My Lords, the noble Lord, Lord Young of Cookham, reminded us last Thursday that we have been talking about the social determinants of health and health inequalities for 40 years. It is now time to act. I want to get practical, and my three amendments are all about the practical detail—the “how” questions—about the transformation of the health culture and about new ways of thinking and working. My focus is on the first small, necessary steps on this journey.
Following my speech at Second Reading, I begin by thanking the noble Lord, Lord Kamall, for agreeing to meet with me and the chairman and CEO of Ashford and St Peter’s Hospitals NHS Foundation Trust in north-west Surrey and allowing us to share with him and his colleagues, in more detail, the work that we have been doing there in recent years. This is set out in Hansard. This work builds on 37 years of work that my colleagues and I have been doing at the Bromley by Bow Centre in east London on the integration and place-making agenda.
The principles of the work in Bromley-by-Bow are now well known and are being shared with communities right across this country, and this work is now starting to have a national reach, through the Well North Enterprises programme, which I lead. I declare my interests. The work in north-west Surrey is one further practical example of what happens when you start to take these principles to scale and apply them to the place and neighbourhood agenda, which I suggest needs to be strengthened in this legislation.
The Minister thought that it might be helpful to the House if I first set out the background to my three amendments, which are focused on the importance of place and the local neighbourhood, before dealing specifically with the first amendment on the Order Paper. What does a modern integrated health service actually look like, and how do we take the first faltering steps towards it? I suggest that the clues are in the micro: in the place and the local neighbourhood.
The NHS is in some difficulty, and much of the narrative that underpins it is from the last century and now well out of date. The chairman of Ashford and St Peter’s hospital describes it as a “financially unsustainable illness service”, not a health service. Science and modern understanding of the integrated nature of life and health have, in recent years, taught us a great deal about the social determinants of health. Ironically, the pandemic has forced all of us—the nation, if not the world—to return to the simple question: what is health? Nowadays, we all know that health is no longer simply a biomedical matter for doctors and hospitals—indeed, it never has been. The Peckham experiment on the social determinants of health was telling us all this early in the last century, but the NHS in 1948 thought that it knew better and chose not to continue with this approach.
Health is everybody’s business. It is not just the domain of health professionals, hospitals and just one government department. If 70% of the determinants of health are social, and if our present business model for the health service is unsustainable, we desperately need to return to the central question: what is health? What changes to the narrative on services and provisions does the state now need to make to respond to this modern understanding of what health is all about? We need to get upstream towards prevention and early intervention. For this modern generation, which takes integration for granted, the siloed approach of the state will no longer cut it.
Over the last 37 years, my colleagues and I have built practical working pathfinder projects in real neighbourhoods with local people. Others may well refer to these in this debate, so I will not waste the Committee’s time now. The Bromley by Bow Centre is in London’s East End and is well known nationally and internationally, but we have been involved in other projects. Today, the Bromley by Bow Centre is responsible for 43,000 patients on four sites in Poplar. Working with local partners, we have built the first independent housing company, which is resident controlled and has connected health, housing, education and jobs and business skills. Today, it brings together people from many nations of the world who live there, around practical place-making, health and social projects. This housing company now owns 10,000 properties, owns 34% of the land in Poplar and has in play a regeneration programme worth many millions of pounds.
Today, the Bromley by Bow centre is visited by over 2,000 people from the public sector and across the world, who we find are desperately asking the same questions as us. These are the practical questions—“how” questions—about how we bring together the health services, local authorities and voluntary and business sectors and generate a 360 degree response to people’s health needs and lives and the opportunities in local
communities. This is not a simple matter, but I suggest that the place to start is not in the macro but in the micro: in local communities and neighbourhoods, where lots of talent and opportunity lie that are not being tapped and never will be if you do not join them up and develop a very different approach.
In 2015, Duncan Selbie, who at the time was CEO of Public Health England, asked me to take this place-making work and the working principles of the Bromley by Bow Centre into towns and cities in challenging communities across the country. In partnership with the NHS, local authorities and business and voluntary sector partners, we created 10 innovation platforms in Bradford, Rotherham, Skelmersdale, Doncaster et cetera. We did not write policy papers or research documents, which, in my experience, often few read; we created practical learning-by-doing environments. The clues that we have found are local—in people and relationships—and not necessarily national.
My three amendments seek to use this legislation to tap into this local talent to take the first steps on the road to integration, with a necessary focus on the local, the place, the neighbourhood and the community. Health is a social matter: it is not just about private individuals, and we now desperately need to get upstream on the health agenda in this country and move forward.
This legislation, and the integration White Paper that is soon to follow, can help us all take the first steps in this century in the transformation of the NHS. I suggest that the micro is the way into the macro; it is not the other way around. In local neighbourhoods across the country, at a human level, we now need to create innovation platforms in local places and neighbourhoods, with public sector leaders and local people willing to support and generate new integrated approaches to health, and learn from them. Let a thousand flowers bloom.
