driving some quite radical thinking about how you can pool resource locally, I totally welcome that.Q243 Andrew Percy: It would be interesting to see this scientific study of the pioneers, but the one thing that concerns me is this. We have been down this path in the past before in my local area when we tried to do it through mental health services in about 2008 and there was a push to community care. In my area the beds went, mental health wards were closed and it was all focused on care in the community. However, what we still find is that everybody talks about integration and about proper community services, but, at the end of the day, the only two services that are there 24/7 are the local hospital A and E department and the ambulance service to get you there. I am interested in how this is all going to work out, because if we are going to have proper community care services-and we have this going on in my area at the moment, where we are trying to put an intermediate care centre in my constituency, costing £3 million, it is very welcome-it means that social care has to be there 24/7. It also means that GPs have to be there and accessible, whether that is weekends, evenings or whatever. But of course whenever we get to the point of saying, 'This is what we need, ' it then comes to a question of, 'Who is going to provide the money for it?' So we are having a debate at the moment about trying to extend GP services in my area, but it instantly turns into an argument, 'But we want more money to do that.' How do we avoid that? The hospital is not going to need less money, social care still needs the same funding, yet the doctors and GPs are saying, 'We want more money as well to remain open longer.' How do we deliver proper community care services when they still end up with the problem of people arguing over their individual budgets?Norman Lamb: The truth is that too many people end up in hospital inappropriately and unnecessarily-frail elderly people. About a third of people in a hospital these days are frail elderly people, often with dementia. Often they are there because of failures of care. If you can get the response much better in the community, supporting people in their own homes, then you can prevent those crises from occurring. Kaiser Permanente in California, for example, whose hospital in San Francisco we visited, has something like 200 beds occupied. Their bed utilisation is massively lower than we have here because they are much better at preventing crises from occurring in the first place. That has to be, I think, the focus of our minds. Ultimately, by shifting the investment from the sort of repair end to the prevention end-and there does have to be a shift- Q244 Andrew Percy: With respect, that is what we are always told. That is what we were told when we had this with mental health services, but when people are in crisis the burden then ends up falling on the family because that has not happened. We have not seen that shift. It is great, I buy into the concept and absolutely accept that we need to see it, but too many examples of where we have tried to do this locally in my area have resulted in-we have not had the shift-beds going and services being taken from the hospitals but not being replaced with community wraparound care. Instead, it is the family who ends up bearing the burden.Norman Lamb: I agree and I am not claiming that this is easy, but first of all you have to agree what the vision should be and I think we are probably agreed on that. The £3.8 billion does represent a real shift-not talked about, but a real shift-from repair to prevention. It is shifting resources to prevent deterioration of health. If you go to Hertfordshire, for example, within their existing resource I visited a 24/7 care response team that responds to crises in the community to make sure that someone does not have to be rushed into a remote hospital but can be looked after and supported at home to prevent that disruption to their lives from happening. There are examples all over the country. This is an early stage in the development of this but there is lots of evidence. Stephen, we were on a panel together last week and you made the point that Torbay always gets mentioned. That is because they are good. Chair: It was 29 minutes today.Norman Lamb: Yes, that is probably a record. I have been trying to avoid it but I cannot. They have demonstrated on their statistics reduced crises, emergency admissions and bed utilisation and so on.Q245 Andrew Percy: I understand all that. I just wonder, given the pace and scale of this, how you achieve that in such a short period of time? Hospitals have to make their Nicholson savings at the moment so they are under extreme pressure on that. My local hospital had to open up 100 extra beds last year to deal with the crisis in urgent care admissions. We only have a certain pot of money-there is not extra cash really-and we almost need to run both systems alongside each other, because there is not this cutoff point where people suddenly stop presenting at the hospital and there are fantastic community care services and all the rest of it. To provide one you need to take money from the other, but that does not end the pressure there. So I am not seeing where the money is going to come from in my local health system to move from one to the other seamlessly. You almost need an overlap.Dr McShane: You are right about the overlap and people are looking at what sort of transition funding might facilitate that sort of change. I have had to think about this as the £2, 000 per