Health Bill
Monday 1st June 2026
(1 month ago)
Commons ChamberRead Full debate Health Bill 2026-27 Read Hansard Text Watch Debate Read Debate Ministerial Extracts
Madam Deputy Speaker (Caroline Nokes)
Mr Speaker has not selected the reasoned amendment.
The Secretary of State for Health and Social Care (James Murray)
I beg to move, That the Bill be now read a Second time.
Madam Deputy Speaker, if you were to ask anyone in Britain what they think about the NHS, I bet they would give you an answer without hesitation. No one would be lost for words, because everyone has an opinion. Regardless of whether they tell you a story about how the NHS has helped them or their family in their moment of need, or whether they share a view on how they would change it for the better, everyone cares about the NHS. The NHS matters deeply to people right across our country because of how deeply it touches all our lives.
For my part, the NHS came to my rescue when I was diagnosed 18 years ago with a serious and rare neurological condition that threatened my ability to run, to write and to talk. After the best care I could have hoped for from my brilliant consultant and his team at the National Hospital for Neurology and Neurosurgery in Queen Square, and from other teams across the NHS, I am now symptom free. It is only thanks to the support of those people working in our health service, and to the faith of the Prime Minister in appointing me to this role, that I am able to stand here today as the Secretary of State for Health and Social Care and set out what this critical Bill will mean for the future of our NHS.
Like me, everyone across Britain will have their own story of the NHS, or a view to share about its future. It is an achievement that we all share together, and one that is personal for us all. My predecessor as Health Secretary, my right hon. Friend the Member for Ilford North (Wes Streeting), has spoken movingly about the importance of the NHS to him. He explained how it saved his life when he was diagnosed with kidney cancer at the age of 38 and how, amidst all his worries, the one thing he never had to worry about was how much the treatment might cost. Let me pay tribute to my right hon. Friend for what he did in the role as a great champion of patients everywhere, and as someone with a huge passion for building a modern NHS—something we can see in this Bill, which he and my hon. Friend the Member for Bristol South (Karin Smyth) put so much energy into.
As a former Chief Secretary to the Treasury and Exchequer Secretary, I have been incredibly proud to support my right hon. Friend the Chancellor in her determination to take the right decisions on the public finances to enable record investment in our national health service. Thanks to that investment, the changes that this Labour Government have begun to make, the leadership at the Department for Health and Social Care and NHS England, and the incredible work of frontline staff across the NHS, in just under two years we have seen: over half a million fewer people on the waiting list; 2,000 more GPs; 8,500 more mental health workers; four in five patients being seen within four hours in A&E; over 100 community diagnostic centres now open in evenings and at weekends; and over 240,000 more people getting their cancer tests on time. That is the difference that this Labour Government are making: an NHS in which more patients get the treatment they need when they need it, and in which taxpayers get better value for money.
Tim Farron (Westmorland and Lonsdale) (LD)
The Secretary of State mentions some achievements and the progress being made within the NHS. May I bring him back to the issue of cancer treatment? According to OECD figures, 53% of cancer patients should receive radiotherapy as their primary treatment. In the UK, the figure is only 35%. In Cumbria and Lancashire, it is only 29%. This is delaying treatment, delaying cures and preventing people from living long lives. Will he take a personal interest in correcting the commissioning so that every single part of this country has access to radiotherapy close to where people live, so that they can be cured with the most up-to-date technology?
James Murray
The hon. Gentleman is absolutely right to draw attention to the importance of having the right approach to cancer, and our national cancer plan sets out what we as a Government are doing to achieve that. He is also right to point to the regional variation in different parts of the country, and to say how important it is not just to raise standards across the country but to ensure that the increase in standards is evenly distributed, so that all areas improve. One of my roles as Secretary of State is to ensure that we not only deliver our national cancer plan but support local areas so that they have the right services.
Catherine West (Hornsey and Friern Barnet) (Lab)
I congratulate the Secretary of State on his excellent speech, and I thank him and my hon. Friend the Member for Bristol South (Karin Smyth) for their work in developing the Bill. Healthwatch Haringey plays an enormously important role in being a champion for the ecosystem within a locality. The Local Government Association is very concerned about some of the discussions. Will he reassure me that as the Bill passes through the House, how we do the NHS, as well as what we do, will be an integral part, so that everybody can feel included in the NHS?
James Murray
I reassure my hon. Friend that what the Bill seeks to achieve, through local health watches across the country, is to bring the voice of patients closer to the people who plan and deliver services. Too often, we have not seen action following feedback. We need to ensure that such feedback is integrated into the planning and delivery of services, so that patient voices are heard.
I have set out some of this Labour Government’s achievements less than two years into office, which shows that decline is not inevitable. Our determination to deliver on what people voted for is making a real difference. We have started to make progress, and we are building an NHS that is fit for the future.
Labour’s choice in government has been, and will always be, to strengthen and improve the NHS as a service that is universal and publicly funded, with use based on need, not on ability to pay. That choice is backed by people across Britain, yet for the first time in a generation, some Members of this House are openly calling for the NHS’s founding principles to be abandoned. The hon. Member for Clacton (Nigel Farage), who I note is not in his place—[Interruption.] He never is—good point. Time and again, he has made it clear that he would tear the principles of the NHS to shreds and bring in an insurance-based system that would benefit only his friends in finance. Be in no doubt: Reform would sell our health service to the highest bidder. That would be a devastating mistake, and we must not let it happen.
Instead of turning our backs on the principles on which the NHS was founded, as some Opposition Members would have us do, I will fight every day as Health and Social Care Secretary to build the modern health service that our country demands and that patients deserve.
Calum Miller (Bicester and Woodstock) (LD)
I welcome the Secretary of State to his place. He has spoken about two themes: the scale of ambition of this Bill, and the need for the patient voice to be heard at the heart of it, given how much all our constituents care about the NHS. In the case of Healthwatch, can he reassure the House that bringing the scrutiny of local voices up to the level of the Secretary of State will not diminish the independence of the local healthwatch organisations that, in Oxfordshire and elsewhere, do so much to promote the patient voice and to hold the NHS to account for its services?
James Murray
I thank the hon. Gentleman for his words about my taking on this post. I can reassure him that, as I will come to in my speech, the Bill sets out to integrate the national Healthwatch into the Department of Health and Social Care through a new patient experience directorate and to integrate local healthwatch organisations into integrated care boards and local authorities, which are responsible for delivering health and care at local level. This measure is about making sure that patient voices at national and local level are closer to those deciding on and delivering services, so that those voices are heard.
Sarah Coombes (West Bromwich) (Lab)
Will the Secretary of State confirm that the heart of this Bill is about modernising the NHS and reducing inequalities across this country, and that since my constituency has the third lowest healthy life expectancy in the UK—it is shocking—my constituents will benefit from this Bill and all the action on inequality that it is intended to deliver?
James Murray
My hon. Friend is absolutely right that this Bill is about modernising the NHS. As a Labour Government, our priority is to boost investment and to modernise the NHS for the future. It is exactly that combination of investment and reform that will deliver the health service that her constituents need and deserve.
Several hon. Members rose—
James Murray
I will give way one more time, and then I will make some progress.
Jim Shannon (Strangford) (DUP)
I welcome the Secretary of State to his place and I wish him well in the role he now takes on. I am very pleased that he has experienced the NHS at its best, and I am glad to hear that.
The Government have called for a duty of candour, so they must ensure that that is still possible, but the decision to scrap independent bodies such as Healthwatch and the Health Services Safety Investigations Body risks silencing the patient voice, so there is a need to be careful. Will the Secretary of State assure us that the Government have taken that on board in this Bill?
James Murray
The hon. Gentleman raises questions relating to Healthwatch and to HSSIB being integrated into the Care Quality Commission. I will set out more detail in a few moments about those decisions, but fundamentally they derive from conclusions arrived at by Dr Penny Dash, whose review of the patient safety landscape found that it was too full of different organisations, and that their impact on the services provided to patients was unclear. We are seeking through this Bill to simplify that landscape, make sure that patients’ voices are heard closer to decision makers and improve the NHS for everyone across the country.
For me, the way to build on the progress of the past two years is not just to maintain the improvement in performance that we have seen, but to accelerate our fundamental transformation and modernisation of the NHS. As Health Secretary, I am absolutely focused on delivery and putting the values that we in the Labour party all share into action. Crucially, I am determined to make sure that we benefit from the fullest possible use of technology, digitisation and artificial intelligence to renew the NHS for the future.
The changes in technology, digitisation and AI are not an add-on to the NHS’s core business. With a determined focus on driving innovation at every level and the confidence to reimagine our approach to the nation’s health for the modern world, they offer us the chance to transform the way the entire NHS works. They will improve the speed of diagnosis, helping people to get the right treatment much more quickly than they do today.
Kim Johnson (Liverpool Riverside) (Lab)
Will my right hon. Friend give way?
James Murray
I am going to make some progress, if I may.
These changes will streamline tasks for NHS staff, freeing them from admin and bureaucracy to focus their energy on caring for patients. They will transform the experience we all have as patients, giving us control and reducing our anxiety over the care we receive. They will reduce the costs of delivering healthcare, so that more of the money we spend goes to the frontline, where it belongs. That is the future we must build, and the road to that future runs through this Bill.
For many years, patient groups have warned about the pitfalls and shortcomings of fragmented information systems in the NHS, and they are absolutely right. Right now, information in the NHS tends to follow the institution, not the individual. That is why we all know the familiar frustration of having to repeat the same story over and over, every time we see a new nurse, doctor or consultant. The reason for this is that too often no one, including the patient themselves, can see a full summary of a patient’s medical record in one place. Those patchy care records are not just an inconvenience or a source of anxiety and distress; they can also be a risk to patient safety.
Ben Obese-Jecty (Huntingdon) (Con)
I welcome the Secretary of State to his place. Hinchingbrooke hospital in my constituency is one of the new hospitals to be built as part of the new hospital programme—it is in wave zero—but it currently does not have an electronic patient record system, so we have the fragmented patient history that he has just mentioned. It desperately needs to increase its rating on the HIMSS—Healthcare Information and Management Systems Society—scale as a new hospital, but it does not have the funding required to install a patient record system. Will he guarantee that the hospital will receive the funding required to deliver a new electronic patient record system?
James Murray
I am happy to look into the specific circumstances the hon. Gentleman refers to and get back to him. More widely, however, the investment is secured across the Government for implementing the single patient record system. That will mean that, rather than data being transferred from where it exists at the moment to a new system, it will remain where it is—in GP surgeries, hospitals and so on—but it will be linked up so that one person, including the patient, can see all that data from the middle of the network of information.
Several hon. Members rose—
Sarah Champion (Rotherham) (Lab)
Specifically on the single patient record, the explanatory notes say that it will
“allow patient information to be shared with patients and their relevant health and social care providers (such as GPs, hospital doctors, social care workers and others involved in their direct care)”.
By my maths, that is probably a couple of million people, so could the Secretary of State please talk about how safeguards will be implemented, particularly for children’s care data?
James Murray
I thank my hon. Friend for raising the very important question of data privacy and security. I will address that in a moment, because I am going to set out some of the protections in our approach to the single patient record, and I think that will exactly answer the questions she raises.
I will make progress, because I am conscious of time. As I have said, the patchy records are not just an annoyance or a source of anxiety or distress; they can also be a risk to patient safety. In other areas of our lives, getting information wrong or not having it immediately available may be an inconvenience; in a health service, the consequences can be profound. What happens to the patient who is rushed to accident and emergency and has complex conditions that require multiple medications, if the emergency team have no way of knowing that? What happens to the dementia patient who cannot keep track of all the different documents from all the different specialists in all the different providers? In today’s NHS, the GP or practice nurse at the clinic, the paramedics stepping through the front door and the consultant at the bedside are doing everything they can to try to solve a puzzle, but without all the pieces. This Bill will change that. It will do so by introducing a new approach—the single patient record—and that is nothing short of a game changer.
Dame Chi Onwurah (Newcastle upon Tyne Central and West) (Lab)
I congratulate my right hon. Friend on his new position.
On Wednesday, my Science, Innovation and Technology Committee will publish our report on the Government’s digital ambitions. My right hon. Friend will not be surprised to know that we will be raising serious concerns about data management, data hygiene and vendor lock-in. Many projects such as the single patient record have failed over the last 20 years. Will he confirm to me that he will ensure that patients can control when and how their data is seen, that he will be building on existing records such as the great north care record, and that this will be treated as critical national and sovereign infrastructure, not subject to capture by a single provider such as Palantir?
James Murray
I thank my hon. Friend for her intervention. She is absolutely right to underscore the importance of data security and data privacy. That is essential in building trust in what we are seeking to do.
To be clear, the single patient record, as I was just saying a moment ago in response to the hon. Member for Huntingdon (Ben Obese-Jecty), does not move data from one system to another; it preserves the data where it is, and builds links between systems so that one person, whether a clinician or a patient, can see all the data at once. The data will still be governed by the same privacy policies on a GP system, in a hospital trust system and so on. When linked together through the single patient record, it will be governed by the highest levels of security: only authorised individuals will be able to access the data, there will be an audit trail of anyone who has accessed it, and the cyber-security protection will be the strongest available.
Kim Johnson
I really appreciate the Secretary of State giving way on that point. This morning on Radio 4, he failed to rule out Palantir being awarded the single patient record. We know that the £330 million offered to it for the current federated data has been highly criticised by unions and the British Medical Association. What assurances can he give us that patient safety will be free from abuse and misuse?
James Murray
As my hon. Friend will have heard, as she listened to the rest of my interview on Radio 4 this morning, the situation with the single patient record is very different from that of the federated data platform, because it is likely that we will let a series of contracts to de-risk the delivery of the single patient record. The situation with Palantir is that the contract for the federated data platform is, as I am sure she knows, being reviewed ahead of a potential break clause in 2027, but the situation with the single patient record is a very different set-up. As I have said a couple of times now, information is stored on individual systems—in GPs, hospitals and so on. The single patient record links them up and will be delivered through a range of different contracts to make sure that the system works in the interests of clinicians and patients.
Jeremy Corbyn (Islington North) (Ind)
Will the Secretary of State give way?
James Murray
I am going to make some progress.
The single patient record will mean that wherever a patient is being treated, even if they are not at their local GP or are in a hospital they have never been to before, those caring for them will have access to all the accurate, relevant, up-to-date information they need. Through this new approach, we will bring together people’s health and social care records digitally, securely and conveniently, and make them available to patients on the NHS app.
A number of Members have raised questions about data privacy, so let me be very clear on that point. Patients rightly expect their highly personal and sensitive medical details to be protected, and they will be. Under our plans, strict safeguards, strong cyber-security and clear controls on who can read information will be backed by an audit trail of who has accessed what. The single patient record will also be subject to existing forms of scrutiny and oversight in the NHS, from data protection officers to legislative safeguards. Where the single patient record is being used for research or planning, it will be treated the same as all other sensitive health data, subject to the same legal protections, ethical approvals and governance.
Dr Luke Evans (Hinckley and Bosworth) (Con)
The Secretary of State is making himself the data controller of all the data that will be in place. What impact does that have on the sections he has just talked about?
James Murray
When the data is held by a GP surgery or an NHS hospital trust, for instance, the relevant bodies will remain the information controllers. Where that information is then shared through the single patient record, the Department of Health and the Secretary of State will take on a role as data controller as well. That will all be governed in the way that data protection currently applies across the NHS, through existing forms of data security. Fundamentally, it will reorientate the NHS to be a service that revolves around patients, rather than patients having to revolve around the NHS.
Ms Julie Minns (Carlisle) (Lab)
Just before my right hon. Friend moves away from the single patient record, may I highlight the challenge remaining in cross-border communities such as mine in Cumbria? My constituents in Carlisle often register with a GP across the border in Scotland. Unfortunately, at present that means that their single patient record will not necessarily flow with them. Will he work at pace with his colleagues in Scotland —and Wales; I can see my hon. Friend the Member for Clwyd East (Becky Gittins) nodding in front of me—to ensure that we get this right for anyone, regardless of where they live?
James Murray
My hon. Friend is absolutely right that the single patient record applies to the NHS in England, but my colleagues in the ministerial team have regular conversations with our counterparts in Scotland and in other devolved Governments to ensure that we are working on such cross-border issues wherever we can.
Becky Gittins (Clwyd East) (Lab)
Does the Secretary of State agree that the introduction of the single patient record will be a huge step forward in the safe treatment of people with allergies? Will he join me in calling on the new Minister in the Plaid Cymru Government in Wales to follow our lead for the betterment of allergy care for people in Wales?
James Murray
I very much join my hon. Friend in urging the new Health Minister in Wales to follow our lead by introducing a way for patients to access the data and, crucially, for clinicians to be able to see all a patient’s data when making those decisions. With complex cases, where people see multiple nurses, doctors, consultants and so on, it can be crucial that clinicians see all the relevant information when making choices on how to treat their patients. I thank my hon. Friend very much for her question.
Madam Deputy Speaker, I should make some progress, as I know that many Members wish to speak this evening. I am getting a nod from you that that is the right thing to do.
As I have set out how the single patient record will help to improve patient safety, I also want to be clear that no Government should ever pretend that things do not go wrong. When they do, it is crucial that the right systems are in place to hold people accountable, and to ensure that we learn from mistakes in order to prevent them from happening again. As I mentioned earlier, Dr Penny Dash conducted an independent review into the patient safety landscape. What she found was a confusing landscape of multiple, overlapping organisations that are responsible for patient safety in the NHS, making it harder for staff and organisations to do the right thing. That is why the Bill simplifies the patient safety landscape, streamlining and consolidating functions to make the system more effective and efficient, and to restore patient confidence.
Tom Gordon (Harrogate and Knaresborough) (LD)
Will the Secretary of State give way on that point?
James Murray
I am going to make some progress.
Following Dr Dash’s recommendations, the Bill will embed the mission and functions of the Health Services Safety Investigations Body into the Care Quality Commission to establish a clearer link between investigating safety concerns and increasing the quality of care. We will ensure that we protect the principle of a safe space for people to share their concerns. To ensure that patients are heard at every stage, from commissioning to delivery, we will make sure that patient feedback is embedded alongside decision makers at every level.
Sir Bernard Jenkin (Harwich and North Essex) (Con)
I am most grateful to the Secretary of State for giving way, and I congratulate him on his appointment. He has inherited this policy—it is not his own. I assure him that the abolition of the Health Services Safety Investigations Body is a dreadful mistake, because which other investigative function in the healthcare system is completely unconflicted in what it does? By abolishing HSSIB he is taking its functions into the CQC, which is a regulator and compliance enforcer, not an investigator, so that there is no longer any independent, unconflicted body conducting healthcare investigations. Has he consulted the royal colleges about this? I have not spoken to a single royal college that is in favour of the abolition of HSSIB.
James Murray
As I made clear, we will protect the principle of a safe space for people to share their concerns. The investigatory function will remain protected within the CQC. The benefit of embedding the HSSIB in the CQC will be to establish that clearer link between investigating safety concerns and increasing the quality of care. That is something on which we can all agree.
James Murray
I am going to make some progress, because, Madam Deputy Speaker, you have asked me and looked at me several times, suggesting that that is what I should do.
I mentioned the changes that the Bill makes to HSSIB and the CQC, but the functions of Healthwatch England—I spoke about that earlier—will move to a new patient experience directorate within the Department of Health and Social Care. The functions of local healthwatch groups will be incorporated into ICBs and local authorities. That approach brings the voices of patients closer to decision makers, so that people have a direct impact on the services they receive. Of course, the changes will neither fix everything at the stroke of a pen, nor take effect overnight, but rather than the voices of patients being kept at arm’s length, the Bill puts them where they should be: right at the heart of the NHS.
Vikki Slade (Mid Dorset and North Poole) (LD)
The Secretary of State has not talked about the role of the governors of hospital trusts, which also appear to be abolished by the Bill. With the creation of mega-ICBs, the removal of healthwatch, and the removal of governors, I am worried that the voice of the local community is reducing rather than increasing.
James Murray
The principle behind the changes to local healthwatch organisations is to bring the voice of patients closer to those who are planning and delivering services. Whether through ICBs or local authorities for health and care, it is an important principle to ensure that feedback is followed by action, and that people can have an influence on the design and delivery of health and social care at an earlier stage in the process.
James Murray
I am going to make some progress, because I need to update the House on the important measures in the Bill to abolish NHS England. Those critical measures will reduce bureaucracy so that more energy, time and funding in the NHS can be focused on the frontline, helping patients. The Bill will abolish the world’s largest quango by merging NHS England into the Department of Health and Social Care and the wider NHS system.
Gregory Stafford (Farnham and Bordon) (Con)
I have asked this question both as a member of the Health and Social Care Committee and on the Floor of the House to the Secretary of State’s predecessor. Given that the new Secretary of State is a numbers man, I hope that he can answer it where his predecessor could not. How much in redundancy payments will this measure cost the British taxpayer, and can he confirm that no person currently employed by NHS England will be fired, paid a redundancy fee, and then rehired by the Department of Health and Social Care?
James Murray
As the hon. Gentleman will appreciate, we are going through that process with the workforces at NHS England and the Department of Health and Social Care. Crucially, however, by 2028, across the Department of Health and Social Care, NHS England and ICBs, we will see a 50% reduction in headcount. That means that the money that would otherwise be spent on those members of staff will now go towards healthcare on the frontline, which is what patients want to see.
As hon. Members will know, NHS England was established by the Health and Social Care Act 2012. That Act established more than 300 new NHS organisations, and has led to too much time, money and effort being wasted on overlapping processes, as good people try to navigate a labyrinthine system that holds them back from delivering for patients. In short, we have a system that gets in the way of what staff, patients and taxpayers want to see.
Wendy Morton (Aldridge-Brownhills) (Con)
I welcome the right hon. Gentleman to his new role as Secretary of State. The point about ICBs and the devolution of responsibility for NHS eye tests is one that we often forget to talk about in this place, as is the case with eyecare—I know that there are some ophthalmic experts in the Chamber. On that point, can the Secretary of State assure me that the changes will not result in a postcode lottery in the provision of eyecare tests? At the end of the day, NHS sight tests are a universal entitlement, so can he ensure that that will continue?
James Murray
The right hon. Lady raises an important point, but local services are already commissioned locally in many cases. The changes that we are making by abolishing NHS England will mean that more power and resources go to ICBs and local areas to allow them to make the right choices for their local area. That is a way of bringing the services that we deliver closer to the people who need them.
Let me be absolutely clear that abolishing NHS England is in no way a reflection on the committed public servants who work at NHS England and in my Department. The truth is that unnecessary structures are getting in the way of them doing their crucial work and it is time for us to change that. The Bill will mean that more time, money and effort will be spent on improving the care that patients receive, rather than navigating the system around them.
Tom Gordon
Obviously, the Secretary of State has just outlined a huge raft of changes that are coming with the abolition of NHS England and everything else that goes with that. Last year, families and MPs got the inquiry into the Tees, Esk and Wear Valleys health trust—the mental health trust in the north of England that had been failing. My worry is that a chair of that inquiry was meant already to be in place. Will that inquiry now be lost amid all the changes to the healthcare system? Will the Secretary of State commit to meeting the families of those affected by the TEWV scandal, and will he get a chair in place as soon as possible?
James Murray
I am happy to look into the case to which the hon. Gentleman refers. The abolition of NHS England and the transfer of its responsibilities either to the Department of Health and Social Care or to local ICBs is being managed carefully, to ensure that we can continue making progress while the structural change happens. To return to my earlier point, the money saved as a result of these changes can go directly to frontline patient care. We expect about £1 billion to be saved, which is the equivalent of 15,000 nurses. I do not see how anyone can disagree with our decision to ensure that resources are spent on the frontline.
As I have explained, abolishing NHS England as a separate organisation will strip out bureaucracy and ensure that we focus on delivery. The decision also has an important democratic role. The core goal of the 2012 Act, brought in by the Conservatives and Lib Dems, was to take politics out of the day-to-day running of the NHS. However, that is a fundamental misunderstanding of the NHS and its place in the democratic life of the nation. The public pay for the NHS; they own it, use it, care deeply about its future, and so they should always have a say in how it is run.
People voted Labour because they trust us to build on our party’s legacy by transforming the NHS for the future, and they will rightly hold us responsible for the decisions we take as we do so. It is not about politics getting in the way; it is about accountability driving change. That accountability has been lost in the confusion of having two separate centres for the NHS, and the Bill will end that.
Dr Ben Spencer (Runnymede and Weybridge) (Con)
I welcome the Secretary of State to his post. Could he explain what the pathway of local accountability is for ICBs?
James Murray
ICBs, as the hon. Gentleman will know, have a board structure that oversees how they operate. The removal of local healthwatch organisations will mean that the voice of patients and their experiences go directly into the bodies that are commissioning and overseeing services. One of the changes the Bill makes is to ensure that strategic mayoral authorities will have a place on the board of ICBs, which helps them ensure that wider objectives in an area of health are aligned.
Several hon. Members rose—
James Murray
I am going to make more progress.
Alongside the removal of confusion and duplication at a national level, the Bill also gives those with local expertise the power, resources and flexibility they need to design and deliver health and care services for their area. The Bill will empower them to innovate, drive progress and do what is in the best interests of the patients they serve.
Under the Bill, ICBs will have more direct responsibility for their services than ever before. They will be at the heart of integrating health and social care, and they will include those people responsible for housing, transport and jobs, so that we can tackle the root causes of ill health, which is better both for patients and for the NHS.
The NHS gave me a second chance at life, and so as Health Secretary I will fight for the NHS every day with the strength it has given me back. The Tories ran down the NHS through 14 years of neglect, and the Lib Dems enabled them. Reform wants to abolish the NHS altogether and replace it with an insurance-based system. The Greens seem intent on ignoring clinical advice and have no practical solutions for the health service. Only Labour has a plan to get the NHS back on its feet. Only Labour is determined to both invest in and fundamentally transform the NHS for the future. Only Labour is showing that change is possible.
We promised to cut waiting lists—we delivered the biggest annual fall in 16 years. We promised an extra 1,000 GPs in our first year—we delivered twice that number. We promised 8,500 more mental health staff by 2029—we have delivered them three years early. We promised 700,000 more NHS dentistry appointments—we have delivered an extra 1.8 million already.
We promised to transform the NHS for the future, and that is what this Bill will do. We are already boosting investment in the NHS where it needs more. We have begun stripping out bureaucracy from the NHS where it needs less. And now we will build a truly modern NHS that will be there for generations to come. The Bill is the next crucial step in our mission, and I commend it to the House.
Madam Deputy Speaker (Judith Cummins)
I call the shadow Secretary of State.
Stuart Andrew (Daventry) (Con)
I begin by welcoming the Secretary of State to his new post, and thank him for sharing his very personal story about what the NHS means to him. I look forward to our future exchanges, however long he is in post. I also pay tribute to the former Health Secretary, the right hon. Member for Ilford North (Wes Streeting), with whom I have had a few moments across the Dispatch Box. I know that the NHS has also been very important to him personally. During my time in hospices, I saw the incredible work that the NHS does, and despite the politics that we may have—and I will be referring to the right hon. Gentleman a bit more later on—we all care deeply about the national health service and want the very best for it.
There are moments in politics when one almost has to admire the confidence of Governments—not their competence, necessarily, or their judgment, and sometimes not their timing, but certainly their confidence—and nowhere has that confidence been more magnificently displayed than in the presentation of the Health Bill. If one had listened carefully to the former Secretary of State for Health and Social Care over the past two years, one could conclude only that this Bill was not merely legislation, but apparently the parliamentary equivalent of the second coming. In every speech, interview and carefully staged hospital visit with sleeves rolled up, they delivered the same message: at last—at long last—the NHS was to be modernised, integrated, digitised, streamlined, revolutionised and transformed into a gleaming technological marvel, where patients floated frictionlessly through a system powered entirely by innovation, efficiency and ministerial self-belief.
I say gently to Ministers that whenever a politician begins using the phrase “once-in-a-generation change” on such a regular basis, it is usually wise to place one’s hands protectively over one’s wallet, given the sheer cost of what is to follow. What became increasingly striking was not simply the scale of the promises, but the sheer showmanship of them, with the former Health Secretary speaking less like a Cabinet Minister wrestling with one of the most complex public services in the world and more like a man auditioning to narrate the trailer for his own leadership campaign documentary. And now, Madam Deputy Speaker, we arrive at the great political twist: the man who spent two years announcing the future has departed before the delivery date arrived, like an architect unveiling magnificent blueprints before quietly moving abroad just before construction begins.
Into this situation walks the new Health Secretary. Members can imagine the scene: the Prime Minister sits stubbornly in No. 10, grinning with all the reassuring confidence of a man standing knee-deep in a flooded rowing boat insisting that the situation merely requires a modest redistribution of water. Into this bunker is summoned the new Secretary of State—formerly the Chief Secretary to the Treasury, the very man who helped to allocate the famous £202 billion funding settlement now repeatedly cited as proof that every problem in British healthcare has theoretically already been solved.
Jessica Toale (Bournemouth West) (Lab)
I would not give the right hon. Gentleman’s political adviser a raise for their speechwriting abilities just yet. Why does he think we are having to talk about once-in-a-generation change to the NHS?
Stuart Andrew
I would point the hon. Lady to how the NHS was being run in Wales—it certainly was not the great success that she is trying to allude to.
In politics there are difficult jobs and there are impossible jobs, and then there is inheriting a Department after one’s predecessor spent two years promising the electorate that this is the one Bill to rule all Bills and fix virtually everything short of death itself. This was not just a hospital pass, but a hospital pass delivered by catapult.
One can almost hear the poor Secretary of State gulping. “Thank you, Prime Minister,” he replies faintly, in the tone of a man accepting command of the Titanic after it has already struck the iceberg. Off he trudges to the Department of Health and Social Care, where the automatic doors open and his nostrils are struck immediately by a strange, lingering aroma. It is not the scent of modernisation or the smell of efficiency, and it is certainly not the fragrance of falling waiting lists. No—it is the unmistakeable odour of political panic, mixed delicately with the perspiration of failed leadership manoeuvres and lightly seasoned with the ashes of abandoned promises. There waiting for him, naturally, is Sir Humphrey—because however much Governments modernise, digitise, integrate, recalibrate or synergise, Whitehall always produces a Sir Humphrey.
I can imagine the conversation. The new Secretary of State says brightly, “Good news, Sir Humphrey. I understand that my predecessor has already solved everything through the Health Bill.” At this point, an eerie silence descends. Civil servants suddenly become more fascinated by ceiling tiles, and one junior official attempts to escape through a stationery cupboard. Sir Humphrey clears his throat in the way only permanent secretaries can; a sound rather like an early—
Stuart Andrew
Give me time, give me time.
“Well, indeed, Minister,” says Sir Humphrey.
“I understand,” says the Secretary of State, “that abolishing NHS England will instantly reduce bureaucracy, improve accountability and unleash vast efficiencies.”
“Well, Minister, it will certainly create a large number of meetings.”
“And the single patient record will revolutionise healthcare, won’t it?”
“Yes, Minister—assuming the NHS IT systems eventually stop communicating with each other via what appears to be medieval semaphore.”
“But we have delivered 5 million more appointments.”
“Certainly, Minister—only 1.5 million appointments behind the last Conservative Government.”
“And integrated care boards now answer directly to Ministers.”
“Yes, Minister.”
“So accountability is now indisputable.”
“Well, Minister, blame certainly is.”
And so the conversation goes on. The Secretary of State asks, “And what about the workforce plan?”
“Still developing, Minister.”
“And social care?”
“Still delayed, Minister.”
“And mental health implementation?”
“Still proceeding at approximately the speed of continental drift.”
“And pharmacies?”
“Still under pressure.”
“And GP contracts?”
“Still alarming GPs.”
“And productivity?”, the Secretary of State asks desperately.
“At present, Minister, the NHS measures productivity in the same way that astronomers in ancient Greece measured distant planets: with great optimism and very limited visibility.”
At this point, the Health Secretary clearly begins searching the office for the exit map. “But Sir Humphrey,” he says, “surely my predecessor left me with a fully deliverable programme.”
After a long pause, Sir Humphrey replies, “Well, your predecessor was primarily focused on a different pathway.”
“A different pathway?”
Stuart Andrew
“Yes—the pathway to No. 10.”
And now I will give way to the right hon. Member! [Laughter.]
Wes Streeting
I am sure that sounded really good in the mirror when the right hon. Gentleman practised this morning, but can I bring him back to the real world, where the permanent secretary is, in fact, a woman and an outstanding leader at that? In the real world, I am able to say something that not one of my Conservative predecessors was able to say when they left office, which is that I left the NHS in a better state than I found it. Why is he so determined to defend the bloated bureaucracy that his party created over 14 failed years?
Stuart Andrew
Well, let me say directly to the right hon. Gentleman that there have been a lot of announcements from the Government. We know all about the fall in waiting list figures, and not just from comments from us in this Chamber challenging what is really happening—we are receiving email after email from people who have been taken off waiting lists despite still needing treatment. Patients are being taken off waiting lists, sometimes without their knowledge. This has not been about more appointments for patients—it is about massaging the figures, and he knows it.
There is a lot in this Bill that we will support, and there are many areas where we would like the Government to perhaps go further, but there is also a rhetoric that needs to be addressed, because there are unresolved problems still. Social care is unresolved. Workforce pressures are unresolved. Mental health backlogs are unresolved. Productivity is unresolved. Pharmacy pressures are unresolved. GP satisfaction is unresolved. The Secretary of State is inheriting not just a Department but an expectations crisis, because the greatest danger in politics is not under-promising; it is convincing the public that complexity itself can be announced away.
The Bill abolishes NHS England and centralises significant powers to be governed by the Secretary of State. It takes control out of patients’ hands.
Jim Shannon
The shadow Secretary of State rightly said that there is a lot in the Bill to be welcomed in principle, including the cutting of red tape, and we must recognise that, but unchecked state control must be resisted. The shadow Secretary of State mentioned accountability. Does he agree that we must ensure that accountability is part of the Bill?
Stuart Andrew
The hon. Gentleman raises an important point, and it is exactly the sort of issue that will need further scrutiny in Committee. I note that local authorities will not have the same seat at the table and that it will be transferred for mayoral regions, but what about regions that do not have a mayor? That measure will create a real democracy deficit in the NHS. I hope that we can look at this in detail in Committee, because that serious oversight absolutely needs addressing.
Gregory Stafford
On the point of accountability and scrutiny, the Government are looking to abolish HSSIB or bring it into the CQC, they are getting rid of Healthwatch—which serves my constituents so well—in places such as Surrey and Hampshire, and they are getting rid of governors from the boards of foundation trusts. That does seem to suggest that they have not really thought the accountability point through. Would not this be the occasion for the new Secretary of State to stamp his mark on this Bill by conceding that some of the changes in the Bill are not what was intended, and to take this opportunity to give confidence back to the public that they will have the accountability and scrutiny that they deserve?
Stuart Andrew
My hon. Friend raises a very important point; it is an area that the Committee will have to look at very carefully.
I listened carefully to what the Secretary of State said, and I believe that he wants there to be a patient voice, but there is a serious flaw in the Bill. Abolishing Healthwatch and HSSIB is a terrible mistake, and I praise my hon. Friend the Member for Harwich and North Essex (Sir Bernard Jenkin) for the work that he has been doing on this. The reality is that HSSIB gives members of staff who work in the NHS the confidence to come forward and be a whistleblower. We need that. We need people to feel that they are in a safe environment. The CQC is a totally different beast in the minds of people who work in the NHS and social care, so to put those functions within that organisation is a terrible mistake and one that I hope the Committee will look at very carefully.
Saqib Bhatti (Meriden and Solihull East) (Con)
The shadow Secretary of State is making an excellent speech, and I commend his speechwriter! I am sure my right hon. Friend wrote it himself.
On accountability, the Secretary of State spoke repeatedly about devolving powers, but this Bill is a massive power grab by the Secretary of State, and our constituents will not get the accountability that they crave and that some of the reforms we implemented in 2022 gave them. Does my right hon. Friend share my concern?
Stuart Andrew
I am genuinely concerned about that. Members of Parliament from across the House have often brought to the House some very serious cases—things that have gone terribly wrong for their constituents, services that have been commissioned in their area, and awful things that have happened to patients. It is because of organisations like Healthwatch and the HSSIB that those issues have come to light, and work has gone into improving those services. That is what we all want to see, but I am really worried that that progress will be lost. If those functions are absorbed into the Secretary of State’s office, I really do not think it will be able to cope with the sheer volume. It needs to be done on a much more localised basis.
Robin Swann (South Antrim) (UUP)
I thank the Secretary of State for raising that. If I read the Bill right, schedule 8 allows the CQC to carry out investigations into Northern Ireland and Wales, whereas the CQC has no presence or remit within Northern Ireland, because health is devolved and those functions are carried out by the Regulation and Quality Improvement Authority. Can the shadow Secretary of State comment on how the Secretary of State is now reaching into devolved matters in regards to regulation, quality, improvement and assessment?
Stuart Andrew
That is exactly one of the issues that needs to be ironed out. I am sure that the hon. Gentleman will ensure that the Committee considers the impact for devolved Administrations, particularly where they have responsibility for health in their areas. I hope that he will raise that with members of the Committee.
Anna Dixon (Shipley) (Lab)
I worked in the Department of Health at the time that NHS England was created. I have always been sceptical about the Lansley fantasy that somehow the NHS could be made separate from the Department of Health and Social Care. I saw at first hand man-marking and duplication of function. This Bill finally puts the nail in the coffin of the complex arrangement of masses of arm’s length bodies that was created by Andrew Lansley. Will the right hon. Gentleman please agree that this is the time to restore stronger democratic accountability for our NHS?
Stuart Andrew
I gently remind the hon. Lady that it was the former Secretary of State who said that he did not want to go through another reorganisation, because it would be very costly. We still cannot get a clear answer from the Government about how much this is all going to cost the taxpayer, and there are estimates of £1 billion. There are still serious questions to be answered. The hon. Lady talks about democratic responsibility and accountability, and she is right to do that. She is fortunate—depending on one’s point of view—to have a mayor, but my constituency and county do not. Will my constituents get less of a voice in their NHS than her constituents in Shipley? That does not seem fair to me.
Jen Craft (Thurrock) (Lab)
Is it not the case that transferring powers from an unelected quango to the Secretary of State, who is directly accountable to this very House, increases, not diminishes, accountability in the NHS?
Stuart Andrew
I am talking about trying to get accountability down to the local area. That is where it matters, and that is where my constituents want to see it. They know their local services and the hospitals in their areas, and they are the ones who should have their voices.
Dr Spencer
I am glad that we are having this important debate on accountability. Is there not a danger that the centralisation of this direction power in the Secretary of State effectively signals to MPs, “Don’t engage with ICBs, as they will not have accountability to local MPs. If you want changes to happen, go through the Secretary of State rather than engaging locally, because that is where the power is going to lie”?
Stuart Andrew
Yes, and this is—[Interruption.] It is slightly patronising to say to someone, “Read the Bill”. Clearly my hon. Friend has, and we have been talking about this in great detail.
There is a real concern here. We need much clearer answers to these questions, which many of our constituents will have. Those who give up their time to work in organisations to make the NHS better deserve decent answers to those questions and concerns. I certainly hope that reflection will be taken on those points.
At its heart, the Bill is not simply a debate about technology or bureaucracy; it is about who holds, controls and safeguards the most personal data that any of us will ever possess. This is one of the most significant reorganisations of the NHS in modern political history, but it is wrapped carefully in the language of managerial simplification.
Perhaps part of the Bill will help, and of course some reforms are necessary. Conservatives are not afraid of reform—definitely not. Indeed, if the NHS is to survive the demographic, technological and fiscal pressures ahead, modernisation is essential. That is because technology matters, innovation matters, integration matters, data matters, prevention matters, productivity matters and, yes, accountability matters too. That is why, where we see good work in the Bill, we will back it, and where we think there are questions that need to be drilled down into, we will do so. We want to ensure that the Bill works.
There is a difference between modernisations rooted in political realism and announcements designed primarily for political theatre, and too much of the approach we have seen so far is Whitehall talking to itself; meanwhile, outside this Chamber, reality continues uninterrupted. Patients still wait, ambulances still queue outside A&E, the family still worries, the exhausted nurse still works a double shift and the GP still battles impossible demands.
Here is the truth: the NHS does not primarily suffer from a shortage of announcements; it is marked by a persistent lack of grip and direction. The Government today increasingly resemble a man frantically changing labels on a filing cabinet while the building itself quietly catches fire.
The Government say that abolishing NHS England will reduce bureaucracy—perhaps it will—but let us not forget that Whitehall sometimes possesses a remarkable historic talent for abolishing bureaucracies ceremonially before quietly recreating them under another name with slightly different headed paper. We need to ensure that that does not happen in this instance.
We also have to think about the huge amounts of public money involved—yes, nearly £202 billion; an extraordinary sum of money. We understand that pressures rise—of course we do—we understand about ageing populations, we understand that medical advancement increases costs and we understand the aftershocks of the pandemic. But when a Government spend record sums while presiding over delays, workforce uncertainty, transformation paralysis, productivity collapse and public frustration, eventually the British public are entitled to ask a simple question: where has all my money gone? The Government are not judged by the size of the press release; they are judged by whether the thing actually works.
We must now do everything to ensure that the Bill goes through with great scrutiny, as it needs to do, because healthcare is difficult, trade-offs are real and workforce shortages cannot simply be rebranded as opportunities. Indeed, the public increasingly suspect something very different here: they suspect that too much of modern politics has become performance without consequences, announcements without accountability and presentation without delivery. That is ultimately why the Bill matters. If this enormous centralisation of power succeeds, Ministers will claim vindication, but if it fails and bureaucracy persists, waiting lists remain stubborn, workforce pressures deepen and promised transformation dissolves into another cycle of reorganisation, the Government will no longer possess anyone else to blame—not NHS England, local structures, quangos or the system—because the Bill places responsibility squarely where the Government claim it belongs, on the shoulders of Ministers. Perhaps that honesty will prove the Bill’s greatest contribution.
The British people are patient, but they are not naive. They can distinguish between serious transformation and political choreography, and they increasingly understand that there is no technological shortcut around the fundamental challenge facing healthcare. The Government cannot run a service this large, pressured and so deeply connected to people’s lives and wellbeing primarily through presentation. Eventually, every Government collides with reality, and reality—unlike leadership campaigns—cannot be managed through slogans. That is the inheritance facing the new Health Secretary, and that is why the House should approach the Bill not with breathless excitement but with very hard-headed scrutiny indeed so that we get the NHS we all want to see.
Several hon. Members rose—
Madam Deputy Speaker (Judith Cummins)
Members will have noticed that about 50 Members want to speak in the debate, so with the exception of Front Benchers I will be starting with an immediate six-minute time limit.
Andy McDonald (Middlesbrough and Thornaby East) (Lab)
May I begin by welcoming the Secretary of State to his place and wishing him well in the responsibilities that he carries on behalf of patients, NHS staff and communities across the country? I welcome the Bill and its intention to improve patient care through investment, modernisation and better integration across the health service.
It is right to acknowledge the progress made on waiting times and waiting lists since Labour returned to government, with the overall waiting list falling significantly and long waits continuing to come down, but may I add my voice to those of others about the appointment of a chair for the Tees, Esk and Wear Valley inquiry? My right hon. Friend the Member for Ilford North (Wes Streeting) gave that commitment, which we were pleased to hear, but we have yet to see that chair appointed. If that could be given attention, we would be most grateful.
I remain concerned about the continuing impact of historic private finance initiative costs on NHS trust budgets, including the pressures facing South Tees hospitals NHS foundation trust in my patch. Too much money is still being diverted from frontline care. I regret that this issue remains unresolved.
The principal reason I rise today is as chair of the all-party parliamentary group on spinal cord injury. Last summer, the APPG’s inquiry into spinal cord injury services reached a clear conclusion: the evidence points to the need for more national co-ordination, not less. Spinal cord injury is a low-volume but highly complex condition requiring specialist pathways, lifelong rehabilitation and co-ordinated support, yet the inquiry heard repeated evidence of fragmented services, postcode variation, delayed rehabilitation and patients being lost within the system. The APPG therefore called for a national strategy and a modern service framework for spinal cord injury care. As we intend to hold a lived experience roundtable shortly, I invite the Health Secretary to come and meet people with spinal cord injury to hear their concerns about the proposed changes to commissioning.
We welcome the excellent constructive engagement from the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson), and NHS England officials, but we remain deeply concerned about proposals to transfer spinal cord injury commissioning from national oversight to integrated care boards. Indeed, NHS England’s own evidence to the inquiry emphasised national standards, national quality metrics and nationally co-ordinated pathways, quality measures and oversight. If national consistency has not yet been achieved under national commissioning, what evidence demonstrates that transferring responsibility to multiple ICBs will improve outcomes or equity?
What is at stake is not abstract. When somebody sustains a spinal cord injury, their life changes overnight. They may require specialist rehabilitation, housing support, benefits advice, mental health support and long-term clinical care. Patients and families should not be left to navigate a fragmented system alone. That is why I welcome the ambition behind the single patient record and Diagnosis Connect.
Connecting newly diagnosed patients directly to specialist support reflects one of the APPG’s recommendations. Organisations such as the Spinal Injuries Association help people rebuild their lives after life-changing injury. I hope that Ministers will consider including spinal cord injury within the early phases of Diagnosis Connect.
The question is not whether structures change on paper; it is whether people living with spinal cord injury will experience safer, more equitable, more co-ordinated care. I hope that the Secretary of State will answer some straightforward questions. If NHS England accepts that national consistency has not yet been achieved, what evidence shows that localised commissioning will improve it? How will national standards, benchmarking and quality oversight remain coherent under a fragmented arrangement? Do the Government accept that spinal cord injury differs fundamentally from standard population health commissioning because of its low volume, high complexity and cross-boundary nature? What safeguards will prevent widening regional inequity, if accountability is dispersed across multiple ICBs?