As we expand our work across the country through practical engagement, we are finding that lots of people already get all of this. Many of them are in the public sector and the NHS and are desperately frustrated with the present state of affairs. They want to be health creators, but the system is not harnessing their creativity and energy—so, often unintentionally, it is pouring treacle into their projects and disempowering them, creating an ill organisation.
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This Bill and the forthcoming White Paper on integration provide us all with an opportunity to start to lay the foundation stones of a new modern health service which understands that health is no longer a matter for one department called the NHS. If what we eat, how we live, whether we have a job, et cetera, is as important—if not more so—than the doctor, this is a matter for every government department. The place to begin to understand what is now needed is local neighbourhoods across this country, to understand the significance of place, neighbourhood and local people and to use this legislation to help us take the first steps along this road.
The three amendments I have put down, focused on place and neighbourhood, are not perfect. This Bill is not perfect, but it might give us an environment to
harness the energy out there in local communities and generate a health-creating society and a learning-by-doing culture. We need to create a solution-focused culture that is entrepreneurial by nature. The modern world is all about facilitating people and relationships in local communities. This is how entrepreneurial solution-focused communities emerge. It is not about central process, strategy and documents any more. It is not topdown or bottom-up; it is about an inside-out approach. As my colleagues and I have got inside local communities through the Well North Enterprises programme, we have spotted real opportunities to strengthen life and health that the present structures are failing to see.
In my Second Reading speech I set out what is happening in one place in north-west Surrey, where the local hospital, four local authorities, the voluntary sector and the business community are starting to build working relationships and do things together. Health is now everybody’s business. The three amendments are not the last word. They are simply an attempt to get this place-based discussion rolling and empower people at the front end in local neighbourhoods and places across the country through this legislation.
I will briefly deal with this first amendment. ICBs must be clear about what a place or neighbourhood is. Neighbourhoods across this country come in different shapes and sizes, be they a place such as Cranleigh village in east Surrey, where my colleagues are working on a new integrated leisure and health campus, with its population of 11,000, or Addlestone, where, with the local authority and health systems in the small town, we are working together on a possible health campus on the street—here, we are looking at 50,000 people. It is not the size that matters, but the local neighbourhood needs to feel real to local people and not an invention of the NHS and the public sector. It must be decided locally.
My professional colleagues in the NHS in north-west Surrey suggest that place-based groups are health and care partnerships at the level of places of a population of about 500,000, encompassing the key providers, which for my colleagues and I means at least NHS-commissioned health providers in that area, including primary care, social care and local government. The neighbourhood is more local and they would work with local partners to agree these. Only those living and working there can possibly know.
The ICS design framework published by NHSEI deals extensively with place-based collaborative partnerships as part of the structure of ICSs, so they are already recognised as part of the structure. For example, on page 23, the framework states that
“as part of the development of ICSs, we now expect that place-based partnerships are consistently recognised as key to the coordination and improvement of service planning and delivery, and as a forum to allow partners to collectively address wider determinants of health.”
Their contribution is acknowledged. My proposal is that they are formally recognised on ICBs as voting members.
We suggest that ICBs need to serve the needs of place and be led by a true understanding of health inequalities at a granular level. This can be done only
through strong representation of those who are tasked with leading a place and thus come with an appreciation of those needs. This is about ensuring that an appropriate person, with real practical experience of delivering the necessary innovation in local neighbourhoods, has voting rights on the ICB. ICBs need to avoid intervening where it would be more appropriate to do so at a place-based level. Balanced judgment on this cannot take place without voting place-based members with appropriate skill and local knowledge. If the micro is now the way into the macro, this knowledge on the ICB is crucial.
The restructuring of CCGs into emerging ICBs has led to a high proportion of senior ICB posts being occupied by previous CCG officers. Moving to the new model will require new perspectives and behaviours to be introduced. This will require those who can balance a primary NHS commissioning paradigm and culture with one representing communities, the wider determinants of health and a wider range of sectoral interests. In reality, this will likely need to be quite disruptive for a time to achieve the change in approach that is now needed.
Through my discussions with health and care organisations, it is clear that, in aiming to deliver against the aims of the strategy, the details of implementation, procurement, practicalities, working relationships, understanding of local issues, specifics of local organisations, funding arrangements, et cetera, often get in the way of achieving what was actually intended. In setting strategies aimed at improving public health and decreasing pressure on the health and care services, strategies may particularly fail to specify the practical ways in which bringing together broad collaborations of local organisations to work on the social determinants of health will deliver measurable improvements in public health.
The people who work in these individual organisations and are, or will be, part of the place-based partnerships envisaged by the Bill are well aware of these issues of implementation. If the strategies designed by the ICPs are to succeed rather than be frustrated by implementation issues, it is important that they are set within an understanding of these issues. Mandating inclusion of a voting member on the ICB who is nominated by the place-based partnerships—a person of real local experience and track record—to represent them collectively in bringing these implementation details into the design of the strategy will enable better strategy to be set and better connectivity between strategy and implementation, bringing benefits faster to those whom the strategies intend to help.
I apologise for taking so much of the Committee’s time on this, the first of my amendments, but I thought it important to set out clearly the rationale behind them, based on practical experience on the ground over many years. I beg to move.