head on average that we have to invest in health for people. So a person has £2, 000. If we look at the way that is split up-these are rough figures and I have made them simple so I can do the maths-about £200 goes into primary care; about £500 goes into community and mental health; £1, 000 goes into the acute sector, £300 goes into specialised commissioning. Up until 2010 I lived through the golden era of the NHS, when we had a yearonyear increase in funding, after the 1980s and the early part of the 1990s it was a pleasure to be a clinician in the NHS. However, that stopped in 2010. If the acute sector goes up by 4%, the gearing in the system means that we would have to take 20% out of primary care to make it sustainable, or 8% out of community and mental health. Reframing that, if general practice, community and mental health worked in a coordinated, coherent and consistent fashion, could you take 4% out of the acute sector safely-that need for 4% in the acute sector? That is a big ask, but we now have the clinical commissioning groups, which are membership organisations. We have a realisation among the profession that, if they do not address this in a coherent way, the decline in investment in primary care, which has diminished relatively over the last eight years in the NHS from 10% to less now than 8% of the share of NHS resource, will continue. If you look at that change, why are people surprised that we have problems of hospitals becoming flooded? All the evidence shows that, if you invest in primary care and community care, you reduce demand for the acute sector, but, because we are very hospital rather than system-focused, we have allowed it to drift that way. We are looking at the financial levers, the quality levers and the information to support local communities to do what Rosie Cooper has asked us to do-to make things happen. A huge amount of work has gone on in the last year or so to do that, we are seeing examples of how that can be applied and putting up opportunities. I would say that the pioneers are at the leading edge, but I was talking to someone this morning who said they just want to be a first adopter. The professionals out there recognise and understand the scale and nature of the problem. Many of those places that we always quote, such as Torbay, came about because of financial crises in that local community, which made people realise they had to do things differently.Norman Lamb: In Greenwich, another of the pioneers, they reckon they have saved 2, 000 admissions to hospital in their first two and a half years of operation. The local authority has saved £1 million just by coordinating things and also making very significant use of the voluntary sector. Voluntary sector and people-communities-have to be partners in this. We will not do it without the power of the wider community.Chair: Lots of people want to make very short interventions. We will have Andrew and then Rosie very quickly.Q246 Andrew Percy: I have a final question on this. As to 'the golden years', I am not sure we would consider them as such locally when we were losing lots of services. Similarly, surely that was the time when this should have been done, when there were bigger increases, it is a shame it was not. But just to go back to the start of the question, what percentage of patients do we expect to be in receipt of proper integrated services by the end of 2015?Norman Lamb: We set an ambition to get the whole system fully integrated by 2017. That was when we published the shared ambition or whatever it was called-I cannot remember the title of it-when we launched the pioneer programme back in May. That was the sort of ambition we set. This has been given quite a turbo charge by the £3.8 billion transformation fund, so by 2015 the whole country will be starting to see a significant change. It does not all happen overnight, but there will be significant changes happening by then.Q247 Chair: Dr McShane, did you want to come in?Dr McShane: In terms of integration, the common thread that comes out time and again is the fact that the places that are successful share information about the person and the person also knows that is happening. One of the things that in the NHS we should be able to do-and it seems to be quite difficult to achieve-is to share. We have the most computerised GP records in the world. We have the ability to share care records. We need to move that. What truly creates integration for people is the fact that the professionals and the person know what is supposed to be happening to them, there is a care plan there and they can understand it. In London, for people who are terminally ill there is a process called 'Coordinate My Care', where, with the patient’s sanction and agreement, their care plan is loaded on to a web portal that can be accessed by services that they may require.Norman Lamb: Including the ambulance.Dr McShane: That includes the ambulance, hospices and so on. The number of people who die in their preferred place of death in the 'Coordinate My Care' programme is 77%. The national average is less than 50%. So it can be done.Q248 Rosie Cooper: I have a very quick question to the Minister. The ITF is currently standing at £3.8 billion. I am delighted to hear, or I heard you say, that an organisation-and I cannot remember which one, which is the reason I am faffing there-said they would be happy to pool a lot more resources.Norman Lamb: I will come back to that when I answer.Rosie Cooper: I have been trying to look at the figures for all this to try and get a handle on what is the