The APPG’s inquiry concluded that spinal cord injury services require stronger national co-ordination and oversight, not greater fragmentation, and I hope the Government will reflect carefully on that evidence. This country led the world in spinal cord injury provision under the leadership of Professor Ludwig Guttmann after the second world war, with the remarkable work that he achieved. We need to return to those days of being pioneering and world-class. As a lawyer who previously practised in this area, I am afraid that over the past several decades services have deteriorated and gone backwards. We must restore those services and bring trust to people who so desperately want reassurance that there is a national system for them to rely on that will address their needs. We are currently not in that place at all. The Bill is an opportunity to address that, and I trust the Minister will take that on board.
Madam Deputy Speaker (Judith Cummins)
I call the Liberal Democrat spokesperson.
Helen Morgan (North Shropshire) (LD)
I start by declaring an interest as a member of the all-party group on patient safety and as a vice-president of the Local Government Association, and also by welcoming the new Secretary of State to his place. I very much look forward to working constructively with him during the passage of the Bill.
We all know that our NHS is in desperate need of transformation. Hospitals are in chaos, social care is overloaded and getting a GP appointment is a huge challenge for many. Labour has promised to put patients and communities at the heart of the NHS, but I fear that the Bill does not fulfil that promise. The Government promised to sort out social care, but two years later they are still only part-way through a three-year review. They promised to treat mental health with parity, but although mental health accounts for 20% of the disease burden, its share of NHS budgets is falling to just 8.4%. The Government promised to protect women’s health, but the women’s health strategy published this year was significantly weaker than the men’s health strategy, which received 60% more funding for new research. Healthy life expectancy in the UK is stagnating, and adult social care is under ever more pressure, putting immense stress on the budgets of councils and other local authorities.
The reality in rural North Shropshire is that people struggle to get GP appointments, 12-hour waits in A&E have become normal and finding an NHS dentist is becoming impossible. The social care crisis has left Shropshire council’s finances in a dire situation. A real NHS reform Bill would have changes to social care, general practice and prevention at its heart. Instead, this Bill passes responsibilities around Whitehall, centralising more power with the Secretary of State, while chaos reigns following 50% cuts to ICB budgets.
Early in his term, the right hon. Member for Ilford North (Wes Streeting) promised that another top-down reorganisation of the NHS was the last thing he wanted to do. Yet the abolition of NHS England is exactly that—focusing on reorganisation at the top, while failing to deliver real improvements for patients and staff. It is true that NHS England has allowed Ministers to shirk responsibility and accountability, but its abolition has been poorly planned, leaving both ICBs and specialised commissioning in chaos. Instead of the Government’s advertised aim of creating a more community-based NHS, the Bill centralises power in Whitehall, giving sweeping Henry VIII-style powers to the Secretary of State. Such powers carry a real risk that political considerations could influence what should be operational decisions about how the NHS provides for patients in future. That is particularly concerning in the current febrile political climate, and the Government must ensure that protections are in place for what may happen in the future.
The Government have made 50% cuts to ICBs, but the Bill gives them new legal responsibilities, different structures and centrally directed spending objectives. It is indicative of a lack of planning that could plunge ICBs into chaos. Meanwhile, the removal of the integrated care partnership and the extension of ICBs to cover multiple local authorities raises unanswered questions about the future of social care planning. In Shropshire, the council already spends around 80% of its budget on social care provision. That has a monumental impact on all services, as constant savings have to be found. Removing the pooling of the better care fund among local authorities and ICBs will discourage integrated working between these bodies on social care. Given existing complications over the sharing of costs and social care provision, the chaos of that reorganisation may only exacerbate confusion.
It is also astounding that the Bill plans to remove the duty of GP representation on ICBs, along with local authorities and NHS trusts. The replacement of council representation with mayors is extremely problematic for the many areas that do not have a mayor, and it removes the local accountability needed to ensure true community representation. Like so much Labour policy, such changes risk benefiting concentrated urban areas, while letting down rural communities such as those I represent.
Steff Aquarone (North Norfolk) (LD)
My hon. Friend will be aware of clause 4 on reducing health inequalities, which I welcome. As a rural MP, like me, she will also know that access and outcomes are poorer in our communities. Does she agree that the Government should go further and ensure that the Bill explicitly refers to equality of access and outcomes for rural and coastal communities such as North Norfolk?
Helen Morgan
My hon. Friend will not be surprised to hear that I agree with his point.
ICBs are already overstretched and underfunded. In North Shropshire, both Shawbury medical practice and Prescott surgery in Baschurch are in desperate need of expansion. Community infrastructure levy money is available and land is earmarked for a new site, but progress is being held up by the ICB’s inability to agree notional rent. That situation is replicated across the country, and there is no sign of such problems being solved by the Government’s changes.
The plan to abolish Healthwatch will ultimately strip patients of their voice. There has been a statutory independent patient voice in the health and care system for more than 50 years. More than half of patients who experienced poor care in 2024 did not take any action, with many citing fears that giving negative feedback directly to the NHS might affect their ongoing treatment. That is why it is crucial that we have an independent patient voice, rather than leaving the Department or the ICB to mark its own homework.
We need only look at the devastating consequences of the failings uncovered during the Mid Staffordshire scandal, and the long list of maternity failings since, to see how important it is to have Healthwatch exposing challenges in the health service and listening to patient feedback, and how the CQC can fail in that operation. In Shropshire more than 200 babies are thought to have died due to maternity failures; in the reviews that followed, the one thing that came up time and again was that grieving parents were not listened to.
Patients and their families must have a voice. The new system will give no incentive to investigate such issues, which are invisible in the main performance metrics of the NHS. To see the value of Healthwatch, we need only look at the Cabinet Office King’s Speech briefing for the Bill, which refers to a Healthwatch report from May 2025 on missing medical records in order to make the case for the single patient record. I urge the Government to protect both national Healthwatch and local healthwatch organisations, and the independent whistleblowing routes that empower and advocate for patients.
The Liberal Democrats welcome the move to create a single patient record; that part of the Bill could prove to be the most transformational for patient experience and, most importantly, for patient outcomes. People are tired of endless NHS admin and of having to reconfirm their medical histories over and over to different medical professionals. Patient harm has often occurred where clinicians have not had a patient’s full medical history, and different parts of the NHS having access to the same patient information is clearly necessary. However, that must come alongside essential new privacy protections and safeguards for patients, particularly given the understandable concerns surrounding Palantir’s involvement with the federated data platform. We would introduce a health charter to set out guiding principles for data sharing across the NHS, ensuring that patients are in charge of their own data.
The Bill’s references to carers are welcome, as is the Secretary of State’s duty to promote the involvement of carers alongside patients in decision-making around care and commissioning. However, the Bill goes nowhere near tackling the social care crisis and demonstrates a pitiful lack of ambition on one of the biggest challenges we face. As I mentioned, the chaos caused by the restructuring of ICBs will only worsen the challenges that local authorities face in providing care for an increasingly ageing population. We want to transform the NHS so that patients are empowered to live more healthily, for longer and in dignity. The nation’s health is stagnating, with an ever-widening gap in healthy life expectancy between the country’s most and least deprived areas and growing pressure on adult social care.
Fixing social care is fundamental to our vision for the NHS. It is the key to providing a better quality of life for the frail and vulnerable, freeing up hospitals and building independence for an ageing population. It also empowers our constituents to live as independently as possible in their homes and near to their families and communities. We cannot fix the NHS and move care to the community while ignoring social care—yet the Bill ignores it and, as I have outlined, the changes to ICB commissioning will undermine the structures that are supposed to integrate social care with the NHS.
Liberal Democrat plans will give people control, rooting services in communities, listening to patients and making it much easier to see a GP. We will give patients a right to see a GP within seven days, reverse surgery closures and ensure proper personalised management of chronic conditions and frailty, with guaranteed access to a named GP for those patients. We will also protect the mental health investment standard so that we can rebuild community mental health services—something that this Government have failed to do— empowering individuals with poor mental health by intervening early and allowing them to access care in their community. Our maternity rescue plan will ensure that Britain is the safest country in the world in which to have a baby, offering one-to-one midwifery care and empowering women at this most important moment.
This Health Bill could have been a moment for real change. Liberal Democrats are clear about what real modernisation of the NHS would look like. Our vision for a reformed, community-based NHS is one where proper care and restored investment in public health ultimately cut NHS waste and empower people to live healthier and more independent lives. This Bill focuses on shuffling responsibility around Whitehall and gives the Secretary of State the role of chief micromanager. The Government continue to procrastinate over bringing in real change to fix social care, empower patients and save our NHS. In Committee and on Report, Liberal Democrats will use every lever at our disposal to deliver the transformation the NHS so desperately needs.
Dr Zubir Ahmed (Glasgow South West) (Lab)
Twenty-one years ago, when I started my NHS career as a junior doctor, there were Labour Governments in every part of Britain, and I was proud to have practised in every single nation of our country. The NHS then exemplified the mood of our nation: hopeful, comfortable in its own skin and confident about embracing, even shaping, its future. And we did shape that future. The Labour Government delivered world-class heart attack care, stroke care and cancer care, regardless of where someone lived and their ability to pay for it. We also drove through controversy to secure a smoke-free generation, starting in Scotland and then delivering it all across these isles. The success of that legislation is perhaps best exemplified in the fact that we now have a whole generation who feel it is their inalienable right to go indoors and never have to inhale passive smoke or suffer all the deleterious effects that come with it.
Now, as then, the NHS is holding a mirror up to our society. For those who rely on it, there is anxiety and frustration about why, so often, we do not get the basics right, from grappling with the uncertainty of simply seeing a doctor or specialist to the anxiety that comes with waiting for a scan or its results. There are 1.5 million people working in the NHS—including once-idealistic surgeons like me, who unapologetically gave our youth to the NHS because we enjoyed our craft so much that sometimes it did not even feel like work—but those staff have been battered by austerity and covid. They are hoping for better days but, despite the improvements that have been made in the last two years, I know that they harbour a quiet hopelessness that perhaps their workplace can never be joyful again. They are good people who are resigned to running faster just to stay still and keep their patients safe.
All that is because of a 14-year-long Tory Government and the choices they made. They made political choices to rob Peter to pay Paul, and to fail to invest in our NHS. In an era of AI, technology and digital transformation, they left highly skilled staff with 21st-century clinical skills and 20th-century equipment, and left the public feeling more adrift than ever from their most prized national asset. Let us also not spare their handmaidens in Scotland, the Scottish National Government, who fared no better: NHS spending going up and productivity coming down; no NHS app to book appointments or get test results; lung cancer screening lagging behind; and 24/7 21st-century stroke care that is more like Russian roulette.
It is in this mood of cynicism and despondency that this Labour Government are charged with the responsibility of modernising our NHS and showing that we dare to go big again: going big on giving more power and control to patients and the staff who look after them; going big on taking the bold decisions, even if controversial, on becoming the healthiest generation that has ever lived; and going big on grasping the opportunity that technology presents us with. That is the path we start on today. It answers the cries of patients and answers the call of those who want to look after them.
Take the single patient record, which has been lauded in the news today as an exemplar of this Bill. It is a programme that, as health innovation Minister, I was proud to start off and bring my NHS experience to. It is a simple concept, demanded by patients and the vast majority of people who look after them, that there should be a single and comprehensive source of truth about a patient’s history when it is most needed. Most of the public believe it already exists, yet it has proven harder than ever to deliver because of conservatism, paralysed by the thought of the worst outcomes and unable to plan for the best outcomes, and by a belief that patient safety and data safety are somehow tangled up in the status quo. There is nothing safe about going from one hospital to another where a consultant cannot see your scans, or your child urgently attending an A&E department where their medical history cannot be seen or, as recently happened in my own practice in the middle of the night, having to turn down an organ donation because we could not access GP records at the weekend.
What about data security? The NHS is dependent on thousands of IT systems born out of necessity rather than design. If we were designing it, we would never have done it this way, but we must now be absolutely committed to making sure that data is safe and that military-grade security prevails. During my time as health innovation Minister, I was clear—as those on our Front Bench today are clear—that NHS data is sovereign and must be used for the benefit of patients.
We can no longer afford to look the other way. We have to lean in to the arguments and the headwinds that say, “No, not yet” or, “Not this much all at once.” We have to say to our citizens, and to our NHS staff who demand we get the basics right, that we are ready to face down those headwinds, those noisy tweets and those vested interest positions and say loudly, “Yes, right now” and, “Yes, as big as we can,” because our NHS can, because its patients expect us to, and because its users demand us to go further. This movement and this party were born of difficult times to deliver in difficulty, and this Bill will definitely and ultimately deliver on that promise.
Dr Ben Spencer (Runnymede and Weybridge) (Con)
It is a real pleasure to follow the hon. Member for Glasgow South West (Dr Ahmed). I did not agree with everything in his speech, but I know of his passion for NHS services and I am grateful for the work that he did as a Minister, particularly in helping me to advocate for my constituents, which I will come to in the main part of my speech. I should start with the standard declarations: I am a former NHS doctor and my wife is a current NHS doctor.
There is a lot of good and very reasonable stuff in this Bill. I very much support the abolition of NHS England and I am glad that is being taken forward. The single care record makes complete sense. It is pretty crazy that we do not already have a national system in place. I think there will be some speed bumps in terms of administration, and the question I have is this: how is it going to encode sex data? What data is the record going to use as sex data, given the problems and the discussion that we had just before this debate?
For me, the problem is about accountability. I have a local integrated care board. I also have NHS trusts, one of which is Surrey and Borders, which has been failing to deliver rapid, timely autism spectrum disorder and attention deficit hyperactivity disorder assessments for children. Frankly, that failure to provide a speedy assessment for ASD or ADHD locally is a disgrace. I have been putting pressure on my local trust to try to change that. My constituents expect me to do that. Some of my constituents expect me, as an MP, to be able to click my fingers to make this happen, but of course I cannot do that because this is the NHS trust, the chief executive and the ICB.
I raised this issue in Parliament with the then Secretary of State, asking him to investigate my local mental health trust and look at the failings, and I am grateful that the then Minister, the hon. Member for Glasgow South West, responded to me and wrote to my ICB. The response I got was that this was within the ICB’s framework, and that what ICBs do is essentially up to them. My ability to go about changing this is therefore very limited.
I get the point about clause 11 and the Secretary of State taking a few more powers to direct ICBs, but that is a very blunt tool. In reality, it will not be accountability. I cannot quite believe that it will work in such a way that, if I raise something in Parliament, a directive will force my ICB to deliver better for my patients. I cannot quite see that that will happen in reality—or perhaps I am wrong and it will. In that case, Parliament will essentially become a forum for MPs—all of whose constituents will expect them to be able to give directives to our NHS trusts and ICBs—to raise these issues so that the Secretary of State can take forward a directive.
It would be far better if ICBs were directly accountable to local politicians. I heard the response that the plan is for ICBs to be accountable to mayors, but we do not have a mayor in Surrey and, even though many of us have been calling for a mayor, there is no timescale for getting one. ICBs need to be directly accountable to locally elected representatives in some way, shape or form, and the logical group is Members of Parliament, because that is what the public believe and expect. I hope that, as the Bill goes through, we will investigate the local accountability of ICBs in the NHS and that perception.
One of the biggest dangers is the sense that we, as MPs, can deliver direct changes in day-to-day clinical commissioning, from which, of course, we have a degree of distance. I reiterate that, at the moment, the public perspective and public belief is that that is what we are empowered to do. We therefore have to be empowered to do that, or we have to have mechanisms to make it clear to people that local NHS care is not in the direct control of myself or anyone else here, apart from Ministers on the Front Bench.
Patient groups are an important mechanism, but they are also important in terms of consultation. I worry about what will happen when ICBs consult on plans. What is the number? What is the survey? What is the metric? Who is appointing the ICB chair? Who is appointing the NHS foundation trust chair? Who is appointing the members of all these quangos? Where do democratically elected representatives sit in these appointment decisions?
Given the time limit, I will finish on this point. Accountability is critical in getting this right. Care models need accountability. I have raised this matter in Parliament for many years now. I hope that we can use the Bill as an opportunity to give our constituents the accountability they need and deserve in the delivery of local health care.
Wes Streeting (Ilford North) (Lab)
That was a characteristically thoughtful speech by the hon. Member for Runnymede and Weybridge (Dr Spencer). It is also a particular pleasure to follow my hon. Friend the Member for Glasgow South West (Dr Ahmed), who was an outstanding Minister in the Department of Health and Social Care and has demonstrated again today why his expertise and integrity are highly valued on the Government side of the House.
I strongly supported the speech made by the Secretary of State. He has hit the ground running, and he knows that he has my full-throated and wholehearted support. He does not need a predecessor being a back-seat driver—something that I am sure the Prime Minister feels about one or two of his predecessors after recent days. I also thank the Minister of State for Health, my hon. Friend the Member for Bristol South (Karin Smyth), for her leadership on the Bill, and the brilliant team of officials, who have worked exceptionally hard to prepare the Bill for its introduction.
It will come as no surprise to anyone that I strongly support the Bill. The latest NHS waiting list figures show the biggest cut to NHS waiting lists for 17 years, and as we heard from the Tories today, they cannot stand it. They cannot stand that within less than two years we have done something that they failed to achieve in 14: lowered waiting lists. Waiting lists are shorter than when we came in—lots done, and lots more to do, but the numbers are there. Despite record levels of demand and strike action by the British Medical Association, we delivered record levels of activity and waiting lists are falling. That is the difference that a Labour Government make.
To understand how and why this happened is to understand why the Bill matters. Those who claim that recent improvements in NHS performance are simply the result of more money are making exactly the same mistake that held the NHS back for years under the Conservatives. Investment matters—of course it does—but, as the Secretary of State outlined, we are combining investment with reform. We are embracing technology, cutting bureaucracy, improving productivity and changing how care is delivered—from cutting £1 billion from spend on agency staff to funding GPs to treat more patients in the community, equipping NHS staff with the latest AI tools, and sending crack teams of top clinicians to bust the backlogs in hospitals with the most patients off work sick. Every single change has been opposed by vested interests, but that is why we are seeing more patients treated and better value for taxpayers. That is the difference between managing decline and delivering change.
For all our progress, we know that there is so much more to do. Too many people are still waiting too long. Too many staff are working against systems that make their jobs harder, not easier. Too many patients have to tell their story over and over again. Too much money is trapped in bureaucracy when it should be reaching the frontline. Too often, accountability is blurred between two different headquarters or two different boards, bodies and acronyms that the public do not know and cannot hold to account. This Bill is the NHS modernisation Bill, and it addresses every single one of those challenges, giving expression to the principle that the NHS should be run for the patient, not the other way around.
The Leader of the Opposition recently claimed that we have not kept our promise to abolish NHS England. In fact, we have already started: 7,000 posts removed from ICBs, and 4,500 more posts going from NHS England and the Department of Health and Social Care. I know that those changes are not easy for the people affected, and I never treated them lightly, but abolishing NHS England is about cutting duplication, reducing bureaucracy and putting responsibility for the NHS where it belongs: with elected Ministers who are accountable to the public.
Every pound wasted on administration is a pound that could be spent on patient care. That is why we are stripping out unnecessary layers and directing more resources to the frontline. Hearing the opposition from Conservative Front Benchers, it is no wonder that they presided over such a bloated bureaucracy. This Bill will save money, but they never once asked how much it would cost to pile on layer after layer of bureaucracy, saddling the NHS with top-heavy management, which frustrated patients and really frustrated staff.
Some will say that there is a contradiction: that centralising accountability and giving patients more control over their own data pull in opposite directions. But that is precisely the point. For too long, power in the NHS has sat in a no man’s land—an accountability sink, too distant from patients and citizens to be meaningful and just far enough away from Ministers that there is plausible deniability when things go wrong. The Bill takes back power in order to give it away: accountability for Ministers where it belongs, and power for the patient where it belongs, too.
The Government must face down powerful producer interests on patient data. Our health data is precious. Two things matter above all else: that our data is held securely and that it is used ethically. However, the single patient record is one of the most important reforms of the NHS for decades. It is frankly unsafe, as well as absurd, that patients are still being asked to repeat their medical history every time they access a different service. We also have to take on the producer interest of those who think patient data belongs to them rather than to patients. Our health, our data, our NHS—patients should control who can access their data, and they should control their own data.
By all means let us scrutinise the Bill and suggest improvements, but do not slow it down. The NHS does not have time to waste. The NHS is on the road to recovery, and this Bill puts the foot down on the accelerator.
Madam Deputy Speaker (Judith Cummins)
I call the Chair of the Health and Social Care Committee, after whose speech there will be a four-minute time limit.
Layla Moran (Oxford West and Abingdon) (LD)
It is a pleasure—and slightly surreal—to follow the former Secretary of State, the right hon. Member for Ilford North (Wes Streeting), because he is very much an architect of the Bill, and I am sure that we would have had many questions for him about what he meant by parts of it. It was a pleasure to work with him when he was in the role, and I look forward to working with the new Secretary of State too.
We all understand what is at stake here: far too many feel that the system is not working for them. The latest British attitudes survey showed that more than half of people in this country are dissatisfied with the NHS. That should give us all pause. When the abolition of NHS England was first announced, I welcomed its boldness because our population faces enormous challenges. Healthy life expectancy has not just stalled; it has gone backwards. We are getting older and we are getting sicker—so, yes, we need to be bold. There is widespread recognition that the three shifts in the 10-year plan, to community, to prevention and to digital, are the right ones, and if achieved—and that is an “if”—they will be transformative, but along with the enthusiasm, which I share, there is a big dollop of scepticism. Twenty-five per cent of the public do not believe this plan will make any difference to them, and we must prove them wrong.
My message to this Government is this: “Focus on the plan. It is the right plan, and achieving it will be an enormous challenge. Also, please do not forget social care.” We must remember that this merger, which could risk becoming a distraction from the plan, did not start with the Bill; it started with the announcement in March 2025, and the effects are already being felt in the NHS. This was not in the manifesto, so it came completely out of the blue, with many people waking up and discovering that their jobs were at risk only from reading the news. It has been brutal. As a result, the Institute for Government told the Health Committee in our hearing just before the recess that there has been a “large drop in morale”, which is unsurprising. There has been uncertainty, poor communication and disruption. I have heard at first hand how decisions have been snarled up as key people have left, and we must learn from previous reforms that the savings often do not materialise because many of the same people who leave first end up being rehired—a point made in the Committee hearing a couple of weeks ago by the chair of NHS England, Penny Dash. So, despite my initial enthusiasm, there is much that we need to chew over.
In the six inquiries and 13 one-off sessions that our Committee has done so far, there are clear themes for change, and it is on those that I will judge the Bill. The first theme is innovation. Pilots and moonshots are good, but they should not replace evidence-based prevention and joined-up thinking. For example, the Government’s obesity moonshot focuses on weight-loss drugs, but ignores the obesogenic environment of advertising, ultra-processed foods and lifestyle pressures. It tackles the symptoms and not the cause. And too often, these pilots show promise but are then never scaled up. What a waste! Innovation should be a mindset, not a buzzword, and we should strengthen clause 6 of the Bill to ensure that the long term is embedded from the outset.
The second theme, which has come up already, is patient voice. Our inquiry into severe mental illness laid bare a system where vulnerable people feel like pinballs in a machine.
Alex Brewer (North East Hampshire) (LD)
In my area, children waiting for ADHD assessments—many already on the standard pathway for years—have been told that they will have to wait until 2027 at the earliest. We know this is happening nationally, because Healthwatch told us in its 2024 report. Does my hon. Friend agree that abolishing Healthwatch—the only statutory independent body holding our NHS to account—will leave the most vulnerable patients without a voice and the NHS marking its own homework?
Layla Moran
I do have concerns over Healthwatch; I have even more concerns over the role of the HSSIB. We cannot have it both ways: people cannot sit at desks near other people who are making decisions and at the same time be perceived as entirely independent. The perception of independence cannot be legislated for—the perception is everything, and that is my concern. Clause 15 talks about co-creation, but getting this point right is key to making the system work. There are many examples of where it has been done correctly, but all too often it is just a tick-box exercise.
The third theme is financial flows and integration. Time and again, the Committee is in rooms with local authorities, social care and the voluntary sector all saying that they know how to do this for their local area and it is the system that gets in the way. Section 75 arrangements are a good start and should be strengthened, and there is a lot of promise in the neighbourhood health plans under clause 24. Our concern is over clause 21, because if local authority representation is removed from ICB boards, then social care is not present in those first conversations. That is critical and needs rethinking.
The fourth theme is data. Recently in my surgery, I spoke to a woman called Freya-Rose, who described how repeatedly recounting traumatic experiences compounded her own suffering. The single patient record could be transformational for her and others who find recounting traumatic experiences difficult. We therefore welcome clause 47, but we must be careful about the risks, especially around sensitive data. On that, the Committee will be having hearings on the federated data platform and Palantir, which has already been mentioned today.
The final theme that has emerged in our work is inequalities, so I am excited about the potential of clause 4. I am proud of the Liberal legacy that this NHS is built on. In his seminal report, Beveridge rightly pointed to want, disease, squalor, idleness and ignorance as the five giants that needed to be slayed on the road to recovery following world war two. Obviously, we have come a long way since then, but I would argue that it is time to define some new giants, and health inequality must be one. It is self-evidently the moral thing to do, but—here is something I think the Secretary of State will like—it is also the economically wise thing to do, because study after study shows that tackling inequalities is the key to unlocking productivity in the NHS. Simply put, helping those who need it the most helps us all. This Bill needs to do more than just “have regard” to inequality; I would urge the Government to make it its core mission.
I end by simply saying what I started with: I will work constructively to help the Government make this the success that I hope they want it to be. I would urge them to think about the downsides, because there are some and they need sorting out. Above all, the Bill will be judged not by us, but by Chris and Freya-Rose, the very patients who deserve to be put at the heart of this legislation moving forward.
Liam Conlon (Beckenham and Penge) (Lab)
Like others, I start by paying tribute to the NHS. I know from first-hand experience how important the NHS and its staff are. When I was 13, I had an accident that left me unable to walk for four years. I spent so much time on NHS children’s wards that I went back a year at school and, as a sixth-former, I was one of the youngest people in Britain to have a hip replacement on the NHS. I want to thank the staff at the Royal London hospital and the Royal National Orthopaedic hospital who cared for me. Last year, I went back to the children’s ward that I had been on and opened a new outdoor play area for the children on the ward today; it was one of the greatest privileges I have had since being elected.
I am pleased that the waiting list for hip replacements has come down and that opportunities for children to access education in hospital are improving, but I want to focus my remarks today specifically on brain cancer and brain tumours. Brain tumours are considered rare, but 12,000 people a year are diagnosed with a brain tumour. Just one in 10 adults diagnosed with brain cancer in England survive five years or more, and it is the biggest cancer killer of children and adults under 40.
Behind those statistics are the real lives of people and their families, such as my friend and constituent, Alex Savage. Alex was diagnosed with a glioblastoma in 2021 at just 33 years old and sadly passed away in April this year, aged 38. He leaves behind his daughter Etta—who is now not even two years old and will grow up without her dad—his wife Anna, his mum Marie, his dad Ed, his brother Nick and his sister Rebecca. Alex was intelligent, warm, funny, fearless and full of life. He spent his final months campaigning for change on brain cancer, working closely with the Tessa Jowell Foundation—a cause close to my heart—and I know he will be much missed by the staff there. Alex spoke extensively about how he lived well with brain cancer, and also how severely it impacted his independence and how his family often had to pick up the pieces. They are a real credit to him and to themselves, but the strain this must have had on them is undeniable.
Our improvements to the NHS must be a rising tide that lifts all ships, not just for common conditions, but for rare and difficult ones such as brain cancer. I believe that we have begun to provide answers, many of which are covered in the Bill. First, we have the creation of a single patient record. It is not acceptable, in 2026, to have a health system that is still operating in the analogue age. It was only after the intervention of this Government —particularly the previous Health Secretary, my right hon. Friend the Member for Ilford North (Wes Streeting), and the previous Minister for Health Innovation and Safety, my hon. Friend the Member for Glasgow South West (Dr Ahmed)—that the last NHS trust stopped using fax machines. The single patient record is an important step towards the digital age, finally bringing together patients’ data in one easy-to-access place.
Secondly, if we want to improve the prognosis for patients like Alex, we need to improve the funding and infrastructure behind research and clinical trials. I am glad that the Government have committed to taking action on this by increasing access to trials, giving greater hope to other families who are suffering.
Thirdly, I welcome the Government’s endorsement of the work of the Tessa Jowell Brain Cancer Mission, which has done so much for brain cancer patients by reducing the postcode lottery and raising overall standards of care. However, as Alex’s case shows, we still need further improvements. This means making a sustained commitment to improving outcomes for those with brain tumours, backed by meaningful increases in funding to reflect the incredible burden of this cruel disease.
I am proud of the improvements that we are making to the NHS. I know the impact they will have on the lives of millions of people across the country, including in my constituency of Beckenham and Penge. However, we also need a specific approach to tackling brain cancer. As Tessa Jowell said in her final speech in the other place, it cannot be
“put into the “too difficult” box”.—[Official Report, House of Lords, 25 January 2018; Vol. 788, c. 1170.]
Through funding, improvements in trials and further expansion of the mission model, I am confident that we can make progress, and I look forward to being a part of that progress throughout this Parliament.
Sarah Bool (South Northamptonshire) (Con)
As an active user of the NHS, I welcome steps that can be taken to help improve patient experience and care, but the NHS is a delicate ecosystem: mistakes and errors do not just lead to a loss of money—they can be life-changing and, quite literally, a matter of life or death—so it is absolutely essential that we get these changes right.
Conscious of time, I will focus on a few points that I want to raise. The single patient record has already been mentioned a number of times. There is no hospital within the boundary of my constituency of South Northamptonshire, so my constituents can be treated at a variety of hospitals, including Northampton, Milton Keynes, Kettering, John Radcliffe or the Horton. Working cross-county and across the country, I can see the value in creating a single patient record, ensuring that notes are available. It really could transform care co-ordination. For example, the wife of one of my constituents was almost given medication that would have killed her—she would have had an allergic reaction—because of the use of old notes. Only her husband’s presence saved her life. We cannot allow that in this day and age.
As the Royal College of Nursing has indicated, we must ensure that any new system has robust safeguards around data privacy, transparency, access, procurement and secondary uses of data. I acknowledge that the Secretary of State has put an emphasis on looking at that, but I think we all need more assurances. Even the Royal College of General Practitioners is asking whether the Government will provide any assurances around indemnity for GPs to protect against liability if there are breaches of data protection regulations or instances of mishandling patient records.
All in all, the single patient record will work only if the system has the confidence of patients and staff. Nursing staff have been asking through the Royal College of Nursing if they will be involved in the creation and design of the single patient record, to make sure that it will actually work in practice. Will the Minister confirm whether that will be the case?
Without careful safeguards, structural changes could risk undermining some of most significant advances that we have seen in recent years. As many Members will not fail to know, I am a type 1 diabetic and I will always passionately talk about diabetes. Diabetes UK has highlighted concerns about some of the changes. We have seen some incredible movements in diabetic technology, including the development of continuous glucose monitoring and, most recently, of hybrid closed-loop systems, which I am wearing and using as I speak. Central co-ordination has ensured that funding agreements are secured and access is prioritised. A shift to purely local decision making risks fragmentation and widening inequalities.
Many new treatments are being created and progressed. For example, I introduced a ten-minute rule Bill about type 1 diabetes screening in children. We need to ensure that this is prioritised, along with access to emerging immunotherapies. As this is an incredibly specialised area, it requires expert national oversight and co-ordination. It would be inefficient and potentially ineffective for such developments to be pursued on a purely local basis. We want to ensure that we do not see any progress falling through the cracks as changes are made.
Finally, I want to touch on patient voices. The abolition of Healthwatch England has been mentioned numerous times during the debate. Many patients have to be incredibly vocal about the care that they need. Often, they cannot make those points as strongly as we might, so it is vital that we maintain bodies that can speak on their behalf, especially those that ensure the voices of young children and youth are prioritised. I am supportive of some of the changes that are coming, but we do need to exercise some care and caution.
Jen Craft (Thurrock) (Lab)
The NHS is at a critical juncture in its existence. In order to survive, it needs radical change in how it is run. I welcome the measures in the Bill to keep the NHS around for generations to come, but there are opportunities for the Bill to go further.
I will briefly touch on the situation in my constituency, where an acute care trust has been under-delivering for decades. It constantly gets terrible CQC ratings, whether they relate to how it is run, specific departments or access to services such as A&E. During a recent inspection, two of the inspectors had to stop the work that they were carrying out to point out that there was a deterioration in a patient that had not been noticed by the medical staff on duty. The previous Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), placed the trust into an intervention programme, naming it as one of five trusts across the country that were “challenged”, which means it will be subject to significant NHS intervention.
I strongly welcome the measures in the Bill, particularly those that put a clear emphasis on accountability and preventing historic patterns of underperformance and that allow the Secretary of State to deauthorise failing foundation trusts, taking away some of their independence and bringing them under the control of the Secretary of State. Ongoing interventions have not delivered the healthcare that my constituents need, so this might be the final measure that ticks the trust into working, benefiting from the wealth of expertise and experience within the Department of Health and Social Care.
I believe that the Bill can go further in the area of special educational needs and disabilities, delivering for children with disabilities or extra educational needs. There is a systemic problem that is not related to individual instances in specific trusts or areas of the country. Far too often, health is not at the table when it comes to commissioning services for disabled children or meeting the needs of children with additional needs, so there is an onus on local authorities, who have a statutory duty to provide services that it is not in their gift to provide. We hear from local authorities, schools, academy trusts, parents and sometimes even children that the absence of health in these discussions is critical.
The crucial role that the Department of Health and Social Care can play in delivering the SEND White Paper relates to the “Experts at Hand” model. These experts provide an early intervention model, so that all children who exhibit an additional educational need can access expert advice from a panel of people who make up part of the allied health professions. We know that there is a huge shortage in this workforce and, again, it is in the gift of DHSC to remedy that. The Bill could go further to create a change in the commissioning and the development of a workforce strategy, moving the responsibility from NHS England to the Secretary of State. The Bill should mention allied health professionals and paediatric allied health professionals, which would put them on an equal footing with normal clinical staff.
Another way in which the Bill could go slightly further is by putting a duty of partnership and a duty of commissioning on ICBs around SEND services, particularly paediatric services. As I said, there is currently a statutory duty on LAs. We have heard time and again that a similar statutory duty on ICBs would help delivery.
Josh Fenton-Glynn (Calder Valley) (Lab)
My hon. Friend is making some powerful points. I hear again and again from parents that while different commissioning bodies argue about who is responsible, children fall through the cracks. Does she agree that we must urge the Secretary of State to go further and ensure that these children do not fall through the cracks?
Jen Craft
My hon. Friend is completely right.
One of the biggest issues with delivering care for children in the SEND system and for disabled children more widely is the lack of join-up between the various services that they should be able to access. The single point of access in this Bill is a great way to deliver on the health aspect of that. I hear from my constituents who parent children with chronic or complex medical needs, and they find it extremely frustrating that they are the one nexus holding all the information about their child’s healthcare and what they need. They are quite often battling a number of healthcare bureaucracies to get their child the healthcare and support that they need.
I believe that with a few tweaks, this Bill could be truly revolutionary in delivering the healthcare and support that disabled children and children with extra educational needs require and in taking the onus and the stress away from their parents.
Steve Darling (Torbay) (LD)
As I am sure is the case in many other constituencies, the NHS is perhaps the most valued service in Torbay, where it is the largest employer. Ironically, while the Government talk about investing in the NHS, Torbay is looking at 300 voluntary redundancies. Rather than the investment that the Government talk about, the reality in Torbay is job cuts, many of which are likely to be to clinicians. That is the background to my comments, which I will limit to the crucial ones.
Torbay has had the luxury of an integrated care organisation, which has been vaunted internationally as the way forward. The direction of travel of the Government is very much toward integrated care organisations, as my hon. Friend the Member for North Shropshire (Helen Morgan) alluded to. We have section 75 arrangements, yet because there has been a failure of focus on this matter by NHS colleagues over a number of years, they have been binned in recent months. We have appealed to the Secretary of State to intervene, but he has failed to do so. In the light of that, how can we have any confidence about greater influence from the Secretary of State? When the appeal happened, he said, “It is a contractual relationship.” The integrated care organisation has resulted in many people being discharged early and people being cared for in the community at a grassroots level. As Liberal Democrats, we know that that is desperately important.
The binning of Healthwatch is disturbing. I pay tribute to Kevin Dixon, who heads up the organisation in Torbay and Devon. Only a few years ago, it identified a failure by domiciliary care workers who were supporting the most vulnerable people in their own homes. That resulted in an investigation, which took away the contract from that provider, and another provider ended up better supporting those people. How can we expect that to happen if we effectively give the duty to providers to mark their own homework?
Let me focus on the better care fund. It is bonkers that this is being handed on a plate to the NHS acute care services. There needs to be partnership working between adult social care providers and the NHS. It should be driving better care—it says that on the label. This is extremely perverse. I hope that as the Bill progresses, common sense will prevail in a number of areas.
Paulette Hamilton (Birmingham Erdington) (Lab)
As someone who has worked in the NHS for 25 years as a district nurse and who has been involved in integrated care systems in Birmingham and Solihull since the very beginning, I will focus my contributions on three areas of the Bill: health inequalities, patient voice and integrated care boards.
Let me start by saying that I support the principles of the Bill. My constituents want services that work better. They want care that is easier to access closer to home and properly joined up, and parts of the Bill help to support that ambition. I want a focus on neighbourhood health plans and shifting more care into communities. Some of the best healthcare happens in people’s homes, in clinics and through early intervention before problems become a crisis. That is why the investment in Stockland Green health centre in my constituency in Birmingham matters so much to my residents and to me. It represents the right ambitions: shifting care into the heart of the community, bringing services together locally and making healthcare more accessible for residents in Birmingham Erdington. The principle of that is absolutely right.
My concern is that parts of the Bill risk moving us away from the original purpose of integrated care. Integrated care systems were created because health is shaped by far more than hospitals alone. I am concerned that the Bill risks moving us away from that local collaborative model and towards something far more centralised. As a former cabinet member on Birmingham city council with governance responsibility for health and social care and public health, and as the chair of Birmingham health and wellbeing board, I know how important local government involvement is in these decisions, yet under these proposals, somebody in that position would not automatically have a seat around the table—they would have to compete for it.
I believe the Bill should protect three things in relation to ICBs: genuine local partnership, a combined focus on health inequalities and prevention, and a strong focus on place, reflecting the needs of local communities like mine. One of my biggest concerns about the Bill is the reduction in independent patient representation, including the abolition of Healthwatch structures. If patient voice is weakened at the same time that local representation is reduced, there is a real risk that health inequalities become even less visible within the system, and we cannot allow that to happen.
The ambition to improve joined-up care and strengthen community healthcare is the right direction of travel. I simply ask the Government to keep a close watch on local representation and patient voice as these changes are implemented. Patient voice must not be lost and health inequalities must not increase. ICBs should not be used as a vehicle to reorganise NHS management structures.
Madam Deputy Speaker (Judith Cummins)
I will call a Member on the Opposition Benches, and then I will reduce the time limit to three minutes.
Saqib Bhatti (Meriden and Solihull East) (Con)
It is a pleasure to follow the hon. Member for Birmingham Erdington (Paulette Hamilton), not least because I agree with a lot of what she just said, especially around accountability and the impact on integrated care boards and Healthwatch. I will try to speak quite swiftly in the time allocated to me.
I campaigned for ICBs, because when I was a new Member of Parliament I had to deal with clinical commissioning groups. In summer 2020, the CCG that I was dealing with told me that I was going to get two new urgent treatment centres at the cost of about £1 million each, but I had a call with the same CCG a month later and it denied ever saying that to me. Luckily, one of my staff members had been on that call. I went to see the Health Secretary at the time, and I thought, “This is not possible.”
I am not a health expert, but I have been in business, and accountability and transparency really matter. That is why I supported the Health and Care Act 2022 and the introduction of ICBs. The consequence of the Act was much more local accountability and delivery. That is why, since 2020, we have seen the introduction of an urgent treatment centre at Solihull hospital, a locality hub, state-of-the-art surgical units with robotics, and the second-largest community diagnostic centre in the country. That was opened under this Government, but it was allocated and instigated by the previous Government.
I am a big advocate for transparency and accountability, which is why I have great concerns about the Bill. I have great respect for the Minister, but I hope she will appreciate that the cross-party concern on the legislation is very valid. There is a bit of a power grab going on here; the central pillar of the Bill is to centralise powers. Despite the Secretary of State—I would welcome him if he was in his seat—saying that the Bill is not about politicisation, it is inevitable that that centralisation of power will be a politicisation. In fact, the integrated care boards in the form that we created them reduce politicisation. I will not stress that point more than the hon. Member for Birmingham Erdington did, because I was in total agreement with her.
Moving on to Healthwatch, I will start with a compliment to the Department of Health, because I wrote to it last year on 12 September and had a response on 15 September. That is pretty good going—long may it continue—but my compliments will stop there, because I am greatly concerned about the abolition of Healthwatch. The Secretary of State kept talking about integrating it into ICBs, but the response I had from the Minister clearly says that the changes will close local healthwatch organisations. I do not agree with the term “integrated”; a new mechanism is being created that will take away patient voices and patient independence.
Healthwatch plays an important role in gathering local intelligence. The hon. Member for Birmingham Erdington talked about inequality, and I have great concerns about that. Two of the most deprived wards in the country are in my constituency, and Healthwatch also plays an important role in giving a voice to the voiceless. I was not reassured by the Secretary of State that that role will be preserved as those powers are taken into the ICB or centralised into the Department of Health, where the Secretary of State will be an important arbiter.
There was one question that I wanted to ask the Minister. The inequality I referred to includes huge amounts of digital exclusion, another area in which Healthwatch plays an important role. When I talk about the voiceless, I mean the people who do not have the strength or confidence to address those issues. What work has the Department of Health done regarding the digitally excluded? That is a really important question, and I share the concerns about accountability and transparency that have been expressed. I hope the Minister can address them.
Daniel Francis (Bexleyheath and Crayford) (Lab)
At the outset, I echo the comments of my hon. Friend the Member for Thurrock (Jen Craft). As fellow SEND parents, we both call for the measures that she has pressed for.
I declare my interest as chair of the all-party parliamentary groups for access to disability equipment and for wheelchair users. I wish to speak about some of those issues, predominantly as they relate to clauses 15 and 16 of the Bill and how ICB commissioning needs to be considered in relation to carers and disabled people. Last October, the APPG for access to disability equipment published a report entitled “Barriers to Accessing Lifesaving Disability Equipment”, which made recommendations that I believe need to be considered as the Bill progresses. Its main recommendation was that there be a national strategy for community equipment, ensuring consistent national standards and accountability at every level.
Disparities exist not just across ICB areas, but within them. In my part of south-east London, there are different contracts in Bexley, Greenwich and Bromley—three neighbouring boroughs within the same ICB, where people receive completely different service levels. My daughter is a wheelchair user. She is in a school class with children from the neighbouring boroughs that, despite being in the same ICB, have completely different commissioning contracts and different levels of service. That postcode lottery, both across ICBs and within them, is something we really need to look at.
Getting the commissioning of disability equipment right is crucial if we are to streamline processes, reduce delays and prevent unnecessary hospital stays. For instance, there is no timescale for equipment when it comes to hospital discharges. A timescale of 18 weeks for wheelchairs is set out in the national strategy, but not for disability equipment. That leads to delayed discharges, but also to operations that in many respects are unnecessary, such as for people with cerebral palsy who do not have the equipment they require. There is clear evidence, as we will see again in the months ahead, that providers of disability equipment and wheelchairs bid lowest for contracts, creating cash flow issues for them. They then have to slow down the ordering and provision of equipment, which has great knock-on effects on both operations and discharges for the NHS. That is why our APPG has called for a streamlining of communication channels between local authorities, health bodies and Government Departments to ensure a more joined-up approach.
I have very little time, but I want to mention the recycling of equipment. Often, one ICB will have the equipment that a patient in a neighbouring ICB requires, because it has recycled it, but it cannot pass that equipment on because the contracts are different. We saw that issue to a great extent last year in the area of disability equipment when the NRS Healthcare contract collapsed. I welcome the Bill, but I believe it can be strengthened to better address the needs of carers and the disabled.
Gideon Amos (Taunton and Wellington) (LD)
This Bill contains welcome elements, such as creating a single patient record and enabling integrated care boards to become commissioners across a wider area. However, I cannot support the weakening of patient voices, nor removing local authorities from oversight of health trusts. I pay tribute to Gill Keniston-Goble and her team at Somerset Healthwatch for all the fantastic work they have done.
In moving to a single patient record, we need to prioritise privacy and rethink putting the American firm Palantir in charge of our data, with its founders such as Thiel opposing democracy and denigrating our NHS as part of a “Stockholm syndrome”. My constituent, whose family member was brutally murdered, is rightly horrified that victims’ NHS records were shared unlawfully online with NHS workers—she called it “repugnant voyeurism”, and she was right to do so. I hope the Minister will echo the apology of the trust and condemn that kind of behaviour.
However, none of the reforms in the Bill will have a positive impact on patients or staff in Taunton and Wellington who use the maternity and paediatric department until and unless the promised new unit is brought forward. One of my constituents, Jeff, told me of their grandson Ryan, who was admitted to the ward a couple of weeks ago. The lack of air conditioning meant that temperatures there exceeded 30°C over the past week—no wonder medical staff have fainted in the heat while looking after mothers and children who are baking in single-storey flat-roof buildings—buildings that were put up for the United States army as a temporary measure during the second world war and never replaced.