future of the health service, where we are going to be. Looking at some numbers I have seen recently, they say that this ITF-that whole area-is projected to be around £59 billion and it should, properly integrated, release around £20 billion, but that £20 billion is to go to the Treasury, not back into the health service. Are those figures that you are familiar with?Norman Lamb: I am certainly not familiar with that and I would be horrified if it went to the Treasury. Have I said the wrong thing?Chair: They are everywhere.Norman Lamb: Basically, the overall picture is that we have maintained funding for the NHS throughout this Parliament and for 201516, but the problem is that health costs are rising at about 4% a year, so even if you have protected funding for the NHS, even with a slight increase, it is not sufficient unless you make the money go further because of this rising demand. That is why you have to free up resources to meet that rise in demand, not to hand back to anyone else.Q249 Rosie Cooper: May I write to you and show you the documents and figures?Norman Lamb: Yes, absolutely. I know that the 'total place' or 'community budgets', or whatever they are called now-the DCLG plan-have some quite dramatic figures about the savings they believe they can achieve by pooling the resource that they have locally to use it in a more rational way. The trouble is that the evidence about savings from integrated care-a joinedup approach-is still emerging. That is why the evaluation of the pioneers is really important. But the starting point is that it provides better care. At the end of the day, all of us ought to be interested in that joinedup care that your dad clearly is not receiving.Rosie Cooper: Forgive me, just to make it clear, the nurses were wonderful. The organisation and the management are absolutely awful. Q250 Valerie Vaz: I have a quick point on pioneers. Minister, welcome. I think this is the first time you have come before the Committee.Norman Lamb: It is. It is the first time I have been before any Select Committee.Valerie Vaz: I did think that. Anyway, we are not as bad as people make out.Norman Lamb: So far so good.Q251 Valerie Vaz: We just try to get to the truth on behalf of the public. I want to ask you about the pioneers. It may be in some written documentation somewhere, but could you tell me what considerations you took into account when you picked these pioneers, did they get any money for it?Norman Lamb: The fascinating thing was that we were not offering any extra money and yet 99 areas of the country came forward wanting to do it, which is quite instructive. The way I see it is that you have a lot of great people doing amazing things around the country despite the system rather than because of it. They often have to fight through endless barriers to join up services, it frustrates a lot of people and a lot of them do not get there. These are the people who have managed to do it despite everything. We set a number of criteria-which I will try to identify, but if I cannot find them before we finish I will make sure we send you a note-about wholesystem integration, ensuring that there was a commitment for the whole of that system through the health and wellbeing board to demonstrate how you can join up care in a more effective way. We invited expressions of interest. We managed to narrow it down to 28 as a sort of long shortlist. We then had a panel, which included international representatives. We had someone from Kaiser Permanente, someone from Sweden and someone from New Zealand-there is great stuff going on in Christchurch, New Zealand. Every area came forward and did a twohour session with panel members in London, it was a pretty robust process, which ended up with unanimity, including the international contributors, as to the 15 originally. Unfortunately, they had set a criterion that, if there was a hospital in special measures, it was not credible to have that area as a pioneer. So, very sadly from my point of view, west Norfolk, my own county, did not make it because of the Queen Elizabeth Hospital in King’s Lynn having difficulties. But we now have 14 that have gone through that pretty exhaustive process and they, as I say, can hopefully lead the way in trying to demonstrate to the rest of the country. There will be a centre of excellence based in NHS IQ. I was very insistent that there must be experts in that centre who were there to remove the barriers to integration. Martin has talked about sharing information. There are horrific problems across the system with bureaucratic rules all over the place, which prevent rational sharing of information between professionals caring for someone. They need to be removed; we need to get rid of them. We need to redesign the financial incentives so that we do not incentivise activity in hospitals but rather get the hospitals to have a stake in keeping people out of hospital, keeping people healthier. We need to ensure that procurement rules do not get in the way of sensible joinedup care. The centre of excellence will be there to remove these barriers and to provide guidance on how to do it.Q252 Valerie Vaz: Great; thank you. Were there any patients’ or carers’ voices on this international panel?Norman Lamb: We had outside organisations. We had Nuffield-Jennifer Dixon chaired the panel-and also National Voices was very much involved in the document that we drew up about setting our ambition for what we are trying to achieve, the whole thing has to be completely focused on the patient. This is all about-Q253 Valerie Vaz: But none on the panel.Norman Lamb: I do not think there were any involved on the panel itself, but they had been involved very much in the document that we drew up about what we are trying to achieve.1Q254 Valerie Vaz: We have all mentioned Torbay, but we do so because it exists, it has worked and we have been to see it and they love it in Sweden, Denmark and everywhere else. So I was wondering why, if it exists, it is taking so long to have this integrated service put through everywhere else. You have the good practice and it works. I would just add the section 78 regulations for you to look at, which I think they are finding very difficult. I know you have been to the House to put through the new regulations, but I think they are finding them difficult to operate-Norman Lamb: Do you mean these competition- Valerie Vaz: Yes, with integration and competition.Norman Lamb: Okay. First of all, it is a bit of a paradox, in a way, that one might imagine that in a state system like the NHS everyone would be doing exactly the same thing and following best practice and so forth, but actually it is a bit anarchic. You have fantastic practice, but you also have people who just fail to follow the best practice. It is often quite difficult to translate brilliant practice like Torbay across the system. In a way, I go back to what I said earlier. The people in Torbay achieved it despite everything placed in their way-all these barriers. They worked their way through it. They created a care trust and made it happen. These were pioneering people and I have enormous admiration for them, but we have to make it easier to experiment and to develop models locally. My ambition, in a way, is to change it from a culture where you do great things despite the system, to the system encouraging experimentation. We also have to be prepared to take some risks. If you never take risks in trying new ways of doing things, you will always end up with mediocrity. We have to be prepared to experiment. There is a lot of diversity among these pioneers. In Cornwall, for instance, they have a very substantial involvement of the voluntary sector in addressing the problem of loneliness, helping with people’s wellbeing and keeping them out of the formal system altogether.Q255 Valerie Vaz: That comes on to my next very short question before we move on, but I think Sarah wants to talk about this point. They seem to have a different population. The population coverage is quite wide and I am wondering what mechanism you are going to use to pull together the best practice for each one because they all seem to be doing different things.Norman Lamb: That is very deliberate. I expressly wanted diversity. I did not want us to impose a model to say, 'This is the way to do it, ' and, 'Who is interested in doing it this way?' I wanted people to empower clinicians and managers at a local level to develop their thinking. They are the ones who know how to run services. Sarah will know this very well from all of her practice. The richness in that diversity will be of enormous value because we will be able to see what is working better and what is not working so well.Q256 Valerie Vaz: You will be able to pull out consistent themes from it.Norman Lamb: Yes, I think so, because there will be this evaluation from the start. It will not be a question of us publishing a report in five years. There will be a constant dissemination. Q257 Valerie Vaz: When is the first lot of dissemination of information?Norman Lamb: Exactly. Valerie Vaz: No, when is it? When is it likely to be?Norman Lamb: I want it to be constant. I want to create a sort of virtual network. We are having a launch event on 3 December, bringing all the pioneers together. I want them linked up virtually, but I want all of those who failed to get to the final 14 to be linked in as well. The fascinating thing is that all of those who failed to get there all say, 'We are doing it anyway. The fact that we have not made it to the final 14 is not going to stop us. This encouraged us to get on and have the conversation locally. We are doing it.' So it has generated a great deal of action; that is Rosie’s point about actually doing something. It has generated that activity locally because they have been given permission to do it.Q258 Rosie Cooper: If I may say so, Kaiser Permanente is working with Southport and Ormskirk Hospital Trust to set up an integrated care organisation. I have not noticed the difference in three years. I say that on the record.Norman Lamb: Rosie, I do not know about the leadership in that area, but if you went to Kaiser you would see how it could be done really well.Q259 Dr Wollaston: I am delighted that we are having a 'Torbayfest' today, as that is my patch, I share your tribute to the enthusiasm of the pioneers there. Dr McShane, you mentioned that the successful places share information about their patients, but you will probably be aware that they have a specific problem in Torbay. They have had to stop doing their virtual ward rounds because of the issue of patient confidential data flows, so they appear to be going backwards in some ways. Despite numerous letters and conversations about this, we are no further on. Could you, Minister, perhaps set out what is being done, because it is not just affecting patient confidential flow? It means that the GPs and the CCG cannot talk to each other on things like sharing information with alcohol teams in very many areas. This is causing real difficulties across the NHS, but, particularly when we look at what is happening in Torbay, who are renowned for