As Jeff put it,
“Walking down the corridor of the old building is an embarrassment. There are literally sheets of plastic attached to the leaking ceilings running into guttering in the corridor”.
I do not need my architectural training to know that guttering should be on the outside of the building, not the inside. It is therefore unsurprising that the previous Secretary of State, the right hon. Member for Ilford North (Wes Streeting), when challenged on BBC Radio Somerset only a month ago, promised that he would speed up the Musgrove Park hospital project if he could. I hope the new Secretary of State will honour his predecessor’s promise to meet me to discuss that.
The Bill is based, at least in part, on the mission to move from treatment to prevention, which is of course the right ambition. Because of its major teaching hospital status, Taunton has a big medical community who know a thing or two about prevention, and I will highlight two areas in which this Bill should be going further on prevention. On prostate cancer, I hope the Government do not decide to hold back from widespread screening, as a recommendation to do so is before them. As a member of a family in my constituency recently hit by that disease told me,
“I am a recently retired doctor and I do not believe the statistics that have been published, with the emphasis being placed on over-investigating patients and the distress this causes. This pales into insignificance compared to a missed diagnosis.”
Finally, more should be done to reform the dental contract. Unless the Bill leads to more NHS dentists, social care reform and better prevention—
Sonia Kumar (Dudley) (Lab)
Today, we stand at a defining moment for our healthcare system. We face a ballooning NHS budget and a social care system in crisis. We ask ourselves what must change to reduce deep-rooted health inequalities, improve patient-centred care and remain financially sustainable. The NHS was designed to treat acute illness and provide healthcare free at the point of use, regardless of income, background or status. Medical and scientific progress has transformed healthcare—people are living longer than ever before, often managing multiple, long-term conditions that once would have been fatal.
The NHS was founded on the simple but powerful principle of equity, yet health outcomes remain profoundly unequal. Research consistently shows that where someone is born and the socioeconomic conditions they grow up in can determine how long they live, sometimes by more than a decade. The wider determinants of health—income, housing, education and employment—shape outcomes long before illness appears. Now we must embrace the global technological revolution; from artificial intelligence to robotics, we must harness it to improve patient-centred care. Used well, technology does not replace humanity in medicine, but restores it, giving clinicians more time to care.
Indeed, we should go further. AI and data analytics should be used not only to treat individuals, but to understand communities, designing healthcare around the real conditions in which people live. A true systemic approach means not just knowing that a patient has a condition such as high blood pressure, but understanding why: the environment that shapes us, rates of poverty or unemployment, housing conditions, education levels, access to green spaces, the density of fast food outlets or accessibility of affordable healthcare services per capita. The reality is that health inequalities are complex, interconnected and predictable. We require a whole-system approach, bringing together the NHS, local councils, hospitals, charities and grassroots organisations.
Having a way to fully map communities and what they look like would allow for tailor-made healthcare services to be delivered to the population. Healthcare and the NHS do not need reform; they need an ecosystem map. I want to call it the health biosystem. It would be a system where health is shaped not in hospitals, but in homes, schools, streets and workplaces. As Attlee once said, we have
“not been elected to try to patch up an old system but to make something new”.
Sir Bernard Jenkin (Harwich and North Essex) (Con)
I very much welcome the idealistic vision that the hon. Member for Dudley (Sonia Kumar) sets out for us, but I am afraid that it is far from what is in this Bill. Like my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer), I shed no tears for the demise of NHS England; it was never an organisation independent of politics, but always looked upwards at the political leadership and did what Ministers wanted. It was created as an unnecessarily complex organisation. However, I ask myself whether reasserting the principle—unspoken in this debate—that somehow the man in Whitehall knows best is not reverting to the previous failures of the system, when we need to be looking for a much more organic and local system.
I speak in this debate to lament the demise of HSSIB, as proposed in this Bill. It is a profound mistake. It represents a downgrading of safety as a priority in this Government’s health policy, because HSSIB is the only organisation that can independently investigate safety incidents in the NHS and is not conflicted by any other function or role. It does not compromise any other functional role in the NHS, yet the Government have decided to get rid of it. It will not save any bureaucracy. This tiny organisation costs a few million pounds, yet it is pioneering a new system of safety management in the NHS that the NHS culturally barely understands.
We forget that NHS reform is really about people and leadership, not management structures and organisational structures. HSSIB was one of the catalysts that was beginning to transform attitudes towards safety. It was a safety valve for clinicians and patients and their families. It was the one place they could go to tell their story, without fear nor favour, in a safe space, and it was instructive.
Saqib Bhatti
My hon. Friend is delivering a passionate speech. Is he reassured in any way by the changes the Secretary of State alluded to that will help strengthen the patient voice?
Sir Bernard Jenkin
Well, no, and the abolition of HSSIB is an example of that. It was the one organisation that could independently hold any part of the system to account. If its functions are transferred to the CQC, those functions will be compromised in their independence —and they are explicitly intended to be compromised. The Government set great store by the Dash review, but it is a flawed and dishonest document that misleads the public by what it says. The Dash review is not about patient safety. It puts far more emphasis on quality. It elides quality and safety, which are not the same thing, even if many people believe them to be so.
That concern is reflected by the fact that there are too many recommendations flying around and too many resources being diverted to recommendations that the NHS does not want to implement. All those recommendations are coming from this plethora of public inquiries that Secretaries of State keep setting up. Surely we want to replace the public inquiry system with something much more effective, as we did for rail accidents. After the Ladbroke Grove rail crash, we replaced public inquiries with the rail accident investigation branch in the Department for Transport.
There has not been a public inquiry into a rail accident since the Ladbroke Grove inquiry, because we have the rail accident investigation branch. There has not been a public inquiry into an aviation accident since 1972, because we have the air accidents investigation branch. Why can we not have the same principle for safety in healthcare, instead of this ridiculous Dash review, which is full of falsehoods and misleading statements? I will give the House just one example of that. The review says:
“HSSIB was not able to retain the maternity programme because the Health and Care Act 2022 does not make provision for maternity investigations under HSSIB.”
That is wrong. It had to give them up, because it did not have the capacity to do them.
Lizzi Collinge (Morecambe and Lunesdale) (Lab)
First, I must declare that my husband works for NHS England, which is a bit awkward, if I am honest. Today I will speak to a few different aspects of the NHS modernisation Bill, including the single patient record, the independence of the Health Services Safety Investigations Body, or HSSIB, and possible changes to the make-up of NHS foundation trust boards.
I welcome the introduction of a single unified patient record, accessible to patients and clinicians in one place. Too often patients are forced to carry the burden of holding together their own medical history. I have heard the same story from countless constituents: they arrive at appointments with records that they have pieced together themselves, having to rehash their medical history over and over again to each new clinician. That clearly does not work for the patient, and it does not work for the clinician either, because when clinicians do not have access to the full picture, decisions are made with incomplete information, and the right diagnosis or treatment might be missed or, even worse, an unsafe care decision could be made.
The single patient record addresses long-standing issues of fragmented records and poor communication between NHS services, and this Bill is an opportunity to make things work that much better, but that needs to come with strong safeguards. People rightly want to know that their personal, private information will only be used for proper purposes and will be kept secure. I urge the Secretary of State to take full notice of the Science, Innovation and Technology Committee’s views on that. In other ways, the single patient record can make our data more secure. I recently received a letter containing personal information, and I had been sent to my last house but one. That is not secure at all.
I will talk quickly about the abolition of HSSIB and its responsibilities moving to the CQC. There is a fragmented and confusing patient safety and regulatory landscape, but independence and the appearance of independence in patient safety investigations is very important. I would like strong reassurances from the Minister that there will be still an independent investigative function that patients and staff can have confidence in. Harmed families have told us just how important that is.
Finally, I flag the changes to the make-up of NHS foundation trust boards. The Bill appears to remove the requirement for registered nurses and doctors to be represented on trust boards. I hope that is an oversight that can be examined and rectified in Committee.
For all its faults, the NHS is there for us right from the beginning and right to the end of our lives, and for the most difficult moments in between. From the birth of our children through to every broken bone and every anxious wait in A&E, we are supported by the NHS and its staff. If we want it to remain for future generations, we have to be willing to modernise it, reform it and make sure it is fit for how people live today.
Shockat Adam (Leicester South) (Ind)
We all cherish the NHS, and all of us in this Chamber have a duty to ensure that anybody who does not believe in the basic principle that care should follow need, not wealth, must be nowhere near the jewel in our crown that is the NHS. I begin with primary care—or, indeed, the glaring inequality in primary care. Practices in the most deprived areas carry, on average, 300 more patients per fully qualified GP than those in the least deprived. That gap has grown by 50% since 2018. In Leicester—my constituency and my home—there are 1,985 patients per GP, which is significantly above the national average. The Bill introduces a statutory duty to reduce health inequalities and, under clause 24, to produce neighbourhood health plans, but a plan without the workforce to deliver it is a plan in name only.
I must also declare my interest as a practising optometrist. Clause 14 gives integrated care boards new responsibilities over primary care services, and the Bill transfers commissioning of NHS sight tests from a national framework to individual ICBs. I completely understand the logic of localisation, but I have already seen what happens in practice. In Coventry and Warwickshire, a community urgent eye care service that was diverting more than 13,000 A&E attendances per year was withdrawn at the end of 2025. In Hampshire, community glaucoma schemes have been moved back into hospitals. This is the postcode lottery in action.
Glaucoma affects approximately 700,000 people in the UK, with about half of them walking around undiagnosed. It causes irreversible sight loss, it increases the risk of falls, and it carries serious long-term costs for both the NHS and social care, and we now have the technology to address it more efficiently than ever. The iStent inject device can be inserted during routine cataract surgery in a single procedure, treating both conditions simultaneously. This is exactly the kind of innovation that the 10-year health plan calls for, yet uptake is inconsistent because there is no national commissioning guidance. I urge the Government to ensure that the single patient record supports consistent clinical decision making across the glaucoma pathway, and that integrated care boards are required, not merely permitted, to commission those procedures.
The Bill also abolishes NHS England, and we have heard much about that. History gives us cause for concern, especially when it comes to private finance initiative arrangements, which have cost the NHS tens of billions of pounds over decades.
Let me end by saying something about the Palantir question. The creation of a single patient record is welcome, but the vessel matters as much as the vision. The £330 million NHS federated data platform contract, awarded by the last Government and inherited by this one, raises serious and unresolved questions, and it must be addressed.
Rachael Maskell (York Central) (Lab/Co-op)
The national must determine the “what”, and bringing NHS England into the Department is therefore the right decision. However, as many Members have said today, it is the “how”—how we do this at a local level—that determines the outcomes we see. Given the huge inequalities in our constituencies, which we have all spoken about today, the question of how we deliver, in particular, the third shift to prevention, is really important. The right integration, the right systems and the right focus will bring our health service together at a local level.
I agree that the accountability processes are not in the right place under the Bill, and I agree with the hon. Member for Runnymede and Weybridge (Dr Spencer) about the need to ensure that we in this place have that connection to the national and the local, while also integrating with those held publicly accountable in our councils and combined authorities. But the focus also needs to be there. It is because there is no coterminosity between commissioners and providers that people are looking in both directions in trying to bring about a system that cannot have the capacity to deliver in such ways. We need to see that bringing together of services to focus on a “population health” approach, but the Bill does not do that.
We need to think about what the outcomes that we want to see. I have lived through so many reorganisations, and I know that it is not reorganisations that ever deliver the satisfaction outcome. Given that ICBs have now been stripped back to such an extent—unable to communicate with us, as MPs, and not having the resources to make decisions—I fear that that delivering the “how” will become harder under this model. However, we also need to ensure that local accountability comes from our communities—and that leads me to the issue of healthwatch.
What we called community health councils were abolished in 2003. We replaced them with public and patient involvement forums, and replaced those with local involvement networks and then with healthwatch, which is soon to be scrapped. If it did not exist, we would invent it, because it has the independence that the new structures do not have, giving patients and people confidence in a system that enables them to raise their voices, and to be sure that their voices will be heard and systems will be held to account. I therefore oppose clauses 64 and 65, with the respective schedules 9 and 10, and ask the Government to reconsider and also to take on board the questions that have been raised about the systems that make it possible to hold investigations. HSSIB has done that well, and I think that its role should continue.
Given what has happened over a decade of raising concern in the House, I welcome the commitment of the former Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), to a public inquiry, but we do not have a chair and we do not have terms of reference. It is therefore really important that we put in place the right structures to hold the system to account.
Adrian Ramsay (Waveney Valley) (Green)
The Government present this legislation as technical, restructuring NHS England and reconfiguring integrated care boards. They also say that they want to devolve power from Whitehall and give patients more control over their care. However, there is a mismatch between this presentation and the contents of the Bill. While some responsibilities are being devolved, other powers are being drawn upwards to the Secretary of State, with greater control over spending, appointments and key operational decisions. There are serious concerns about how the patient voice is to be treated, and hearing that voice is essential if we are to address inequality and replace the negative health impacts of austerity, bad planning, poor housing, weak transport and divisive social policies.
With the Bill, we have the chance to address the totally unacceptable 16-year gap in life expectancy between different postcodes in the UK. I therefore urge Ministers to amend the Bill to include clear legal frameworks and a cross-Government strategy to mirror new duties on strategic authorities for tackling health inequalities—inequalities that I see in my constituency, where those without the means to pay for a private dentist endure horrible pain and suffering, and where children go without care; inequalities that mean men in the most deprived areas can expect to live, on average, 11 fewer years in good health than those in the least deprived areas.
It is a real concern that the Bill will permit the Secretary of State to vary the proportion of public and private provision of health services if they consider that to do so is in the interests of the health service. How might that power be used in the hands of a pro-privatisation Secretary of State?
As for the issue of patient voice, it beggars belief that, as drafted, the Bill abolishes the statutory duty underpinning local independent patient and public voice, including the entire network of local healthwatch organisations. That must be rectified. We need independent challenge, because without it accountability is at risk. Healthwatch Norfolk has pointed out that it has a legal power to visit health and social care services and see them in action, but the Bill does not mention that statutory power, or how it might sensibly become the responsibility of the ICB or the local council. What will happen to it? Healthwatch Suffolk has pointed out that recognition of an independent voice for patients has been a principle supported by Governments for 50 years, but if this Bill passes into law unamended, it will end that recognition.
Finally, ensuring that the different records in the health system are in one place so that patients do not have to repeat their stories is an important principle, but that single patient record must be safeguarded. I therefore urge the Minister to rule out awarding the contract for its development to Palantir, so that we can ensure that clear safeguards are in place.
Lewis Atkinson (Sunderland Central) (Lab)
The history of the NHS shows that there is no one way of securing improvement or accountability, and that a range of different mechanisms have a role. Patient voice, patient choice, performance management—including centralised performance management—planning, democratic challenge, competition and collaboration all have a place, and it is for the Government of the day to make a judgment about the right blend of mechanisms with which to pursue their objectives. Overall, I think that the Bill represents a good attempt to do that, given the NHS that this Government inherited and their ambitions, as set out in the NHS plan. There was undoubtedly duplication between the DHSC and NHSE, and returning to the situation before 2012, when there was direct departmental oversight of the NHS, is not a radical step.
There are, of course, costs to this transition. Unfortunately, in terms of morale, I think that these costs were somewhat exacerbated by the regretful manner in which the original announcement about NHSE abolition and ICB changes were made, which did not do justice to the commitment and professionalism of impacted staff. But that does not change the fact that the Government’s overall diagnosis is correct: since the 2012 reforms, accountability has been muddied, and a total reset of regulation is required to empower NHS providers to meet the urgent health needs of the population with the resources available. However, I agree that there are significant questions about the role of HSSIB, and I hope that this issue can be resolved in Committee.
The Government have been clear that they see the future role of ICBs as strategic commissioners. That capability needs to be developed, and I echo the point made by my hon. Friend the Member for Middlesbrough and Thornaby East (Andy McDonald) that it needs to be done with particular care in relation to specialist services. There also needs to be a resolution of how the development of neighbourhood health services will be strategically led. ICBs must retain the capacity to work at place level, and I join others in questioning the proposal to remove local authority representation on ICBs. Combined authority representation does not suitably replace that. Mayors’ responsibilities are entirely different and do not include anything to do with social care or public health that rightly sits with councils, and we need that to be hardwired into ICB membership.
I want to end on an area of healthcare that is the subject of a manifesto commitment that is not currently in the Bill: delivering parity of esteem for mental health. It is unconscionable that waits for NHS mental health services are significantly longer than physical health waits and that, as yet, there is no specific commitment to bring them down. The Health and Care Act 2022 introduced a duty on the Secretary of State to report annually to Parliament on NHS mental health spend. I wonder whether, as part of this Bill, there is scope to widen that duty to include reporting on the different waiting times for physical and mental health, and to make some progress on the very welcome cross-Government mental health strategy that has recently been announced.
Freddie van Mierlo (Henley and Thame) (LD)
All too often in my role as a local MP, I have been frustrated by the buck-passing in the NHS. My local ICB cuts a service, pleading no money, or refuses to fund a new one. It tells me to ask the Government, the Government tell me it is a local decision for the ICB, and the cycle goes on.
With this Bill, I welcome the accountability conferred on the Secretary of State, but I am slightly gobsmacked that he has agreed to it. Every Back Bencher should be rubbing their hands with glee. This legislation makes the Secretary of State personally responsible for commissioning arrangements in all ICBs. I look forward to sending him a letter on the day the Bill receives Royal Assent listing every change I want him to make. My ICB has one of the worst offers on IVF, it has been far too slow to adapt to new dynamics in ADHD and autism, it has left commissioning gaps in palliative care and closed down step-down beds, and now it wants to close down child and adolescent mental health services.
I make this prediction: the office of the Secretary of State for Health and Social Care will balloon under this legislation, because every Back Bencher will appeal to him to make sure that they get their local commissioning arrangements sorted. This reform is, of course, fully in line with the UK’s overly centralised Whitehall system, but it is not in line with the Government’s supposed devolution agenda. Mayors could be the answer, but the Government have been too timid about the role of mayors, who merely sit as members of the ICB. What of areas that have been slow to get mayors?
Although the Bill addresses ICBs, there is no reform of the sclerotically slow-to-act Joint Committee on Vaccination and Immunisation or UK National Screening Committee; they have been painfully slow to act on spinal muscular atrophy screening.
Although I welcome the single patient record, I would like to raise a serious concern. In my constituency, I was recently made aware of a case of a patient’s record being accessed multiple times, unrelated to their care. In fact, they were not receiving care at the hospital at the time; instead, they were campaigning on maternity care. Clinicians had no business looking at the record. Although a single patient record of this scope is welcome, it opens up the abuse of data privacy on steroids. What steps will be taken to protect data and confidentiality?
Finally, I want to discuss how the National Institute for Health and Care Excellence recommendations are implemented. Trusts have 90 days to implement NICE technology appraisals, yet this Bill confers on the Secretary of State the right to change that. How will that be handled? It should definitely be considered further in Committee.
Alex McIntyre (Gloucester) (Lab)
Since the general election, there are 10,000 fewer people stuck on NHS waiting lists in my constituency of Gloucester, we have the green light for two new NHS dental practices, and a new GP surgery is being built in Hucclecote. But now is not the time to pat ourselves on the back and say, “Job well done.” It is not even job half done. We must go further and start to deliver change at the pace that my constituents expect. Too many people in my city still struggle to see their GP or dentist when they need to, are placed on excruciatingly long waiting lists—particularly for mental health—and have to battle just to get a diagnosis. We have to go further.
I am pleased to see the creation of the single patient record. I hear time and again from constituents who are fed up with having to explain their story several times to different medical practitioners. Keeping records that do not speak to each other just does not make sense in the digital world in which we now live. It is inconvenient, frustrating and, most of all, it threatens patient safety. I am also grateful to the Government for taking the bold decision to abolish NHS England. It is clear that the model has not worked and does not provide the value for money that Gloucester residents deserve.
We are facing a health crisis in the UK, with significant gaps in life expectancy across the country. Someone from Gloucester who, like me, lives in Abbeymead is likely to live a whole decade longer than someone who lives just 3 miles down the road in Kingsholm. That is just not acceptable, and it highlights the entrenched health inequalities found in constituencies like mine up and down the country. Deprivation, poverty and a lack of adequate healthcare are harming life chances in every part of our United Kingdom. I therefore urge Ministers to meet the charity Health Equals, and to consider its proposal to strengthen the requirement for the Secretary of State to tackle health inequalities. The Bill should also introduce a duty requiring all Ministers across Government to consider the impact of major policy decisions on health inequalities.
Speaking of cross-governmental missions, I read with interest the report by Alan Milburn last week about young people not in education, employment or training. He sets out in damning detail the impact of the failure of the Conservative Governments to properly invest in mental health services. Today, mental health conditions account for 20% of all ill health in UK, but only 9% of NHS spending. Our Heath Committee has recommended making the mental health investment standard a statutory requirement, and the Government should make such a change.
I also ask the Government to consider amendments that confirm our commitment to tackling the obesity epidemic. I and several other Committee Members were concerned to read press reports that the Government are considering scrapping measures included in the 10-year plan to tackle the obesity crisis. Will the Minister confirm at the Dispatch Box that the Department of Health will not bow to pressure from the supermarkets and large food manufacturers to scrap our important work on obesity? We spend billions of pounds every year on tackling obesity-related illnesses, while food manufacturers and supermarkets lobby to avoid scrutiny. Of course we need to do more to tackle the cost of living, but the food lobby’s argument that we must choose between the cost of the weekly shop and tackling the fact that one in three children are overweight or obese is disingenuous at best.
This Bill is great, but there is more we can do to tackle mental health waiting lists, to tackle obesity and to tackle health inequalities in places like Gloucester.
Andrew George (St Ives) (LD)
It is an enormous pleasure to follow my hon. Friend the Member for Gloucester (Alex McIntyre)—I call him my hon. Friend as he is a fellow member of the Health Committee.
The 2012 Act was mentioned earlier, and I am one of the few Members who was in this House when it was passed. I was sitting on the coalition Benches at the time, but I eventually voted against the Second Reading and the Third Reading of the Bill because it broke the coalition agreement. We had agreed that there would be no top-down reorganisation, but it was the biggest reorganisation that the NHS had ever seen. Although the Liberal Democrats made the Bill significantly less bad—and I congratulate all those involved in that—there was still far too much that damaged the NHS. I welcome this Bill as it addresses some of those deficiencies.
On the points made by the hon. Member for Harwich and North Essex (Sir Bernard Jenkin), I strongly agree about the abolition or the merging of the Health Services Safety Investigations Body into the CQC.
Sir Bernard Jenkin
Clause 59 states:
“The Health Services Safety Investigations Body is abolished.”
It is going to be abolished.
Andrew George
I am grateful to the hon. Gentleman, but the representations made by both the CQC and HSSIB itself seem to refer to its amalgamation into the CQC. The point is that, as he rightly says, a really important role is played by HSSIB, which could be lost as a result. It is a vital safety agency, and its independence is really important. There needs to be a safe space giving those working in the service the confidence that they can blow the whistle confidentially to that service to improve, protect and enhance patient care. There is a major risk, as the evidence has shown, that the protected disclosure of important legal information could in fact be compromised as a result.
Many Members have also referred to clause 4, on reducing inequalities. I entirely agree, but I hope the Minister will also look at geographical inequalities. In my constituency there are places where, as a result of clinical improvements and sub-specialty developments, services are moving further and further away for people facing emergencies. For example, in 10% to 15% of stroke cases, mechanical thrombectomies are required, but in west Cornwall, people need to travel 80 miles to Plymouth to get that service. That geographic inequality is reflected in other areas of sub-specialty too.
Clause 10 refers to not
“causing a variation in the proportion of health services provided by the public or private sector”.
I would be interested in the Minister’s explanation of whether that is to protect the public sector or the private sector.
Other Members referred to the federated data platform. My hon. Friend the Member for Newton Abbot (Martin Wrigley) made an excellent speech on that on 16 April, which I hope the Minister will look at.
Andy MacNae (Rossendale and Darwen) (Lab)
I very much welcome the Bill and the modernisation it will bring. To deliver the change needed requires a fundamental redesign of NHS structures and practices. Without a willingness to make the big changes, we will never deliver on the aspirations of the NHS 10-year plan.
At the same time, patients and NHS staff need to see change now. We cannot reasonably expect our residents and frontline workers to buy into this long-term vision of the NHS when they face so many issues with services right now. How will the Bill and the ongoing change process impact on some of the areas of most concern to my residents in Rossendale and Darwen? Top of the list for us is Blackburn A&E, which is one of the busiest in the country. I fully recognise the work being done by brilliant doctors and nurses to try to manage demand. None the less, the indignity of corridor care remains a blight. Almost every week I hear of patients spending hours and hours in the corridor, not knowing when they will be seen, often in discomfort, feeling exposed, anxious and unsupported. Ending that sort of experience is a crucial test for NHS modernisation. Only when we see the end of corridor care at Blackburn A&E and others will the residents of east Lancashire feel that something has really changed for the better.
As we have heard, the Bill is also about improving patient safety. It includes some significant steps, but, again, what about the practicalities? For years now we have been stuck in a vicious cycle of investigating shocking cases of patient harm and system failure, making numerous recommendations to improve safety and yet failing to implement them, and repeating the same mistakes. We must break the cycle. This cannot only be about simplification; it requires bold action as well. For example, as we have heard many times in this place, we have a crisis in maternity safety and soon Baroness Amos will deliver the report on her national investigation, which is likely to identify a requirement for some really fundamental systemic and cultural change. There will also be areas outside her remit that need to be addressed, such as the role of the regulators in a fit-for-purpose patient safety landscape. I therefore wonder if the Bill goes far enough and if there will be a need for amendment after Baroness Amos reports. Perhaps the Minister will share some thoughts on that.
Finally, I will touch on prevention. The move from sickness to prevention is one of the three big shifts in the NHS 10-year plan. It is surely the key to a health service that is sustainable in the long term. Although the Bill makes some reference to prevention, frankly, a lot of it feels pretty peripheral and leaves some key questions unanswered. For instance, how—in a practical sense—are we enabling ICBs to support prevention at a local level and at a scale that will make a difference? How are we driving the prevention agenda across Government Departments? Are we doing enough to ensure healthy lifestyle habits are developed in early years and at school? Why are we not putting the social prescribing of proven interventions, such as exercise programmes, on the same financial footing as pharmaceutical interventions? And so on and so on.
I suspect the Committee stage will be crucial in ensuring the Bill matches its aspirations. I look forward to the Minister’s thoughts on how we can balance long-term modernisations with delivering change today.
Martin Wrigley (Newton Abbot) (LD)
I will focus on two things: the changes in data privacy and access to support a centralised single patient record, and the abolition of Healthwatch.
Healthwatch is not the same as the other regulators and it should not be amalgamated. Regulators can be amalgamated only if they have a single purpose and a single viewpoint. Healthwatch today is not a regulator but a patient advocate and there are no others in the system. Without Healthwatch, the remainder of the checks and balances come from the medical profession and the health establishment—and we have seen cases where that goes wrong. Healthwatch guards against that. It is a vital body to speak up for the patient, rather than the NHS itself.
James Naish (Rushcliffe) (Lab)
I have had a look at the parliamentary record; Healthwatch has been mentioned over 100 times in the past five years. One key area of focus is its reporting and the insights it provides to Members of Parliament. Does the hon. Gentleman agree with me that whatever replaces Healthwatch must retain that research focus?
Martin Wrigley
I absolutely agree with the hon. Member. We heard earlier how Kevin Dixon of Devon gives us excellent reports of what is happening with Healthwatch.
The modern NHS must run on data, but critically, on data that carries the consent of patients. A single patient record is undeniably critical to see the data of patients all in one place, but it must be built from a patient’s point of view, not from a centralised data-analysis point of view, and with privacy by design from day one. We obviously need GPs to see hospital data and vice versa, and ambulances to see everything that they need to help, but we do not need the new regulation to do that.
The single patient record already exists in a federated model; in Greater Manchester, Merseyside, Shropshire and more, trusts already run interoperable access for care services, GPs and hospitals. The Government admit that but claim it is partial and fragmented. They also claim that the data will remain in the systems where it currently exists. However, with the Bill, the Government are asking to remove all protection of patient data—look at proposed new sections 250E(1) and (3) to the National Health Service Act 2006 as set out in clause 47(2) of the Bill. We are asked to trust somewhere below primary legislation that it will all be okay—we should trust the regulation. It is a big-tech approach to deliver an overreaching centralised system, rather than a distributed interoperable solution.
NHS England has ignored and discounted UK sovereign systems that can and do provide what is required along with patient trust. Systems built over years with focus on patient treatment and defined use cases could be rolled out today with no change required in law and privacy by design built in from day one. Greater Manchester and others have the single patient record capability and the hard-won foundation of trust.
I will be tabling amendments to remove the relaxation of data privacy from the Bill. The measures are unnecessary if NHS England does not follow the Palantir advice and instead follows what has been proven to work in Greater Manchester, Merseyside, Shropshire and many other places. Perhaps it is an example of something that has worked in Manchester that might work everywhere.
Mary Kelly Foy (City of Durham) (Lab)
The NHS needs reform, not least after years of Conservative underfunding, fragmentation and neglect. I strongly support the Government’s commitment to shifting the NHS from sickness to prevention. As co-chair of the APPG on smoking and health, I was proud to support the landmark Tobacco and Vapes Act 2026, but smoking still remains one of the greatest drivers of ill health and inequality. Prevention must be built into the machinery of the NHS, and that must apply to mental health provision too. My constituency office deals with huge volumes of casework involving people waiting too long for support, families in crisis, and vulnerable people being passed between services.
On the safety and voices of patients, we have seen the devastating consequences of failures in breast cancer care at County Durham and Darlington NHS foundation trust. I pay tribute to the brave women who have spoken out after unimaginable distress. Their experience was in sharp contrast to the excellent cancer care that I received only 12 miles away at a neighbouring hospital. I hope that clause 4 of the Bill addresses the postcode lottery in quality of care.
I think of a husband who lost his wife and two sisters who lost their mam after tragic failings in what should have been routine care. Their fight for justice continues. The Bill must not weaken independent scrutiny or make it harder to raise the alarm when things go wrong.
I briefly raise dentistry; as co-chair of the dentistry and oral health APPG, I know that access to NHS dentistry is one of the clearest examples of where the system is failing constituents. Dentistry is public health, and Ministers must explain how ICBs will be held accountable for NHS dental care.
Finally, on the single patient record, there is real potential for better joined-up care, but patients must have confidence that their information is safe, confidential and used in their interest. That means safeguards on NHS data, including the role of private technology companies such as Palantir, and transparency around access by private providers and consultant partnerships, including limited liability partnerships. The point of reform is not to move boxes around Whitehall; it is to ensure that when people in County Durham and across the country need care, they can access it, trust it and be listened to.
Brian Mathew (Melksham and Devizes) (LD)
All of us want to see a better NHS, but there is a profound contradiction at the heart of the Bill: the Government are handing ICBs more responsibility and authority with one hand while cutting them off at the knees with the other. ICBs are being merged, clustered and completely reorganised with no idea of what the landscape will look like in six months, let alone six years down the line.
In my constituency, the Bath and North East Somerset, Swindon and Wiltshire ICB is cutting 50% of its staff. In the midst of this, HCRG Care Group, a private equity-owned provider, has taken over essentially all community health contracts. It has arrived with a rapid programme of change, new technology and frontline staffing cuts, promising efficiency and ease of access, yet patients are facing new barriers, unanswered calls and a mounting backlog of referrals. The ICB is supposed to be overseeing and scrutinising all this while running at half capacity, mid reorganisation, with its own future uncertain. Can the Government assure us that no patient will be lost in the shuffle?
On the subject of robust scrutiny and oversight of our health services, I am alarmed at the proposed abolition of Healthwatch, which has been an independent champion of our patient care for more than a decade. Part of its function will be transferred to ICBs, to add to their ever-growing list of responsibilities. My late friend Anne Keat, a long-serving Healthwatch member, would be highly concerned at the prospect of the NHS being given the role of marking its own homework. Independent scrutiny is vital and healthy for the future of our NHS. Will the Secretary of State please reconsider this element of the Bill?
Dave Robertson (Lichfield) (Lab)
We are here tonight to talk about a very large piece of legislation, but I would like to focus my remarks on just one part of it, which is the changes the Government want to bring in around planning for the future in the NHS, which are so very needed. There is perhaps no better example of where that planning is going wrong than in Burntwood in my constituency.
Almost 20 years ago, a new doctors surgery was planned for the town. The NHS at that time was very good at knocking things down; however, when the coalition Government rode into town in 2010, all the funding for the replacement was cut. Here we are, almost 20 years later, with no replacement. That has been to the detriment of the town: for well over a decade, people in Burntwood have had to see their doctor in portacabins in the leisure centre car park. In all that time, nobody has stepped up to right that wrong.
We thought there might be light at the end of the tunnel in 2023, when we were promised a replacement by the end of last year. But before that happened, some pen pusher at NHS England decided that the existing surgery in that temporary structure had to close, which meant 5,000 patients distributed to other surgeries in the town. In a town of 30,000 people, that is a significant number. They were told simply to disperse them—“It’ll be fine, don’t worry. We’ll just disperse them.” That dispersal was so traumatic that an existing surgery has had to pick up the same temporary structure and is now operating out of there as well. There was also all the paperwork, legal matters and everything that went with that, because NHS England said that it could not extend for two years. I am very pleased to see the back of that particular quango, which so disadvantaged my constituents.
However, that structure is still being used because the replacement is still not here—it was not delivered by the end of 2025. We do not have the planning application yet. We have once again been promised that it will be here by the end of next month.
I am aware that the Reform-led county council inherited this situation and promise from a Conservative-led county council, but it has not sought to talk to the people in Burntwood. The council has not sought to explain why that promise was not going to be met; it just blew past it. It broke the promise with very little expectation. We now have another one, and that must be met, because so many people across the town have seen so many broken promises and false dawns that they are failing to believe that anything will actually come good.
This entire saga reinforces exactly why the Bill is needed and why these changes are needed. I do not want any other community in any other constituency to be overlooked and forgotten in the way that Burntwood in my constituency has been for so long.
Ian Sollom (St Neots and Mid Cambridgeshire) (LD)
Reducing duplication, streamlining priorities, and getting resources close to frontline care—these are reasonable aims. My concern is that in pursuing simplification the Bill makes a series of choices on patient safety that it is not clear have been fully thought through and that risk repeating mistakes that this country has paid a very high price to learn from.
Through successive inquiries, including Mid Staffordshire, Morecambe Bay, Shrewsbury, Ian Paterson—I could name more—Parliament has repeatedly recognised that the NHS cannot be relied on to scrutinise itself. Each found the same pattern: concerns present within the system but not acted on, problems developing in isolated services, and a culture in which those who raised concerns were treated as the difficulty rather than as sources of vital information.
Yet the Bill’s general approach is to remove independent scrutiny rather than improve it. I am not arguing that all the bodies that have been created—Healthwatch, the National Guardian’s Office, which has been absorbed into NHS England, which will now be abolished, and HSSIB—have worked exactly as intended. In fact, I have been working with families and others affected by failings at Cambridge University Hospitals trust. It has been suggested that the trust has not published independent information, commissioned by the trust, that found 32 missed opportunities to identify and address concerns about a paediatric orthopaedic surgeon between 2012 and 2024, and children were harmed as a result.
Sir Bernard Jenkin
I am most grateful to the hon. Gentleman for raising the HSSIB question. The Dash review accused HSSIB of exceeding its remit. That is completely wrong in law, and it was always intended to look at systemic problems across the system. The new investigation function in the CQC will not be able to do that, because it will not be independent.
Ian Sollom
The CQC and HSSIB themselves have expressed concerns about how those two organisations might be brought together. The AAIB is separate from the Civil Aviation Authority, and that model was created for a good reason. The hon. Member made good points about the statistics on that earlier.
Returning to the case I was talking about, a clinician at the trust who did raise concerns formally in 2015 was simultaneously subjected to disciplinary proceedings and told by the trust that they did not want to hear any more complaints. I wish I could say that I had not heard similar stories from NHS staff several times in a little under two years as an MP.
Just because there are some flaws in those independent systems for the NHS, it is not a reason to remove the independence. That would represent a return to conditions that so many of the inquiries warned us about, and I think that patients would rightly question whether lessons have really been learned.
As the Bill proceeds to Committee stage, I urge the Government to ask a simple question about each body that it proposes to absorb or scrap: not just whether the function will still be performed somewhere but whether it will be performed with genuine independence from the organisations that it scrutinises. That independence has been hard-won, and I hope that Ministers will reflect on that carefully before legislating to remove it.
Several hon. Members rose—
Madam Deputy Speaker (Ms Nusrat Ghani)
Order. Interventions are going to make it very difficult for everyone to speak in the debate. I call Dr Beccy Cooper.
Dr Beccy Cooper (Worthing West) (Lab)
I will try to keep my remarks brief. The NHS is one of the most unifying institutions in our country today. It is a huge employer, a major source of pride, and a safety net for us all at our moments of greatest need. We all know that it has been creaking under significant strain for some time now, so it is good to see new life and new energy in the 10-year plan. I welcome this Bill as a response to some of the purpose outlined in the strategy.
A lot of the detail in the Bill has been covered by colleagues already and will doubtless be covered further in the Bill Committee, so I will limit my remarks to single patient records and the role of public health in the Bill. I am fully supportive of a single patient record finally being realised. Our health and care system should revolve around patients, rather than patients revolving around it. It is over 20 years since I was a junior doctor, but I still remember my and my patients’ frustration when I once again had to ask them for their clinical history after they had already told it to the GP, the paramedic and the triage nurse.
This endeavour has been tried several times before. The financial cost of NHS Digital and the litany of platforms, software and systems that have been tried and abandoned provide a wealth of lessons learned to ensure that it is successful this time—which, let us face it, is long overdue. Public trust is very important for health data systems. We could consider new safeguards such as a public interest test for sharing data or bringing back requirements to report to Parliament. The NHS must ensure that the technical know-how is sound, as well as being fleet of foot.
I turn to the role of public and population health in this NHS Bill. Public health must be front and centre to provide the right health services in the right place at the right time. At an ICB level, there is now an explicit requirement for population health considerations to be understood. Integrated care boards will be responsible for commissioning the vast majority of our local NHS services, so they need to know the population health need.
That has been demonstrated in my ICB area of Sussex over the past couple of weeks. In the discussions about proposed sites for neighbourhood health hubs, it became clear that the population needs of my constituency of Worthing West had not been entirely understood when considering sites: there is a large area containing several villages with an ageing population and limited access to transport, whose requirements had not hit the radar of the ICB.
To be clear, this is not about blame—anyone who thinks that planning for population health needs is straightforward is welcome to sit the public health exams in epidemiology and statistics. Expertise is there to be used, and we should draw on it. I therefore suggest that we require a statutory appointment of a lead director of public health to represent the area covered by each integrated care board.
Finally, to guard against a focus solely on reorganisation, alongside this NHS Bill and as a key focus of the 10-year strategy we must have a whole of Government approach that recognises health as a strategic and shared asset—
Navendu Mishra (Stockport) (Lab)
I declare my interest as chair of the all-party parliamentary group on cancer and the donations made by trade unions to my constituency Labour party.
I welcome a Bill to modernise the NHS, but our local hospital in Stockport, Stepping Hill, needs a lot of modernisation. The building is quite old and lots of problems have presented themselves over the years. I am grateful to the Minister for meeting me a few weeks ago to talk about Stepping Hill. The former Health Secretary and I had several conversations about the Stepping Hill estate. I urge the Government to work with me and other Stockport MPs on a long-term solution for Stepping Hill. I am very grateful to all the doctors, nurses and volunteers at Stepping Hill hospital.
I want to mention ICBs, as they feature quite a lot in the Bill. My experience of the Greater Manchester ICB has been quite poor. I thank the British Fertility Society and the charity The Fertility Alliance for all they have done on protecting access to in vitro fertilisation. I also thank in particular my local councillor Karl Wardlaw and his late wife Jodie, and place on record my gratitude to them for all the work they did on protecting access to IVF.
The Greater Manchester ICB consulted on levelling down the offer for NHS-funded IVF treatment across Greater Manchester to just one cycle in each borough, including Stockport; 74% of respondents completely disagreed or disagreed with that proposal. The ICB did the consultation—I am not sure how much time and money it wasted on it—but then proceeded with the levelling down offer of just one cycle of IVF. My experience of the ICB is therefore very poor.
Many constituents have written to me about their concerns about Palantir and access to their data. I know that Unison has also raised significant concerns about the damage done to public confidence by Government data initiatives and the use of organisations such as Palantir, the spy tech firm.
I have limited time. On a more positive note, as we are talking about the NHS, I am always keen to encourage more people to donate blood; I have been donating blood myself for almost 10 years. I place on record my thanks to everyone at the Plymouth Grove donor centre in Manchester. In particular, I thank Connor, Phil, Vivian and Dorcas, who always look after me. May I ask the Government to do more to promote blood donations?
I welcome the Government’s reforms to bring more democracy and accountability to the NHS, but we must ensure that health inequalities are addressed and reduced. In the richest part of my constituency, people can expect to live almost nine years longer than those who live in the most deprived part.
Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
I know of a quite frail diabetic patient with cancer, who underwent several operations as well as complicated chemo in London. He eventually decided that he was well enough to take a short holiday, so he went to Cornwall on the train. Unfortunately, shortly after arriving he was found in a state of collapse by his daughter, and taken to the nearest hospital late on a Saturday night. The doctors had no access to his medical notes, and no answer when they called the hospital in London, so they were puzzled. That situation is familiar to doctors. Patients are incredulous when they are told that we are unable to see all their medical records: “Surely everything is on the computer?”
As a surgeon before becoming an MP, I worked in at least three different hospitals. There was no compatibility between the records, which meant that transferring care was complicated and hazardous. I would be asked to advise on a patient from another hospital, relying on a dictated note from the referring doctor, but I could not access the clinical records, the results of investigations such as the pathology test, scans or, crucially, the operating records. Consultations were delayed as I stared at creaking computers, with numerous software programmes, each individually protected by ever-changing and forgettable passwords, that slowly booted up. That obviously needs to change.
I would link the NHS number to an unique single patient record. I would give ownership of the record to the patient, and let the patient be the custodian and the gatekeeper. That is the truly revolutionary idea. If someone could easily look at their medical record, with appropriate physician safeguards, they could monitor everything—blood pressure, heart rate—and perhaps there would be an incentive for them to look after their health a little better.
Let us imagine for a moment the power of anonymised medical data for a population of 70 million people. The NHS is perhaps the largest complete set of health data on a whole population in the world. That is a huge resource for informing health policy and medical research. By tracking the health outcomes of millions of our fellow citizens, we can sort out all kinds of diseases, such as heart disease, cancer and mental health disorders. I can think of no greater innovation, or more helpful measure to improve the health care of this nation, than a single patient record.
Martin Wrigley
All the features that the hon. Member is asking for are available to people within the Greater Manchester area. Exactly those things are there and work today, even down to the remote monitoring he mentions.
Peter Prinsley
I am grateful for that intervention, and I am aware that in various bits of the country such systems do exist. I would like to see a single patient record that is genuinely single, so that when my hon. Friend the Member for Stroud (Dr Opher), who is sitting next to me, writes something in the record, I can see it, and when I write in my record, he can see it, and no letters are passing back and forth between us. That is why I am sure that legislating for the mandatory single record is what we must do, and as a surgeon who has worked for 40 years in the NHS, I will do everything I can to help.
Dr Simon Opher (Stroud) (Lab)
It is a pleasure to speak in support of the Bill, which I believe has the power to transform patient care in the NHS. Particularly after the remarks of my hon. Friend the Member for Bury St Edmunds and Stowmarket (Peter Prinsley), the House will be aware that I also have a vested interest in this, as I have been a working GP in the NHS in Stroud for at least the last three decades. Indeed, I did a surgery last Friday, and I excitedly told the other doctors that we are going to have a single patient record. Instead of being excited, they said, “It’s about time.”
Those of us working in the NHS have been calling for a single patient record for years, so it is about time that a patient can tell their story just once, and about time a GP knows what a consultant is saying and the consultant knows what the GP is saying. It is about time that, when a patient gets admitted to A&E, the doctors know what the GP has already done, and that, when a patient gets referred to a psychiatrist, they know which antidepressants have been taken. As my hon. Friend said, patients struggle to understand how all the doctors do not know what is going on. We got rid of the fax machine in our surgery only last year, so we are fairly behind on communication, but the Bill lays the foundation for that to be remedied.
The benefits of the Bill for patients are huge—their medical knowledge at their fingertips, just as they are for clinicians and for integration. We cannot have integration without a decent single patient record. On research, our data is a national asset. I fear that a company such as Palantir owning our data is a derogation of our duty, and that we should use that data as a fantastic resource. I am also worried about Palantir’s involvement with death in Gaza and the infringement of civil liberties under the Immigration and Customs Enforcement agency in America. Also, at the Chelsea and Westminster hospital, it seems that the benefits that Palantir said it would bring to the operating theatre were not provable. The data is owned at the moment by GPs, and if there is a spillage of data, GP practices are unlimitedly liable. We must change that; otherwise, no one will become a GP partner. We must also be careful, because excessive and over-the-top safeguarding could obstruct the single patient record, and that would harm patient care.
Peter Prinsley
Does my hon. Friend agree that we must have a single patient record, not simply federated records from other sources?
Dr Opher
I do agree, although that is a much bigger job. At the moment, mental health uses a different system from the hospital, and it would be great to unite them. I agree with that, but whether it would possible in the next couple of years, I am not so sure.