their data sharing, it is going backwards. Is there anything that is being done actively to put this right?Norman Lamb: This drives me crazy. We had some events as we were developing the 'Vulnerable older people’s plan', I attended and spoke at a conference in London and wanted to test it. I asked people in the Q and A section-these were a whole load of people from the health and care system-'Is information sharing a problem?' You would have loved the reaction; it was just overwhelming. So I went straight back to the Department and set about finding a way of removing this barrier. My starting point was, is it legislative or cultural? Is it people being overcautious because they fear that they might be doing something wrong? I have the latest advice today, because I said I wanted it before the session today, on this issue about sharing between commissioner and provider. If a commissioner wants to do risk stratification, for example, or wants to commission well for people with learning disabilities or mental health, there needs to be some sharing of data, information. The advice I have had today-and we can copy it to the Committee-is that there is no legislative barrier; this is a sort of cultural thing where people are behaving overcautiously. What we need is very clear advice. The Caldicott review, which was published earlier in the year, was supposed, in a way, to give permission to share, but it has not had that effect. That is the honest truth of it.Q260 Dr Wollaston: In fact, people have actively been told that there is a problem. You are saying there is not a problem but they are being told there is a problem. This has been going on now for many months and directly impacting on patient care. It would be helpful to set out for the Committee exactly what is the problem and how it is going to be fixed.Norman Lamb: I was told first of all that it was the Health and Social Care Information Centre that was responsible for issuing advice. I am now advised that that is not the case. They will be providing highlevel advice for largescale organisations using data, but, for the purpose of advice to the system to practitioners and provider organisations, it is the Department and NHS England that have to collaborate to do this. I have made it very clear to officials that we have to publish advice as quickly as possible-this is an urgent priority-which will make it absolutely clear not that there is a sort of option to share but that there is a duty to share. To get good, coordinated care you have to share. Indeed, commissioners have to have the capacity to do the risk stratification that is central to any integratedcare approach for a whole population.Q261 Chair: You did offer to share your advice with the Committee, to which I think, if we may, we would to like to say 'snap', just in case anybody missed it in the transcript. Norman Lamb: Thank you for leaping on that.Q262 Dr Wollaston: I am sorry to press the point, but it is directly there in the update to Dame Caldicott’s guidance that there is a duty to share in the patient’s interests and that there is just as much harm by failing to share. But that was some time ago and is still not happening. Could, for example, the virtual ward round be confident that they could reopen tomorrow without a penalty, or are we going to have to wait for more guidance specifically?Norman Lamb: On the basis of what I have been advised, I absolutely understand that that should be perfectly possible. What appears to happen is that local areas end up, because of a fear of breaching confidentiality rules-data protection rules-creating their own bureaucracy around the sharing of data, which puts impediments in the way, whereas it is not needed.Q263 Dr Wollaston: But they were directly told to stop doing the ward round, so it was not just that they feared it: they received instructions that they could not do it.Norman Lamb: Who gave the instructions that they couldn’t do it?Q264 Dr Wollaston: The CCG were told that they could not carry on doing this.Norman Lamb: By whom-NHS England?Q265 Dr Wollaston: I understand it was from the information, from Chris Outram’s office.Norman Lamb: I would love to get to the bottom of this. In a way, dealing with an example like that is a good way of perhaps addressing the problem. The centre of excellence that I referred to earlier for the pioneers, which will be available to Torbay, will be there precisely to unlock this sort of problem. But there is an urgency about this because it is, as you say, affecting patient care all over the place.Dr Wollaston: Thank you.Q266 Chair: Can I deal with another specific example, because I would like to turn, if I may, to the process of who is going to do all this? You have described, we have been in many evidence sessions where we have heard, a verbal picture painted of how services would be better if they were more patient-focused, more integrated and so forth. I did a thought experiment in my own county of Leicestershire the other day going through the commissioners, all of whom have to cooperate to make this happen. We have three CCGs, two local authorities, NHS England as the holder of the primary care contract and NHS England as the specialist services commissioner. Those are the obvious candidates; no doubt there are other small players as well. Who moves the system from where it is to where it is going to be, what are the constraints on them doing it?Norman Lamb: The reality is that leadership in any area-are you talking particularly about how you achieve the change at a local level or are you talking about- Q267 