Let me quickly go on to NHS England. The administrative burden on GP surgeries from NHSE has been huge, as my hon. Friend has mentioned, and it will be fantastic to get rid of that. When GPs undergo CQC inspections we have to do pointless protocols to fulfil the criteria, and they involve weeks of work. I want to make a little bid here for a much more supportive, lighter touch approach when looking at proper data around GP surgeries, which we would not have to prepare for. That would be very popular with GPs.
I warmly welcome this Bill. It is about time we reduced the ridiculous administration around patients and allowed clinicians to properly care for patients, and it is about time we had a single patient record.
Liz Twist (Blaydon and Consett) (Lab)
First of all, I very much welcome the Bill. It has been designed to deliver and work with our 10-year plan in that bigger picture.
I will touch on three issues raised with me by my constituents in Blaydon and Consett. The first is the single patient record. Of course it makes absolute sense for everyone to be able to access up-to-date records when a patient is admitted. I think of the groups I have worked with who have rare conditions, for example, who find that when they are taken into a different hospital, the doctors there are unable to access the records of their specialist treatment. That is the first thing, although there is also a good deal of concern among my constituents and others about how that will be managed and brought about, and how the data will be handled and the contracts awarded.
The second issue I wish to raise is Healthwatch. I understand that the Government’s real intention, through the Bill, is to strengthen the patient voice and the ability to raise issues, but there is real concern that an organisation inside the Department of Health and Social Care will not provide that independence. Will the Minister commit to looking again at how that independence can be built in and linked with the ability to pull the levers that Ministers have talked about, in order to make a real difference for patients? It is about getting that balance right.
Finally, I want to talk about parity of esteem for mental health services. As we move from treatment to prevention services, we need to use this legislation to reinforce parity of esteem for mental health services, including in the ability to access them. We need to build in preventive measures and access to those mental health services. I would just like to comment on the point made by my hon. Friend the Member for Worthing West (Dr Cooper) about building public health issues into the overall health framework. We need to look at re-establishing that public mental health function within DHSC under the new arrangements, and indeed within ICBs. We need also to link this to our mental health strategy, which we are expecting in the very near future. I welcome the Bill greatly and look forward to seeing those issues addressed in Committee.
Josh Fenton-Glynn (Calder Valley) (Lab)
This Bill has to be set in the proper context of the mess that we are clearing up from the previous Government. The Darzi report laid bare the crisis in the NHS. We must learn from that Government’s disastrous reorganisation, because we cannot afford to make those mistakes. I approach the Bill as a critical supporter of the changes that we have made and that we seek to make.
I have not always given my right hon. Friend the Member for Ilford North (Wes Streeting) the easiest time, but I pay tribute to his leadership, both on this Bill and in the NHS more generally. Waiting lists are down, treatment is up and we are seeing a real shift to the priorities that we need—from sickness to prevention, from analogue to digital, and from hospital to community. We have seen an overall reduction in NHS waiting lists of more than half a million since July 2024.
I welcome the new Secretary of State to his place. He has a famed eye for detail, which this job demands, and I hope that his background in local government means that he will take seriously the need to get to grips with social care.
Clearly, there is a real problem that needs fixing. Over the past decade, the centre of health policy has increased: staffing across DHSC, NHS England and local commissioning bodies has doubled since 2013, from 20,000 to 40,000. The Lansley reforms were one of the most high-handed acts of sabotage that a Government have ever committed on the health service. They were meant to reduce bureaucracy, improve efficiency and save money, and they achieved none of those things.
Some concerns about the Bill came up in a recent sitting of the Health and Social Care Committee. I am curious as to how, in practice, the merger will be able to concurrently reduce headcount from NHSE, DHSC and ICBs by 50% without causing unintended consequences. I am concerned about that and want to see more detail on it, particularly given the scale of the changes that we are trying to make in the NHS. A report published in 2012 by the Institute for Government entitled “Never Again?”, which looked at the Lansley reforms, warned against making redundancies that are quickly undone as organisations recognise that essential roles have been lost and end up rehiring the same staff. The cost of redundancies under the Bill is estimated at about £1 billion. The cost of the Lansley redundancies was about half that, but one in five of those staff ended up being re-employed by the same organisation. The Select Committee heard before the recess that some areas of the NHS are under-managed, and I do not want clinicians to take on those roles.
Overall, I support the Bill, but we should be clear that a reorganisation of the centre at this scale is not simple. It has to be properly planned, co-ordinated and communicated. I welcome the new Secretary of State, but I hope that the Bill can make the changes we need.
Sojan Joseph (Ashford) (Lab)
We have already seen the difference that a Labour Government can make in improving our NHS. That is the result of the difficult choice that this Labour Government made to prioritise investment in the NHS and our other public services, but I know from my 22 years working in our health service that investment on its own is not enough. That is why I am pleased that this Bill will reverse the legislation passed during the Conservative and Liberal Democrat coalition, which made NHS overly rigid and too prescriptive, increasing bureaucracy and weakening accountability. The Bill is an important part of delivering a reformed NHS by implementing the elements of the plan that require legislation.
I particularly welcome the parts of the Bill that will amend the National Health Service Act to make provision for the establishment of a single patient record. Patients too often receive care that is not as co-ordinated as it could or should be, meaning that they must repeat their story each time they see a different medical professional. From my experience in mental health services, I know that mental health patients go to A&E, explain their story to the doctors there, explain the same story to a mental health worker, and then explain the same story the next day when they are admitted to a mental health ward. That is very challenging for professionals and patients. The single patient record can therefore be very useful.
We also have patients coming from other parts of the country. For example, a patient from Manchester could be admitted in Kent, where the doctors and medical professionals will, in some cases, be unable to access that patient’s records for many days. That delays the treatment, so it will be a big step to have a single patient record.
The other area I welcome is the abolishment of NHS England. During my time in the NHS, I saw layers and layers of management structures and scrutiny by different organisations, which caused lots of repetition, so I welcome the abolishment of NHS England. I would like to see that money go to the frontline, so that we can recruit many more nurses for hands-on patient care.
Finally, I would like to raise the issue that many other colleagues have raised: parity of esteem for mental health services. I would like to hear from the Minister that the single record system will be implemented not just in other parts of the health system, but in mental health services.
Josh Newbury (Cannock Chase) (Lab)
Before becoming an MP, I worked in communications in our NHS. Combined with numerous stories from my constituents, that gives me a view of the NHS at its best, but also where things do not work as they should. Very few of our constituents think about the structures of the NHS. For them, whether it is working right comes down to whether they can see a GP and how long it takes to get a diagnosis and treatment. I welcome the Bill because all of us have constituents who have had to give the same information over and over, wasting their time and their clinician’s time and undermining trust in the fundamentals of a unified national health service.
A member of my team told me about one of her family members who suffered a stroke two years ago. He got to A&E at 11 am, was diagnosed after several hours and then at 6 pm, after several scans, was told that he needed to travel to another hospital to see a specialist. When he got there, he was told that the data had not been passed across, so all those scans and tests had to be done again. Stories like that demonstrate why the single patient record made possible by this Bill is so vital for patients, who should not have to repeat their symptoms, and for clinicians, who want to focus on care.
On the abolition of NHS England, the Government are right to shift money currently tied up in monolithic bureaucracy to frontline services. But as one of, I assume, very few former NHS communicators in this House, I want to dedicate the time I have left to them.
The abolition of NHSE comes at a time when ICBs are shedding half of their staff and are busy clustering. It is a time of immense change and anxiety for staff. I have recently seen a slew of posts from brilliant NHS communicators who are signing off for the last time, or posting bittersweet celebrations of securing a role while many colleagues are leaving. Some see NHS communications jobs as a “nice to have”, but the reality is they are the people who ensure that patients, from general practice through to discharge, know how to get the right care at the right time. They are the ones who spring into action when the phone lines go down. They tell the stories of real people working and getting treated in our NHS, which is so vital to encouraging others to spot early warning signs and come forward.
Comms in the NHS literally saves lives, and that is why when I see comms professionals leaving the NHS, I fear that we could be throwing the baby out with the bathwater through this important and justified process of change. I pay tribute to every NHS communicator, and I hope the Minister will say a little about how these legends will be valued and retained. The Bill will do so much to improve the NHS for millions of people in our country, so I will proudly support it, but let us ensure that we know the value of everyone who makes our NHS world-class.
Luke Murphy (Basingstoke) (Lab)
I welcome the NHS modernisation Bill as the next step in improving our NHS. When I was elected as the Member for Basingstoke, access to GPs, dentists and mental health services was not good enough. There were unacceptably long waits for elective care and at A&E, poor conditions of our hospital building and an overstretched primary care estate, so I welcome the progress made since my election, nationally and locally, through the investment, reform and hard work of NHS staff. We have seen 3,500 fewer people waiting for healthcare at Basingstoke hospital under a Labour Government, more GP appointments delivered across Hampshire than ever before, money to upgrade the practice at Chineham surgery from the Government’s upgrade fund and, after significant pressure from my office, the local council providing developer contributions of nearly £1.4 million for the same surgery. But we do need to go further; we have made progress, but there is so much more to do.
I particularly want to recognise in the Bill the importance of bringing about the single patient record. Before my dad died at the end of last year, he spent many days, weeks and months, over many years, in hospital, including in diabetic foot clinics and dialysis units, and in far too many intensive care units and wards. While the single patient record will bring about safer and more efficient care, the most important thing for me, as many other Members have mentioned, is the reduction of the burden, anxiety and stress placed on both the patient and their carer. When my dad was in hospital, I remember vividly that my mum carried around several sheets of A4 paper with his medical history and medications written on them. She did not just have to present that record to different parts of the NHS—she often had to present it to different units within the same hospital. Rather than worrying about my dad, she was worrying about whether she had brought that record. Clearly, that record should be held by the NHS. I know that many patients will recognise what an advance that will be both for their care and for hospital efficiency.
I recognise that the streamlining and abolition of NHS England will put more services on the frontline. As I said earlier, that is still badly needed in Basingstoke. It will help to improve GP access, deliver the health centre at Winklebury, ensure that there is a neighbourhood health centre across the constituency and further improve the A&E wait, for which there is plan in place.
Jessica Toale (Bournemouth West) (Lab)
In his opening remarks, the Health Secretary set out our record in office on waiting times, patient experience and investment. My local area has benefited from this record level of investment. The BEACH—births, emergency and critical care, children’s health—building at Bournemouth hospital opened in March 2025, improving maternity, children’s and emergency care services. Poole hospital will this year become the largest planned care hospital in the country.
Over the past month, I have been to the opening of two new mental health facilities, representing a £70 million investment in the local area. One of them, the Seastone building, is a high-intensity unit for young people, the first of its kind in our region, and it will stop young people from being sent to Manchester or Newcastle from Dorset or the south-west. I am particularly proud of the commitment to get Winton health centre back open, and we have now secured £1.3 million in investment to do that. It will open in the summer and will bring care closer to my community and alleviate pressure on our local GPs.
I have not met a person in the health system, in education or in the community who does not agree with the NHS 10-year plan’s ambition to move the health system from treatment to prevention and to get more care into the community. The Bill helps us to get closer to delivering this ambition for all people. I want to talk in particular about three often vulnerable communities. My hon. Friend the Member for Thurrock (Jen Craft) spoke eloquently about the experience of children with SEND and their parents, so I ask the Minister to reflect on how the Bill helps with joined-up services and access to specialist care for those young people.
HealthBus, a local charity that I support, brings direct nurse-led care to people experiencing homelessness. Their core ask has been to have access to system 1 records and local NHS historical records to better help their patients. I am grateful to the civil servants who have been helping them to date, but I ask that particular attention is paid to ensuring that the single patient record is rolled out to benefit communities who struggle to engage and get support from existing structures.
We must support our elderly population to get the care they need. I met staff at Lewis-Manning hospice care this week. They have done an incredible amount of work on the number of hospital admissions that people have in their last 12 years of life. They are proposing hospice at home hubs to ensure that up-front investment can help people to spend their last days in dignity. Will the Minister provide reassurance that any frontline services that become available are put into end-of-life care as well?
Finally, when this Labour Government came into office, the fundamental promise of the NHS, that it would be there for us when we need it, had been broken by decades of under-investment, by bureaucracy and by ditching reforms that had been made under the last Labour Government. I am proud of the progress to date, and I support the Bill to improve the patient experience, to put more resources into frontline services and to deliver our NHS 10-year plan, getting care closer to the communities who need it.
Several hon. Members rose—
Madam Deputy Speaker (Ms Nusrat Ghani)
Order. To ensure that the final four speakers can get in, the speaking limit will become two and a half minutes.
Anna Dixon (Shipley) (Lab)
I welcome the Government’s plan to make it easier for doctors and clinicians to share critical information in a single patient record, but I would like the Minister to confirm whether access to patient records could be extended to carers, giving them the ability to access information concerning the person they care for. The NHS often fails to look after our amazing carers, so I am keen for ICBs to have a duty to identify and support the health and wellbeing of our fantastic unpaid family carers, and give them the right to a break.
Our health service needs to do a better job of identifying the next of kin of people who die in its care. There are currently 4,000 public health funerals each year for people whose loved ones cannot be reached, including Ken Bower, a friend of my constituents Cathy and Richard. In his memory, they launched the “Next of Ken” campaign. I invite the Minister to meet me and my constituents to see how this could be embedded in the patient record.
Ministers should promote integration between local authorities and the NHS, and I urge Ministers to implement a stronger duty to integrate health and care services. I welcome the duty to reduce inequalities in access to care, but the Bill needs to go further. I echo calls from colleagues for a cross-Government duty to have due regard to health inequalities.
Finally, as an officer of the APPG on patient safety, I know that the relevant Minister has received many representation on the issue of patient safety, not least from the hon. Member for Harwich and North Essex (Sir Bernard Jenkin). I hope the Minister will provide reassurances that when harm occurs, there will continue to be fully impartial investigation by HSSIB and clinicians will be able to speak openly about safety incidents.
The Health Bill is a comprehensive and ambitious piece of legislation, but I hope that, on the matters I have mentioned, changes will be considered in Committee. Our ambitions must be bold, our delivery must be rapid, and our NHS must be renewed.
Jim Dickson (Dartford) (Lab)
I warmly welcome the priority and the additional investment in our NHS over the first two years of this Government. In my constituency, we are seeing positive change with our newly opened North Kent community diagnostic centre, which is delivering vital tests and results for residents in a few short days from a great building with amazing staff.
On top of that, we are seeing major investment in our local Darent Valley hospital, with £27 million being spent on a new intensive care unit. That said, there is still a long way to go to reduce the length of waits in A&E, and the hospital remains in a building that is prone to problems, as illustrated by a recent water outage that lasted several weeks and affected patient care across half the hospital.
Above all, we need Kent and Medway ICB to recognise the speed of population increase and ensure that there is new primary care capacity to meet it so that GP practices such as Swanscombe health centre are able to cope with patient registration numbers—an extraordinary 38,000 in its case. Health infrastructure must be properly planned alongside new homes, and a test of the powers for the ICBs in this Bill must be that this happens.
I also warmly welcome measures in the Bill to provide a single patient record. This new information must drive fully integrated care, the absence of which is causing worse outcomes for my residents. One of my constituents, Frank Fitzpatrick, suffers from severe coronary artery disease and a separate condition that affects his oesophagus, and he has also had a stroke. He has recently received severely disjointed care, including discharge without medication or a letter, unsafe transport, and a lack of co-ordinated follow-up to provide physiotherapy or monitor his range of conditions. The result has been a major worsening of his health and quality of life. We must urgently bring in proper patient-centred care for Frank and so many others.
I have two final concerns. The winding up of NHS England must ensure that more resources are available and that decisions are made at or near the frontline. With the abolition of Healthwatch, independent scrutiny must not be lost. We will need to be convinced that the patient experience directorate, alongside the local service user voice, will genuinely hold the system to account.
Amanda Martin (Portsmouth North) (Lab)
I do not think there is a single person who thinks the current recording system is working. Navigating this system, whether as a patient, a family member or indeed an MP on behalf of constituents, is a nightmare. When it comes to safety and accountability, it is not transparent, and the experience is made harder for people who regularly move, so I would like to speak about the single patient record and what it will mean for the tens of thousands of people in my city who serve or have served in the armed forces.
Thousands of serving personnel, veterans and their families call Portsmouth home, and many more pass through it at various points in their careers, because one of the defining features of military life is mobility. Serving men and women move regularly at short notice, sometimes across the country and sometimes overseas and back again, and often their families move too. Every new posting means a new GP practice—starting from scratch with a folder of letters and a bag of medication boxes, hoping that the new surgery can piece together a medical history from scraps of paper or that the patient themselves can remember every diagnosis, allergy and procedure. For young families, those expecting a baby or those waiting for a diagnosis or tests, it is stressful, but for someone managing complex or chronic conditions, it is dangerous.
Veterans in Portsmouth have also described to me the exhaustion of having to re-explain their medical history every time they register with a practice, including mental health histories that are deeply personal and difficult to revisit. That is not good enough, and this Bill will help to put it right. The single patient record will mean that when a family moves from Norfolk or Plymouth to somewhere near Portsmouth, their medical records will move too. However, it will not work for those who move from Scotland to Portsmouth, so I urge the Government to work cross-border to rectify that situation.
I also want to acknowledge what the single patient record means for mental health. The mental health needs of veterans are well documented and often unmet. Continuity of care is critical for those managing post-traumatic stress disorder, depression and other service-related conditions. Losing that thread every time a file fails to transfer or a referral gets lost between trusts could cost lives, and the single patient record can hold that thread together.
Military personnel already sacrifice an enormous amount in service to this country. The least we can do is ensure that their health service keeps pace with their demands and those of their families. I am proud to say that this Labour Government are delivering a Bill for our armed forces, and I am proud to say to those people: we see you and we see your family, and your health matters to us.
Sureena Brackenridge (Wolverhampton North East) (Lab)
Given the lack of time remaining in this debate, I will focus my remarks on the long-overdue move to a much-welcomed single patient record.
Many Members will have had constituents get in touch with casework, raising blunders and delays that stem from fragmented patient records. When they have been in severe pain or at their most vulnerable, patients have been asked to repeat the same medical history again and again to different clinicians, whether in hospital or in the GP setting. It is frustrating, and in some cases distressing, especially if the patient is elderly or with neurological conditions such as dementia. A single patient record will ensure that clinicians have the right information at the right time, including on allergies, medications and previous diagnoses, so that they are better placed to make the right decision quickly. Today, we have heard of surgeons who have had to cancel operations because patient histories were incomplete or did not arrive quickly enough. There is consensus that a single patient record will make a significant difference in A&E, for paramedics at the roadside and even in routine care, where small details can have significant consequences.
I must, however, also make clear the concerns of many of my residents in Wolverhampton North East. Bringing together such large volumes of highly sensitive personal data into a single system will inevitably raise questions about cyber-security and data protection. We know that patient data in the UK would be extremely lucrative to some, and many will be acutely aware of international interest in getting hold of our data-rich NHS in order to profiteer. As such, can the Minister set out in more detail the safeguards that will be built into the system from the very start to guard against cyber-attacks and unauthorised access? How will this be controlled, and what oversight will exist to ensure that public confidence is maintained if threats evolve?
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
Before I start, I must declare an interest as an NHS consultant paediatrician, a member of the British Medical Association and a member of the Royal College of Paediatrics and Child Health, as well as someone who has been moved to the back of a waiting list, after asking for a consultant review for the third time, and finding that I still do need it but it will have to wait a bit longer.
Churchill once said:
“Healthy citizens are the greatest asset any country can have”.
Good health is perhaps the most important asset that any individual can have, and I am sure that across the House, we all want the very best healthcare and the most efficient NHS for our constituents. As such, I am confident that this Bill has been brought before the House with the very best of intentions, but does it achieve its goals?
In general, organisational restructure involves some sort of assessment of where we are now, followed by a vision of what the future should look like, and then a focus on how to get smoothly from A to B. The Government started with a review of the current system. They called it the “Independent investigation of the NHS in England”, although the House should note that it was independently conducted by a former Labour Minister. In his report, Lord Darzi said that
“a top-down reorganisation of NHS England and Integrated Care Boards is neither necessary nor desirable”.
The then Secretary of State, the right hon. Member for Ilford North (Wes Streeting), seemed to agree. In September 2024, he was reported as saying that a top-down reorganisation was the “last thing” he wanted to do. Within six months, he seemingly changed his mind, which he is allowed to do, but it is regrettable that, having begun the last thing he wanted to do, such little progress has been made on his promised first acts, such as the roll-out of fracture liaison services. So many other promises are delayed, undelivered or, in the case of the promise to double the number of medical school places, somewhat bizarrely denied.
Another of the Government’s stated objectives is improving the patient experience. At the moment, we have Healthwatch—an independent organisation that listens to patients and provides feedback. More than 300,000 people a year share their experiences with their local Healthwatch to improve services, and that feedback has led to positive change. The Government cited Healthwatch data in their King’s Speech publication. Against the backdrop of rising clinical negligence claims, concerns about maternity care and even reports of abuse in hospitals, it is clear that more must be done to listen to patients and address the problems, but this Bill abolishes Healthwatch England and effectively ends local Healthwatch organisations. The Government plan to replace it with a patient experience directorate within the Department of Health and Social Care. As Councillor Dr Wendy Taylor of the Local Government Association has warned that this
“risks organisations being seen to mark their own homework.”
There is another concern. Facts are stubborn, but statistics can be pliable. How can the public ensure that they are getting reality and not spin from the Government? Ministers keep celebrating falling waiting lists, when in fact patients are being removed from the list without treatment because their appointments have been cancelled, because they missed an appointment they were not told about, because they have not filled in a form, or because they were called several times asking if they still needed an elective operation and agreed to see a consultant to check.
My hon. Friend the Member for Harwich and North Essex (Sir Bernard Jenkin) made a passionate speech about the importance of HSSIB. This Bill seeks to abolish the Health Services Safety Investigations Body. It provides a safe space, modelled on air accident investigations. Through the avoidance of blame and liability, it can get to the truth and prevent future tragedies. The Bill abolishes HSSIB apparently to simplify the patient safety landscape and reduce the number of organisations. In response to criticism, the Government have attempted to provide reassurance by saying that HSSIB will retain autonomy within the CQC, but the Government cannot have it both ways. Is HSSIB being abolished, or is it being hidden within the CQC?
Either way, the new unit within the CQC will face a number of challenges, such as the undermining of confidence in safe spaces, because it will be within a regulatory body. Its independence will be undermined, because Ministers have now signalled their intent to direct the vast majority of investigations and because the national quality board will prioritise any recommendations that they make. We will also have a CQC board without full oversight of what it is accountable for and, somewhat bizarrely, a risk that if the regulatory part of the CQC wants information from the safe space, and the other part of the CQC does not want to publish it, we could see the CQC suing itself. We have all this upheaval to have one less—or at least the illusion of one less—organisation. How on earth does that improve patient safety?
As many have said, including my hon. Friends the Members for Runnymede and Weybridge (Dr Spencer) and for South Northamptonshire (Sarah Bool), the single patient record is a good idea in principle. Patient information is currently fragmented across different parts of the healthcare system, and bringing it together could save lives, save time and improve prevention. However, the introduction of such a system must be well executed.
First, there are practicality concerns. Do patients want their full medical records, including sensitive conditions and perhaps including sexual health records, visible to every health professional? The hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) talked about the difference between a single patient record that is all of the same type and one that is part of a federated platform. The Secretary of State talked about linking up people’s ability to see the current system, but there is huge variety in systems. Even within one hospital, there might be a different system for maternity, A&E, blood results, historical notes and current clinic appointments. Will NHS staff be required to learn all those systems for all over the country, or will data be transferred to a new system? Either move has its downsides, but I am not clear which the Government intend to do.
Secondly, there are security concerns. As has been said, the NHS has the most valuable health dataset in the world. The Government must provide clarity in relation to who controls the data, who is responsible for maintaining its accuracy, and how it will be kept securely. Hackers are already trying to gain access to it, knowing that even if it is encrypted, quantum computing will be able to unpick encryption in the years to come. The Government must ensure that they are quantum-ready. What role is the National Cyber Security Centre playing in this regard?
Life, in all things, is a balance. If arm’s length bodies are in control of things for which Ministers are nominally responsible, we have a democratic deficit, and it is understandable that the Government want to recoup that, but, as we heard from my hon. Friend the Member for Meriden and Solihull East (Saqib Bhatti), the powers in the Bill for them to take control of everything risk the creation of a politicised service in which those who shout the loudest get preferential treatment. Those with very rare conditions such as corticobasal degeneration, Wiskott-Aldrich syndrome, Lafora body disease, Friedrich’s ataxia and many more such conditions may not have as well-funded or celebrity lobby groups acting on their behalf as those with other conditions. How will the Secretary of State ensure that clinical need drives the provision of services, rather than the resources of lobby groups or access to Ministers or, indeed, the Secretary of State?
As the NHS is undergoing a massive reorganisation, I am mindful of what the Minister once said:
“The reorganisation of health services always distracts from people’s jobs, destroys morale and wastes money”.—[Official Report, 22 September 2022; Vol. 680, c. 809.]
It also stalls progress and takes a lot of staff time, which may be why we have a 10-year health plan that took a year to write, why the workforce plan has still not been produced, why the so-called “rapid” national maternity investigation has not been completed, why waiting lists are up for patients referred for admission in several specialities, why we have a glacially slow roll-out of fracture liaison services, why the mechanical thrombectomy service promised for stroke victims by April is not available, why there is no response to the Hughes report, why there is a denial of the promise of an increase in the number of medical school places, and why doctors have announced their 16th strike, costing millions of pounds in appointments. The Government promised results, but all they have delivered is disruption, delay and disappointment.
I feel for the current Health Secretary. His predecessor was more focused on unseating the Prime Minister, and he is left to pick up the pieces. However, despite our political differences, I do have hope. Previously, he insisted that trans women were women, but I understand that he has now changed his mind. He has listened, and he has accepted that biological women are distinct and require single-sex spaces, in line with the law, biology, and common sense. I am therefore hopeful that the new Health Secretary will also listen to concerns about the Bill, and that we can work together in Committee to improve it. As I said at the beginning, we all want the best possible health service for our constituents.
The Minister for Secondary Care (Karin Smyth)
I was going to say that sometimes it is the hope that kills you, but instead I will say that it is a pleasure to close the debate on behalf of this Government.
Let me begin by commending the many fantastic speeches that we have heard this evening. My hon. Friend the Member for Middlesbrough and Thornaby East (Andy McDonald) made some excellent points about spinal cord injury and specialised commissioning. His comments apply to many people, and I take them on board. My hon. Friend the Member for Beckenham and Penge (Liam Conlon) talked about the experience of Alex Savage and his work with the Tessa Jowell Foundation; we thank Mr Savage for that, and mourn his passing. The Chair of the Health and Social Care Committee, the hon. Member for Oxford West and Abingdon (Layla Moran), made a number of valuable points, and I will continue to engage with her and her Committee. I also note the points made by my hon. Friend the Member for Calder Valley (Josh Fenton-Glynn). My hon. Friends the Members for Thurrock (Jen Craft) and for Bexleyheath and Crayford (Daniel Francis) talked about the experience that they bring to this place in relation to SEND, supporting disabled people—particularly children—and joining up services. My hon. Friend the Member for Dudley (Sonia Kumar) drew on her experience of designing services for the future around people and patients.
As ever, I thank my hon. Friend the Member for Sunderland Central (Lewis Atkinson)—another excellent manager from the service—for the expertise that he brought to the debate. My hon. Friend the Member for Cannock Chase (Josh Newbury) made some excellent points about professionals in NHS England, and about communications professionals as well. We know that it is difficult, and we want to use their expertise as we go forward. My hon. Friends the Members for Gloucester (Alex McIntyre), for Rossendale and Darwen (Andy MacNae) and for Stockport (Navendu Mishra) talked about mental health, obesity prevention and their local services. I thank the former Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), for his support for my work in presenting the Bill, and I am relieved that he is still here in support this evening. That is good to know. A week is a long time in politics.
As I often tell people—you have heard it before, Madam Deputy Speaker—I have Lord Lansley to thank —or blame—for my being at this Dispatch Box. I left the NHS and stood for the Bristol South constituency because I could see the coming catastrophe of those coalition reforms. In 2010, patient satisfaction was an all-time high; in 2024, it is at an all-time low. In 2010, the last Government inherited the shortest waiting lists in history; in 2024, they left the waiting lists at record highs. In 2010, the NHS was efficient and delivered value for money; by 2024, we had dropped down international rankings despite a massive increase in headcount at the centre. That is the scorecard that the last Government left for the 2012 reorganisation.
In preparing for this debate, I have looked through my past comments since becoming an MP. In 2016, I said that despite being a non-executive director and manager in the NHS, I could not easily navigate the plethora of bodies in the health and care field. From 2016, it got worse. Each crisis or scandal brought more so-called independent bodies, but no more efficiency, effectiveness or, crucially, safety. We on the Public Accounts Committee were desperately trying to get clarity on accountability for spending, but we did not get it. In 2019—this is on the record—I did an interview with the Health Service Journal in which I highlighted how the role of Parliament in nodding through the estimates bore no relation to financial accountability or spending in my local NHS, and how it was impossible to follow through on funding allocations for facilities for my constituents, or even to understand the decision making of local commissioners, trust boards, regions, NHS England, the Department or the Treasury. When I sat on the Opposition Benches, I watched Tory MP after Tory MP chastise their own Government about what was happening in their constituencies, which was met with a shrug of the shoulders to say, “It’s all down to NHS England.”
The Opposition spokesperson, the hon. Member for Sleaford and North Hykeham (Dr Johnson), talked about ICB accountability, but there is none. Many MPs come to me and say that they cannot get a response from their ICBs. At the moment, some people cannot even get a response to their emails. It is shocking, as my hon. Friend the Member for Lichfield (Dave Robertson) outlined so clearly. The Conservatives’ approach was to hand £200 billion of taxpayers’ money to one body, and more taxpayers’ money to a host of others that were charged with delivering, monitoring and checking a health system in which there is a lot of monitoring, a lot of checking and no end of tick boxes but, crucially, too little delivery of the high-quality services that the British public deserve and the staff want to give.
That cavalier approach changed with this Labour Government, why is why we are bringing forward this Bill. We are abolishing NHS England, devolving commissioning budgets to ICBs, putting patient voice at the heart of the new directorate, and making local commissioners in councils and ICBs embed patient voice and experience in their commissioning, rather than outsourcing their responsibility and then ignoring it. The system does not work, and Members know it. Patients deserve better.
This is the biggest transfer of power to local systems that we have seen. Most significantly, this Government are delivering on giving power to patients, who are frankly astonished to find in 2026 that their records are not joined up in the NHS. My hon. Friend the Member for Portsmouth North (Amanda Martin) made an excellent point about the impact that that has on veterans. Although we have a patchwork of local workarounds that benefit a few people—in Manchester, Bristol or the north-east, for example—patients across England have the right to their own record, and for their clinicians to have access in order to deliver the care they need. That point was well made by my hon. Friends the Members for Glasgow South West (Dr Ahmed), for Ashford (Sojan Joseph), and for Bury St Edmunds and Stowmarket (Peter Prinsley), all of whom gave us real examples of patient experience. As my hon. Friend the Member for Stroud (Dr Opher) says, it is about time that we had single patient records. We heard about the impact on patients from my hon. Friend the Member for Basingstoke (Luke Murphy), who spoke about the sad passing of his father.
A lot of questions have rightly been asked about the single patient record and data, including by the hon. Member for South Northamptonshire (Sarah Bool), my hon. Friend the Member for Morecambe and Lunesdale (Lizzi Collinge), the hon. Member for Newton Abbot (Martin Wrigley), and my hon. Friends the Members for City of Durham (Mary Kelly Foy), for Worthing West (Dr Cooper), for Bournemouth West (Jessica Toale) and for Wolverhampton North East (Sureena Brackenridge). We want to make sure that we get this right. They should know that although the Bill establishes the legal framework for the SPR, much of the detail will be in secondary legislation. I can assure the House that all Members will have a chance to scrutinise the regulations in due course. However, we firmly believe that pursuing a single patient record is the right thing to do. We have found that patients and staff support it, as long as it is built with the strongest safeguards for security and privacy. We hear their concerns, and we will make sure that those safeguards are built in.
The single patient record will protect personal data by default. It will be considered critical national infrastructure, with the highest standards of cyber-security and information governance, so that only the right people can access the right information at the right time and for the right reasons. There will be audit trails of who has accessed a patient’s data, and UK GDPR and the Data Protection Act 2018 will apply. The Bill does not create new legal gateways for purposes other than direct care. It does allow data to be used for research, population analysis and service improvement, but only where there is a separate legal basis for doing so.
Let me pick up on the issue of accountability, which is very important to me personally. I agree that it is important to get this right, and we need to work both nationally and locally. I am old enough to remember the world before 2012. For 60 years, the Secretary of State had overall responsibility and accountability for this service. I think the comments about local accountability were well made by the hon. Member for Runnymede and Weybridge (Dr Spencer) and my hon. Friends the Members for Birmingham Erdington (Paulette Hamilton) and for York Central (Rachael Maskell). Let me be clear: the Bill puts more power, not less, in the hands of local organisations. ICBs will be responsible for commissioning a wider range of services, including primary care, and they will hold a large proportion of the NHS budget—over £179 billion, as before—but at the same time the public expect Ministers to be accountable for the NHS they pay for.
Therefore, Ministers should have the tools to hold ICBs to account and direct the system where necessary. That is why the Bill provides the Secretary of State with a power of direction, but with important safeguards on appointing specific individuals and directions to intervene in decisions about services provided to a particular person. If a NICE recommendation on a drug or treatment exists, this takes precedence over a direction. The powers in the Bill will ensure the Secretary of State is able to create the conditions for ICBs to succeed with effective and proportionate forms of intervention, where necessary.
Another major point made this evening was about Healthwatch. I think there is an important philosophical point about independence, the perception of independence and effective decision making, which we will discuss in Committee and it will be important to do so. However, as the Liberal Democrat spokesperson, the hon. Member for North Shropshire (Helen Morgan), outlined very well, we have had these bodies for 50 years. Patients are saying that the system does not work and are not reporting to it, so the system does not work. I listened carefully to the hon. Member for St Neots and Mid Cambridgeshire (Ian Sollom) and my hon. Friends the Members for Blaydon and Consett (Liz Twist) and for Dartford (Jim Dickson) about getting the balance right, and we will discuss those really valuable points.
Currently, the patient voice sits isolated in separate organisations, which criticise the status quo but are not able to change it. That is why we want a new director of patient experience in the Department to ensure that voices are heard as part of every decision. Locally, it is the job of the commissioner—and I have been a commissioner—and of a good commission organisation to include the patient voice and experience in all its decision making. That is where the difference is made, and such organisations should not be outsourcing those decisions. That is the difference, but a debate is to be had, and we have to assure people on the perception issue. We want to ensure local ICBs incorporate the patient voice and experience appropriately—including digitally excluded people, as the hon. Member for Meriden and Solihull East (Saqib Bhatti) said— into their decision making. How that happens is not set in stone. It is our job to set the destination, not exactly how we get there. If an organisation can provide a good service locally for the patient voice and experience, the ICB could continue to contract with it.
Briefly on HSSIB, I hear the points from the hon. Member for Harwich and North Essex (Sir Bernard Jenkin), whom I have met, and my hon. Friend the Member for Shipley (Anna Dixon) and other Members have raised these issues. The Dash review is very clear—I recommend Members to read it—and it is why the new CQC will combine its regulatory functions with the depth of HSSIB’s investigatory capability to the benefit of both. As was rightly raised by the hon. Member for St Ives (Andrew George), the safe space is important to enable people to share concerns in confidence, and that is safeguarded in the Bill. I understand that there is a perception issue, but we must ensure that that is real. The CQC has also raised some operational issues with implementing the integration of HSSIB, and we are working with it to ensure that, when passed, the measures concerned will be implemented effectively.
To conclude, the Bill is only one part of our modernisation agenda, but it is a crucial one, because for decades Governments have failed to grapple with this fragmentation. Like capital and the workforce, the problem was put in the “too difficult” box and left to this Government to solve, but solve it we will. The single patient record will finally mean patients get the joined-up, proactive care they deserve. By voting for this Bill, we can have a fresh start in NHS history. I commend it to the House.
Question put and agreed to.
Bill accordingly read a Second time.
Health Bill: Programme
Motion made, and Question put forthwith (Standing Order No. 83A(7)),
That the following provisions shall apply to the Health Bill:
Committal
(1) That the Bill shall be committed to a Public Bill Committee.
Proceedings in Public Bill Committee
(2) Proceedings in the Public Bill Committee shall (so far as not previously concluded) be brought to a conclusion on Thursday 16 July 2026.
(3) The Public Bill Committee shall have leave to sit twice on the first day on which it meets.
Consideration and Third Reading
(4) Proceedings on Consideration shall (so far as not previously concluded) be brought to a conclusion one hour before the moment of interruption on the day on which those proceedings are commenced.
(5) Proceedings on Third Reading shall (so far as not previously concluded) be brought to a conclusion at the moment of interruption on that day.
(6) Standing Order No. 83B (Programming committees) shall not apply to proceedings on Consideration and Third Reading.
Other proceedings
(7) Any other proceedings on the Bill may be programmed.—(Jade Botterill.)
Question agreed to.
Health Bill: Money
Monday 1st June 2026
(1 month ago)
Commons ChamberRead Full debate Health Bill 2026-27 Read Hansard Text
Health Bill (Second sitting)
Tuesday 16th June 2026
(2 weeks, 2 days ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 16 June 2026 - (16 Jun 2026)
The Chair
We will first hear oral evidence from the NHS Alliance and the Royal Berkshire NHS foundation trust. We have until 2.30 pm for this panel. Gentlemen, I will be grateful if you would be kind enough, from left to right, to introduce yourselves for the sake of the record.
Sir Ciarán Devane: I am Ciarán Devane, chief executive of the NHS Alliance.
James Blythe: I am James Blythe, chief executive of the Royal Berkshire NHS foundation trust.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
Q
Sir Ciarán Devane: First of all, the ICBs have had their 50% cuts and they are in the middle of reorienting themselves and joining up, so there has been a degree of distraction. The second thing, though, is the idea that the ICBs should be strategic commissioners, working well to commission plans that genuinely reform services. I think we all support that, and the move to give them GP commissioning, pharmacy provision and so on. All of that is good.
The challenge will be that the baseline for the current year is not necessarily the outturn of last year, because there were some one-off savings in that, so our members across the NHS are saying that this is the year when the trade-offs have to be made. Some of those trade-offs will be good, in the sense of we can reconfigure this service, move some services into the community and do some good things—I am sure we will hear about some of those—but some of them will require difficult decisions to do with whether we shut down the service in this hospital and double down on the one over there. Making those decisions will need political cover locally as well as nationally, so we are in a tricky place.
What we are saying is that we all understand the state of the public finances and suchlike, but we need some capital to allow places to reconfigure and redesign their services, whether that is new IT, AI or diagnostic services. Those are the things that will allow the transformations to take place, which is where the productivity and the money will come from. What we and chief executives, finance directors and chairs across the NHS are saying is that there is only so much heavy lifting that asking people to run around the hamster wheel a bit quicker can do. We have to make some of those big decisions.
Dr Johnson
Q
Sir Ciarán Devane: We are unclear and concerned about what the nature of those interventions could be. In theory, we fully understand that the Secretary of State and the Government need the ability to say, “In the unlikely event an ICB goes rogue, we have to have the right to sort it out,” but we need to guard against the alternative of a Secretary of State who is intervening too much and making decisions on particular services, commissioning decisions or reconfigurations. We want the legislation to prescribe the circumstances in which the board of an ICB can be overruled. That should be transparent, it should be published, and intervention should be rare. We recognise that that backstop needs to be there for the sake of good governance, but we need checks and balances. The powers are needed if somebody is operating outside their licence, but we need to guard against the Secretary of State or the regions or the new departments reaching in and second-guessing local decision making. If this is really about empowering strategic commissioners to do what is right for their populations, working closely with local authorities, interventions that second guess their decisions need to be very rare.
Dr Johnson
Q
James Blythe: Councils of governors across the NHS have added significant value since they were instituted and brought into foundation trusts. The foundation trust councils of governors play two roles. The first relates to the appointment and holding to account of the non-executive directors on the board. The second relates to securing public and patient involvement and voice in the organisation and the management of our services.
Since councils of governors were instituted, we have developed increasingly sophisticated ways of getting public and patient voice into services. If you look at innovations such as maternity and neonatal voices partnerships, which really involve service users in how services are developed on the ground and are very close to the teams that are running them, that gives us different ways of involving patients and the public in services where possibly councils of governors have not been able to do in the past. Councils of governors have played a really important role in foundation trusts, but certainly in terms of that patient and public voice function, we have moved on as a system and developed more sophisticated ways of doing that.
The Minister for Secondary Care (Karin Smyth)
Q
Sir Ciarán Devane: The biggest difference should be that the local providers and ICBs are incentivised to get together to make collective commissioning decisions. That means that, whether you call it a neighbourhood, footprint or local authority area, they make those decisions based on population evidence, which is why the single patient record is important, and they have the autonomy to do that with a lighter-touch centre that is set in guidance saying, “Look, this is broadly what we’d like you to do.” That guidance should be developed in conjunction with the people who have to do the job on the ground. That is what it should be; if the Bill allows that, that is fantastic.
The second bit is that the mechanism—it is not necessarily a legislative thing—by which the NHS is managed day-to-day will still need to exist. Who is going to be keeping an eye on things 24/7, 365 days a year? What happens if there is a fire—maybe even a literal fire—in a hospital? How is the NHS going to be corralled and brought in to help out a trust where something like that happens? That management function—the day-to-day operational management—needs to remain strong enough in the target operating model, as it is called, in the Department. If it is not, that could prove very difficult. Not necessarily day to day or in the short term, but in the long term, that bit has to be got right. One of the big risks of the legislation—there is not a legislative solution to this risk—is how day-to-day management works. We all have views on the relative strengths of the regions, of NHS England and so on, but how is that going to work in the new world? If one loses “grip”—that word is used a lot—then the risk to service delivery is quite high, and the risk to financial control is even higher.
James Blythe: Put simply, as an NHS organisational leader I think there are always a lot of things from which you can take your guidance on what you should be prioritising and focusing on as an organisation. If the result of this legislation is that we as organisational leaders have a really tightly defined set of priorities to deliver, articulated as far as possible as outcomes for local people and our population as a whole in terms of waiting times, quality and improving population health, I think that will allow us locally to get on with the partnerships that we already have as a day-to-day part of running local public services. We can focus on that very small set of things and do them really well.
Over the last year, there has been a sense of increasing clarity about those priorities as NHS England and the Department of Health and Social Care have worked more closely together. The NHS has delivered on those priorities to a large degree, but it all comes down, as my colleague says, to how senior officials and Ministers operate the system, because there is to be significantly more freedom to set priorities, and to design and run the system that essentially delivers them for the NHS. How that is done, retaining clarity about the things that we want to have delivered through the system and empowering local systems to do them will be really important.
Karin Smyth
Q
Sir Ciarán Devane: No, we are not.
Karin Smyth
Q
Sir Ciarán Devane: Yes, completely.
Karin Smyth
Q
James Blythe: I think the single patient record offers enormous opportunities to improve patient care. We know that we see patients every day whose quality of care and patient experience would be improved through having access to a continuous record that ran through primary and secondary care, mental health care and other services. To my mind, having had experience of working with systems that have introduced to some degree the single record or a single care plan, it will be extremely important that we take the time to train our clinical staff and adapt our operational systems so they use a patient record productively and consistently in the interests of better patient care. If we just put a single patient record into clinical settings without doing anything with the staff or services to make it useful, at best it will be inconsistently used and sometimes it will just be missed altogether. If we are going to invest, which I think is right, in a single patient record, we also have to invest in those systems and human factors around it, and make sure that we train people to use it well.
Helen Morgan (North Shropshire) (LD)
Q
Can I ask about Healthwatch? We heard this morning that ICBs will be taking on a chunk of the current operations of local healthwatches, but that they will not have any additional budget to enable them to do that. In fact, we know that their budgets have been significantly reduced. Could you elaborate on how you think that will work, and will it be as effective as the current system?
Sir Ciarán Devane: The ICBs have a capitation fee of £19.40, which they have to do everything out of. This is an additional duty placed on them. They will have to work out how to do it if there is no extra money coming, but it will be pressured.
I hear the argument that local healthwatches were variable. This function has been slightly outside and independent, playing back into decisions; we have to ensure that the level of independence remains somehow in how this is constructed, but that the variability is not just transferred from local healthwatches to how it is done within or across ICBs. Again, the implementation will need to be done well. That leads into the question about local authorities and the connection with them, making sure the democratic voice is brought in and equally the local voice. The legislation does not stop an ICB doing this well. Therefore, without the legislation, part of what we can be doing collectively is trying to make sure that what was good about healthwatches is preserved and is understood by ICBs. There are only 25 of them, so it should be a manageable task for the rest of us.
The effectiveness comes back to whether you believe this is a good thing. One of the things we have to do is secure that the benefits of having the patient voice in there, along with the clinical voice and the voice of the manager, at the same time, so that it is not a case of saying, “Oh, now we’ll go and consult the patients on the font size of the report,” but is authentic. That puts a lot of work on to the ICBs and on to those of us who believe passionately in engaging with the patient voice, but there is a risk because of that pressure. Done well, it will enable strategic commissioning and ensure the quality remains, but they are starting, if maybe not from scratch, from a new place.
Helen Morgan
Q
Sir Ciarán Devane: According to the ICBs we are talking to, which is all of them, they are saying that they believe in local authority engagement. We will be saying, “You may not be told you have to, but we would encourage you to do it.” I am sure that should be coming from the Department as well.
The witness to my right is an example of that; we know that when the NHS has really good local connections, you can get things done in the interests of your patients much more easily. The belief is there, but we need to make sure that the legislation is not seen as a signal that this is unimportant. That is a risk. As a representative organisation, we have to say to people, “We hear you saying that you really believe in this. Therefore, you need to demonstrate, not least to the Secretary of State, that you are following it through.”
I have a small additional point about mayors in unitary authorities being able to appoint somebody who is both the chair of the ICB and the local health commissioner. That should help. Those individuals will have to work out how to serve two masters, but that is okay—other people learn how to do that, too.
James Blythe: I would focus on a slightly different part of the Bill in terms of how this needs to work. There are 25 ICBs; that is quite a large footprint. From my experience of delivering meaningful collaboration and joint working between health and local government, I think it tends to happen at a more local level than that. The neighbourhood health plan in the Bill becomes extremely important. As a system, we should be very ambitious for those neighbourhood health plans. They should go a lot further than just describing what should happen in terms of improving health outcomes at a local level.
We should set an aspiration as a system that there should be a responsibility on health bodies and local government bodies to describe how changes will be made. The role of ICBs is to enable groups of providers and other organisations in local areas—most ICBs will have several places—to come together and not just work out what a local population needs, but actually do it. That will mainly be about relationships on the ground between an acute hospital team, a community services team, a mental health team and a social work team.
The role of ICBs is very much to give the contractual tools and mechanisms to local NHS organisations to work effectively with their local authorities so that there are really good neighbourhood health plans. Most importantly, they should not just write them but actually see them through.
Liz Twist (Blaydon and Consett) (Lab)
Q
Sir Ciarán Devane: I go back to our having to convince people. Many people are convinced—that is probably the first thing to say. But we have to convince people of the benefit of doing this. Delivering the ambitious neighbourhood health plans that James describes will happen only if everybody is in the room and doing it.
I do not necessarily think that the legislation can mandate that belief or the way to do that. However, it can set an expectation for the ICB that, in developing its plans, it should be able to demonstrate that it has engaged with the local authorities, patient organisations and the public local to it. The legislation can set an expectation that the ICB is using population evidence to make the right commissioning choices and that, if reconfigurations, which may well be locally contentious, are to happen, engagement happens beforehand. As elected Members, the Committee will know that those conversations should start early and that local populations should not just be bounced into something.
It will be incumbent on the new department to set those expectations with the ICBs about the new way of working. That is the only way we are going to create an NHS that will be able to cope with the number of frail, elderly people with multiple morbidities. Those people are a consequence of the success of the NHS over decades. People are living longer with cancer; the prevalence of cancer—the number of people alive with cancer—has doubled in 20 years. But that means that there are four million people who are not necessarily well. The only way to cope with that is to make a significant and radical change to the neighbourhood health plans and bring the public with us. That will happen only with proper patient and public engagement.
Liz Twist
Q
Sir Ciarán Devane: Yes, I do. I was in Epping recently, at St Margaret’s. I talked to the lady who runs the patient engagement: she is a volunteer and is a patient herself. They are a very good example, because they have said, “If we want to provide good services and avoid people turning up at the A&E in Harlow, we can do a neighbourhood diagnostic service.” The patient representatives got in very early. They ran some public meetings ahead of it and said, “We are thinking of doing this: what do you think? We’ll feed it back.”
Everything good is happening somewhere. It is the variability that is causing the problem. We need to make sure that good practices are deployed across the sector. That has to be the expectation: if this reform, which is huge, is to deliver value, that is the value that it has to deliver.
Gregory Stafford (Farnham and Bordon) (Con)
Q
James Blythe: With a lot of foundation trusts, as the NHS has moved into a period of increasingly tight financial control and as we have needed to recover from the covid pandemic, far closer working has been required between all NHS providers and the centre, to manage both the financial implications and the pandemic’s implications for patient access and patient quality.
Having recently moved from a senior leadership, board-level role in an NHS trust to two roles as chief executive in a foundation trust, I do not feel that in the day-to-day relationship with the centre and with our local and regional representatives there is an enormous difference in how we balance quality, finance and performance now. Those foundation trust freedoms were most relevant when we were in a system in which expenditure on health could grow and we were not trying to recover from the challenges that we have had recently.
Day to day, the relationship between NHS trusts and foundation trusts feels quite consistent now, so I am not sure that the changes proposed in the Bill will necessarily make a huge difference. As I said in response to an earlier question, it depends entirely on whether the provisions of the Bill are used to set a small number of priorities and let NHS organisations get on with delivering them, or whether they are used more regularly to intervene more directly in our day-to-day operations. A lot comes down to how the regime is operated.
The Chair
Sir Ciarán and Mr Blythe, thank you very much indeed. Sadly, we have just about run out of time for this session, but we are most grateful to you.
Examination of Witnesses
Sarah Tilsed, James Cooper and Professor David Croisdale-Appleby OBE gave evidence.
The Chair
We will now hear oral evidence from the Patients Association, Together for Short Lives and Healthwatch England. We have until only 3.10 pm for this panel of three people. Would you be kind enough to introduce yourselves for the record? Let us start from the left.
James Cooper: Hello. I am James Cooper, associate director of external affairs and membership at Together for Short Lives.
Sarah Tilsed: Hello. I am Sarah Tilsed, head of partnerships and involvement at the Patients Association.
Professor Croisdale-Appleby: Good afternoon. I am David Croisdale-Appleby, chair of Healthwatch England.
Dr Johnson
Q
James Cooper: I think that there are both opportunities and threats for families of seriously ill children and the professionals and services that provide them with palliative and end-of-life care. When we talk about seriously ill children, we mean children with life-threatening conditions, life-shortening conditions and severe medical complexity. They have a range of emotional, psychological, social and physical needs that need to be met across health, education and social care services.
Part of that care involves specialist children’s palliative care, which is predominantly provided at a regional level by teams led by specialist paediatric palliative care consultants. They often have Grid training, and there are not many across the UK—there are only about 24 whole-time equivalents. They are often based at children’s hospitals or children’s hospices and are often co-located across both. These specialist teams also comprise senior nurses and other specialists involved in emotional, psychological and practical support for families.
Our issue is that these services are often quite patchily commissioned at the moment; even though there has been a specialised children’s palliative care specification from NHS England since 2012, we think that money and commissioning has flowed to these services to only a very limited extent. For example, we have a successful service in the east of England, which provides 24/7 end-of-life care at home for seriously ill children, supported by nurses and these specialist consultants. But the provision is really patchy across England.
The Bill presents some opportunities through the additional powers for the offices for pan-integrated care board commissioning—the OPICs—to mandate ICBs to work together to commission these services. We would like to see that. However, because of the small numbers but highly complex needs of these children, the services often need to be planned and funded at a regional level, although they often are not.
We are concerned by the increased devolution to ICBs because of the extent to which other children’s palliative care services—the core services—are being commissioned at the moment. We have a range of evidence that shows that it is possible in some areas for that care to be commissioned well—for example, 19% of ICBs currently commission end-of-life care for children at home 24/7, provided by nurses and specialist consultants. However, at the moment ICBs are not taking on their full functions and implementing national guidance.
I would like to see much more rigour and accountability from the centre, the Government, to make sure that such specialised commissioning works for this particular group of complex children and families.
Dr Johnson
Q
Professor Croisdale-Appleby: Obviously, I am not here to speak on behalf of the CQC, although I am a non-executive director of the CQC. You are quite right that it has been in a challenging position, from which it is taking very substantial steps to recover, principally in changing back to a system of having chief inspectors who are very knowledgeable about their particular area of expertise that they can apply. The Department has asked the CQC to take on additional responsibilities in its regulatory capability and, to some degree, in an inspectorate capability. I cannot really agree that it is too much for the CQC to take on, but a substantial amount of work is certainly being added to the CQC.
Dr Johnson
Q
Professor Croisdale-Appleby: It is quite interesting to think that we have had 52 years of independent organisations representing the patient voice, as well as that of the carer. I think everyone here will be aware of it, but there was a step change in impact after the Mid Staffs situation, when Healthwatch—both Healthwatch England and the 153 local healthwatch bodies—was set up. We have produced over 20,000 reports; if anyone is interested in accessing any of them, we can certainly provide access by the end of the week.
Since I joined Healthwatch in 2023, in my view it has been very successful in reaching out to those communities often referred to as “difficult to reach”—diasporas and so on, where we all know the health inequalities are often the deepest. I think Healthwatch has been very successful in ensuring that we have not just listened to the easy-to-reach groups but deliberately sought information and views from those other parts of our society, which form an increasing part of it.
The research being done with those communities has recognised that there is quite often an investment of some six months for one of our people go into a particular community—whether a cultural community or an ethnic community—and win the confidence of the people so that they actually talk to us about the problems. I have to ask how that depth and focus is to be replicated under the arrangements suggested in the Bill. That is my extended first point about Healthwatch.
I think we have had a lot of impact, and I use the word “impact” as a researcher myself. Impact is measured by the change that you make. When we produce reports, whether national or local, we include recommendations. The important thing is that we always follow up on those recommendations and ask, “Are they being implemented? Are they being listened to?” Each year, we produce a report that says, “What change has occurred as a result of the recommendations that we make?”
I think that is extremely valuable, because it is about independence and holding organisations to account. Clearly, those organisations report in line function to the Department of Health, NHSE or local authorities, but we are not only the ears of the patient and the carer; at times, we hold feet to the flames over whether something sensible is being done. We do not give up on this; we pursue it down the rabbit hole.
The Chair
Q
Sarah Tilsed: Professor Croisdale-Appleby said absolutely everything that I was about to say, so I will make just a few points without going back over everything.
The main thing is that we need to make sure that this does not divert attention from the main priorities, which obviously relate to patients: timely access to care, clear communication and involvement in decisions about their treatment. As the professor said, we need a truly independent patient voice. Abolishing healthwatches creates a fragmentation of patient engagement responsibilities across ICBs and local authorities. The evidence we see every day consistently shows that patients are not feeling informed, involved or treated as equal partners in care.
We need to ensure that any replacement model is, as Professor Croisdale-Appleby said, genuinely independent, transparently accountable and resourced equally across the country, to ensure that we do not lose sight of the people it is supposed to serve. Trust is really important here, and patients trust independent organisations. I feel that that trust might be lost in local communities.
Lastly, this is, as Professor Croisdale-Appleby said, about reporting. We need to consider the way that patient feedback data is reported, and ensure that that is not getting lost. Themes and demographics still need to be included to make sure that we know who we are listening to, and that services are provided for those who feed back and those who do not—usually, it is those who are not feeding back who we really need to consider.
The Chair
Thank you. Those opening comments were extremely helpful, but I now ask for brevity in your answers, as several Members wish to put questions to you.
Karin Smyth
Q
Professor Croisdale-Appleby: Sorry, I had some difficulty in hearing the question, but I hope I heard it correctly. Was it about the patient record?
Karin Smyth
Yes.
Professor Croisdale-Appleby: Fine. The Government’s move to the integrated patient record is absolutely excellent. Most of us have wanted that for a very long time, but we also recognised the IT difficulties in doing it, as well as the question of security. However, as digital has advanced, we have nutcrackers that we did not have before to crack that particular nut. I can but support that move.
From the point of view of the things that really matter, the ability of a person to feel that they can tell their story once—not time and again—comes up all the time in our research. With great respect to everyone here, we are very capable of standing up for ourselves and insisting that we get answers, but the people I deal with and have the privilege of representing are often not in that position at all. They are overwhelmed when they are repeatedly asked the same question, often in a language—medicalese, if you like—that they do not really understand and feel threatened by. The single patient record is going to go a long way towards helping with that situation. It is not the complete answer but at least it does the hygiene part, as opposed to the motivator part, very well.
Sarah Tilsed: It is an excellent initiative—1as the professor said, we have been calling for it for such a long time—but we really need to consider the consent and data elements. A lot of pieces of work that we have done with patients shows that people are happy with their data being shared for these electronic records, as long as they are transparent and patients know what is being done with their data—that is a really important point.
The care.data initiative and general practice data for planning and research—GPDPR—were great, but unfortunately, because they did not have genuine patient involvement right from the beginning, they failed. We need to ensure that the SPR does not fail. In terms of reaching underrepresented or less-heard communities, we need to ensure that we hear from those people straightaway. How do they want this to work? Do they want to know how their data is being used? How can we ensure that people who do not use the NHS app are involved and that their data is being shared? How do we approach people who are understandably very hesitant about digital technology and electronic records?
Helen Morgan
Q
Sarah Tilsed: I said a lot about that earlier, in response to a previous question, so I am not sure how much more I have to add. I think my main point is that we must not divert attention away from the urgent priorities that patients are facing at the moment, ensuring there is a truly independent patient voice and trust—there is a lack of trust among patients, as I keep saying. How are we going to ensure that the reporting system is there for this?
Ultimately, patients need reform to lead to better care, not simply to different structures, which I fear is what often happens. Sir Robert Francis said, following the Mid Staffs situation, that patients must come first. Throughout the passage of the Bill, the Patients Association question will remain simple, and we will ask it time and again: will these changes actually help patients to receive better care, and how will we know if they do? That is the first principle to come back to. When everything is happening—all this restructure—how are patients going to be affected and involved in it?
Helen Morgan
Q
Professor Croisdale-Appleby: Thank you for that question. One of the reasons there is a difference or variation among the 153 is that the amount of funding is very different. Some of them get 10 times the funding of others, which makes a difference to the scope of what they can do. What it does not allow—and I think Healthwatch England has an important contributory role in this—is a change in the quality of the way in which the research is done.
One of the things that I have encouraged very strongly—although it happened before I joined Healthwatch—is the use of qualitative as well as quantitative data. The system is awash with quantitative data, but that does not necessarily cut through to the way that people are, the way they think, the lexicon they use, the concepts they use in communication etc. One of the great strides that Healthwatch England and our 153-member network have made is the intelligent use of qualitative data. That is an art in itself—I would like to think that is a science, but it is certainly an art.
It would be easy to remedy that, in the sense that if the funding were more equitable, some of that variation would disappear, but the variation is not in the quality, the effectiveness of the listening or the ability to look thoroughly at the impact, and it does not affect the fact that the organisations concerned are held responsible for what happens to the recommendations in terms of implementation. That is uniform across the system—it is just the amount of it that will vary naturally, because of the differential funding.
Laura Kyrke-Smith (Aylesbury) (Lab)
Q
James Cooper: There are some big opportunities in the single patient record, with the caveats that Sarah mentioned on data governance and consent. For families of children who are seriously ill, it presents huge opportunities, as I said earlier, because of the complexity of their needs. Often, huge amounts of information need to be conveyed to any professional who the children come into contact with, wherever that is across health, education or social care.
Many professionals have a long-standing relationship with such families, whether they are NHS community children’s nurses, consultants with a speciality in the child’s condition or children’s hospice teams, but families often need to access emergency unplanned care, perhaps in the middle of the night or at weekends. In those instances, when they speak to paramedics and emergency doctors, it is imperative that they can convey the information as quickly as possible. In those instances, I can see huge benefits.
With issues such as advanced care planning, to reflect the needs and wishes of those families, in particular as the child is coming towards the end of their life, I think it is critical that the whole range of professionals involved in the care of children has access to that information. I will welcome much more clarity from the Government about when the families will benefit from that particular initiative.
Professor Croisdale-Appleby: May I add a short comment?
The Chair
By all means.
Professor Croisdale-Appleby: We have to recognise that a tremendous amount of work is done in the health and social care system with people who have multiple comorbidities—not just one thing, but a number of things that often interact together. Without a single patient record, we can find that a consultant or a GP has access to only one part of that multiple comorbidity, as it were. That can lead to all sorts of unforeseen errors. I think that that is an important point to make about the great advantage that we can get from a single patient record.
Joe Robertson (Isle of Wight East) (Con)
Q
Professor Croisdale-Appleby: You make a pivotal and focused point. The independence is vital, not just because of the quality of what Healthwatch produces, but because of the confidence that it gives people that they are speaking to an independent organisation. In the background, some communities distrust being critical about the care that they receive in case it rebounds on them. If the same organisation is responsible for marking its own homework, as you put it, that problem will be much greater than it has been in the past. In terms of what to do about it, I think that you stick to some basic principles. If we are moving forward positively, we have got to be locally driven. We must reach out to communities. They will not reach into us; we have to reach out to those communities and the individuals within them.
I mentioned the value of qualitative evidence. It is not always easy for big institutions to go through all the work of evaluating qualitative work. It is easy to look at quantitative statistics, but the patient voice must be highly visible and central to policymaking. That was the basic idea behind the Bill: it would be about the patient and the patient voice, putting the patient right at the centre of the multiple discourses. As my colleagues have said, we should be totally transparent about priorities, impact and holding people to account. If all five of those principles are followed, it will work. If they are not followed, it will not.
Sojan Joseph (Ashford) (Lab)
Q
After each incident, there is a recommendation or an action plan, but clinical staff or patients do not have much involvement with those and do not see any difference. Healthwatch helpfully finds the issues, but it may not actually go back and see what changes are made following its recommendations. The CQC physically goes into clinical areas to see the difference, and has the power to take action against those responsible, so is it not a good change that more accountability will sit with the providers, and the CQC—or local authorities and ICBs—can take action against them?
Professor Croisdale-Appleby: Forgive me; you asked several questions. Which would you like me to start with?
Sojan Joseph
I asked whether it is not a good change to streamline these bodies so that fewer of them have powers to take action like the CQC?
Professor Croisdale-Appleby: There is always a danger, if I may say so, in the use of the word “streamline”. We have to think what is lost in the streamlining process. I do not want to repeat what I have said and waste your time, but one thing that is important is whether there is a golden thread running through seeking out and listening to patients’ views, putting those together in a coherent form, making recommendations for improvement—that is what we do all the time at Healthwatch—and then holding people accountable for that. I remember Penny Dash saying that one of the points of the Bill is to bring this closer to those who commission and those who deliver. I am not sure that it necessarily takes it closer to that simply by embedding it—as a colleague asked earlier—within the formal structure. There is a danger in that that the patient voice is often a spiky voice. As a former chair of hospitals and so on, I know that patients do not always say things that are convenient. That point about independence is vital. If I may, sir, I take slight issue with your term “streamlining” and would try to take that apart into the different components that might comprise it.
Sarah Tilsed: I cannot comment too much on the CQC, but on the point about a rise in complaints but nothing seems to be happening, we are finding that patients do not want to complain any more because they are finding that they are getting a worse service of care. That might be a slightly separate issue, but considering that there are so many complaints and that patients are not wanting to complain because they are scared, I do not think that streamlining is the right way. We need an independent voice that will focus solely on the patient voice, which I think we are completely losing at the moment.
Gregory Stafford
Q
Professor Croisdale-Appleby: If we talk about money— I will be quantitative here—Healthwatch England currently costs £3 million per year and the network receives £25 million per year. To people like me, £3 million and £25 million is a lot of money, but in the greater scheme of things it is not a significant amount, particularly when you think what is being produced for it.
I cannot speak appropriately, in my role as chair of Healthwatch, about Government policy. It is not my job to do that; it is the Government’s job. If you want to ask me a question on a purely personal basis so I can step outside of that role, I will be happy to answer, but I always have to draw a very distinct line on anything that I say. Everything so far has been said in my formal position as chair of Healthwatch as opposed to any personal views, because I certainly do not want to comment on Government policy.
The Chair
Let us see if either of your colleagues would like to be less cautious. Mr Cooper?
James Cooper: The key here is making sure that the independent patient voice is well-resourced, is held accountable for doing its job and works particularly for those the system finds it hardest to reach. Families of seriously ill children definitely fall into that bracket, so the interest of Together for Short Lives and the children’s palliative care sector is certainly in making sure that those structures do that.
Sureena Brackenridge (Wolverhampton North East) (Lab)
Q
Sarah Tilsed: I disagree with that. It is fine for ICBs to be involved, but it is all about local partnership working—bringing in the voluntary sector and really going into the community, and doing it in partnership. That is the only way of doing it. If you are bringing it into the ICB, consider how much funding there was when Healthwatch was doing it and—I do not want to repeat this point, but I will—the fact that it will be marking its own homework. For me, it is about partnership working going from the community—not within the system and not within the NHS, but going out to the community and feeding inwards.
Edward Argar (Melton and Syston) (Con)
Q
As a Minister, I was on the receiving end of some quite sharp recommendations from Healthwatch, but they were always constructive. Whether right or wrong, my fear is that this measure risks a perception among patients that it will be down to NHS managers and ICBs essentially to make recommendations that reflect their priorities, rather than the priorities and voices of patients. Professor, even if the principles that you have enunciated that might mitigate that risk were applied to the new model, are you really confident that they could mitigate the risk to patients’ confidence that their voice is genuinely and independently heard, loud and clear, however unhelpful it is perceived to be by bits of the NHS?
Professor Croisdale-Appleby: I cannot be confident of that, because we are in the foothills, not up the slope, and the details have not been given. ICBs have received something approaching a 50% cut in their running costs. I will not comment on the appropriateness or otherwise of that, but one has to be realistic and think about how high a really informed patient voice—particularly one that seeks out the views of both communities and individuals where the health inequalities are the greatest—will be on the priority list. I would question that, but I will leave it there.
Liz Twist
Q
James Cooper: It is key that ICBs are given that support. In the conversations that Together for Short Lives and the services we represent have with ICBs, we certainly get the sense that they want support. They want to know how much they should be funding certain services, and they want to know how to plan. A lot of guidance is already out there, particularly in children’s palliative care, where we have service specifications and NICE guidance and quality standards—there is even a legal duty to ensure that ICBs commission palliative care for children and adults. That accountability and support from the centre, and making sure that resource is there, is key.
The Chair
Q
Professor Croisdale-Appleby: I just want to reassure colleagues here that Healthwatch England and the Healthwatch network are still fully functional—I think that is important for you to know. Although we are sensibly on a reducing trajectory in line with the Government’s abolishment plans, we will maintain that full functionality and the ability to meet our formal mandate right through until the Bill is enacted, and until the guidance that will probably follow is in place. I just wanted to reassure the Committee of that.
The Chair
Thank you very much. On that note, Mr Cooper, Ms Tilsed and Professor Croisdale-Appleby, thank you very much for attending, and for your guidance and wisdom—we appreciate it.
Professor Croisdale-Appleby: Thank you for the opportunity.
Examination of Witnesses
Councillor Megan Wright, Sally Burlington and Maria Higson gave evidence.
The Chair
Good afternoon. We shall now hear oral evidence from the Local Government Association, the Association of Directors of Adult Social Services, and South East London ICS. We have until 3.50 pm for this panel. Could you identify yourselves for the benefit of the record, please?
Maria Higson: My name is Maria Higson. I would like to state for the record that I am here to bring to the panel the experience of a director of transformation within the South East London ICS. I do not represent the organisation, but hopefully I bring that experience.
Councillor Wright: I am Councillor Megan Wright. I am the vice-chair of the Local Government Association health and wellbeing committee.
Sally Burlington: I am Sally Burlington. I am chief executive of the Association of Directors of Adult Social Services, which represents directors of adult social care in England.
Dr Johnson
Q
Councillor Wright: I assume that was directed at me, as I am a representative in local government. We feel it is going to weaken it. Having someone on the ICB is useful to help shape health strategy and ensure that the wider determinants of health are taken into consideration when planning health. We would like to see some kind of structure where local authorities and other partners involved in determining health from a wider perspective have a voice within the NHS delivering health locally.
Dr Johnson
Q
Maria Higson: Whenever we introduce these changes into the system we have to remember that we are talking about a group of professionals who are trying to deliver for the NHS, citizens and patients. This Bill was first announced back in March 2025. It would be fair to say that since then, for an awful lot of people, there have been organisational and personal unknowns. The best intentions to deliver against the agenda and the three shifts can be hindered by that uncertainty. As with everything, implementation is absolutely critical.
Dr Johnson
Q
Sally Burlington: The better care fund is a really important source of funding for statutory core services. It funds about 80% of social care—in terms of the use of the better care fund by social care, 80% is statutory. While the ability to use it differently could be really valuable, we would be worried about diverting it from those core services into other functions. We have also benefited from the fact that the better care fund is uplifted at the same rate as NHS funding. If we lost that, it would be significant, because social care is systematically less well funded over time compared with some other services.
Dr Johnson
So you are losing a protection with the Bill.
Sally Burlington: Exactly.
Karin Smyth
Q
Councillor Wright: The main problem the abolition of NHS England has caused is upheaval and uncertainty with our health partners. Many of the health partners at our health and wellbeing board meetings or our place committee meetings are almost saying to us, “I don’t know if I will be here at the next meeting.” Such turmoil in the changeover creates instability from a lack of being able to plan what will happen next. That is one of the challenges that we feel. We are working with our health partners and getting assurances that there will be continuity, but it is quite hard when the person we are working with is changing.
We are really excited about neighbourhood health sitting under health and wellbeing boards. We love the idea of neighbourhood health looking at the wider determinants of health and having a very localised health response to the issues that that community needs to help it. One of our anxieties is that a lot of ICBs have become bigger and have less connection with the place. They are also shrinking; I think NHS England is losing 30%—
Maria Higson: Larger geography, fewer people!
Councillor Wright: Exactly. We have had a letter from our ICB giving us the heads-up that they might not be able to guarantee that they can send the right person to our health and wellbeing committees, which will obviously make it difficult to plan neighbourhood health.
The other challenge we find in neighbourhood health is that local authority boundaries might not necessarily match neighbourhood boundaries. I will give an example from Bracknell, where I live. Bracknell is very clearly a neighbourhood, but the south of the borough, which is within the Bracknell Forest council area, probably sits within Bracknell and Wokingham and a little bit within Reading. It will be hard to bring in true neighbourhoods with the current structure, but that is something we are working around, and we are hopeful that we will be able to sort it out.
Karin Smyth
Q
Sally Burlington: Health and wellbeing boards will probably become even more important following the removal of local government representation from the ICB. It will be the only place we have NHS and local government partners with the specific statutory responsibility to work together on social care. As others have noted, they are at place level and will therefore be crucial for connecting with the neighbourhood.
The other factor that is helpful to note is that there is a huge amount of pressure on systems at the moment, and the cuts to ICBs are having a profound effect on the relationships they have with local government partners. We are hearing from our members that continuing healthcare is a real point of concern, with reviews leading to the withdrawal of that care, placing challenges on local authorities. In that context, making sure that we are supporting health and wellbeing boards to be as effective as possible for neighbourhood health, and in that strategic joining-up role, becomes even more important.
Karin Smyth
Q
Sally Burlington: Neighbourhood health is a really important vision that we strongly support. In a way, it is obviously the right thing to do to move services closer to the people they serve and to work very closely with communities. Health and wellbeing boards have an opportunity to drive that neighbourhood health agenda because they are responsible for neighbourhood health planning and have the connection to local government, to the voluntary sector in many cases, and to the NHS. It feels like that is a real space of opportunity to drive neighbourhood health and realise the benefits that it could offer.
The Chair
Q
Maria Higson: A couple of things. One is that it is not possible to overstate the importance of the partnership working between the NHS and local authorities. If we want neighbourhood health and the shift to prevention more broadly to be successful, working closely with local authorities, including the public health teams—which were not in the question but deserve a mention—is imperative. I am sure we will come to the question about the relationship with the mayoralties. There is something about that geography question. The insight and experience that local authorities bring is really important. That is the one thing that I think ought to be mentioned.
Helen Morgan
Q
I am really concerned that that will become even more problematic because they cannot work together, given that we are not a combined mayoral authority, that we will not have a mayor sitting on our ICB and that our ICB merged footprint does not fit with our local authority geography. How can the health and wellbeing boards work between the two organisations to deliver good social care?
The Chair
Let us start with our councillor in the middle.
Councillor Wright: It is a challenge. I completely hear that; continuing healthcare is a really difficult one. It is right to say that residents are seen as a financial burden, which should not happen. That is why we need strong health and wellbeing boards. We need strong, honest conversations between local authorities and the NHS for ensuring that good continuity of care.
Obviously, I think the overall aim of the 10-year health plan is to move much more to a model of prevention and treatment in the community, where we hope that we could intervene earlier and set up good standards of care before it gets to a stage where it becomes so adversarial. That is what we are aiming for. We have challenges in our local authority and have had to push back on a few cases where we felt the NHS should be helping those people.
Sally Burlington: The problem is getting bigger over time. We did some joint work last year with the NHS Confederation to look at those difficult issues on the boundaries between health and social care, including continuing healthcare and mental health aftercare. That identified some good models. We see arrangements for joint commissioning of continuing health care, which can work well. We have seen a little bit of withdrawal from that by some ICBs.
Part of the issue has to be that we are seeing a real intention to cut costs, and that leads to lots of reviews taking place that do withdraw continuing healthcare. We have seen that trend while the demographics are pointing to potentially more demand, not less. I do not think there is a substitute for better relationships. The legal framework is pretty clear. A helpful way into the problem would be to find a way to have a set of conversations at a national level about what the right solution for people is—start there and then think about whether the reviews are right in the ways that they are taking place.
Maria Higson: The only thing I would add is that it is tricky when we apply a broadbrush approach of, “Well, it’s going to be about the mayoralty and so on.” In reality, certainly within London, we can describe ourselves as a system of systems. We work with six local authorities across one ICB, now partnering with south-west London as well. It is not as easy as “one approach fits all”. As this Bill goes through implementation, it will be important to be conscious of that to get the best out of those relationships.
Helen Morgan
Q
Councillor Wright: I chair a health and wellbeing board, and everyone comes to those; there are really good conversations and really good reviews of what is happening. I think they are in a really good position. What I worry about is how much influence they will have over NHS wider strategy.
I was at a King’s Fund day, and someone said something that I thought was so true: the Health Bill and the NHS 10-year plan is the NHS 10-year plan. The NHS will be judged on how it achieves what it is meant to achieve. Although, as local authorities, we want to help with prevention and those wider determinants of health, ultimately the responsibility sits with the NHS.
It is about trying to work out how we have better conversations with the NHS, to say, “We have done neighbourhood health for years; this is what we do as local authorities. We look at all these things and we use public health and our adult social care system to create healthy environments. We need you to be on board with us.” I therefore think there is something about the power dynamics regarding health and wellbeing boards and how we address them. But overall, I feel that they are the best way of ensuring community health.
The other thing is about geographies. Health and wellbeing boards might not match neighbourhood health geographies, so there are also some challenges in working out how that will work.
Edward Argar
Q
I was the Minister who created ICBs, and I sat on that Bill Committee with the current Minister for Secondary Care. I am getting a sense of déjà vu—we are on different sides of the Chamber now, but we sat through the Committee stage of the Health and Care Act 2022 together. I deliberately created ICBs to match the geography of upper-tier authorities because health and social care is essentially one system. If one bit does not work, the other bit does not work.
Since then, we have seen significant mergers and larger areas, further removing them from that direct relationship and read-across. Although the good ones do, I fear that a lot of NHS ICBs do not fully reflect the intention behind their creation, which was to see them as a genuinely collaborative exercise with equal voices in the room.
My question is: if we see ever-larger areas or fragmented areas, whether through neighbourhood health plans or mergers and acquisitions among ICBs, how do we maintain genuine local accountability and the relationships that underpin any structure written in law, on a piece of paper or in guidelines?
Notwithstanding what is being done about the health and wellbeing boards’ increasing involvement, do they actually have the teeth they need? In my experience, however good the collaboration, it is within the ICB boardroom that the decisions are actually made. However well things have been discussed beforehand, the ICBs will make their own decisions based on their own priorities. Does the removal of that voice from the ICB strengthen or weaken the ability to see this as one local system and to deliver a genuinely holistic local solution?
Councillor Wright: It will probably weaken it, unless we are given more say in our local health and wellbeing board. Our Thames Valley ICB has one director of public health. Thames Valley ICB I think has nine local authorities, and one chief executive and one director of public health sit on the board, so already the voice on it is quite small. If we lose that voice, where would we have those conversations? That brings me back to the whole thing about health and wellbeing boards needing to be stronger, definitely.
Sally Burlington: We would agree with that. If you take away the voice that is able to speak on behalf of social care, public health and wider public services, it will be harder and an additional job to bring in that consideration. It will be even harder to expect there to be notional teeth in that relationship, so we have concerns about that.
Maria Higson: It is also worth recognising that the delivery of any strategy or plan will require partnership working with local authorities, so whether or not they are in the room, they will be needed for delivery, and the proof is always in the pudding. For me, the partnership is somewhat non-negotiable in order to achieve delivery.
Sureena Brackenridge
Q
Councillor Wright: At the LGA, we are arguing for a single person record, so that we have a single patient record that brings in social care providers, or at least the local authorities’ social care statutory provision, too. Someone discharged into the community would therefore still have access to records and know what was going on, while others would know what has happened to that person and what they need. Yes, we agree: we hope that a single patient record would make things as smooth as possible from hospital discharge to home and would help when someone comes into hospital, so that the clinicians have a better idea of what the patient’s quality of life was like, what treatments they were on, and so on. We are definitely in support of the single patient record for that, and we would like it to become a single person record.
Sally Burlington: We are supportive as well. The Bill itself is unlikely to solve all the problems in this space. A huge number of practical cultural system problems exist in data sharing, so the regulations that follow the Bill will be important to enable that to work for social care providers and commissioners. It is worth noting that there are thousands of social care providers, so the implementation of the Bill and subsequent regulations will be important. We are keen to ensure that any approaches are co-produced with the social care sector, as well as the NHS. It will be a lot of thinking, a lot of planning and a lot of hard work to get it right, and social care providers will need lots of notice to upgrade their systems in the right, consistent way to enable them to speak to each other, if we are to see the vision of the single person record delivered. I guess it would also be helpful to think about the role of carers as we move into that space, because we know from covid that data sharing among carers was one of the issues that came up.
Gregory Stafford
Q
Maria Higson: Any time we go through an NHS reorganisation, it is distracting—that is the reality of such situations. It is unfortunate that, over the past 15 months, this has been a large distraction for people who are genuinely trying to deliver the three shifts—prevention, digital and neighbourhoods. It is true that it has been a distraction. I am not sure that this Committee is the right space to go into these, as I am aware that we are here to discuss the Bill, but there are probably opportunities to go further on some elements, which may help us in future.
Gregory Stafford
Q
Maria Higson: To take one example, I would love to see an NHS where we step away from short-term activity metrics, and towards outcomes—that is mentioned in the Bill. The constant firefight on activities is quite challenging, so how can we move that dialogue to ensure genuine transformation? That is an example of where we could potentially go further than the Bill suggests, but I am conscious that I am supposed to comment on the Bill, not give my own random thoughts.
Jo White (Bassetlaw) (Lab)
Q
The Chair
I could not hear the question from this end of the room; I do not know if our witnesses could.
Jo White
I was talking about bed-blocking in hospitals and how neighbourhood health plans can work more cohesively with hospital trusts.
Councillor Wright: I think we can answer this together. The whole point of neighbourhood health is to bring in everyone in the voluntary sector, your patient transport and all that, so that your joint strategic needs assessment has a good understanding of what is available to someone in the community when they come home. We talked before about having a strong single patient record so that good communication is there, and neighbourhood health is able to strengthen that. Neighbourhood health should be not just about shifting the need from hospital to community, but about reducing that need in the first place so that fewer people need to go to hospital. At the same time, we are seeing some good developments in the NHS, such as frailty teams and hospital at home teams, all of which help to prevent people from being admitted to hospital in the first place, and to ensure that when people come home, there is a team to visit them.
You are right about the communication issue, although it has not been an issue where I am, as we have very good communication with our local ICB about the people being discharged, to make sure that someone is there to meet them and that nurses come out to see them when they come home—I cannot remember the word for that. We have the right systems in place and they are working. I do not know how neighbourhood health will work everywhere, but in our borough we have a step-down unit called Heathlands, which people quite often go to when they come out of hospital and which does quite a lot of rehabilitation. That already starts the plan to get them home: to go from hospital, to the step-down place and then to home. It is about having good systems in place, all of which should hopefully be supported by neighbourhood health, which should have a good knowledge of what is available locally.
Sally Burlington: It should definitely help, if it works well; we should see more capability and capacity available in the community, closer to where people live, to help them when they come out of hospital. There is a lot of good practice and understanding about good discharge and how you plan from the point that somebody is admitted to when they come out of hospital. The emphasis on integrated neighbourhood teams will be important. It would be helpful if we could all remember that those must include social care and wider local government services and connections in to those, not just integration within NHS teams. It is definitely a positive step forward and, if we can try to make sure that the relationships between health, social care, public health and wider services are brought to life in neighbourhood health, that will help us in this way and in lots of others.
Janet Daby (Lewisham East) (Lab)
Q
Sally Burlington: As I understand it, the safeguards around data sharing remain in place under the Bill—they do not change. The part of the single patient record that is really attractive to our world is that people will not have to repeat themselves to every professional they meet; they will not have to tell their story again and again or be retraumatised by explaining the detail of what they have been through.
The potential advantages are there, but there are obviously concerns about data protection and how data is used. It is incumbent on us all to take those seriously, think them through and make sure that safeguards are appropriately implemented locally and in all the institutions that have access. That is probably a matter less for the Bill and more for the implementation and supporting regulations, but we and other partners will be keen to be a part of that process to make sure that the safeguards are appropriate.
Laura Kyrke-Smith
Q
Maria Higson: I think we are all agreed that working at the neighbourhood level is absolutely the right way to go about that. That is where health inequalities can best be addressed, because that can be most nuanced and tailored. Working on that smaller footprint is really important. You mentioned voluntary, community and social enterprise organisations, and I think that is a hugely important part that has broadly been missed out from the conversation around these changes. We work closely with VCSE partners and we know they deliver huge amounts for the communities and understand the communities in which they are embedded very well, so making sure that the VCSE voice is part of those neighbourhood teams will be important for that nuance and tailoring in the local element.
Councillor Wright: I agree entirely. Local authorities are in a good position to engage the voluntary and community sector. But again, we are fighting for a voice with the NHS and they are fighting for a voice with us, so we need some honest conversations with ICBs, and a real strategy looking at those health inequalities and what is driving them. It will not purely be access to hospitals; it will also be access to meaningful employment, housing, transport, mental health or social isolation—there will be so much driving those wider determinants of health that are affecting healthy life expectancy. Local authorities are in a prime position to do that, and they need to be listened to. I think the challenge will be how we collectively say, “What needs to be done, other than implementing the Bill? How do we look at the whole health inequality picture and address it?”
Sally Burlington: I would agree with the others: tackling health inequalities is really difficult. Doing it the same way in every area would not work, particularly in a world where there is not enough resource to do everything we would all like to do. You have to tailor how you approach local service delivery and what is needed locally according to local needs, the local community capability, how people work and what their preferences are locally, and the neighbourhood health agenda is our best shot at tailoring in that way.
I think you will come on to Healthwatch, but we would have concerns that, in separating the Healthwatch duties to look at NHS and social care, we risk missing some of those who are most likely to need both, and that that could exacerbate health inequalities rather than make them better.
Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
Q
Councillor Wright: That is quite interesting; I was at a session this morning looking at communities, and there was a comment that for the NHS communities are about buildings, whereas for the local authority they are about people. I think it would be the ICBs and whoever they commissioned to provide neighbourhood health centres. I hope there would be enough input from the voluntary sector, the local authority, adult social care and public health—from everyone—but I see the ICBs as the commissioners and the people who organise them.
Peter Prinsley
Q
Maria Higson: If we want to be as open to change as possible, my argument would be that that should be decided locally. Would it not be fantastic if, for example, some of them were led by VCSEs that worked in close partnerships and had clinics where GPs came in? You can envisage a whole number of different scenarios, led by local communities and local organisations. This plays back to the health inequalities point, but that is how you do it, although it relies on you being open to different models and not trying to do a one-size-fits-all, which is really tricky when you are trying to implement.
The Chair
Last word, Sally Burlington.
Sally Burlington: I strongly agree with that. If you were asking who is best placed to run them, the answer would be that it probably looks different everywhere, because it will rely on local leadership and local capability and capacity, which varies across all our sectors, so this is a really good opportunity to make the most of that leadership ambition and skills and capacity locally.
The Chair
Thank you, ladies. The Committee is most grateful to you.
I will just explain now, while we are changing over witness panels, that after I introduce the next panel there are likely to be—in fairly short order, because the Minister is on his feet—four Divisions in the House. I shall suspend the Committee from as soon as the first Division is called until 10 minutes after the start of the last Division, when we will start again. I hope that is clear. It does mean, I am afraid, that we will have to ask our witnesses to be very patient. It is extremely tedious and very discourteous, but that is the way this place operates, I am afraid.
Examination of Witnesses
Emily Holzhausen, Paul Farmer CBE and Kath Abrahams gave evidence.
The Chair
We will now take evidence from Carers UK, Age UK and Tommy’s. Could you introduce yourselves for the record, please?
Paul Farmer: I am Paul Farmer. I am the chief executive of Age UK and also the chairman of the Richmond Group of Charities, which comprises 15 of the larger health charities as members.
Kath Abrahams: I am Kath Abrahams. I am chief executive of Tommy’s, which is the pregnancy and baby charity looking to stop the heartbreak and devastation of baby loss and make pregnancy and birth safe for everybody.
Emily Holzhausen: Hello, everyone. I am Emily Holzhausen, director of policy at Carers UK, representing England’s 4.7 million unpaid carers. I also have lived experience as a carer.
Dr Johnson
Q
Paul Farmer: From the perspective of older people and people with long-term conditions, the single patient record will be, broadly speaking, welcomed. I will explain very briefly why. If you are an older person with multiple long-term conditions and you find yourself in hospital, you often have to explain your experience and health needs, time and again. That is often because of a lack of join-up between the current data systems. Single patient record means the individual patient does not need to repeat their stories or lived experience—and, more importantly, it allows clinicians to have a clear overview of an individual patient’s health records. There are issues that need to be considered, particularly around making sure that people are not digitally excluded, and I am sure that we will get into those, but at a high level we would welcome the introduction of a single patient record.
Kath Abrahams: There are some very similar themes for us. A lack of shared patient record is a particular issue in pregnancy and maternity. You are being seen by your GP, early pregnancy unit and maternity unit. You might have other conditions that affect pregnancy or could affect the outcome of your baby being born. At the moment those systems are very disjointed. The other piece in maternity, which will not come as a surprise to you, is that, if you have lost a baby, you end up having to retell your story over and over again and that can be very traumatic. Sometimes that can lead to people disengaging from care, but also in many cases being retraumatised.
We broadly welcome the single patient record, but with lots of caveats around people feeling able to trust the data and trust that their data is safe. Overall we are very supportive.
Emily Holzhausen: Again, similarly to my colleagues, we are supportive. When we ask unpaid carers what matters to them, sharing of information is really critical, but we have a slightly different perspective here.
First, carers would like to have access to the record, with the right permissions. That is not on the face of the Bill, but it is suggested that that may be covered in regulations, and we would like to see some assurances of that. It would change things, again, because of not having to retell information, which carers call “triggering” and “exhausting”. They will be more able to spot errors or things that are not quite right, which is important for the person they are caring for. As an unpaid carer, when you are responsible for caring for someone, that is a huge weight on your shoulders and you really want to make sure that it is being done right. Finally, most of us care remotely—we do not all live with the person that we care for. This could really help to transform carer’s lives and the pressure they feel.
I have one statistic for you: just under one in eight carers spend over 40 hours a month on NHS admin. If the NHS app and the single patient record can reduce that, that would change things. The only other point I would like to make is that where this tips over into social care, this is something that we need to build with social care and all those people who go across all these different services.
Dr Johnson
Q
Emily Holzhausen: Yes. That is a lot of different questions. It has to be done with the right permissions, with the patient being in control of their data—that is a very strongly held principle within the NHS. There will be situations where people do not have capacity and their primary carer, who might be their partner, their son or daughter, might need access. We have lasting power of attorney in England, which could be used as a mechanism, or other assurance mechanisms.
As for digital access, that is an issue that I am sure Paul will want to come on to. Especially when digital access costs money and we have people in poverty, we have called for that to be supported by Government to ensure that everybody has digital access. People have to feel confident about it. While we have seen a doubling in the number of carers using the NHS app to manage their own health and care in the past two years, there are key groups that are being excluded: older carers, people on lower incomes and people who feel less confident with technology, for a whole range of different reasons.
Some of this stuff is delivered very well through voluntary and community services—I know that Age UK has helped my family locally, for example, but I will stop there, because I am sure Paul will want to come in on that.
The Chair
Paul Farmer, you have been given the floor.
Paul Farmer: I would very much like to come in on this subject. We see probably the greatest risk and the greatest opportunity here, in the context of digital exclusion and digital inclusion. The risk of digital exclusion is that older people in particular, although it is not exclusively an older people’s issue, will lack the access to their own care record, as it is electronically based. We need to bear that in mind when we think about the roll-out of that and the availability of the content of that patient record to people who are digitally excluded.
I do think, however, that this is a significant opportunity. It is part of a much broader question about digital inclusion more generally, and inclusion into accessing public services more generally, which is a key theme of the work we are doing at Age UK. We had funds from DSIT to support the work of our local Age UKs, where we run a number of digital champions programmes—Members are very welcome to come and visit them at any time. We worked with 8,000 older people in a two-month period; we engaged more than 1,000 of that group into our digital champions programme, and two thirds of people took up the offer of engaging in a training module on accessing the NHS app.
In particular, we were able to enable people who are partially digitally excluded. We are publishing a report later, which we will share with the Committee in time, about the opportunities for people who are not fully excluded, but partially excluded. We think people are able to go on that journey, but it does need support. We encourage the Government to think about putting a really thorough programme of digital inclusion alongside the implementation of the single patient record, to support older people, people with long-term conditions, people with learning disabilities and other conditions who might need extra help and support to access the NHS app. There is a risk here of people being excluded, but also an opportunity for inclusion.