Chair: I am talking about one health economy and I think I listed seven commissioners, all of whom will tell you they have resource constraints and all of whom have different accountability mechanisms and so forth. The purpose of commissioning, surely, ought to be to achieve the kind of change that you describe, but each one of those commissioners is working in a silo with legal constraints on their ability to move resource from one silo to another, never mind the accountability constraints. My challenge to you is that we all embrace the picture but who holds the monkey?Norman Lamb: At the local level, the CCG can, in a way the health and wellbeing board has the potential to do so. The potential does not mean it is necessarily there yet, but it has the potential to bring people together, the various commissioners that you talk about in your thought process in Leicestershire have the potential to pool their resource, expertise and ambition to work together to achieve that.Q268 Chair: To interrupt you for a second, take one element of this. Primary care, we all agree, is an important contributor to this process. NHS England is bound by a national contract with the BMA. How does NHS England as the commissioner of primary care play its part in refashioning community health? That is difficult enough on its own, never mind coordinating all the other commissioners on this landscape.Norman Lamb: I agree.Dr McShane: There are a number of points there which I will try and answer. The first is that clinical commissioning groups bring together clinical leadership and membership at a local level of people who are at the front, if you like, they can make or break the system in their behaviour. The second point is that we have always had a problem over the last 20 years. I was a fundholding GP and, unfortunately, the reputation of giving finance to GPs to commission a system was tarnished by a few rogues in the system. We then had a situation where the 2004 contract came along and devolved, creating a business contract rather than a professional contract. So there has always been a bit of a problem about the governance of investment in primary care. Currently, there is work ongoing in NHS England around our primary care strategy and the way that we work with CCGs. The legislation has one key clause, which is really important-that both NHS England and CCGs have a duty to the quality of primary care. It is about NHS England and the CCGs working shoulder to shoulder on that, but it also creates an opportunity to ensure that the governance of investment does not become tarred in the way that it has in the past. Then you have the specialised commissioning. I have worked in specialised commissioning for 10 years and it ain’t easy. We are now beginning to see what bringing together one system can do for specialised commissioning across England. There is still work to be done about reconnecting the levels of commissioning and, if you like, the skin in the game between specialised commissioning and commissioning done by CCGs, then linked back to primary care. This comes back to some of the stuff that we are doing around changing the national, community and personal approaches towards longterm condition management, which we are talking about here, so that we create enablers at the national level, use the community resources, insight, intelligence and understanding, to work with NHS England and the CCG side by side, so unified on commissioning in that part of the system, but also then, as the Minister has mentioned, the potential of health and wellbeing boards. Certainly, having been involved in commissioning for a long time, one of the big changes for me was a few years ago when we were told we had to commission some social care from health. That brought us to the table, made us talk to each other and think about how we could make sure we both got value for that. I think the Integration Transformation Fund will support that as well, the accountability is for the clinical commissioning group. There is an accountable officer; there is an area director in each of those areas who will be responsible for making sure that they work with the CCGs and with the health and wellbeing board, then there is the local authority, which has social care and all the other pertinent parts of a community that contribute to health and care. I was talking to a CCG accountable officer this morning, who has done a lot of work on integration in the last few years, they are now exploring what role housing has to play in improving care and how they can align their purpose with the local authority to make sure that that supports better care. If you want a 'command and control system' we could have that, but we have been there and done that, the nature of the challenge and the context have changed and we need to do things differently.Q269 Chair: I agree with that, but I want somebody who is actually going to change things.Norman Lamb: Can I add two quick points? In Barnsley last week the local authority leadership was saying to me that their collaboration with the CCG, with the doctors leading the CCG, was much richer and more effective than the old PCT because there was the clinical leadership there, which was encouraging and positive. But I have also been struck by some of the leading innovative CCGs saying, 'We want to do things to primary care and we are frustrated by the fact that it is commissioned by NHS England.' I raised that with the leadership of NHS England, they appear to be very much up for their area teams working-as Martin says, because