Mrs B, in Lincolnshire, was helped by Age UK Lincolnshire. She was a carer to her husband, who has had a stroke; she had a home visit from the local Age UK and they were able to set up the NHS app for her. She said she would not have been able to do that without that extra help and support.
Dr Johnson
Q
Kath Abrahams: On digital exclusion, the same risks apply, although there is a different age demographic. If you have somebody who has a particular disability, has English as a second language, or has difficulty reading, we need to ensure that alongside the single patient record we are not excluding people without meaning to. Having said that, there are real opportunities to reduce inequities as a result of this change, such as by ensuring that everyone’s information is there, and that people do not have to retell their story if they find it difficult to speak to their clinician.
What the single patient record will not do is solve all the problems found in the national maternity and neonatal investigation. An action plan will come out of that investigation, and it must be looked at really seriously. A single patient record does not replace compassionate care or somebody really being looked after well, but it can potentially provide a safer environment—I am very happy to go into detail on that.
The national maternity ambitions have expired, but we are pushing very hard for them to be restated. There is potentially an opportunity to use the data at a broader level to measure progress. If it was possible to use the single patient record to understand how things were going towards improvement, that could be very helpful.
Karin Smyth
Q
Kath Abrahams: Right now, the situation is really tricky and people are being failed in their pregnancy and maternity care. Women report constantly having to retell their story—highly sensitive or traumatic experiences of loss—and that repetition can happen across the early pregnancy unit and maternity services. There is a common misconception that the NHS is one system, so when they find that people in another bit of the system do not know something, that can be really frustrating and annoying, because they assume that it exists.
There is also a lack of continuity. A clinician can be completely unaware of a sensitive or traumatic experience that somebody has had, and there can also be genuine dangers in outcomes. We know from the reports into Morecambe Bay, Shrewsbury and Telford that the lack of joined-up sharing of information and good communication between different parts of the system has led to some really difficult outcomes, particularly if somebody also has gestational diabetes, for example, or another condition and they are taking a particular medication that could cause harm to an unborn baby.
There are lots of situations in which not having the complete history is preventing people from getting not only really good, compassionate care, but the safe care they need. If someone is in an emergency situation and they are bleeding out, or their baby is not moving as much as they should, there is not time to start from scratch; they might not be in a position to explain what is happening to them and what their history is. They might not even know all the relevant bits of their history. Having that complete record, if it was done really well, would give clinicians the information that would allow them to make really timely decisions. Maternity can often be high risk—I do not need to say that to you; you know that—but these are often fast-moving situations where time is absolutely of the essence.
Emily Holzhausen: To build on what I said earlier about the amount of co-ordination and admin that people do, I will just refer to some carers’ words. One said that if they had to phone, they would end up in a long waiting queue or having to travel to the GP in person. There are people juggling work and care, so this has real, everyday impacts on their lives and their time.
When I refer to errors, I mean things such as medication errors or diagnosis errors. When you care for someone with very complex conditions, you can have health appointments every week—sometimes twice a week—and it is so hard to stay on top of it. When I say it is so hard, and talk about unpaid carers, we know that caring is a social determinant of health: in itself it is a single factor for poorer health outcomes. We know that 600 people a day give up work to care.
We have done a report on the tipping point: what tips carers out of work? One such thing is social care; another is how they are treated in the health system. If we reduce the pressure on carers and put information at their fingertips to help them to manage care, we improve outcomes for everybody: the health and wellbeing of the carer and the safety of the person that they care for. People are trying to do their best in quite a difficult situation.
One of our members, Norman Phillips, has talked about that a lot. He was in contact with more than 24 professionals, knitting up care around his wife who had advanced multiple sclerosis and dementia. That is an incredible amount of co-ordination of care. You can see how a single patient record, as it is envisaged in the future, could really help to support people who provide care. It is critical, given that we have an ageing population, that we recognise and support families in what they do.
Paul Farmer: I would start by talking about people with long-term conditions. Let us bear in mind that by the time we are 65, 82% of us will have one long-term condition, and half of people aged 70-plus have more than one long-term condition. Most of those long-term conditions are diagnosed within primary care, but of course they have a huge impact on access to secondary care services. For a clinician not to be able to see that whole picture and for the individual to have to explain again and again their physical health issues, and potentially their comorbid mental health issues, creates a huge challenge for people in getting access to the right help and support in a timely manner.
I would build on that to think about two areas that particularly affect older people: frailty and dementia. In this context, we know that assessment for frailty can make a big difference to ensuring people receive the right kind of help and support. That should be done in primary care, but often, sadly, people with frailty will present in hospital with a range of conditions. Understanding the frailty assessment score and what help and support is needed is key. For people with dementia and their family carers, having access to the right information for the clinician and for the individual concerned can make a huge difference. A disjointed experience just exacerbates what can often be a very challenging time.
Helen Morgan
Q
Paul Farmer: Listening to patients is an incredibly important part of any health system. It is necessary to make sure that the right mechanisms are in place at both the individual and the systems level. The aspects of the Bill that cover patient experience need careful consideration.
Many people were fans of what Healthwatch delivered, and others were not, but it had a clearly established system and mechanism in place to ensure that patient voices were heard. It is important that clear systems are established to ensure that that patient experience is heard. I have operated around the health system for a number of years, seeing a number of incarnations of patient voice organisations and representation; you really have to think about it from the individual and the whole-system level—from top to bottom.
It is important that the Committee looks at the provisions in the Bill in that context to make sure that where there are good supports, they not only are preserved but can be built on. For example, how do you make sure that patient voice is heard at ICB level, in providers and, in particular, in the new world of neighbourhood health?
Kath Abrahams: Helen, it is a great question. Clearly, the Bill itself, and certainly the single patient record, are never going to replace wonderful, kind and compassionate care where people feel they are listened to. As I have already said, but I will say again, a combination of people not being listened to at all, despite knowing their own health better than anyone else, or having to retell their stories has very challenging consequences. Both leave somebody feeling that nobody really cares or understands them.
I spoke to a supporter of Tommy’s this morning who has had five miscarriages. She was saying it appears to be quite a small thing, but every time she went to see a clinician, they said, “Oh, you’ve had four losses” or “You’ve had three losses.” It was about them not understanding, and her having to correct her records and getting letters through. It is about that sense of not being listened to.
As we develop the Bill, women and birthing people, from a maternity perspective, should have the opportunity to contribute to the way something like the single patient record is shaped. You could have a digitally accurate system that did nothing to reassure women or help them feel looked after or listened to, or you could have a beautiful system where the information was recorded in such a way that it really helped.
Alongside that, clinicians need to continue to receive the right sort of training. They need to have enough time. As Paul said, you need those patient voices involved in overseeing how things are going, and able to contribute and help. The Bill itself, as a mechanism, will not do enough. This is about designing it carefully with patients in mind and, in the case of maternity services, involving women right from the start.
Emily Holzhausen: There are provisions in the Bill that transfer responsibilities from NHS England to the Secretary of State in relation to involving patients, and it is very explicit that this also involves carers. It is very important that explicit Healthwatch duties to involve carers have been transferred into the Bill in relation to integrated care boards. That matters because their portfolio of commissioning different services is increasing, as is that of local authorities.
Those are strategic duties. The reason why that is important, to be very specific about carers, is that they provide £152 billion-worth of care. They outnumber staff three to one. They are experts in care over time and they want to be involved. Of course, what colleagues have said about good practice is critical to look at.
The changes to Healthwatch—others have raised this—do not consider the person’s journey across different services, health and care. There is an independent voice that we do not have, and will not have, in quite the same way. A very small proportion of carers felt that, if they raised a complaint, it would be acted on. That kind of independent voice is actually very important.
As Kath said, those duties are really important, but we need top-to-toe listening to patients. We also need to be explicit about listening to carers, not just on behalf of the patient, but by asking, “What is your experience as a carer of managing this care?” because that is very different. To be honest, I do not think we have the right data flows behind that to collect and understand people’s journeys and improve things. I hope that that is also something that will be looked at.
The Chair
I do not think there are any further questions. I am sorry to have kept you waiting so long for what has been a relatively short period of time, but it was important that all Front Benchers, and any other Members who wished to do so, had the opportunity to question you. Thank you all very much for being so patient and for giving us the benefit of your thoughts and wisdom.
Examination of Witnesses
Dr Michael Cocker, Dr Towhid Imam and Dr Nicola Byrne gave evidence.
The Chair
If everyone is ready, we will proceed to the next panel; as you will see, one of our guests is on the screen. We have Dr Michael Cocker, from East Lancashire hospitals NHS trust, Dr Towhid Imam, from Croydon health services NHS trust, and Dr Nicola Byrne, the National Data Guardian for Health and Social Care. We will get through this as reasonably swiftly as we possibly can without cutting corners, if that is all right. I will try to bring this to a logical conclusion within—[Interruption.]
The Chair
For the sake of the record, starting with the two people in the room, will you identify yourselves, please?
Dr Imam: Hello, I am Dr Towhid Imam. I am a consultant geriatrician, working in Croydon university hospital, where I set up the front-door frailty service. I am also a clinical lead in South West London ICB and an adviser to NHS England.
Dr Byrne: I am Nicola Byrne, the National Data Guardian. I am also still a practising clinician, as a consultant psychiatrist in south London.
Dr Cocker: I am Dr Michael Cocker. I am a consultant obstetrician in the north-west of England, in Burnley general hospital. I am the clinical informatics officer for maternity at my trust.
Dr Johnson
Q
“rather than data being transferred from where it exists at the moment to a new system, it will remain where it is—in GP surgeries, hospitals and so on—but it will be linked up so that one person, including the patient, can see all that data”.—[Official Report, 1 June 2026; Vol. 786, c. 890.]
How easily will that work in practice? In the trust that I work in, we have different systems for blood results, results, tracking patient appointments, maternity and A&E. Is it realistic to expect someone to be able to log on from one part of the country and to understand all the different systems in all the other parts of the country, or do you think that it needs to work in a different way?
Dr Imam: About a month ago, we published some NHS England guidance on best practice for frailty. Included in that are examples of shared care records, where people who are living with frailty who have been assessed by health services can actually view one record. The way those work is to take information from multiple different records and place it into one shared care record, in order for clinicians from various different backgrounds and multidisciplinary teams to work together.
Dr Johnson
That would be moving it on to a new system.
Dr Imam: That is in a separate shared care records system.
Dr Byrne: As I understand it, the architecture is not yet decided, so how we solve those technical challenges will be determined by the choice of architecture.
Dr Cocker: Similarly, I believe that the technical solution for how that will be delivered has not been finalised. When we did the maternity-based pilot in the north-west, the wireframe prototype that was developed pulled information from all the separate systems—the maternity system, the hospital central electronic patient record system, the GP system. The pilot was based on pulling it from each individual system into one place where it can be viewed, but that is a future aim. The focus is on phased implementation, so it would not all be immediately available like that, but that is the vision.
Dr Johnson
Q
Dr Cocker: That is a pertinent question. I know that that has been the focus of a lot of concern since the Bill was publicised. I believe that the structure of the SPR would be recognised as a critical national infrastructure-type of project, so it would have access to more resource to protect it. But there will always be inherent risk, when you have something centralised, that it is a single target rather than multiple targets that could be attacked—for example, in a cyber-attack.
Role-based access would be important—for example, having an understanding that the information should be accessed only for the provision of clinical care. How it would be delivered on a technical level would have to be finalised; that was not the type of the prototyping work we did, because it was more about a proof of concept than those more minute technical challenges.
Dr Byrne: I am glad that Dr Cocker took that question first, because he has given you a helpful technical answer. As National Data Guardian, my mission and concern is primarily around public and professional trust. Trust in whether this system can be relied on in terms of people’s confidentiality is something that concerns me very much, as well as people’s trust and confidence in secondary purposes, how the system will be used and what the safeguards around it will be. I would be happy to answer from that perspective when it comes to people’s confidence.
I think you have heard a lot about the potential benefits of this system, but it is important to bear in mind that if people do not trust it, the programme will fail, however great the potential benefits are. As a clinician, I would share the excitement, and I am very supportive of the ambition, but people will not trust it if they perceive the risks to the security of their data and confidentiality to be too great.
With that in mind, I want to draw attention to two things that concern trust. I want to emphasise that trust is not simply important—I know that the word “trust” has come up repeatedly today—but absolutely foundational to the success of this. The question about how demonstrably trustworthy the system is should be the primary foundational question; all other questions, including the technical ones, flow from that one question.
On the confidentiality aspect, I think there is a provision under clause 47 that potentially has very significant unintended consequences. I understand that that is not the intention of the drafting, but I have concerns about it and I have a potential solution to suggest. In clause 47, proposed new section 250E(3) creates the power for the Secretary of State to remove the duty of confidentiality for any processing in the SPR in line with regulations. I need to register my concern about that wholesale lifting of the duty of confidentiality from the entire system.
At a system level, there are two risks. One is to patient and professional confidence in the confidentiality of the data once it is accessed or in a system. Confidentiality is absolutely the cornerstone of all clinician-patient relationships. It means that people are comfortable to share the most sensitive information about themselves and often loved ones—it is not just information about ourselves on our records; it is often also information about our loved ones. If people do not trust that that confidentiality is a constant ethical constraint for anyone accessing the record further on, they may be less able to share information about themselves or their loved ones. Clinicians may also be less likely to document that information if they have ethical concerns about who may access it further on if it is particularly sensitive. That will negatively impact on care and the quality of data for any secondary purposes in future.
The second point I will make about that confidentiality provision is that I understand that the drafting intent is to remove any ambiguity in terms of people’s concerns about duty of confidence when allowing access to their data at an organisational level. However, as currently drafted, the provision could be interpreted to remove the duty of confidentiality for not just direct care but secondary purposes. Secondary purposes in future could be dealt with by regulations. That lack of clarity poses a risk.
The solution I suggest is to redraft that provision, drawing on the precedent already set in the Health and Social Care Act 2012. Section 259 prevents disclosure of data from an organisation from being a breach, so people could allow access at an organisational level with confidence. You have removed that ambiguity, but it does not remove wholesale that duty of confidence—that ethical safeguard for the data in the system itself. I think that that is important for people’s own direct care, and, as I said, it is particularly important if there are any questions around secondary uses in future.
Dr Imam: That was a comprehensive answer; I have nothing to add.
Dr Johnson
Q
We keep hearing that it is difficult for people to have to repeat their story. I understand that stories can be traumatic and repeating them can be unpleasant, particularly if it must be done many times, but is there sometimes a clinical value in asking people to go through their story? If so, what is it?
Dr Imam: My specialty is frailty, which is a medical condition characterised by a loss of independence. Although it is associated with ageing, it is not an inevitable part of ageing. The treatment that I deliver as a clinician is called a comprehensive geriatric assessment. It is evidence-based and we know that it improves patient outcomes and maintains independence. What it describes is a multidisciplinary team approach to a holistic assessment that focuses on what matters most to the patient.
One of the issues that we have right now, however, is that the NHS does not consistently identify people who are living with frailty right across the system from community to hospital. If we are identifying people and diagnosing them with a condition, you would expect treatment options to be offered, yet we do not consistently do that across the country. That is essentially driving ineffective and inefficient care. Sometimes, therefore, when a crisis sets in—we have seen this in other reports around corridor care—that can ensue in older people living with frailty.
In my day job, where I look after people in a busy A&E department, I see people who have may have had a fall or become confused, or where there has been a breakdown in their social situation. My practitioners and I are spending hours trying to piece together information from multiple different sources. Those could be paper-based, digital or telephone—we could be trying to phone people to get up-to-date information. As you can imagine, sometimes they do not pick up the phone, so we are sometimes working from incomplete information and things that are not up to date.
Once we have done that, we try to create a care plan for a patient that allows them to be looked after in the community. However, that care plan may not follow the patient, because everyone uses different electronic patient record systems. Some important partners in that care, like social care or ambulance services, cannot actually see the care plan that I have developed for my patient.
Unfortunately, if a patient with frailty then succumbs to a crisis of some kind, the default setting is, in many cases, to trigger an admission to hospital. If a patient does not need to be in a hospital environment and they are frail, they can end up becoming more frail and weak, and lose their independence. That means that they will need even more social care than would otherwise have been required.
Where the solution comes in is that a nationally rolled-out single patient record system could fundamentally reshape this form of care, because we would be moving it from the fragmented, reactive model that I just described to one that is proactive, co-ordinated and truly centred around a patient. Another thing about frailty is that there are so many different people involved in that person’s care, so we need to try to restore the continuity of care for that type of patient, which has become eroded over time. The SPR addresses that with a single up-to-date view of a patient. It enables earlier risk identification, faster clinical decision making and that whole-system integrated response I have been describing, which is lacking at the moment.
There is often duplication; one of the other issues is that assessing patients in this manner can take a long period of time—up to two and a half hours is often quoted by the British Geriatrics Society. You can imagine that if you had an electronic record that could be auto-populated or could rely on the most recent, up-to-date plan done by someone else, that would avoid reassessment as we would be working from contemporaneous information.
Over time, you can see how, for frailty and many other conditions, that could lead to a more preventive approach that is more community based, that reduces the need for admissions, and that provides a better overall experience for staff and patients. Importantly, there needs to be a shift towards neighbourhood working on frailty, and this allows the multidisciplinary team to work towards one plan. You have also heard today about patient voice and carer voice, and this type of care plan also gives them the opportunity to become partners in looking after themselves.
Dr Cocker: The brief answer to the original question would be that communicating and getting a history from a patient are the cornerstone of the patient-doctor relationship. I do not think that the SPR is ever intended to replace that. Where I see its value within maternity, although I am sure that this is the same across all specialties, is that it would form a reliable means of cross-referencing information and being able to get information that—as we have alluded to previously—is often held on many separate systems. As a clinician, you will often not have the ability or the credentials to access that.
For example, in maternity care at my trust we use a certain piece of software. If you do not work in maternity, although you might be able to get generic access to it, you might not be able to navigate that system. The idea of the SPR is that it would pull out those key bits regarding current concerns about the pregnancy or what follow up has been arranged—all those kinds of things. That would not rely on the ability to use lots of different systems; instead, the information would be available. If there is information that requires cross-referencing or checking, it would also give you the ability to do that rather than replacing the process of taking a history and working out what is wrong with someone.
Dr Byrne: It is a terrific question. Healthcare is a relationship; it is not simply a transaction of facts. At its best, it is a working relationship between a clinician and a patient, but that is also why it is so hard sometimes. Our stories are a combination of two things: the facts and the interpretation of those facts. We heard a moving example earlier of someone saying that they had had five miscarriages and those facts were then not known and how distressing it was that they were not. That is a good example of why getting the facts from conversation to conversation could be really helpful.
Our life story changes over time, however, as does the interpretation that comes up in a conversation. As a doctor in the moment with a patient, I am sometimes as interested in what they are choosing not to tell me at a particular time as what they are choosing to tell me. For all of us, the story changes and is fluid. I think that is a potentially helpful distinction to make.
Karin Smyth
Q
Dr Cocker: Having seen the maternity-focused prototype that NHS England developed in the north-west, we learned that it is technically difficult because there are lots of systems. There needs to be a level of interoperability that allows you to pull the data or it is not going to be much use as a reliable system.
The other thing was about trying to ensure that we design those systems for the patients most in need. That might be social or medical need, and there are many different facets to that. That was one of the other challenges. A lot of the focus went into trying to determine a set of theoretical patients who were very high need, and ensuring that you have encompassed all those possible needs, so that if you design the systems for those in most need, they will cater for as many people as possible.
Dr Imam: To expand on Dr Cocker’s point about the identification of problems, people living with frailty often have multiple under-identified issues. In the prototype we have been shown, the SPR has the potential to analyse the wealth of data on a person and summarise it in a manner that makes sense to the clinician logged into the record. It can also piece together a timeline of what has been happening with a person.
As I said earlier, we often follow a manual process to try to understand what has been going on recently for a person. The SPR will not only enable the automation of that process, but give us the ability to know who the key individuals involved in that person’s care are, so when that person is in a crisis or emergency situation, we know exactly who to call and who the last person to touch the patient was.
There are other important functions. It is not only about sharing information across an entire pathway and having the whole-system approach that I described—from community to hospital, and vice versa. Importantly, many people living with frailty require multiple different referrals and the involvement of multiple different people in their care. The SPR will be able to streamline some of those processes and make recommendations for certain referrals that a clinician, who, under an earlier version, would have logged into the record, may not have otherwise thought about, so it may even improve outcomes for patients by providing solutions to improve their care that we would not have come up with otherwise.
Karin Smyth
Q
Dr Byrne: You have to show that you take the risks and people’s concerns seriously, and give a credible analysis of the risks. The key thing is to engage with the risks meaningfully. You should then think about what safeguards you could put into the Bill and future regulations that would actually be effective and be seen as credible, depending on what risks you are trying to address.
I know it is difficult to get into the detail on the primary legislation at this stage, not least because you are trying to sequence things when we do not yet know what the SPR will be, which I appreciate is a further constraint. I would suggest that you consider putting in the Bill one particular safeguard relating to secondary purposes. People have concerns around two main things: confidentiality and their privacy, and secondary uses—who might access their data in future, and why and for what purpose, other than for their direct care. Focusing on that second factor, there are lots of things that might come up that you could do in regulations, but right now, I would suggest that you could build in the safeguard of an independent oversight mechanism for how decisions are made on who gets to access the data and why. In that, you can involve public and layperson representation to bring in that consideration of the risks that matter to the public, alongside the potential benefits.
That could be helpful for two reasons. First, it would be a safeguard against having any unchecked decision-making power on access, whether now or in future. Secondly, it recognises the reality of human systems and organisations. No one expert or small group of experts, however wise or whatever their integrity, can see the whole picture and have a 360° view of what matters to the public. It would be a meaningful way to give the public agency and representation in that decision making—a meaningful exercise of citizen control, if you like. As humans, we are at our best and our decision making is at its safest and strongest when we get a diversity of perspectives involved—as, indeed, the Committee is doing right now. In this context, that should involve patients and the public.
My second point, which is perhaps germane to your wider discussions around the Bill, is that no one organisation can effectively and consistently scrutinise and challenge itself. That goes for questions around data use and access—and wider, as well—in your considerations.
Helen Morgan
Q
Do you have any advice for us on the development of that single patient record and how we make sure that the data is clean and consistent between trusts and different systems, so that the single patient record is actually meaningful? I will ask Dr Cocker first, if he is the technical expert.
Dr Cocker: I would not go that far—my involvement in this whole project is clinical, rather than having any sort of particular technical expertise. I think that is a pertinent issue, however, because, as has been discussed previously, if an error enters the SPR—say, a code is incorrectly followed through into the system—that error can then perpetuate. That is the risk of a single record: a documentation error can ripple out, rather than being contained within the system it originated in.
Does safeguarding that involve putting requirements on the providers of systems to mean that data can be exported in, maybe not a standardised format, but a set of formats that the SPR recognises? It is a technical question that I do not know the answer to, or the possible solutions to, but that would be one of my suggestions. Rather than having hundreds of different systems that all require slightly different solutions in order to be fed into the SPR accurately, there could be some sort of framework setting out requirements on the providers of the software products used by all the different organisations that will feed into the SPR.
Dr Imam: Like Dr Cocker, I am not technical but, from previous pieces of work that I have been involved with, some of it is to do with the data architecture and making sure that you can agree on the fields being used across the various systems. On frailty specifically, we have had the question of, “If we have multiple source systems that have the same field, which one should we be showing within the single patient record?” Our thinking at the moment is that we would show various entries, with who they have been done by and at what time, so that the clinician could decide how to interpret that data.
Helen Morgan
Q
Dr Imam: That is a really important question; it is something that needs to be thought about very carefully when it comes to the implementation. From my previous NHS England experience, where we have had digital innovations implemented in the older age group, or among those who are perhaps traditionally digitally excluded, that has included partnerships to enable people to have the option of someone coming around, and there has been a thought process regarding people who perhaps cannot engage with technology as easily. That could involve people from the voluntary, community and social enterprise sector—for example, we had Age UK in the previous panel. There are lots of good examples of that type of work to ensure that people are not disadvantaged.
Dr Byrne: There is an opportunity here in the context of digital exclusion. In a digital-first NHS, it is really helpful to think continually about what the analogue version of the system is in the event of further cyber incidents and outages of the system. We need to continually build and maintain a resilient system for the times when digital-first is not available. It is an important opportunity to do so if we think about that question of exclusion.
Sojan Joseph
Q
Dr Byrne: Those things are very important, yes. There are some technical solutions. Again, the SPR is an opportunity to look at that across the system, because systems vary greatly in the sophistication of their audit function, for example. Even when there is an audit function, if someone has legitimate access through their role as a doctor or a nurse, it can be difficult to know whether their access in any particular case is legitimate. These are not common occurrences, but it is extremely distressing for patients if their confidentiality is breached for any reason.
It is not simply a matter of technical controls. We need to look at how we build stronger, more effective deterrents across the system by having effective sanctions when incidents do occur. I am keen to look at that and delighted that the Department of Health and Social Care and NHS England are, I think, very interested in having that conversation with me. At the moment, it certainly seems that there is a variable response across the system to inappropriate access.
Looking ahead to the SPR, we need to look at that make improvements, so that the public can have faith that, given the harm that it can cause them, it will be taken very seriously if anyone does access their records inappropriately. There are technical, cultural and system aspects to think about here. The SPR is definitely an opportunity to do that, and I am very keen to work with other stakeholders on that.
Peter Prinsley
Q
Dr Byrne: It is an interesting idea, but I am not sure. I heard your question earlier about data controllership specifically in this regard. You will not necessarily like my answer. There are two ways of answering the question; perhaps straightforwardly, legally, but also clinically. I will start with the legal answer, which in some ways is easier. Data controllership in data protection law is a very technical term; it is determined by who is making the decisions about processing the means of the data. An organisation running and controlling an electronic patient record would be the data controller. Obviously, this is ultimately a question for the regulator and the Information Commissioner’s Office to determine, but that would be the legal position, nevertheless.
Clinically, we have to come back to thinking about what a patient record is for. Primarily, it is to provide good care in the context of the clinician-patient relationship. If you prioritise the needs of either side of that relationship, I think it is problematic; the needs of one must not outweigh the needs of the other.
The clinical record is there to enable clinicians to record what someone is presenting with, the difficulties they are having, what investigations are appropriate, the findings and what the plan is. It needs to be there for that tool to work. To take you on a slight thought experiment, if it was entirely held within a patient’s control—however loosely we use that term, legally or otherwise—and we could all amend, correct, change or add our diagnoses, findings and treatments, that might be clinically problematic. That may not be the answer you want, but it is the straight answer, if I am honest, from both a clinical and legal perspective.
Peter Prinsley
Q
Dr Byrne: I totally support that ambition. Patients and the public having more agency in their care, strengthening that relationship, and them being able to access their information through the NHS app is a great thing. That is hugely helpful, and there is real potential with the SPR to strengthen that. We have landed on agreement.
Dr Johnson
Q
Dr Byrne: At the moment, I think it is too early to say. Those are absolutely important questions that will have to be addressed in the design. At the moment, I am not sure how the programme intends to deal with those questions, but clinically, that needs to be thought about. There are complications that need to be thought about very carefully in terms of the record and the access. Sometimes that is clinically complicated, but I am not aware of what the plans are for that.
Dr Johnson
Thank you. You are nodding, Dr Cocker.
Dr Cocker: I was just going to say that we did do some exploratory work in relation to safeguarding, because that is quite a key part of safe maternity care, but because of the issues with confidentiality for other involved parties—say, a mother’s partner or someone else in the family—and the risk of that information being pulled through to someone else’s single patient record, it was felt that we could not include any information that contained information about anyone else. That aspect has been considered, but as Dr Byrne said, it would need careful consideration of all those different sources and whether there would be any option to change what feeds in. The only one I am aware of that we have looked at specifically was safeguarding, and it was primarily due to confidentiality issues for other involved parties.
Dr Johnson
Q
Dr Cocker: Yes, and those are concerns with the existing systems. There are multiple sources of information we record on a clinician-facing basis that might be deemed sensitive or confidential that are not available from a patient-facing perspective. It might be sexually transmitted infections or previous pregnancy history that a mother does not want someone else to be able to access on the patient-facing aspect of the record. Being able to provide that is very important in realising the end product of the SPR.
The Chair
Dr Byrne, Dr Imam and Dr Cocker, thank you very much indeed for your patience and for affording us the benefit of your experience and wisdom. The Committee is most grateful to you.
Examination of Witness
Jon Restell gave evidence.
The Chair
We will now hear oral evidence from Managers in Partnership. We have until we have exhausted ourselves—I will say that for the moment—for this session. Would you be kind enough to introduce yourself for the record?
Jon Restell: I am Jon Restell, the chief executive of Managers in Partnership.
Dr Johnson
Q
Jon Restell: There are lots of different ways to answer that. Obviously, some functions of NHS England moving into the Department, with powers going to the Secretary of State, feels like a centralising measure. I know that the ambition of Government is to give local NHS bodies more freedom and autonomy, but the Bill is very careful and goes into a lot of detail to leave powers with the Secretary of State to intervene in the running of those local bodies. On the whole, it is probably more of a centralising measure.
Another way that some changes outside the Bill process are centralising is through the merger of ICBs and, arguably, quite a lot of providers. Whereas before you might have two or three ICBs covering an area, you now have half the staff covering much bigger geographies. I would argue that that centralises decision making to a higher level than formerly.
Dr Johnson
Q
Jon Restell: This, for us, is the crux of what is going on. The Bill is the Bill, but there is a finite management resource in the health service. I think that, internationally, it is considered to be quite low. Certainly, Lord Darzi, the Institute for Government and Institute for Fiscal Studies have all pointed to a shortage of management being one of the potential weaknesses of the NHS, so what is going on right now is knocking another big hole in an already limited resource of managers in the health service. That has the potential to create very large workloads for people in the new system, such that, inevitably, certain things will not get done or will not get done well enough. It certainly feels like we have gone into an environment where we are cutting a management cost without thinking about the management capability the health service needs to innovate, deliver reform, and do basic safety and resource management.
Dr Johnson
Q
Jon Restell: Our members have been on a bit of a journey on this one. I think that they would broadly support the regulatory proposals that the Government will bring forward after the consultation. I think the real impacts will be very limited, covering a relatively small number of people and being used in very exceptional circumstances, so I do not think that they will transform management culture and deal with the management capability issue we have. They are a very personal form of professional regulation that will have very limited impact.
Dr Johnson
Q
Jon Restell: That is probably driving most of the anxiety and uncertainty that people are experiencing, and it is why, for some members, this is becoming psychologically very difficult. You have a change programme that started in March last year with the announcement by the Prime Minister of the abolition of NHS England and the halving of the staff of NHS England and ICBs. For 18 months, that process has dragged on, with lots of design decisions still to be taken about how the organisation will look, what functions it will have, what will be going to the Department and what might be going elsewhere, and what will potentially go to trusts from ICBs and from ICBs to regions. Despite all that uncertainty, people are being told to make decisions about voluntary redundancy and the future where they do not understand where that future potentially sits for them. That is undoubtedly driving a lot of people to feel psychologically unwell and distressed, and they are leaving. People are beginning to leave, because they need to protect themselves.
There is another part to this. Obviously, that is a very personal issue for our members, but the other thing is that they are really worried about the service to the public, the safety of the changes and what will happen to various functions that they are responsible for, if teams get halved and responsibilities are taken to a higher level in that more centralised model.
For example, we have a lot of members working in ICBs who have really hands-on roles in the care of individual children, particularly where providers fail. Those kinds of concern are not being properly addressed in terms of risk and continuity of service to those people. We are going to survey our members—we will share the results with the Committee—in the next week or so about what specifically is worrying them about the way that change is being managed. With due respect to the Minister, this was all announced without a plan, and we are now waiting for a plan to emerge, 18 months into the process.
Dr Johnson
Q
Jon Restell: Obviously, we have the 10-year health plan, which most people broadly see as a good vision for the service, but there are too many key design questions around the new department, the role of the department’s regions, what ICBs will be doing and what trusts will take on as part of this reorganisation. Behind it, there is a lot of capacity and resource organisational memory being taken out of the system.
We do not talk nearly enough about the work of the commissioning support units staff, who are providing internal consultancy and a huge range of business services to the health service, including overseeing child immunisation programmes in some cases. It is really unclear what the future of those functions is. We are taking out a lot of staff who have skills, expertise, organisational memory and commitment, but we do not quite know yet what the precise form of those organisations will be. It is a very difficult change to manage.
Karin Smyth
Q
We had a lot of change with the Health and Social Care Act 2012, and the Bill seeks to reverse that in terms of the architecture of the NHS. We absolutely appreciate as a Government that that is very difficult for staff working in it. I appreciate that the operating model and so on is coming forward, but could you say a bit about people’s feelings about the Bill? There will be more clarity to the centre and the role of providers is not changing, while the real change is around commissioning functions and, as you said, commissioning support organisations. We heard earlier that everything is being reorganised. That is not true, but there is a big change in the geography and the functions of ICBs and commissioners, and the Secretary of State’s role will clearly be different. What might people’s approach to that be?
Jon Restell: Clarity, definitely. No one wants to start with the system that came in in 2011 and 2012. Successive Governments started to correct it almost as soon as it was put in place. I think most people would welcome sorting out the clarity around commissioning there, but I do not think that is the same thing as cutting 50% of those organisations’ staff and running costs. You are clarifying the relationship between the centre and ICBs, commissioning and providers. You still need enough managers with enough skills working in the right system to deliver. That is the nub of what we are doing.
For us it is not really about how the Bill will eventually pan out; it is about the cut and how that is being administered by NHS England, the Department and ICBs. The whole system of management is under strain across the health service. You say that providers are not changing but they are also being asked to take out quite significant amounts of management resource. They are merging to form bigger, potentially more centralised units that may be less responsive and less innovative. I think that organisational form is really important, even if the headline of the Bill might tidy up and clarify those relationships, which would be welcome.
A point made by a lot of members, particularly those in ICBs, is that they do not think that the model design—where we started with ICBs, then went to regions and we are eventually going to get to the target operating model for the Department—is being done at a time where you can see the proper connections that need to be made between those organisations. When the system is up and running, how well will it work together to share information, share risk and so on? It feels like the Bill is very high level and the detailed design of the organisations is being undertaken in a completely fragmented way. People see that as potentially requiring the next round of reorganisation. You are a former NHS manager, Minister; you know how often reorganisation is reached for as the solution. I genuinely feel that people have got to the point where enough is enough. That kind of continual change will create more and more problems for doing the things that the public actually want to see: innovation, improvement in the quality of service and happier staff—all the things that managers should be focused on, not the merry-go-round of organisational change.
Helen Morgan
Q
Jon Restell: It certainly needs to be clarified. Whether it needs to be clarified in legislation, I do not know. Leaving aside the fact it took a very long time to get permission to move forward with their consultations, ICBs were thinking about what they needed to do around May or June last year. They will have made a lot of decisions and a lot of staff will have gone already based on the then understanding of what an ICB was supposed to be doing, based on the ICB blueprint that was published by NHS England, so I think that resource has gone. The people who may be connected with the functions that you are talking to have also gone in many cases. The question for me is: if the ICBs are to get more things to do, what is the implication for their running costs? As you know, they are currently capped at about £19 per head. If they get more functions, will they get more resources to do that? Will there need to be other ways of delivering those functions? I do not think that a lot of them can stop doing statutory functions, but that means all the good stuff that we want to see done in health systems—the innovation and the discretionary stuff, much of which is already on hold—will probably be the stuff that goes while they deliver their statutory obligations.
On the providers side, we need urgent clarity about what is going to go to the providers’ responsibility because they are taking out a lot of costs. I do not think that all, or many, providers know that these plans are afoot for them. That will create quite a shock. Again, they are choosing people to go now based on their current understanding of what is needed.
Helen Morgan
Q
Jon Restell: A lot of the concern is to do with the political make-up of mayoralties in the future and what that might mean; if mayors have an ever-growing responsibility and say in the who, what and where of health services, that is probably different from the more representative, advisory function that they have had. That really needs to be thrashed out: is that the new democratic accountability for health services, or does it remain, as now, with the Secretary of State, accountable to Parliament, making provision for healthcare? It feels a little unclear how much decision-making power those new local government voices will have on ICBs. Have people raised that as a concern? Of course they have; it is uncharted.
Helen Morgan
Q
Jon Restell: I cannot comment specifically on the BCF, but a general theme coming out of what our members are telling us in surveys, and in the regular surgeries and meetings that we have with them, is the sense that policy at the moment is trying to get you thinking in terms of your own organisation again, and thinking less about system-wide transformation, innovation or co-ordination. ICBs are getting bigger and providers are getting bigger. It is some of the system stuff, where I think a lot of our members would say the innovation will come in the way different organisations try to solve problems around patients and populations, that they feel is at risk, by the way—not just from the Bill putting things together, but from the stripping out of resource to do anything different.
The Chair
Thank you very much indeed, Mr Restell. Thank you for your patience, thank you for coming and thank you for the evidence you have given. It is greatly appreciated.
Examination of Witness
Sir Andrew Dilnot gave evidence.
The Chair
We shall now hear oral evidence from Sir Andrew Dilnot. Sir Andrew, for the benefit of the record, could you identify yourself, please?
Sir Andrew Dilnot: I am Andrew Dilnot; it is great to be here.
Dr Johnson
Q
Sir Andrew Dilnot: It is largely absent from the Bill—indeed, when I was asked to come and give evidence to this Committee, I was initially somewhat puzzled, since it is so largely absent. The question you ask is absolutely to the point: certainly, we can improve the efficiency of the NHS without doing anything about social care, but we cannot really address many of the fundamental problems facing the NHS if we do not sort out social care.
That is partly because not having a good social care system means that we are not achieving the levels of human flourishing that are the objective of the health service and the social care system. It is also the case that the social care system is now under such pressure that it is leading to direct challenges for the NHS. We hear a lot about delayed transfers of care, which are an important part of this, but it is not just those; it is people who end up needing healthcare because they have not had appropriate social care support.
The short answer to your question is that we can make the NHS a bit more efficient without reforming the social care system; but until we address social care we have at least two hands, and probably one foot, tied behind our back. It seems pretty astonishing to me that we have a 10-year NHS plan but no real plan for social care.
Dr Johnson
Q
Sir Andrew Dilnot: I would not claim to be expert here, but I have read the Bill and the briefings. The role of local authorities in social care is a very interesting one. If we were to stand way back and honestly answer the question, “Why is social care managed by local authorities at the moment?”, we would say, “Because it was forgotten in 1948, when the rest of the modern welfare state was created.” At that stage, social care was a pretty small activity, and it was just left with local authorities. What has happened since then is that it has grown and grown, and it is now putting enormous strain on at least many local authorities.
I think we should draw a clear distinction in something that is definitely appropriate—that is, care being provided within a local context. The kind of care that is appropriate in Camden will be different to the type of care that is appropriate in the highlands of Scotland. Local delivery seems relevant, but whether local financing makes sense in 2026 is a very big question. That is the context.
On its own, it is hard to see the potential reduction in the role of local authorities in ICBs making things better. It will not necessarily make things significantly worse, but I do not think it will help local authorities and the NHS in trying to integrate these two essentially non-integrated functions.
Karin Smyth
Q
Sir Andrew Dilnot: The question of the fine details of how legislation should be passed is certainly outside my skillset, so I have to be agnostic about whether the Bill should have addressed the wider questions of social care. On the question of whether we could address social care or not, the answer is definitely yes. After all, several Governments over the last few years have promised to do so. The former Secretary of State for Health and Social Care, when he was the shadow Secretary of State during the election two years ago, promised that he would do it. Such measures have received Royal Assent twice, but they have still not taken place, even though they were promised by the then shadow Secretary of State for Health and Social Care, before he became the Secretary of State.
Yes, we definitely could do it. The amounts of money involved, while of course significant, are small relative to the aggregate costs of the NHS or the uplift in spending on the NHS that, with my full support, we have seen in the last couple of years. I think it is a genuine puzzle and a black mark for all of us, including me, that all these years have gone by and we have done nothing. We have a social care system that is supported by millions of wonderful informal carers and about 1.5 million formal carers, benefiting hundreds of thousands of people, but it is creaking under intolerable strain. It really makes no sense to me, and I really do not know why or how we have managed to go for so long without addressing it. We should do so, not only because it is the right thing to do, but because it is now so bad that it is doing direct, instrumental damage to the NHS.
Helen Morgan
Q
Sir Andrew Dilnot: I think there are two main ways. The first, and perhaps the one that has received most attention, is that there are people who have been hospitalised, perhaps following a fall or infection, who have some mobility challenges and need some care, but who cannot leave hospital because a social care package is not available for them in the community. That is extremely damaging for the NHS, because if we have somebody in a bed that they do not need to be in because they have nowhere else to go, not only are we spending money having them there but we are then not able to use the bed for other activities.
If you have somebody with a delayed transfer of care that means they are stuck in hospital, when they do not need to be, for 20 days, which is not uncommon, very large numbers of elective procedures cannot take place because that bed is being used. That is a dead-weight loss from the system.
There is another thing that I think is at least as important, which is that, because of the lack of good social care, we have people falling, injuring themselves and needing to be hospitalised. We have people sustaining more urinary tract infections than they perhaps would if they had good social care. That is adding an additional burden, which the NHS deals with as well as it can, but all of this just seems unnecessary.
Social care appears to be so invisible to us all. It is easy to blame politicians, and of course it is politicians like you who ultimately have to vote for these things, but the electorate—the whole of our society—have to look at ourselves and ask, “Why can’t we make this challenge, which is so significant, better?” Any of you who have experienced it in your own family know how brutal and difficult it can be.
If I can be allowed one more general point, we should reflect that this is the result of the great triumph of the last 150 years. At the beginning of the last century, across the world, average life expectancy at birth was 32, and now it is 73. In this country, average life expectancy at birth in 1900 was 46, and now it is 81. We have added 35 years to the expectation of life from birth, which is an astonishing transformation. Some consequences come with that, one of which is that there is much more social care to be done, but we should be celebrating this, delighting in it and doing it well, instead of hiding it away and ignoring it for so long that it is doing real damage to the NHS, let alone to the lives of people who need social care.
Helen Morgan
Q
Sir Andrew Dilnot: Yes, it is very odd. It is worth doing the odd thought experiment: imagine that the bit of healthcare that was underfunded and available only subject to a means test, and not free, was for heart disease. We cannot imagine it. The fact that it is dementia and severe arthritis means we have drawn an arbitrary line, and while that line still exists and there is still inadequate funding, even in a means-tested system, we are hamstringing the NHS. Now, that is not the most important problem, which is that we are failing to give people flourishing lives and allow them to live to the full, but it is now so bad that it is actually making it hard for the NHS to work.
Joe Robertson
Q
Sir Andrew Dilnot: That is a very good question, to which I do not have a very immediate answer. Well, I do have an immediate answer, which is that, as far as I can see, it is nothing very substantial.
The single patient record offers some prospects here, and it is terribly important for people receiving social care, which again reflects how much longer we are living. There is much more multiple morbidity now. Many of the people who can and are benefiting from social care will have quite complicated medical experiences and histories. That is the kind of group that could particularly benefit from a single patient record, so that we are not having inappropriate prescription and so on. That is going to help, but it will be a second-order issue.
Let me be very blunt. There are two fundamental challenges facing the social care system. The first is that the means-tested bit of it, where we say, “If you don’t have any resources of your own, the state will look after you,” must be a minimum for any humane society. Essentially every year for at least the last decade, the Treasury has announced emergency funding for that in year. That money then does not get spent well. Honestly, if you are announcing an emergency package every year for 10 years, it is not an emergency package. You should wake up, pay attention, have a mature response and fund that system properly. That is the minimum.
The second is that the only big risk we all face that is not pooled is social care. Our risk of healthcare is pooled by the state, our risk of having a car accident or our house burning down is pooled by private insurance. This is the one risk that is not pooled, and the reason is that the state does not, and the private sector cannot. The reason the private sector cannot is that it is too far ahead for a private insurance market to deal with it, so only the state can pool the risk. If there is any area where the case for social insurance is absolutely clear, it is social care; the case is even more powerful in social care than it is in health.
At the moment we have a situation where often people will feel that the best thing that can happen to them, if they think they might have a social care need, is that they die before too long. It is a bit like standing in the middle of the road with a lorry driving towards you and hoping that the best thing that might happen is that you die before it hits you. That is not a good way to be running any kind of society or country. Those challenges—the lack of adequate funding of the means-tested system and the lack of any risk pooling for the population as a whole—lead directly to the kind of experience that you are describing in the Isle of Wight, where there is simply excess demand and so we are trying to ship people across to the mainland. It is a reflection of the fundamental challenges that we have ignored for 35 years.
Dr Johnson
Q
Sir Andrew Dilnot: You are absolutely right to emphasise the importance of non-elderly adult social care, which is roughly half of all of the expenditure and growing. One reason that we see particular pressures in the elderly care sphere is that the less-elderly need has grown very dramatically, again because of the scope for increased human flourishing.
On the whole, as far as I can see, there is very little understanding of the integrated nature of these costs between social care and the NHS, so I think there is very little thinking in budgetary terms about the consequences of the squeeze on social care leading to increased expenditure and needs elsewhere in the NHS. That is not easy to resolve. Moving to a system that properly integrates those trade-offs will be difficult, and it requires a different sort of funding regime, but while we do not, those costs exist. My sense is that they are second order at the national level, but where they are certainly not second order is for the individuals concerned and their families, for whom this kind of thing is an eruption of anxiety and grief, in the context that families are already under pressures that most of us would find hard to imagine.
The Chair
Thank you very much indeed, Sir Andrew, for affording us the benefit of your considerable knowledge in this area, and thank you again for your patience. We are most grateful to you.
Sir Andrew Dilnot: Thank you. I am delighted that you are thinking about social care in the context of this Bill.
Examination of Witness
Karin Smyth gave evidence.
The Chair
Minister, for the sake of the record, would you identify yourself, please?
Karin Smyth: I am Karin Smyth, the Minister of State at the Department of Health and Social Care.
Dr Johnson
Q
“The reorganisation of health services always distracts from people’s jobs, destroys morale and wastes money”.—[Official Report, 22 September 2020; Vol. 680, c. 809.]
In response to a written question this week, though, which asked what assessment you have made of the disruption of development of new services caused by the abolition of NHS England, you said:
“The abolition of NHS England is causing no disruption to the development of new services.”
I wonder which of those statements you agree with the most and whether you want to change your mind in the light of any of the evidence you have heard today.
Karin Smyth: I do not know exactly what year you are quoting from, but I am happy to take that full on. Of course, change, reorganisations and changes in legislation have consequences at different times depending on what they are. That will determine changes to some services at local level.
I think that quote probably relates to the 2012 changes, which, as I have often said, brought me into Parliament. The entire infrastructure of the health service was destroyed and changed in order to bring forward that legislation. I can never find anybody—I think I have heard Lord Lansley say this—who thinks that was a good thing. I am very happy to say that part of the rationale was the fact that, despite lots of warnings about the damage to that infrastructure, that lesson was not learned. We will not go through the history of the passage of that Act. It even had to be paused mid-way through to enact other ways of making things work.
I am sure that you will come back in your second question to decisions about some of the provisions in this Bill. It is true, and a matter of record, that as an incoming Government we did not intend to abolish NHS England as an organisation; in our determination to change the outcomes of the health service, that decision was made some eight months into our being in government. Today, we have not heard a single person suggest that that decision is wrong. Dr Johnson is from the Opposition. The Bill was not opposed in principle on Second Reading. There is overwhelming consensus on the major provision in the Bill—the abolition of NHS England—and on the single patient record.
I am mindful, on a personal level, of the consequences for individual people’s jobs and of trying to get that right. I accept much of the criticism from Mr Restell about how it would be better to do it much more quickly, and about making sure that it is done in a different way, but the consequences of abolishing NHS England are some of the things that we are seeing.
Dr Johnson
Q
Karin Smyth: In terms of service delivery—I think the written question was about delivering services— I stand by that.
Dr Johnson
Q
Karin Smyth: Do you mean the future state of ICBs?
Dr Johnson
No, I mean the system as a whole. My right hon. Friend the Member for Melton and Syston spoke earlier about how ICBs were designed to link in with upper-tier local authorities, and he gave a reason why. Under these reforms, Lincolnshire ICB, which was part of a mayoral authority, will now link in with Derbyshire and with Nottinghamshire, which are part of another mayoral authority but not a complete mayoral authority. You have things jumbled up. I wonder whether that is because, rather than having a vision, you have started to unpick somebody else’s work because you did not like it. Likewise, with the single patient record, we have heard that lots of necessary decisions were not made before the Bill was introduced, so people are being asked to deliver things that have not been properly considered. Is that fair?
Karin Smyth: I think they are two separate things. On the provision made in the Bill, abolishing NHS England brings with it a lot of technical detail to ensure that the legal responsibilities and duties are placed, rightly, on the Secretary of State and into ICBs. It clarifies the landscape on very technical matters such as licences and foundation trusts, and there is a large chunk of detail on the consequences of abolishing NHS England.
Alongside that, there is a move to give ICBs a larger footprint, in parallel with the Government’s agenda on devolution. I accept that that is a lot of change in all our constituencies and for all our areas. We are making sure that we make the most of mayoral authorities to allow mayors to be on ICBs, as they are largely determiners of a lot of economic development, transport and indeed the wider determinants of health. We are still going through some of that change; you will recently have been written to for your views on it as local Members of Parliament, along with local government. We need to make sure that that is embedded as quickly as possible so that we can stabilise that side of the system.
On the single patient record, the Bill will provide enabling powers to bring it forward in regulations. There will be further detailed consultation both with clinicians and with patients and the public, as we have heard, because building trust is critical. That will come next, which is usual in parliamentary terms: as legislators we understand that primary legislation makes provision and secondary legislation sets out regulation. I thought Dr Byrne was very helpful earlier on the point about bringing public trust with us and explaining the two stages of bringing this forward.
Dr Johnson
Q
Karin Smyth: There is a fundamental philosophical, and perhaps political, difference in the approach that this Government are taking compared with what has gone before, in terms of the notion of responsibility and accountability for both commissioning and delivering services, and the position of independence. We talked earlier today about perception and reality.
The system has not worked. To my earlier question— I think I said this on Second Reading—we have had what is called an independent voice in some of these bodies for over 50 years, and we have had numerous recommendations. I disagree with Jeremy Hunt on this. Under his stewardship of the new NHS England, we had a plethora of recommendations and new organisations, and layer upon layer of bureaucracy, totally remote from any kind of democratic accountability or oversight. That is not working, and I do not think that anybody is really defending that.
It is the job of the NHS—both providers and commissioners—to include patient voice and patient experience in their work. I think Ciarán Devane from the NHS Alliance said that getting boards right, in terms of their managerial, clinical and patient experience work, is their responsibility. Outsourcing lots of that work to other bodies has not worked, and I think it is outsourcing that responsibility. We have to make boards work at a local level; they have to step up to the plate, and I think they want to. They are certainly equipped to be able to do that—not taking into account that people will need some skilling in some of these areas. There is a debate to be had about independent organisations, and I think we will have a good debate on it in Committee.
As a final comment before you come back, this is a bit of a bugbear of mine, and perhaps as I am speaking on behalf of the Department I should not say it, but I will: none of my constituents are hard to reach—not a single one of them. We know exactly where they are; we largely know what is wrong with them; we largely know what their health outcomes are going to be; we know their ethnicity, demographics and so on. What are hard to reach are the remote organisations that have not served them well, and that is what we are determined to put right. Putting that right in this Bill is the start of doing that.
Dr Johnson
Q
Karin Smyth: I will come back to the waiting lists, but you are absolutely right about trust. In saying that I expect this to be the board’s job, I think it is its job to get this right, and we need to support it to do that. We heard a bit from Penny Dash about the national quality board and the patient experience directorate inside the Department of Health and Social Care reporting directly to the chief executive and the permanent secretary. That has to be part of the wider architecture, which is of course outside the Bill, so we need to be able to tell that story to the wider public.
We know from all the recommendations, reviews and the support that we give as Members of Parliament to our constituents that trust is really important. Getting that right and bringing people on that journey with us will be really important. Independence helps with that, and that it is why it is good to debate it as we consider the Bill—it is good to be able to air some of it—but I think people accept that things are not working and have not been working.
I think your question about waiting lists is about the data and the information that says where we are at. It is really complex. To follow NHS England’s data, of which there is a lot—I commend the amount of data that is available—you need to be quite clever at spreadsheets, and at finding and articulating data, in order to bring it back to your own constituency and local place. These things are complex. It is complex to record, track and recognise how people move through a waiting list, for example.
It is good that we are transparent about that. One thing that I am keen to push out is data on performance in trusts. Making so-called league tables is controversial, but the more information that we have out there, and the more we have honest debates about how complex and difficult it is—I am happy to take your questions around how that moves in order to for us to explain that—the more that helps to build trust.
Liz Twist
Q
Karin Smyth: I will come to the single patient record because I think it is a gamechanger. We have heard today from some fantastic experts about the work they are doing to identify how it might work and how we might bring patients and the public with us. Again— I do not think we should just bank this—we have not heard anybody object to it.
We did have some evidence highlighting how things have gone wrong in the past. I worked at a primary care trust and clinical commissioning group at the time when care.data was brought forward. We can all point to where it has gone wrong, but nobody has said that this is not the right thing to do. That is good, but there is still a lot of detail to go through.
We need to keep highlighting the benefits. We heard from Peter Prinsley about whether patients have more control—we do think this is about empowering patients. That was what we said in the 10-year plan. The 10-year plan is about empowering patients in this very large system, for which they are now paying £200 billion of their taxes.
We heard from the excellent clinical panel. I defer to clinicians about what they need, both if they are dealing with chronic long-term conditions—we heard that it can sometimes take two and a half hours for an assessment—or if they are working in a busy emergency department. The fact that this is needed will be controversial. There will be a lot of questions about it and a lot of concern about privacy, data, cyber and so on. We need to hold on to those benefits, which are huge in clinical terms and for patients.
Another point we heard, which is also true, is that people think this already happens. People do not understand why, when they turn up at an A&E in Whitby, as we heard, or somewhere else, and then go back to central London, the systems cannot talk to each other. For me, that is about people’s trust and belief in what is a public service. It is a really important part of that.
On abolishing NHS England, I do not think anyone has come to one of my constituency surgeries and said, “Please do this,” or talked about it in great detail, but people do understand. My experience in opposition and so far in government is that MPs are perplexed when they try to intervene on behalf of patients, or to get an answer locally as to why on earth chief executives of ICBs or trusts sometimes do not respond even to a Member of Parliament’s requests for meetings. I find that shocking, but it does happen. How on earth is a patient or somebody struggling through the system expected to get a response? Getting it right is not black and white, and it is not easy to get the balance right between the Secretary of State’s democratic oversight and autonomy at a local level, but the Bill starts the process of doing that, and it is fundamentally important.
Regarding the other provisions, I accept that great work has been done by many people in Healthwatch and its predecessor organisations, and by people working in the patient safety landscape, but again it is not working. I think that those bodies have been allowed to abdicate responsibility for the core role of patient experience and patient voice. That is not their homework; it is their actual job. It is not something that should be outside, and that is why I think this Bill is really important.
Helen Morgan
Q
It would, however, be helpful to reflect on where there is not agreement: on abolishing Healthwatch and HSSIB. You make the very good point that they have not been successful in their current incarnation, but it is important to consider whether that is because they do not have teeth, or because the organisations that they are trying to change are defensive.
We heard earlier about the culture of fear, and I think that we have probably all had people in our surgeries who can describe being frightened to speak up about their own personal care because they feel that they might be victimised for it. I know of clinicians who are frightened to speak up about their own experience in the organisation in which they work, because they feel that they will be punished for it.
In the light of that defensive culture that we know exists in the NHS, and has been highlighted time and again—Mid Staffs; the Shrewsbury and Telford maternity scandal—is the answer not to put the patient voice in the organisations that have a culture problem, but to give those other organisations the teeth they need, or confer a duty on the ICBs or providers to act on recommendations that are given to them, because I think that might be a more helpful way of dealing with this problem?
Karin Smyth: I think that gets to the crux of some of this. We will discuss it a lot in Committee, and I am obviously very open to keep discussing it.
Thank you for your support on the main provisions. I do not take that for granted because, again, they are still controversial. However, as I think I said earlier, you are right, although it is not true everywhere. I am not blaming individuals, because I think that people have been trying to do a difficult job, particularly in getting us through the pandemic and beyond. But they are defensive. That is why Members of Parliament and others do not get responses to their phone calls or their emails. That is a culture that we have to change, and we need to support people to change.
One of the things that we will do is to bring in regulations—that is a manifesto commitment from the Government—but another commitment that we have made outwith the Bill is to develop a leadership college to support in particular clinical and non-clinical managers, who have a very difficult job, in having the right skills for the new world, which patients and the public rightly expect to be more open and more transparent. We have to change this defensive culture.
However, even since Francis, the adding of bodies and the adding of recommendations, and with the bad experience that you have done so much around, something different has to happen. Again, what we heard from Jeremy Hunt was that we needed to put more prescription into the system and yet more requirements to do something without actually making that someone’s central function and job.
Now, it is a source of disagreement. As I have said, I think that there is a philosophical disagreement about the best way forward. It is not an antagonistic disagreement; there are fundamentally different views about what to do. We will continue to have discussions, because I think that ultimately we all want the same thing: a more open, transparent and supportive culture. By the way, nobody wants to work in a defensive culture, so I think people want that outcome.
It is up to us as politicians to support difficult conversations and trade-offs that happen locally. My view has always been that politicians will support difficult conversations and trade-offs—we heard a little bit about reconfigurations earlier—if the system provides good clinical rationale, good data and good evidence, but those bits of it do not always line up.
That is what I would like to get to. I absolutely understand and hear what you say—we will hear more about it and discuss it more, and I have read all the amendments about the best way forward. I think that we all want to get to the same place, but what is the best way to do that, given that we all know that this is really not working and cannot continue?
Helen Morgan
Q
Karin Smyth: I will need to come back to you on the detail of that. In much of the Bill, we are trying not to over-prescribe. However, we need to get foundation trust licensing right. There are some things that are needed in the Bill, which is what we have put in as far possible, and some things that are not. Can I come back to you on that specific point if that does not answer your question?
Jo White
Q
Karin Smyth: That is a good question. When I was in opposition, I spoke frequently about accountability and democracy, as the hon. Member for Sleaford and North Hykeham was trying to highlight—I am sure that we will hear some more quotes. I cannot speak for the former Secretary of State, as he is not here, but it did surprise us going into the financial year when, despite very clear direction and expectation about the financial situation that the Government inherited and what needed to happen, we were still faced with a very large projected deficit. The duplication meant that there were a lot of people in the room and clearly things were being handed off and that was not working. Ultimately, this is a question that always lurked. I know that the right hon. Member for Melton and Syston is here, and during the passage of the Bill that became the Health and Care Act 2022, we said to the Department that that might have been the opportunity to act. I think that previous Secretaries of State, as was alluded to earlier, thought that they might do that. Ultimately, the benefits of doing it now outweigh the risks and that is the only way to make the system change. We heard from the King’s Fund about opportunity costs and that the benefits do not outweigh the risks—we do not think that is true.
The Chair
That brings us to the end of the time allocated for the Committee to ask questions. On behalf of the Committee, I thank the Minister for her evidence.
Ordered, That further consideration be now adjourned.—(Emma Foody.)
Health Bill (Third sitting)
Thursday 18th June 2026
(2 weeks ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 18 June 2026 - (18 Jun 2026)
The Chair
Before we begin, I remind all Members to switch their electronic devices to silent, please. I am sorry to tell you that tea and coffee are not allowed; you are limited to water. As you are able to see, I am content if Members wish to remove their jackets, so please do so if it makes you more comfortable.
Before we go any further, I believe that the Government Whip intends to move an amendment to the programme order agreed on Tuesday.
Ordered,
That the Order of the Committee of Tuesday 16 June be varied, in paragraph 1(b), by leaving out “and 2.00 pm”.—(Emma Foody.)
The Chair
We will now move to line-by-line consideration of the Bill. The selection list for today’s sitting is available in the room and on the parliamentary website. It shows how the clauses, schedules and selected amendments have been grouped together for debate. A Member who has put their name to the lead amendment in a group will be called to speak first. Other Members will then be free to indicate, by bobbing, that they wish to speak in the debate. Please do that on each occasion on which you wish to speak during proceedings.
At the end of a debate on a group of amendments and new clauses, I shall call the Member who moved the lead amendment or new clause again. Before they sit down, they will need to indicate whether they wish to withdraw the amendment or the new clause, or to seek a decision. If any Member wishes to press any other amendment—including grouped new clauses—in a group to a vote, that is at the Chair’s discretion. My fellow Chairs and I shall use our discretion to decide whether to allow a separate stand part debate on individual clauses following the debates on relevant amendments.
I hope that that explanation is helpful and that no Chair needs to give it again during the course of proceedings.
Clause 1
Abolition of NHS England
Question proposed, That the clause stand part of the Bill.
The Minister for Secondary Care (Karin Smyth)
Clause 1 formally abolishes NHS England as a statutory body, which is one of the key aims of the Bill. The current structure, with its two centres, has led to layers of unnecessary bureaucracy, duplication and unclear lines of accountability, and has come with significant cost, with the centre growing significantly in size since 2013. Through the Bill, we are simplifying the organisational landscape of the NHS and removing unnecessary complexity and overlapping roles among NHS England and the Department of Health and Social Care. The reform will enable leaders and staff to focus on delivering care, rather than on navigating bureaucratic hurdles. Importantly, it will also restore Ministers’ central role in national oversight and setting strategy, which the public rightly expect as part of a democratic system. The creation of an arm’s length body of this size was a mistake, and we seek to rectify it.
Clause 2 is integral to the orderly abolition of NHS England. It empowers the Secretary of State to establish transfer schemes, which will provide a structured and transparent means of moving property, rights and liabilities from NHS England to the Department of Health and Social Care, the integrated care boards and other relevant bodies. This robust legal mechanism is required to ensure a responsible transfer of NHS England’s assets and staff. It ensures that all necessary legal powers and permissions for the transfer are in place, preventing uncertainty or loose ends for staff, patients, service users and partner organisations as NHS England is abolished. The clause allows provisions to be made similar to those under TUPE to ensure the protection of employment rights for staff who are transferred from NHS England. In addition, the clause allows for the shared ownership or use of property, ensuring that assets can be distributed and used in a way that supports service continuity for patients and the broader health system.
Clause 3, at its core, provides a power for His Majesty’s Treasury to ensure through regulations that transfers from NHSE to the DHSC, ICBs and other bodies are delivered smoothly and on a tax-neutral basis. In particular, it allows HM Treasury to make adjustments to how existing tax legislation applies to transfers of NHS England’s property, staff and liabilities in a scheme made under clause 2. That will ensure that no tax charges arise, and that neither NHS England nor the transferee organisations end up with a different tax position due to the organisational changes. Importantly, the scope of the power is tightly constrained: it applies only to specified existing taxes and only for the purpose of ensuring tax neutrality in relation to transfers made under clause 2. Without the power, there would be a risk that transfers could trigger unintended tax liabilities that would divert public money away from frontline services and undermine the policy intent of the legislation. Clause 3 therefore protects value for money and ensures that organisational change does not come with avoidable fiscal costs.
Without the changes made by clauses 1 to 3 we will not be able to meet the ambitions set out in the 10-year health plan. The abolition of NHS England, delivered in an orderly, proportionate and considered way that safeguards the interests of staff and taxpayers, is a necessary precondition for an NHS that is more effective for patients, delivers better outcomes across the country and achieves the ambitions that the public expect of us. I therefore commend the clauses to the Committee.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
It is a pleasure to serve under your chairmanship, Sir Jeremy. First, I declare a number of interests. I am a consultant paediatrician working in the NHS, a member of the British Medical Association and a member of the Royal College of Paediatrics and Child Health. Like the Minister for Secondary Care, I got into politics after working in the health service. I am sure she agrees that what you see when working in the health service stays with you when working in the House, and that it benefits the House to have people who have done all different jobs working here.
The NHS constitution says that health services should
“improve, prevent, diagnose and treat both physical and mental health problems with equal regard”,
yet in my work as a doctor—and I worked across several hospitals during my training—the gap between the vision of what should be delivered and the reality of what is being delivered has become apparent to me. The answer frequently given seems to be top-down reorganisation. As I will talk about in a minute, such top-down reorganisation has been done so many times but does not seem necessarily to have delivered in practice what it promised. Indeed, to an extent, we seem to be changing things from how they were to how they are to how they were, backwards and forwards. This Government have decided, in pursuit of better outcomes and cost savings, once again to reorganise the health service, and they seek to do so with this Bill and particularly clause 1.
Clause 1 formally abolishes NHS England. The clause may have very few words, but they represent one of the biggest changes to our health service in decades. Abolishing NHS England is not just a decision about organisational structure or trimming bureaucracy, but a break with the direction of travel the health service has been on since its inception.
Prior to the creation of the NHS in 1948, health services were fragmented: some people used contributory workplace schemes, people who could afford it paid out of pocket, and everyone else relied on very limited state and voluntary provision or went without. In the aftermath of the second world war, the national health service created a state monopoly provider. The Minister of Health had a duty to provide a comprehensive health service free for all at the point of use and a bureaucracy was created to manage it.
There was a tripartite split between hospital services, local authority services and independent practitioner services. The hospitals provided secondary care for those with serious disease and those requiring emergency response. The NHS also took over many cottage hospitals in rural areas that had previously been run by GPs, and larger hospitals that used to be run by local authorities and the voluntary sector. At that time, hospital staff were managed by hospital management committees appointed by regional hospital boards. Those boards implemented Government policies and oversaw the budget. Meanwhile, teaching hospitals kept more independence, directed by their own boards of governors.
Councils, operating as local health authorities, had a duty to provide several personal health services including health centres, maternity care, home nursing, immunisation and ambulance services—some of those are now provided by NHS England. They also had substantial powers to prevent illness and to care for the disabled. Independent practitioners—GPs, dentists, pharmacists and opticians— delivered services to local communities under contract from the health service. Now they deliver under contract from NHS England and the ICBs.
The health service underwent significant reorganisation in 1974, not long before I was born. The main objective at that time was to create a unified, integrated system. Community health services previously operated by councils moved into NHS control. These functions were put under the control of new area health authorities, which took control of most NHS hospitals. Some larger area health authorities had their own distinct management teams, which managed services on the ground—we can look at the current process and ask how it is similar and how it is different. The majority of teaching hospitals lost independent governance, in the way that we, too, are seeing that go back and forth. Above the new area health authorities sat regional health authorities, which were responsible for planning and allocating financial resources. Their members were appointed by the Secretary of State.
In the 1980s, Ministers recognised that the system had become very bureaucratic—perhaps similarly to today—and in 1982, area health authorities and district management committees were scrapped in favour of new district health authorities, with the aim of reducing what was in effect a three-layer structure to two layers. The thinking was that the new district health authorities would be closer to local populations, but primary care was left mostly unchanged. Once again, there are parallels with what is happening now.
From its inception to the end of the 1980s, the NHS had gone through several waves of rationalisation, but the model remained that of a centrally planned public service. However, during that time, there was an intellectual change—the concept of choice. Previously, people had been happy just to get a health service, which they had not had access to before, but that changed and people wanted choice. We now see the benefits of giving patients choice, and we will hear about how the Government’s changes through the Bill will apparently improve patient choice.
Of course, individuals have different values and preferences and live their lives in different ways, which makes it impossible for there to be a single public interest for the Government to pursue. Against that backdrop, the new public management approach to Government administration emerged, advocating for the introduction of market mechanisms and performance metrics—we have heard about the targets that NHS England follows—in public institutions. In theory, if elements of the state could operate more like the private sector, perhaps Ministers could achieve both cost savings and better outcomes.
In 1991 the Government introduced market logic into the health service. They created an internal market by splitting the purchasers—mainly, at that time, the district health authorities—from the providers, which were the hospitals. The Secretary of State gained the power to create NHS trusts—hospitals with the freedom to acquire, hold and dispose of assets; make bids for capital directly to the NHS management executive, in the way they might for NHS England; borrow money within limits; develop their own management structure; and employ their own staff with their own terms of employment. Within three years, almost all providers had become trusts. GP fundholding was established, enabling larger practices to receive budgets to buy secondary care on behalf of their patients, but that was short lived and was shelved in 1999.
When new Labour came to power in the late ’90s, one might have thought that things might swing back the other way, but in some respects the trajectory was similar. Initially, the Labour Government talked critically about the internal market. In 1998 the then Health Secretary told Members that the Government were
“sweeping away the internal market”—[Official Report, 1 July 1998; Vol. 315, c. 314.]
and the NHS plan published in 2000 claimed that
“the internal market introduced competition but failed to bring improvements.”
However, the policy choices of that Government furthered, rather than dismantled, the marketised aspects of the health service. They were saying one thing but, to some extent, doing another. There are similarities with this Bill: we have talked about decentralising power but, as we heard in evidence on Tuesday, many people feel it is more of a centralising Bill than a decentralising Bill.
It was clear that the new public management approach had been adopted across the political divide. The NHS plan promised patients more choice about how to access the NHS—a good thing. It promised a system of inspection, accountability and far greater local autonomy. It said:
“For the first time the NHS and the private sector will work more closely together not just to build new hospitals but to provide NHS patients with the operations they need.”
When GP fundholding went, the Government introduced primary care groups, which meant that GPs, nurses and other staff came together to commission for local populations. Those groups then evolved into primary care trusts, which by 2002 were responsible for spending 80% of the annual NHS budget—a budget that is now distributed by NHS England.
Karin Smyth
This is an interesting point, and it is always helpful to have one’s comments put back to one. I am happy to come back to this again. I ask my question again: do the Opposition oppose the abolition of NHS England? I do not think the Opposition oppose the abolition; they think it is the right thing to do. I appreciate that that was confirmed on Second Reading. As I have said before, the previous Government had the opportunity to do this in 2022 and chose not to. The fact that it has not been opposed suggests that it is the right thing to do.
As for what we found on coming into Government, we thought that delivering on our manifesto through the existing powers, flow of funds and priorities would be possible. We were clear that we did not seek this as an initial outcome, but having got into that position, we immediately found, even while developing the 10-year plan and bringing together one team, that it was not possible. I am afraid that the line through which ministerial intentions could be delivered was convoluted, and obstructed by various measures throughout the system. That independence—
The Chair
Yes, that was the point I was about to make. I know the Minister is trying to help and answer the point that was raised. As she knows, she has another opportunity to speak at the end of the debate. If she wants to briefly summarise the point now and then come back to it in more detail, she is more than welcome.
Dr Johnson
Thank you, Sir Jeremy. I will be grateful if the Minister clarifies at the end, because she seems to be suggesting that Lord Darzi’s report was wrong in some way. He was assessing the NHS at the same time that she was, with the experience of having been a Minister, and made the counter-suggestion.
It is not just about what one does; it is about how one goes about it. As we heard on Tuesday, there is in general a plan of what is going to happen, but so many decisions have not been made yet in relation to this. In particular, one of the witnesses from the union talked about how unsettling that was for staff and how difficult it is for staff to be asked to go from the current location to a destination unknown. It is very difficult to make transformation in a direction when it is not clear where one wants to be.
In March 2025, the Government announced that NHSE would be abolished. The largest healthcare union described the handling of the announcement as “shambolic”, coming only days after the announcement of a 50% cut to staffing levels at the centre. In the days and months since, Ministers have provided only some clarity about what they are trying to achieve. According to the Government, the restructure will cut red tape, save money, devolve power and improve accountability, all with a view to improving patient outcomes. Those are not new objectives; they are the same objectives that underpinned the creation of NHS England. How is it that the same objectives require dismantling the institution created to deliver them? Again, I just do not understand what has changed the Government’s mind.
Let us look at cutting red tape. As a Conservative, I welcome the ambition to make the health service more efficient. My constituents do not want to pay for staff in the Minister’s Department duplicating the work of those in NHS England, particularly when thousands every day are subjected to care that could certainly be improved. On Tuesday, we heard from the former Health Secretary, my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt), that
“the bureaucracy has got completely out of hand.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 33, Q58.]
However, that bureaucracy is not confined to NHS England and any medical practitioner will explain that bureaucracy exists across the entire health system. Can the Minister explain how the changes will improve that?
Lord Darzi’s independent investigation said that, taken together, there are nearly 80 people employed in regulatory and headquarters functions for each NHS provider trust. Can the Minister say how many people will be in such roles once the abolition of NHS England is complete? Can she talk about how abolishing NHS England will review the volume of paperwork on patient safety, some of which is helpful for patient safety and some of which is not. That was identified by Dr Dash in her report.
I remind Members that abolishing NHS England is not a prerequisite of undertaking a robust cost-benefit analysis before introducing changes. We have had difficulty in getting answers on numbers. We have been told that this will save money—£1 billion a year, I believe—but no sums have been produced for us to scrutinise to explain where that will come from. Indeed, when asking questions about where it might come from, it has been quite difficult to establish that. We have heard that the redundancy package will be worth £1.1 billion to £1.3 billion. It does not seem clear exactly where that will come from or how it will benefit patients. It is also not clear how many of those staff will end up re-employed by the new organisation, having received redundancy from the first, and what effect that will have on the country’s finances.
More than a year on from the Government’s announcement that they will abolish NHS England, how much progress have Ministers made? In March 2025, Lord Scriven tabled a question about the legislation required to abolish NHS England. In her response, the Health Minister in the other place, Baroness Merron, wrote:
“Ministers and senior Department officials will work with the new transformation team at the top of NHS England, led by Sir Jim Mackey, to determine the structure and requirements needed to support the creation of a new centre for health and care.”
One year later, in March 2026, the Liberal Democrat health spokeswoman, the hon. Member for North Shropshire, tabled a question asking what functions had been transferred over since the announcement was made. In response, the Minister for Secondary Care wrote:
“Work is progressing at pace to develop the design and operating model for the new integrated organisation, and to plan for the smooth transfer of people, functions, and responsibilities.”
One does not need to enlist the services of Hercule Poirot to see that, one year later, that work has not been done. The Government have no comprehensive plan for how they will abolish NHS England. They can write a line in the Bill to abolish it, but how that will happen, to which clauses 2 and 3 relate, is, as yet, really uncertain.
Jo White (Bassetlaw) (Lab)
We all know how important our NHS is to the people we represent. I know how frustrated patients and staff have become after years of rising waiting lists, cancelled appointments and growing bureaucracy. Since coming into office, this Labour Government have already started to turn things around by delivering more than 3 million extra appointments ahead of schedule, cutting waiting lists and agreeing a new GP contract that begins the work of restoring the family doctor.
However, the challenge remains enormous. We inherited an NHS facing the worst crisis in its history, and public finances under severe pressure. That means that every pound must work as hard as possible for patients. That is why I welcome the decision to abolish NHS England and bring its functions back into the Department of Health and Social Care. The complex structure created by the 2012 reorganisation has left us with duplication, inefficiency and too many layers of management, separating decision makers from the frontline. Far too many NHS leaders and clinicians tell us that they spend their time filling in reports and navigating bureaucracy, when they should be focused on delivering care. We owe it to taxpayers and patients to change that.
These reforms are not about criticism of the dedicated public servants working in NHS England; they are about creating a simpler, more accountable system that supports staff rather than holding them back. By reducing duplication and cutting unnecessary bureaucracy, we can redirect hundreds of millions of pounds to frontline services. That will cut waiting times, improve access to care and give local NHS leaders more freedom to innovate. This is about one simple principle: fewer checkers and more doers; less bureaucracy and more patient care. It will create a stronger NHS that delivers for communities such as Bassetlaw and for people across the country.
The NHS is facing huge challenges. With the right reforms and leadership, we can build an NHS fit for the future and there for every patient when they need it most.
Helen Morgan (North Shropshire) (LD)
The Liberal Democrats broadly support the abolition of NHS England. As constituency MPs and users of the NHS, we see a huge amount of duplication and unnecessary bureaucracy as our local health organisations try to navigate the processes of securing capital investment, for example. Reducing duplication between the Department and NHS England is clearly welcome if done well, but we have concerns about the way in which that is being undertaken.
We think that this centralising process, under which the Secretary of State takes on more powers, risks political capture. That may not seem like a huge risk considering who the current Secretary of State and shadow Secretary of State are, but given the febrile political atmosphere that we are working in, it seems a poor time to give a Secretary of State sweeping operational powers over the detailed functioning of the NHS, with few checks and balances. I will speak about the most concerning elements and make the argument in greater detail when we debate cause 11.
As the hon. Member for Sleaford and North Hykeham said, the former Health Secretary, the right hon. Member for Ilford North, said that top-down reorganisation of the NHS was the last thing he wanted to do, and yet that is where we find ourselves today. It feels as if the plan has been pulled together very quickly, and that it has been complex to turn into a piece of workable legislation. It has taken a long time even for the Treasury to agree on the funding of the redundancy bill. We have found out that redundancy costs of £800 million will be taken out of the future operating costs of the NHS. I hope that the Minister will describe how that will be delivered to ensure that the costs do not detract from patient care on the frontline.
There is still some uncertainty about the new structures within the DHSC and NHSE reorganisation. We have heard that the previously announced plan for three top-level roles—a permanent secretary, a chief medical officer and an NHS chief executive officer—might be changed, and that there is a proposal to merge the permanent secretary and NHS CEO roles. At this stage, as we start to consider the legislation, it would be helpful to have clarity on who will be in charge of the NHS and how the layers below will be organised. We have also heard that hours of staff time, leadership focus and money have been directed away from frontline services. In the oral evidence session, Sarah Woolnough of the King’s Fund and Jon Restell of the Managers in Partnership union suggested that that has been distracting and that, in any body, a significant reorganisation has an opportunity cost.
In my previous life, I was an accountant at Centrica plc—one of those back-office checkers everybody wants to get rid of, but who turns out to be quite important in providing the information that enables the business to run smoothly. We found reorganisation hugely distracting; it took away from our ability to do our day jobs well. Then, within a couple of years, a lot of the equivalent roles were re-hired and we were back to square one. It is critical that the Government avoid that scenario in this big reorganisation of the NHS. I hope that the Minister can provide reassurance that it has been well thought through and that we will not find ourselves, two or three years down the line, with similar numbers of people replicating the roles that exist currently, following a huge distraction that resulted in no improvement in patient outcome or experience.
My questions are fairly limited. Does the Minister know, at this point, what the impact the reorganisation has had on the system and how much it has cost in secondary impacts? We have had eight Health Secretaries in the past 10 years. After all that swapping and changing, how can the Minister ensure a degree of continuity when the new Secretary of State takes over? One benefit of quangos is continuity over a long time, divorced from the political turmoil of Westminster. We must be clear about how distractions will be avoided in the new structure.
Finally, we heard in evidence on Tuesday that the new structure feels like a centralisation of power in Whitehall, when what is needed is more power devolved down to local level so that local services can be shaped to reflect the demographics that they serve and to address the important point of health inequality. Will the Minister explain why she is confident that measures to ensure local accountability and local shaping of services will be able to go ahead? Tackling health inequalities is the priority of everybody in this Room, and we need to ensure that we have an efficient structure in place to ensure that it happens.
Dave Robertson (Lichfield) (Lab)
It is a pleasure to see you in the Chair, Sir Jeremy. One of the most powerful things we can do as Members of this place is bring our constituents’ stories here so that they can form part of our discussions. That is what I will do as we discuss the future of NHS England.
I openly admit that I have never knocked on a door and found that someone’s burning question was about the abolition of NHS England. I have never had that particular discussion, but I do have regular discussions about the NHS. We know how important it is to people. They value the greatest gift that the Labour party has ever given the United Kingdom. As we have those discussions, one thing that comes up time and again is that people will always want more; they will always want better healthcare, and they should be able to expect it.
Across my constituency, the biggest health need is access to primary care. Two towns each make up one third of my constituency, so a third of my constituents live in Burntwood, 4 miles up the road from Lichfield— I believe my constituency is misnamed, but that is a matter for the boundary commissioner, not for me. When I talk to people about healthcare and access to primary care in Burntwood, one thing comes up time and again: the new health centre for Burntwood that was promised but never delivered.
That centre was promised in 2009 when the old one was demolished, but its funding was cut in 2011 following the change of Government, and we are still waiting. A modular building had to be put up in the car park of the leisure centre—“modular building”, by the way, is a grand term for what are portacabins stacked on top of each other. A huge number of people have worked at that site for a long time, delivering the best care they can, but they are being failed by the facilities that they are forced to work in. When I have conversations about primary care with people in Burntwood, they are never unhappy about the care they receive, about their doctors or about others who work in the NHS; they are unhappy about the facility that they are forced to use. I am standing here in 2026 and we still do not even have planning permission for the replacement centre. It has been promised so many times that people are beginning to doubt that it will ever happen. That is so hard to hear.
Edward Argar (Melton and Syston) (Con)
I approach this with a sense of déjà vu—standing in a Committee Room in the Palace to debate a Health Bill opposite the Minister for Secondary Care, the only difference being that our sides and places have swapped over in the interim. It is a pleasure to be on this Committee opposite the now Minister.
I will focus my remarks largely on clause 1. My hon. Friend the Member for Sleaford and North Hykeham raised a number of questions about clauses 2 and 3 and their breadth, but I consider them to be necessary and consequential on clause 1, so I will focus on the points made in that clause, which sits behind them. One thing I want to address is the Minister’s question about why, in the Health and Care Act 2022, the Conservatives did not abolish NHS England. I have to say that arguments were made on both the pros and the cons, but the simplest answer is the context of that legislation. At the time, we were just emerging from a pandemic, and I wanted that legislation to retain a clear focus on my vision for the NHS: a linking of ICBs at the local level with the upper-tier local authorities, so that we could deliver social care through a permissive model, rather than a prescriptive one, allowing that local co-operation. I was also conscious that, emerging from the pandemic, there was only so much that the system could realistically bear while it was still grappling with its immediate aftermath, hence the approach we took.
In reality, it cannot be disputed that, inevitably, this is a top-down, centralising reorganisation, and it was not in the manifesto. As Sarah Woolnough said in her evidence on Tuesday:
“These arguments were very well rehearsed by the previous Secretary of State. He undertook personally that he would not follow this course of action, exactly because these things take longer and cost more, and because the benefit realisation case is not always clear.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 10, Q23.]
On that point about centralisation, Jon Restell in his evidence said:
“Obviously, some functions of NHS England moving into the Department, with powers going to the Secretary of State, feels like a centralising measure… On the whole, it is probably more of a centralising measure.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 79, Q122.]
We have to recognise that this is a centralising measure, rather than any sort of devolution that provides local areas with greater autonomy.
For me, there is a worrying lack of clarity at this stage in the process—around 15 months later—on the actual plan and approach. The hon. Member for Lichfield gave a very good speech that not only highlighted the local issues but drew a national read-through from those local examples, and he rightly highlighted that he did not want a protracted reorganisation. However, 15 months on—with the hare having been set running by the Prime Minister’s announcement back in March 2025— we still have protracted uncertainty on what will happen. That is having a very real impact on not only staff but the opportunity cost, through its impact on how services are actually being delivered and what the NHS is focused on.
On that lack of clarity, when asked how this measure will work and whether it can save money, Sarah Woolnough of the King’s Fund said:
“I think, on the basis of the question, we do not know. Our worry has been about the opportunity cost. The Government, when in opposition, said that they would not launch wholescale reorganisation, because they understood the potential opportunity cost on time and other resources. As this has played out, taking longer than anticipated, we have had multiple examples of teams left in limbo about where they will end up in the target operating model.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 10, Q12.]
Jon Restell also highlighted the impact on staff when he said,
“this is becoming psychologically very difficult. You have a change programme that started in March last year with the announcement by the Prime Minister of the abolition of NHS England and the halving of the staff of NHS England and ICBs. For 18 months, that process has dragged on, with lots of design decisions still to be taken about how the organisation will look, what functions it will have, what will be going to the Department and what might be going elsewhere”.––[Official Report, Health Public Bill Committee, 16 June 2026; c. 80, Q125.]
Dr Danny Chambers (Winchester) (LD)
I too think the hon. Member for Lichfield gave an excellent speech on the need for clarity, but there is another factor to consider. Not only is NHS England being abolished, and ICBs are having their budgets halved, but in Hampshire and other areas we also have local government reorganisation. We are going from having district councils and county councils to unitary authorities, and a mayor will be coming in next year. This is another level of reorganisation in the delivery of healthcare and social care, so there is a huge amount of change. However, there seems to be no clarity, at any level, on how this will affect services on the ground, because there are so many moving parts coming in at once.
Edward Argar
The hon. Gentleman makes his point very clearly and he is absolutely right. Not only is there a lack of clarity in the legislation and in the plans for how the NHS will look, but, as was alluded to during evidence, the missing bit from the Bill, which is highly relevant, is social care. It will be deeply concerning if, when the implications of local government reorganisation emerge from the Ministry of Housing, Communities and Local Government in a few weeks’ time, the two are not properly meshed together, because we will risk, yet again, a widening disconnect between the two vital parts of our health and social care system, both of which have to work well in tandem for the whole system to function. The hon. Gentleman makes a pertinent point. He also highlights ICB budgets. I suspect hon. and right hon. Members around the country are already seeing the genuine impact of those changes to the budgets, which are actually pulling through into the frontline services that our constituents receive.
I know that the Minister cares deeply about our health and social care services, and has a wealth of experience from in this place and outside it. Given the comments from our witnesses and the impact assessment, which has page after page listing the risks associated with this approach, I ask her how she will mitigate that loss of focus and that distraction, which is an inevitable human reaction when there is uncertainty. When she comes forward with the plan to merge NHS England into the Department, how will she ensure that she retains the best, most experienced staff? In any organisation where there is a change, it is often the most able and experienced who find it easiest to go to another role, by virtue of their skillset. How will she ensure that there is not a loss or drain of that expertise and knowledge?
I turn to a deeply concerning element that links to the lack of clarity. The impact assessment on the abolition of NHS England is pretty much silent on the monetised costs and benefits and specific figures. The first two pages with the boxes and the summary just say “N/A” in pretty much every box on assessing the costs. If I flick through to the section headed “Monetised and non-monetised costs and benefits of each option”, I see page after page. There are lots of words but virtually no figures, and where there are figures, there is no breakdown of how they were reached, and no explanation of the degree or range of confidence in the few figures that are there.
I ask the Minister whether a detailed spreadsheet of all the statistics, costs and benefits, risks, confidence levels associated with the numbers, and the phasing over years of savings and costs will be published during the Commons passage of the Bill so that Members of the House can consider it. If not in Committee, could it be published at least before Report so that we can have an informed debate? More broadly, once the Bill in whatever form is passed—I expect, given the Government’s majority, that it will be—what mechanisms will the Government put in place to ensure that when a target operating model and all the other details are available, Parliament will have an opportunity to not only debate them, but have a meaningful say, potentially with a vote, be it through delegated legislation or in the House?
Joe Robertson (Isle of Wight East) (Con)
It is a pleasure to serve on the Committee with you in the Chair, Sir Jeremy.
I echo and endorse all the comments made by the shadow Minister, my hon. Friend the Member for Sleaford and North Hykeham, who was comprehensive in setting out our position. I therefore speak from a broad consensus surrounding the Committee that the final days of NHS England as a body are here, and so be it, because there are advantages to be gained from its abolition. The Minister set out some of the leading reasons why she and the Government are abolishing NHS England. She referred to the growing bureaucracy, the unnecessary complexity, and the overlap of roles and responsibilities between the organisation and DHSC. She also spoke about being able to better focus on delivering care rather than navigating bureaucratic hurdles.
Dr Johnson
My hon. Friend talked about how the ICBs have merged. There are lots of different types of reorganisation going on at once: the abolition of NHS England, the changes to local authorities, the introduction of mayors in some areas, and the changes and cuts to ICBs. What effect is that having in his part of the country?
Joe Robertson
The shadow Minister points to a much wider issue entirely relevant to the Government’s plans here: the more reorganisation we do, the more we shrink the bandwidth to deal with smaller and more operational problems because so much of the resource has been pulled in. In my area, although it is probably true everywhere, reorganisation of Department or Government responsibilities causes endless frustration that while Governments and politicians—I take some responsibility for my own side’s actions at times in the past in very limited ways—talk about reorganisation when so much can be done on what might be termed low-hanging fruit.
I worry that the Government are missing out on opportunities here to make a much more meaningful difference day to day and much more quickly than this huge reorganisation will achieve. Everything is about priorities. Plainly, no Government can do everything they want to do all at one time. It slightly surprises me that reorganisation of the NHS and doing away with NHS England has become such a major priority, considering it did not feature in the Labour party manifesto just two years ago. I do not seek to put words in the Minister’s mouth, but the gist of her evidence to this Committee was that within eight months of this Labour Government coming into power, they realised that NHS England had to go. Eight months is eight months, but it seems a short timeframe in which to decide to do away with a fundamental way that health is organised and delivered in this country.
Going back to priorities, I recall that before the election, the former Secretary of State for Health and Social Care—then the shadow Secretary of State—the right hon. Member for Ilford North, talked about introducing a national care service. That was the Labour party’s big priority. Although Conservative Members and, frankly, the majority of the public were slightly sceptical of his intentions, we all agree that social care needs reform and that ultimately, the success of the NHS will be delivered only if we deal with the long-standing crisis in social care, which extends back three decades or more, as it is entirely dependent on that.
Before the election, the priority was the national care service, but since the not-so-random date of 5 July 2024, when the right hon. Gentleman became the Secretary of State, he ceased to refer to reform of social care, and it seems once again to have been put on the back burner. I wonder whether the Government’s plan to abolish NHS England has gotten in the way of equally large, and perhaps even more substantial, reforms, which might ultimately have made a much more meaningful difference to the delivery of not only healthcare but health and social care, as well as to the overall wellbeing, including financial wellbeing, of so many people in this country. Social care refers to people living with frailty or dementia, and the family carers, and families more widely, on whom that has an impact. Every decision made is a decision not made, given the resource and bandwidth of those whom any Government ask to implement change, such as the civil service, advisers and the hundreds or thousands of people who are relied on to deliver in their day-to-day job.
I and, it seems, all the other Committee members do not disagree with the fundamentals of what Government are trying to do; their reasons for doing this are broadly sensible, so who could disagree? However, because of the manner in which it is being done, I urge caution and a check on being too optimistic—just doing it and expecting all the good things to flow. It will take an awful lot more than simply passing the Bill to make the NHS the success that, to take the Minister at her word, she intends, wants and will do her best to achieve.
Ordered, That the debate be now adjourned.—(Emma Foody.)
Health Bill (Fourth sitting)
Tuesday 23rd June 2026
(1 week, 2 days ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 23 June 2026 - (23 Jun 2026)
The Committee divided: - Ayes: 3 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Chair
I remind the Committee that with this we are considering clauses 2 and 3 stand part.
The Minister for Secondary Care (Karin Smyth)
Casting my mind back to before the weekend, we had a wide-ranging debate on clauses 1 to 3 but, I think, substantial agreement about the central proposition to abolish NHS England. I pay tribute to my hon. Friend the Member for Lichfield, who succinctly put his finger on the key issue: it is fundamentally right that people and their elected representatives should be able to hold Ministers to account for the performance of the health service. It is also right that Ministers should have the tools to make the changes that are needed. The abolition is a necessary result of restoring that principle.