there is that duty to do so-collaboratively with a CCG that wants to do things differently, to be able jointly, in effect, to commission primary care, for instance, to extend access or to improve outofhours support in that area, or whatever it might be. So there are mechanisms to achieve the change that you and I both desire.Q270 Valerie Vaz: The Chair has asked the questions around commissioning support generally, but I want to push you on the dialogue you are having. I know you want to bang heads together, but what dialogue are you having with the CCGs to support them in the wholesystem approach?Dr McShane: It is massive. It is a very new dynamic and, as I say and I will reiterate, it has only been going seven months so we have been through the storming of the transition and we are now in the forming. We have a commissioning assembly. It meets once a year but that brings together NHS England and all the CCG leads, there was one held a couple of months ago, which we attended. But the most important thing about this is that the commissioning assembly is a virtual entity that exists for the rest of the year. In the last few weeks, when I have been trying to work out how I can get delivery done, I have used the rapid reference process with the CCG chairs and accountable officers. So I can posit a question, send it out through that network and get a response within hours or days, that then informs decision making within NHS England. At the moment I am doing work on the House of Care model and iterating that with colleagues in CCGs-and not just CCGs, but in the colleges, with National Voices, NESTA, the Health Foundation and other people-to build a model that people understand and have helped create, rather than sitting here coming up with a model and saying, 'Right, everyone go away and apply this because I think it is a good idea.' We have a really strong interrelationship with the CCGs.Q271 Valerie Vaz: Everyone knows where they are going. Do you have any examples where NHS England has supported a wholesystem approach? Can you give any examples of that?Dr McShane: Yes. It is partly through NHS IQ. NHS IQ is 'improving quality'. As the Minister has said, they are supporting the whole integrated transformation movement. The other example I would give, for instance, is as to some of the enablers we are trying to put in place. I am trying to get the money out of the system and into the ground to support commissioning development for mental health. The national clinical director for mental health, Geraldine Strathdee, worked in London previously and established a commissioning development course for mental health, which ran with the CCGs. That has had an impact already in London where the CCG leaders who have been through that development course really understand the potential, the purpose and the wherewithal to commission mental health better on a whole system, both in primary care, community and specialist as well. Is that the sort of example you were looking for?Q272 Valerie Vaz: Yes; I do not know. You have to give the example; I do not know the example.Dr McShane: Off the top of my head, that would be a clear example. We are taking that, as you said about the early adopters, when I sat down with Geraldine earlier this year, one of our objectives was to try and ensure that that programme gets rolled out nationally and that we have one person in every CCG trained in mental health commissioning. We are making progress on that.Q273 Valerie Vaz: One thing I need clarification on-and it is partly probably me-is that NHS England has commissioned specialist services. Is there an overlap with what the CCGs do in terms of longterm conditions? You can be both, can you not?Dr McShane: Absolutely. Let me give you another clear example if I can find it. If you give me a second to shuffle through my papers, I wrote down the details this morning. If we can think about obesity, this straddles all three domains in effectiveness. The guys from safety and patient experience will kill me now. In Rotherham they established a service to address obesity. Obesity, we know, leads to a fivefold increase in diabetes, a triple increase in cancer risk and osteoarthritis and all the other problems. They set up a tiered system, with primary care interventions, then GPs could make referrals according to certain criteria. Then, of course, there is the specialised commissioning service, which is bariatric surgery where you put constraints around someone’s stomach. They launched this two or three years ago. They have had over 7, 000 referrals now and I think the cumulative weight loss was 14.7 tonnes.Norman Lamb: What an awful thought.Dr McShane: But, seriously, they predicted on their model, on their trajectory, that 67 people in 201011 would require bariatric surgery. They predicted that would be 78 in 201112. The actual numbers fulfilling the criteria for bariatric surgery were 33 in 201011, so there were 67 predicted and 33 actual. It was 78 predicted in 201112, 28 actual, in 201213 they had 15 people go through for bariatric surgery. That shows why we need to take that wholesystem approach. In fact, the commissioning group for bariatric surgery has said that every CCG must have a level 3 intervention in place. The fact of the matter is that the reduction in bariatric surgery funds the level, it is again this matter of shifting the money around and making sure the investmen gave evidence related to MANAGEMENT OF LONG-TERM CONDITIONS on 12 Nov. [2]

July 2011

Prime Minister's Office

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