The debate raised a number of questions, a substantial number of which we will address during the course of the Committee as we reach the relevant clauses. However, I will pick up a couple now. I reassure the right hon. Member for Melton and Syston that the Government do take the impact of this process on staff seriously. We will treat people with the care, respect and fairness that they are owed through this process, now and in the months ahead. I am also committed to consulting recognised trade unions and I have a joint partnership forum to support ongoing engagement. More broadly, we recognise that change of this type is never easy, but we will need to go through the process quickly, which means, of necessity, proceeding in parallel with the legislation on the detailed internal design work for the new Department. That is in the interests of staff, patients and the public.
The hon. Member for Sleaford and North Hykeham raised the issue of whether the Bill was the cause of delays to the workforce plan. To be clear, it has not been, and we will publish that imminently. She also asked about the opportunity costs for other programmes, and I assure her that the Department, NHS England and Ministers are clear that we are here to deliver the 10-year health plan and other changes that make a difference to patients. We can, should and will do several things at once, and the Bill will help us with that by providing clarity of roles, greater freedom to local organisations and other positive changes.
To take just one example of the real impact, we are already saving on agency costs, and this is the first time in many years that the Department has not had to go back to the Treasury for a further injection of cash mid-year. That is getting a grip on the system. I add that the opportunity costs of not acting are very clear to the public, to staff and to patients in every single staff or patient survey that is issued. Those are the opportunity costs of not doing something; that is why we are acting. Clauses 1 to 3 are a necessary requirement for an NHS that is more effective for patients, delivers better outcomes across the country and achieves the initiatives that are expected of us.
Edward Argar (Melton and Syston) (Con)
This brings back memories of being in probably this same Committee Room a few years ago. I made this point during the previous sitting, but is the Minister able to commit that before the Bill leaves the Commons, a full and detailed statistical breakdown of the costs and benefits will be published, given their absence from the impact assessment?
Karin Smyth
I can tell the right hon. Member that we expect that NHS England coming into the Department will deliver up to about £1 billion in annual savings by the end of the Parliament, driven primarily by reductions in headcount, calculated using the average staff costs—about £77,000 per staff member in the Department and £94,000 per staff member in NHS England—including all pension and employer costs, which I think should help contribute to those numbers. As I think he knows, we will publish all accounts in the usual way.
I commend the three clauses to the Committee.
Question put and agreed to.
Clause 1 accordingly ordered to stand part of the Bill.
Clauses 2 and 3 ordered to stand part of the Bill.
Clause 4
Reducing inequalities
Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
I beg to move amendment 13, in clause 4, page 3, line 22, leave out lines 22 to 29 and insert—
“1C Health improvement and health inequalities duty
(1) In exercising any functions relating to the health service, Secretary of State must have regard to the need to—
(a) improve the health of persons in England,
(b) reduce inequalities between the people of England with respect to their ability to access health services, and
(c) reduce inequalities between the people of England with respect to the outcomes achieved for them by the provision of health services.
(2) Health inequalities ‘between the people of England’ means health inequalities between persons, or persons of different descriptions, living in, or in different parts of England.
(3) ‘Health inequalities’ means inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants.
(4) Under subsection (3) ‘general health determinants’ are—
(a) standards of housing, transport services or public safety;
(b) environmental factors, including air quality and access to green space and bodies of water;
(c) employment prospects, earning capacity, and any other matters that affect economic security;
(d) access to public services;
(e) the use, or level of use, of tobacco, alcohol or other substances, and any other matters of personal behaviour or lifestyle, that are or may be harmful to health;
(f) any other matters that are determinants of life expectancy or the state of health of persons generally, other than genetic or biological factors.”
This amendment would amend clause 1C of the National Health Service Act 2006 to introduce a duty on the Secretary of State to have regard to health improvement and health inequalities.
The Chair
With this it will be convenient to discuss the following:
Amendment 29, in clause 4, page 3, line 22, leave out lines 22 to 29 and insert—
“1C Health improvement and health inequalities duty
(1) When considering whether or how to exercise any functions, the Secretary of State must have regard to the need to—
(a) improve the health of persons in England,
(b) reduce health inequalities between persons in England, and
(c) reduce inequalities between persons in England with respect to their ability to access health services and to the outcomes achieved for them by the provision of health services.
(2) Health inequalities ‘between persons’ living in England means health inequalities between persons, or persons of different descriptions, living in, or in different parts of England.
(3) ‘Health inequalities’ means inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants.
(4) ‘General health determinants’ are—
(a) standards of housing, transport services or public safety,
(b) environmental factors, including air quality and access to green space and bodies of water,
(c) employment prospects, earning capacity and any other matters that affect levels of prosperity,
(d) the degree of ease or difficulty with which persons have access to public services,
(e) the use, or level of use, of tobacco, alcohol or other substances, and any other matters of personal behaviour or lifestyle, that are or may be harmful to health, and
(f) any other matters that are determinants of life expectancy or the state of health of persons generally, other than genetic or biological factors.
(5) In subsection (1)(a), the reference to improving the health of persons includes a reference to mitigating any detriment to health which would otherwise be occasioned by the exercise of the Secretary of State’s functions.
(6) In subsection (1)(b), the reference to reducing health inequalities includes a reference to mitigating any increase in health inequalities which would otherwise be occasioned by the exercise of the Secretary of State’s functions.”
This amendment would amend clause 1C of the National Health Service Act 2006 to introduce a duty on the Secretary of State to have regard to health improvement and health inequalities, reflecting the duties placed on combined authorities and CCAs in the English Devolution and Community Empowerment Act 2026.
Amendment 34, in clause 4, page 3, line 29, at end insert—
“(c) reducing inequalities between the people of England with respect to hospital transportation access.”
This amendment would create a duty for the Secretary of State to have regard for reducing inequalities in England with respect to hospital transportation access when exercising functions in relation to the health service.
Amendment 30, in clause 4, page 3, line 29, at end insert—
“(2) In discharging this duty the Secretary of State must have regard to the need to involve all departments of government in reducing health inequalities, and must take reasonable steps to ensure that other all departments consider the impact of their policy proposals on health inequalities.”
This amendment would require a whole government approach to addressing health inequalities by requiring the Secretary of State to involve all departments in the discharge of their duty in relation to health inequalities and took reasonable steps to ensure other departments consider the impact their policies might have on health inequalities.
Clause stand part.
New clause 19—Health improvement and health inequalities strategy—
“(1) Within six months of the passage of this Act the Secretary of State must publish a health improvement and health inequalities strategy.
(2) In preparing the strategy under subsection (1) the Secretary of State must consult all bodies which they consider appropriate.
(3) The strategy under subsection (1) must include—
(a) long-term targets related to health improvement and the reduction of health inequalities in England,
(b) provision for the establishment of a public authority with functions for additional monitoring and reporting on progress towards the targets set by subsection (3)(a), and
(c) any other provisions the Secretary of State considers appropriate.
(4) All Ministers of the Crown must have regard to the strategy under subsection (1) in carrying out their functions.
(5) Within 12 months of the publication of the strategy under subsection (1), and every 12 months thereafter, the Secretary of State must prepare and publish a report on the implementation of the strategy.
(6) ‘Health inequalities’ means inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants.”
This new clause would require the Secretary of State to publish a strategy for health improvement and the reduction of health inequalities.
Peter Prinsley
I apologise for being a little delayed, Sir Jeremy. I am moving the amendment on behalf of my hon. Friend the Member for Stoke-on-Trent South (Dr Gardner). It would place a clear duty on the Secretary of State to have regard to health improvement and health inequalities when exercising functions.
Between 2011 and 2021, the UK was one of only five high-income countries where healthy life expectancy fell. Over the same decade, we faced a cost of living crisis, the covid-19 pandemic and economic decline across the post-industrial regions. We cannot shy away from the fact that ill health is rising. Economic inactivity due to sickness is at its highest level since 2012, and we witness a widening disparity in health outcomes. People living in the most deprived areas of the UK, on average, live just 52 years of healthy life. There is now a 16-year gap in life expectancy between the richest and poorest parts of the UK. Even within individual constituencies, the life expectancy gap can be as wide as seven years between local postcodes.
The purpose of the amendment is to ensure that decisions taken at the highest level of the health system consistently reflect the reality that health outcomes differ sharply depending on where someone lives, the conditions that they live in and their opportunities to achieve good health. The amendment would require the Secretary of State to have regard to the need to improve the health of persons in England. The intention is that this duty would include the need to reduce inequalities in health. That is in addition to the duties that are already in the clause, relating to inequalities in access to and outcomes of healthcare.
At present, the Bill brings together old duties on the Secretary of State and NHS England to reduce inequality in access to and outcomes from NHS services. Those are too narrow and do not reflect the wider determinants of health that the Government have pledged to tackle through their 10-year plan. The amendment would strengthen the duty to reflect the wider cross-Government goals for health improvement and health inequalities. That would make an important statement of the Government’s commitment to improving health and tackling health inequalities, and would set in train an important step towards achieving them.
The amendment also provides a clear definition of “health inequalities” and “general health determinants”. Health inequalities means inequalities in respect of life expectancy or general state of health, which are wholly or partly a result of differences in respect of general health determinants, including housing standards, environmental factors, public transport, economic factors and other wider determinants of life expectancy. The amendment has been drafted to mirror the wording of the newly enacted section 45 duty on combined authorities in relation to health improvement and health inequalities under the English Devolution and Community Empowerment Act 2026.
Accepting the amendment would ensure consistent focus on the mission of creating a fairer country where everyone lives for longer, from the top of Government to regions and neighbourhoods. By setting this out explicitly, the amendment would ensure that future Secretaries of State cannot overlook the wider conditions that shape health outcomes. In sum, the amendment would require that when decisions are made, the Secretary of State must consider their impact on health improvement and on distribution of health across the population.
The amendment is supported by the Health Equals coalition, including 27 organisations that wrote an open letter to the Minister on 15 June. Those organisations range from the Health Foundation to the King’s Fund, Ramblers UK and the Wildlife Trusts, showing the breadth of support from across the sector. The cross-party Health and Social Care Committee also recommended that the clause be amended in this way.
Embedding this duty in legislation would strengthen accountability and ensure that the reduction of health inequalities is treated not as a secondary consideration, but as an integral part of how the health system is led and managed. If accepted, the new duty would ensure clear alignment at national and local levels about the importance of prevention.
Joe Robertson (Isle of Wight East) (Con)
It is a pleasure to serve under your chairmanship once again, Sir Jeremy. I will speak generally about the amendments on health inequalities, and specifically about some points that the group of amendments homes in on.
On the general principle of dealing with health inequalities, the sentiment behind amendment 13 is important, and I support hon. Members’ motivation for tabling it, but I question exactly what “persons of different descriptions” means. Does it relate to protected characteristics, which employment law deals with, or to geography? I suspect that it is both, and I wonder whether there are more considerations than those two. It would assist us if the amendment were clearer on that, notwithstanding the fact that clarification may be made during the debate or to the amendment itself if it is accepted later. I have concerns about what “persons of different descriptions” means. Certainly, in everyday English, every individual could be described as a person of a different description, so the phrase does not have any particular legal meaning.
If the phrase means something equivalent to protected characteristics, I wish to say something about health inequalities affecting those of different ages. I am the Member for Isle of Wight East, which, of course, has an older population. I want people of all ages to have equal access to health and social care, and inequalities in access to be levelled out and removed, but it is not only older people who find accessing health services difficult, not least for reasons of physical access; the entire population within an area with an older age demographic is affected. The Isle of Wight has a small local authority. We are fairly unique, in that we are surrounded by water and have a higher age profile, which, taken together with other challenges, makes health equality a challenge for the entire population, not just older people. The issue is aggravated by other considerations, primarily relating to geography.
Amendment 34, tabled by the hon. Member for Winchester, refers to hospital transportation access. That can mean a lot of different things in different places. I support at least the aim of putting more pressure on the Secretary of State and the Department and encouraging them to recognise and eradicate inequalities in hospital transportation access. For my constituents, accessing specialist services means crossing a body of water, which is not only a physical barrier—a ferry has to be taken—but a cost barrier, because ferries cost money. I understand where the hon. Gentleman is coming from, given the challenge in my constituency, but of course other places have different but challenging hospital transportation issues.
Amendment 30, tabled by the hon. Member for Oxford West and Abingdon (Layla Moran), the Chair of the Health and Social Care Committee, refers to cross-departmental working to ensure that health inequalities are taken into consideration. I think this is key. Of course the primary responsibility for health inequalities rests with the Department of Health and Social Care, but it is by no means the only Department with that responsibility. The more we think about the various inequalities that exist in this country, the more we realise that other Departments have considerable responsibility. We hear from politicians—of all parties, but particularly the Labour party in government—about better joined-up working between Departments, but without something more concrete in Bills such as this one, that will remain one of those aspirations that many talk about but few actually achieve.
The most obvious Department to help achieve the reduction in health inequalities is the Ministry of Housing, Communities and Local Government, given its responsibility for local government funding. Of course, local government has primary responsibility for delivering social care and public health within its area. It is a well-known feature of the system we have in this country that healthcare is free at the point of use and delivered effectively by central Government, while social care is a combination of different provision but private funding and local government have the largest role to play, and too many people fall through the gaps in those fundamentally different ways of funding two parts of the system. Unless MHCLG is bound into the way we reduce health inequalities, even with the best intentions of the Secretary of State for Health and Social Care, it clearly will not be delivered in a comprehensive and holistic way.
I refer again, as an example, to my area, which has a higher age demographic but a small unitary authority with a lower funding base. It is a matter of public record that the funding decisions made by the current Government at the beginning of this year have meant an effective reduction in funding for my local authority, notwithstanding its responsibility for an older population and the existing challenges in delivering social care. That is an argument that I and my constituency neighbour, the hon. Member for Isle of Wight West (Richard Quigley), are making to the Government in an ongoing conversation about how we can resolve that issue. We are having that conversation with MHCLG, notwithstanding the fact that it has a very direct impact—the biggest impact, in my view—on health inequalities in my constituency and the effectiveness of the Government’s 10-year health plan and their intention to improve the general health of the population. That is the probably the key departmental relationship that will be relied on to deliver the reduction in health inequalities.
The Department for Transport also has responsibility for this. If we refer to its responsibilities for reducing health inequalities outside the context of this argument, people might scratch their heads and wonder what we are talking about. but as soon as it is brought into a real-life example within this debate, it makes sense that the Department for Transport has some responsibility for reducing health inequalities. However, we will not achieve all we want to unless that responsibility is made more obvious and specific, named somewhere in some Bill. We have an option to achieve our intention to have joined-up decision making, and to ensure that every decision in any Department that has the potential to impact health inequalities is considered, whether in a formal impact assessment or just in the ordinary day-to-day decision making and mindset of the relevant Ministers, Secretary of State or departmental officials.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
It is a pleasure to speak to clause 4 and this group of amendments. Health inequalities are commonly defined as the systemic differences in health status and distribution of health resources between different population groups. There are limits to how far the state can equalise health in a free society, but I am sure all Members would agree that the service should not preside over differences in access to health resources. Unequal access runs contrary to the vision of the NHS as a comprehensive service, available to all and based on clinical need, not ability to pay. Those principles are violated when people without fixed addresses struggle to access general practice, or patients in rural areas, such as my constituency, miss out on treatments—for example, specialist cancer treatments—that are available in more urban areas.
The Health and Social Care Act 2012 inserted section 1C in the National Health Service Act 2006, placing a duty on the Secretary of State to consider the need to reduce inequalities in the benefits that people obtain from the health service. As the explanatory notes to the 2012 Act made clear, the intention of that was to
“include consideration of the need to reduce inequalities in access...and the outcomes”.
Clause 4 of this Bill takes that which was understood and makes it more explicit.
The Minister will be pleased to hear that I support updating that duty—she is smiling. The word “benefits” in the original section is a nebulous and subjective term. The wording introduced by the clause is less imprecise and requires the Secretary of State to consider the whole health pipeline. None the less, I have some questions about the lens that clause 4 and its predecessor, section 1C of the 2006 Act, invite the Secretary of State to look through, particularly in relation to other statements made by the Government.
In the Government’s policy paper “ICBs as strategic commissioners”, they say that increasing the commissioning responsibilities of integrated care boards will result in them being
“better placed to support innovation”
and
“design new models of care”.
Innovation can produce disparities; that is true in healthcare as well. If one ICB decides to innovate and produces a better service, that area will have a better service than another, and the Secretary of State will have the job of undoing that. That could be done by spreading the innovation across the whole of the country, but if the innovation is expensive or difficult to roll out, it could in effect be quashed. Does the Minister recognise that empowering health leaders to innovate and do things differently could widen inequalities, at least in the short term? Is she willing to accept that?
A problem with using inequalities as a stand-alone metric is that it does not really tell you whether things are getting better or worse; it must be taken into consideration alongside a wide range of other metrics. An often forgotten fact is that disparities can be reduced by levelling down as well as by levelling up. Fixating on determining the size and cause of disparities can, in some cases, come at the expense of eliminating them. I recently tabled a written question to ask the Government if and when they plan to
“set an explicit target to close the Black and Asian maternal mortality gap.”
I note that the Minister stood on a manifesto pledge to close that gap. The Government response to my question indicated that they are waiting for Baroness Amos to finish looking at the drivers of inequalities before they do anything. It is possible to produce tomes on the nature of disparities; I suggest that energy would be better spent on addressing them.
Amendment 13 would require the Secretary of State to consider health inequalities arising from differences in general health determinants. I understand the sentiment behind the amendment, as statistically, those with lower earning capacity, limited access to green space or unhealthy lifestyles have comparatively worse health outcomes, but would placing a duty to take stock of that on the Secretary of State make the health service any better for such groups, or for the population as a whole?
What would be the practical purpose of the amendment? As somebody said to me yesterday evening, do we have a section in education legislation stating that the Education Secretary has to consider that their job is to ensure that people are educated? Do we have clauses in defence Bills saying that the Defence Secretary must consider the defence of the realm? I cannot be sure, but the amendment seems to be a statement of the blindingly obvious, so what effect would it have? Does the Member who tabled the amendment think that the Secretary of State will not consider those factors—essentially, that he will not do his job properly? Do they not have confidence in him or in future Secretaries of State?
Under the amendment, the Secretary of State would need to consider inequalities arising from people’s employment, environmental conditions and lifestyle choices, which his Department has little to no control over. If poverty is the problem, the solution is employment and welfare policy, which is not in his gift. If poor environment is the problem, the solution is environmental policy. If a well-informed adult chooses, despite knowing the detriment it may cause them, to consume unhealthy food or an excessive volume of alcohol, or not to exercise, what can and should the Minister do about it in a free society?
Amendment 13 would risk distracting from the focus of clause 4, which is, as I see it, to ensure equal access to health resources regardless of a person’s standing in society. What is the practical effect of making it a duty on the Minister to do these things? Will it cause a whole load of bureaucracy? Will the Minister have to produce impact statements for every new hospital? If, for example, one opened on the Isle of Wight—my hon. Friend the Member for Isle of Wight East was talking about that—would we need to consider what effect it would have on smokers, people who do not exercise or people who have a lower earning capacity, and produce an endless list of assessments? It would take a lot of money and effort and not really add anything. The amendment would also risk the Government getting bogged down in litigation, as people who disagreed with the Government’s or the ICB’s decision would spend their time litigating the question whether something that may or may not even be relevant was considered properly.
Members will not be surprised to hear that my thoughts on amendment 29 are similar to those on amendment 13. I do not doubt for a minute that its supporters have the best intentions, but this type of public sector equality duty language does not do anything to improve public services. Too many arms of the state have been so concerned with disparities that they have become incompetent at getting on with the job that they are actually meant to be doing; they are distracted by trying to measure all these different equalities.
Amendment 30 would require the Secretary of State to involve all Departments in reducing health inequalities and take all reasonable steps to ensure that all other Departments
“consider the impact of their policy proposals on health inequalities.”
Is this spreading the bureaucracy and the impact assessments more widely? If the Government decide to buy a new submarine, do they have to consider what effect it would have on people who smoke on the Isle of Wight? It does not make sense to me. It is a statement of the obvious that members of the Cabinet and Government have to work together to deliver better health for the country. Of course that is true, but what would be the practical effect? The Minister may be able to tell us.
New clause 19 would require the Secretary of State to publish a health improvement and health inequalities strategy within six months, and an annual report thereafter. Again, that would invite more glossy brochures from the Government, using the precious time of civil servants. The new clause seeks a cross-Government approach by mandating that all Ministers of the Crown must have regard to the strategy when carrying out their functions. Again, it is basically stating what their job is.
Joe Robertson
My hon. Friend hits the nail on the head. Although all these amendments come from a very good place, they are so obvious that they should already be happening, and are too obvious to be enshrined in some overriding duty in a Bill.
Dr Johnson
I agree. The amendments include, in many cases, a statement of what someone’s job is. Does the Member who tabled them think that the Secretary of State is not doing his job and therefore needs to be told what his job is? That could create a whole load of bureaucracy detracting from the actual job in hand.
Amendment 34 concerns transport access. I understand that that is a problem for many people in rural areas, such as my constituency. They often have a harder time, as the distance they need to travel is longer and public transport services are infrequent. Healthwatch, which will be cancelled by this Bill if the Government get their way, has heard from patients who struggle to book transport online, and whose transport turned up several hours early or was cancelled with little or notice at all. Those problems are well documented.
I visited Lincoln county hospital, which has a unit for renal dialysis, where I heard that although transport is provided for individuals having dialysis, which is good, it often does not turn up when it should or does not pick people up at the time that it is supposed to. More concerning is the fact that if they need a transplant and transplant assessments, most have to go to Leicester to have that done, which is several hours’ drive from some parts of Lincolnshire. Most disturbingly, I heard concerns that some people would choose not to go through the transplant programme, and a factor in that decision would be the ability to get to the transplant centre to have the significant amount of testing and follow-up that needs to be done. Clearly, that is not equal access, so I urge the Minister to look at that.
Imposing a duty on the Secretary of State to consider reducing inequalities is a good thing, but it does not magic up the resources necessary to fix them. In exercising his functions, it is a problem the Secretary of State is already capable of addressing. I am sure the Secretary of State, like the Minister, is a good person and wants people to be able to access the services. If Members believe the Government are failing in that regard, I would advise that adding another legislative duty is not likely to bring about the change desired. If we are being honest with the public, we must challenge the premise that every disparity is evidence of a policy failure. The duty placed on the Secretary of State should be to ensure that care is of an equally high standard across the board.
Dr Danny Chambers (Winchester) (LD)
It is an honour to serve under your chairship, Sir Jeremy.
The hon. Member for Isle of Wight East highlighted extremely well the difficulties of accessing hospital services on an island, but it can be a problem anywhere, including in rural constituencies. Winchester is about 60% rural. Since I was elected, an issue that I have had a great deal of correspondence about—even protests and petitions—has been the cancellation by Hampshire county council of bus services, particularly from rural villages such as Colden Common. People need buses for a variety of reasons—obviously to get to work and school—but the No. 1 issue concerning people is that of mainly elderly people using the bus to access hospital and GP services. They are really worried. It is causing a huge amount of stress that they will not be able to access hospital and GP services and not be able to remain living independently in the village that they have lived in for years.
One of the new hospitals in Hampshire is due to be built in south Basingstoke. Extraordinarily, the consultation on the location of the new hospital did not include consultation with the South Central ambulance service. When moving an A&E department and maternity service to another location, it seems blindingly obvious that the ambulance service should be heavily involved in deciding where a new hospital may be located, given that it is primarily responsible for ensuring that people can get there in a timely manner. Although there is obviously a need for local councils to ensure their constituents can get to a local hospital, it is important that we have some kind of obligation. I assume it would have been an obligation that when setting up the location of new hospital services, the ambulance services must be consulted and engaged with to get their input.
Sureena Brackenridge (Wolverhampton North East) (Lab)
On amendment 13, the shadow Minister asked why my hon. Friend the Member for Stoke-on-Trent South felt the need to table amendment 13. One can only assume it is because health inequalities have continued to widen for far too long. In a 20 or 30-minute drive across my Wolverhampton North East constituency, life expectancy drops by seven years. I accept that tackling health inequalities is not just about health; it is about a wider web of societal issues, including educational, employment and housing inequalities. That very long list is beyond the responsibility of the Secretary of State for Health and Social Care.
Amendment 13 will put the tackling of preventable ill health and health inequalities at the centre of national decision making by ensuring that the Secretary of State must consider not just NHS treatment but wider social and economic factors. Will the Minister assure the Committee that future Secretaries of State will not overlook the wider social and economic factors that drive ill health and unequal life expectancy, and that there will be a responsibility to work across Departments to tackle that wider and growing inequality?
Karin Smyth
I am grateful to all hon. Members who tabled amendments in this group, some of which have not been spoken to. I will address the central points that Members have rightly highlighted. I am grateful to the Chair and members of the Health and Social Care Committee for their report and recommendations for the Bill.
Before I turn to the detail of the amendments, I will set out what clause 4 does. As my hon. Friend the Member for Wolverhampton North East highlighted, the wider determinants of health inequalities are important. On the point that the hon. Member for Isle of Wight East made about the Labour party, they absolutely run through our DNA. Clause 4 restates and reaffirms our commitment to tackling health inequalities. It reformulates section 1C of the National Health Service Act 2006, aligning it with the duty imposed on NHS England by section 13G of that Act. It makes plain the need to achieve greater equality between the benefits that people receive and the provision of health services—for their ability to access those services and for the outcomes achieved. Importantly, “outcomes” includes the safety and effectiveness of health services and the quality of the experience undergone by patients. The clause will ensure that the Secretary of State must have regard to reducing inequalities in respect of all those benefits.
The wording of the revised duty more directly encapsulates the benefits that must be taken into consideration and obtained from the health service to support action that reduces or prevents inequalities. Fundamentally, the clause underpins our commitment to improving the health of the population and tackling the stark inequalities that blight the health of communities up and down the land, which have got worse over the past 14 years. That is central to this Government’s ambition, which is why we highlighted it in the 10-year health plan.
We also recognise that this is not a matter for the Department of Health and Social Care alone, which is why we are already working across Government to address the root causes of health inequalities and the barriers to accessing health and care services. We are ensuring that our action on health is embedded in policies that shape people’s daily lives, from the homes they live in to the air they breathe.
Helen Morgan (North Shropshire) (LD)
Before the general election, I was the Liberal Democrat housing spokesperson, and one thing that came up regularly was how important housing is, and not just for obvious physical conditions—mouldy houses can cause breathing issues. Temporary accommodation is devastating for the long-term health outcomes of the people who are placed in it. Does the Minister agree that working with MHCLG to improve housing—particularly social housing—is critical to achieving the Government’s objective?
Karin Smyth
The hon. Lady pre-empts my next comments. I absolutely agree with her, and so do the Government. That is why we are improving living conditions through the new decent homes standards, which set standards across all rented sectors. Awaab’s law requires social landlords to act promptly to fix housing hazards. Since coming into government, we have launched the warm homes plan, the Keep Britain Working review and the homelessness strategy. In April, we published a renewed women’s health strategy, marking a decisive shift to ensure that women and girls receive the care, respect and outcomes that they deserve. Last November, we published England’s first ever men’s health strategy, to improve the health and wellbeing of all men and boys. Within the Department, we are reviewing the Carr-Hill formula and the Advisory Committee on Resource Allocation to ensure the funding matches need.
However, there is much more to do. The Minister for Public Health and Prevention, my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson), will continue to engage with key stakeholders, including representatives of Health Equals. I have a meeting with representatives of that body this week.
I sympathise entirely with the motivation underpinning amendment 13, which was moved by my hon. Friend the Member for Bury St Edmunds and Stowmarket, and I commend hon. Members for working on this important agenda, but I am not convinced that the amendment is necessary. I note that it draws on the duty that was recently placed on combined authorities by the English Devolution and Community Empowerment Act 2026, with a view to creating a similar duty for central Government.
Fortunately, I can reassure hon. Members that the Secretary of State already has a duty to secure improvement in the health of people in England, and the power to take such steps to improve public health as they consider appropriate. We would not want to narrow the definition of the existing duty, because health inequalities come from many causes, as has been discussed. As I have said, we are already working across central Government and local government to address those wider inequalities, including in housing and air quality, and by getting more people into work.
The hon. Member for Sleaford and North Hykeham said that innovation might expand inequalities across our country, but we have seen a shocking expansion in the inequality gap across our country. That is what we are seeking to reverse, as we have made clear in our 10-year health plan, and the Bill will ensure that that happens. That is why we say that we will take the best to the rest; we are not about taking people down.
Finally, I turn to amendment 34 in the name of the hon. Member for Winchester. He has spoken before about his constituents’ experience, and I have spoken with him about the new hospital programme, his constituents’ reliance on transport to access hospital appointments, and the difficulties experienced in more rural areas, which the hon. Member for Isle of Wight East also mentioned. That is why, in our 10-year health plan, we are very clear about our strong commitment to rural and coastal communities—we are the first Government to do that.
We agree that reducing inequalities in hospital transport is important. The Bill already places a duty on the Secretary of State to
“have regard to the need to…reduce inequalities between the people of England with respect to their ability to access health services”.
Inequalities in access to transport to receive care fall under the scope of that duty. As such, the amendment is superfluous.
I also offer the reassurance that NHS England has been implementing a range of actions to reduce inequalities in patient transport, including the speeding up of reimbursement for patients eligible for the healthcare travel costs scheme. I also inform the Committee that the cancer plan included a commitment to provide up to £10 million a year to pay for the travel costs for cancer care for children and young people, and their families, as people have long campaigned for.
Some important issues have been raised in this debate, and I am sure that we will return to them. In the meantime, I ask my hon. Friend the Member for Bury St Edmunds and Stowmarket to withdraw the amendment. I commend clause 4 to the Committee.
Peter Prinsley
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 4 ordered to stand part of the Bill.
Clause 5
Patient involvement and choice
Dr Johnson
I beg to move amendment 59, in clause 5, page 4, leave out lines 2 to 4 and insert—
“(1) In exercising functions in relation to the health service, the Secretary of State must act with a view to enabling patients to make choices with respect to aspects of health services provided to them, including to make choices as to the provider of those services.
(2) For the purposes of subsection (1), the Secretary of State must ensure that patients who are referred for a service to be provided outside a hospital setting (‘out-of-hospital services’) are offered a choice of provider of that service from among the providers available in their integrated care board area and, where relevant, in neighbouring areas, in accordance with regulations made under section 14Z45B.
(3) Regulations under section 14Z45B must provide that, where an out-of-hospital service is to be provided to a patient, the integrated care board must—
(a) offer the patient a meaningful choice of at least two providers capable of providing the service, which may include NHS bodies and independent sector providers approved to provide that service under arrangements with the integrated care board;
(b) provide the patient with information to support an informed choice, including for each available provider—
(i) indicative waiting times;
(ii) the location at which the service would be provided;
(iii) the quality ratings or outcomes data applicable to that provider for that service where such data is available; and
(iv) whether any costs would be incurred by the patient in travelling to or receiving the service at that provider;
(c) not exclude from the list of available providers any provider approved solely on grounds of commercial interest or organisational type; and
(d) take all reasonable steps to give effect to the patient's choice within a clinically appropriate timeframe.
(4) For the purposes of this section, ‘out-of-hospital services’ means services—
(a) provided in community, primary care or ambulatory settings rather than in a hospital inpatient or outpatient department; and
(b) which the Secretary of State specifies by regulations as being within the scope of the choice obligation under subsection (2),
and may include diagnostic services, audiology and hearing aid care, podiatry, dietetics and nutrition, physiotherapy, ambulatory cardiac monitoring and such other services as the Secretary of State may specify.
(5) In specifying services under subsection (4)(b), the Secretary of State must have regard to—
(a) the potential for the expansion of choice to reduce waiting times for the relevant service;
(b) the availability of sufficient independent and NHS providers to make genuine choice meaningful; and
(c) the desirability of ensuring access to choice for patients in all parts of England, including in rural and deprived areas.
(6) The Secretary of State must publish, and lay before Parliament, within 12 months of the date on which this Act is passed, a statement setting out—
(a) the out-of-hospital services for which choice obligations under subsection (2) will initially apply;
(b) the timetable for extending the choice obligation to further services; and
(c) the support that will be made available to patients, in particular those with limited digital access or literacy, to exercise the choices to which they are entitled under this section.
(7) The Secretary of State must review and update the statement required by subsection (6) at intervals of not more than two years.”
This amendment strengthens the new patient choice duty inserted by Clause 5 from a general aspiration into a specific, enforceable right to choose between providers for out-of-hospital services.
Dr Johnson
This group is about how patients can exercise choice. When the national health service was founded in 1948, patients could select their own GP, but it was difficult to change things and exercise choice elsewhere in the system. The health service has come a long way since then. Successive Governments believed that they could make state institutions more responsive by treating the public, to some extent, like customers. Today, patients can choose their GP, hospital, consultant and different types of end-of-life care and mental health service, but choice is about more than just selecting among providers.
Gregory Stafford (Farnham and Bordon) (Con)
I rise to support my hon. Friend the Member for Sleaford and North Hykeham on amendment 59.
The amendment fosters competition. That is not ideological; the Government themselves have accepted, in clause 5, that competition and choice are important. As my hon. Friend said, this is about ensuring that patients have real choice, and not just something that the Secretary of State has thought about. If one provider has a waiting list of 30 weeks, for example, while another can see patients in just four weeks, patients should clearly be given the opportunity to choose the faster option. By expanding patient choice and making better use of the available capacity, my hon. Friend’s amendment has the potential to reduce bottlenecks without necessarily increasing overall NHS spending—that is a good thing.
Importantly, the amendment allows patients to choose between all approved providers, including NHS bodies and independent sector providers. It prevents integrated care boards from excluding suitable providers simply because of their organisational type. I think all Committee members believe in provision that is free at the point of use, but that can come from a number of different providers, including the independent sector.
Peter Prinsley
Does the hon. Member recognise that there are circumstances in which independent provision within a district has the effect of disabling the NHS service? A pertinent example is the ophthalmology world. Services have become difficult to deliver in NHS hospitals because large numbers of NHS staff have chosen to work in the independent sector. That makes the comprehensive provision of a service in an eye department difficult, as the staff are all off operating on cataracts.
Gregory Stafford
I do not recognise the characterisation that the hon. Gentleman puts forward. He is essentially saying that, by allowing the private sector to carry out operations and procedures, we are somehow making the NHS unsustainable. The follow-on from that logic is that we remove all private sector providers and practice so that every single doctor, nurse and therapist is working in the NHS. I do not think that he is arguing for that situation, but it is the logical progression of his argument.
Dr Johnson
When I met surgeons, they said that one reason they like working in elective independent sector hospitals is that they can do more operations on a given day. The shadow Secretary of State visited a provider of cataract treatment yesterday. It is able to perform more treatments on a given day, partly for organisational reasons. The NHS, which is quite frustrating for surgeons, could learn from that. Does my hon. Friend agree?
Gregory Stafford
My hon. Friend is absolutely correct. I do not want to go down the cataracts route, but she and the hon. Member for Bury St Edmunds and Stowmarket have both mentioned them. Clearly, cataracts are a relatively low-complexity, high-volume type of operation. My hon. Friend is absolutely right to say that some providers can do five or six operations per list, while other places are doing two or three. That is often about the private sector being able to move more quickly, which is obviously better for patients, as well as for clinicians, who want to do the surgery that they have trained for.
Unlike the hon. Member for Bury St Edmunds and Stowmarket, I think that competition can play an important role in driving improvement. When providers must attract and retain patients, they have a stronger incentive to deliver timely, high-quality services, and to innovate in how they provide care. In that sense, competition is not an end in itself but a means of improving outcomes and responsiveness for patients. If both sides of the Committee support clause 5, because we are interested in choice and competition, amendment 59 is the logical extension of that.
The amendment is also clear about where the new obligation choices would apply. It covers a range of out-of-hospital services, including diagnostics, audiology, hearing-aid care, dietetics, physiotherapy, ambulatory cardiac monitoring and so on. By clearly defining the services in scope, it provides a realistic and workable road map for implementation.
As I said, the amendment is not about ideology—I think we all agree about choice and competition—but about ensuring that patients receive timely care and have a meaningful choice about where that care is delivered. By fostering healthy competition, making full use of the capacity in the system and putting patients at the centre of the decision-making process, it offers a practical route to improving access and raising standards of care. For those reasons, I support it and commend it to the Committee.
Karin Smyth
I am grateful to the hon. Member for Sleaford and North Hykeham for bringing this discussion before the Committee. We almost went down a cataract rabbit hole, but I think the points were well made. I will outline the Government’s general approach to choice and then move on to the amendment.
I recognise that hon. Members from both sides of the Committee are committed to protecting and upholding patient choice in our system, as are the Government. That is why clause 5 introduces new duties that require the Secretary of State to promote
“the involvement of patients, and their carers and representatives”
in decisions relating to the prevention or diagnosis of their illness, and their care or treatment. That applies when the Secretary of State is exercising health functions.
The clause also requires the Secretary of State to
“act with a view to enabling patients to make choices”
about the health services provided to them. The Government are committed to involving patients and carers in decisions about their care. We know that supports a better experience of care and, in many cases, better outcomes. Furthermore, if they want to be, patients should be active participants in decisions about their own care, rather than passive recipients of services.
I appreciate the sentiment of the amendment in the name of the hon. Member for Sleaford and North Hykeham, but I do not think it is necessary. It turns a general duty into one with more prescriptive detail, which risks adding complexity. Details on service types and operational details currently sit in secondary legislation, which allows them to be updated and amended as services evolve. I reassure the hon. Member that we will protect and maintain all the existing rights and duties set out in the choice regulations.
In any future consideration of expanding patient choice, which this amendment requests, I hope the hon. Member would agree that we would need to build up and test the evidence base to ensure that any changes were effective and meaningful for patients, before legislative changes were made. I am not sure what problem the hon. Member is trying to solve.
The Government are committed to protecting patients’ rights to choose. It is absolutely right that the duty to involve them in decisions will remain a central principle of the new health system and that patients are empowered to make informed, meaningful choices. I believe that the clause, unamended, does just that. For that reason, I ask the hon. Member to withdraw the amendment, and I commend the clause to the Committee.
Question put, That the amendment be made.
Dr Johnson
I beg to move amendment 58, clause 6, page 4, line 10, leave out from “promote” to end of line 11 and insert—
“(a) innovation in the provision of health services and in the arrangements made for their provision;
(b) take steps to ensure the timely adoption and spread of clinically effective innovations across the health service in England;
(c) identify and seek to remove barriers to the uptake of innovation by NHS bodies, including procurement barriers, regulatory barriers and cultural barriers to change;
(d) promote access to innovation so that patients in all parts of England, and patients from all socioeconomic backgrounds, have equivalent access to effective new technologies, medicines and care models; and
(e) have regard to the economic and industrial benefits to the United Kingdom of developing and deploying healthcare innovation in the NHS.”
This amendment would further define the meaning of promoting innovation in health services in England.
Dr Johnson
In healthcare, as in many parts of life, innovation is the way in which new ideas, products and services are developed to solve problems and improve patient outcomes. Here, the entire country has a record to be proud of that goes back a long time. Dr John Preece, a GP and research fellow at the University of Exeter, was the first general practitioner to use a computer in a patient consultation. He co-designed a model with IBM in 1969, and his work led to the creation of the electronic patient record, the forerunner of the electronic patient record that we will discuss later. Innovators working with NHS England have also been seeking to reduce single-use plastic in gastrointestinal procedures, improving outcomes for haemodialysis patients, as well as improving the environment.
Peter Prinsley
Does the shadow Minister accept that, in order to encourage innovation within the health service, we need to do whatever we can to support clinical academics? It is within the academic departments of universities, where people are working in hospitals and teaching in medical schools, that we see the most fruitful innovations.
Dr Johnson
The hon. Gentleman is right, but there are pressures and challenges for clinical academics, which he will be aware of. I am sure the Minister, in summing up, will tell us what she is doing about those.
We need to support innovation in all parts of the health service, not just in university hospitals. One of my concerns is that there has been a drive towards a hub and spoke model. There are good reasons for that, and there have been some good outcomes for patient care, but in some cases it restricts innovation in the peripheral parts of the model; it can disincentivise innovation and make it more difficult. We need to consider how we support innovation in all areas of the NHS.
Helen Morgan
One of the challenges of recruiting staff in Shropshire relates to exactly that point: some areas of the health service are perhaps less exciting to work in than others. Ensuring that innovation is driven across every NHS site and every region will help us understand the recruitment and retention problems that have plagued some of the country’s more rural areas.
Dr Johnson
The hon. Lady is absolutely right. When I was a very junior doctor, whether one wanted to work in a small hospital in the countryside or a large teaching hospital in a big city mostly related to whether one wanted to study a specialist, narrow field of medicine or a wider, broader field of medicine with a variety of different conditions. During my career, I have seen consultants make choices that meant they had to move from their district general hospital to a teaching hospital in order to make progress—in one case, a consultant was told he would not get a professorship unless he moved. The hon. Lady is right: we need to carefully consider how we support innovation.
I have concerns with the clause as it is drafted. Section 13K of the NHS Act 2006 gave NHS England the power to award prizes in support of innovation. Clause 6 ensures the Secretary of State has that power, but there is a big difference between an arm’s length body of technocrats awarding prizes and a political office holder awarding prizes, because then the prizes come out of taxpayers’ money and Governments are particularly short of that—not because they are not taking higher rates of tax, but because they are squeezing the economy.
There is a risk that those awards, and funding for innovation more broadly, become exposed to political cycles. When Governments face a fiscal straitjacket, Ministers are often quick to slash discretionary spending, even though it provides a long-term return on investment. There is also a risk that prizes will be awarded on the basis of who shouts loudest. Certain charities will want the Government to focus on awarding innovations in cancer care, for example; some unions will want the Government to focus on awarding innovators who achieve greater equity in service delivery. There is little doubt that Ministers will have a tough time batting away lobbyists calling for more funding to incentivise this or that type of innovation.
Clause 6 also gives the Secretary of State the power to set up a committee to provide advice on awarding prizes. It is right that the Health Secretary should solicit expert advice when determining which trusts, teams or individuals deserve incentive payments, but does that require the power to set up what is effectively a whole new quango? The Government created more than 25 arm’s length bodies and advisory councils in their first six months. Does the Secretary of State require the power to pay members of the advisory committee when there are many experts in their field who can give their time charitably? I notice there is no requirement for any prize committee to include the chief scientific officer or representatives from ICBs. It is ultimately an unchecked spending power.
Gregory Stafford
What my hon. Friend describes is the real nub of the Bill. If we are to abolish NHS England and move most of its functions to the ICB level or to the Department of Health under a Secretary of State, it would be utter madness for us to, at best, move one set of bureaucrats from NHS England to the Department of Health and therefore gain no extra efficiency, or at worst, as seems to be the case in this clause, not only transfer the NHS England bureaucrats, but create a whole new set of bureaucrats and committees to continue the functions already performed under NHS England.
We need to understand whether the Bill is really about making our NHS more efficient by removing levels of bureaucracy, as was the stated intent of the Minister and the previous Secretary of State, or whether it is simply a political power grab where we keep all the bureaucrats and the inefficiency of the current system.
Dr Johnson
My hon. Friend, as ever, puts things very succinctly. Much of what is said about the Bill is different from what it seems to mean in practice. We have heard the Government talk about the decentralisation of power so decisions are made locally, but in the oral evidence session, even the union rep said that the Bill is more of a centralisation of power. I agree that creating new bureaucracy to replace old bureaucracy—particularly if that involves redundancies—does not help to save money or to make the system more efficient.
I tabled amendment 58 to make the duty on innovation more robust. It would make clause 6 specifically require the Secretary of State to promote innovation in the provision of services, ensure that innovations are spread and adopted across the NHS, tackle barriers to innovation and consider the wider economic benefits of innovation. That is important, because when we talk to people in the life sciences industry, they tell us that one of the biggest challenges is the roll-out of innovation. They can develop innovations in the UK, but it can take a long time to get them on to the shop floor, which is a disincentive to innovating in the United Kingdom. That process needs to move more quickly.
As currently drafted, the clause does not make it clear what innovation is for or whom it is meant to benefit. Amendment 58 would make it clear that innovation should be to benefit patients, no matter their location or socioeconomic status. I welcome the principle of keeping innovation on the statute book, but innovation is an organic process, and it does not begin in the Department of Health and Social Care or in NHS England—that is a fundamental principle that I think the Government fail to understand across many areas. Innovation begins with the frontline workers: the scientists, the technologists and the people who have ideas about better ways to care for patients. I am encouraged that the Minister understands that.
The Government’s vision for ICBs is that they will have more responsibility and more freedom to innovate—although we will discuss whether the legislation actually delivers that later in the Committee’s consideration—and I hope that vision extends to other areas of health policy. The clause is not disagreeable, but it must be made more robust. If Committee members agree, I hope they will support amendment 58.
The Chair
I gently suggest to all Committee members that it would help me tremendously if they could stand at the beginning of the debate on a group if they wish to be called.
Liz Twist (Blaydon and Consett) (Lab)
I will speak in support of clause 6 and against amendment 58. I work with a great many rare disease groups as part of my work as a Member of Parliament. Those people have specific health needs, and innovation is key to developing ways of dealing with their needs and to making their lives better, so innovation is at the heart of what we do.
We have many great institutions. In my region of the north-east, I will mention Newcastle University, which is doing a huge amount of research into a range of rare diseases and is working collaboratively with other institutions, particularly in partnership, to address those health needs. The clause allows the Secretary of State the breadth to encourage that innovation and to help to make it into a viable spin-off. We too often lose the benefits of the innovation that we create, and it is adopted in other countries.
Amendment 58 would put this important clause in danger of being too prescriptive, and sometimes, if we prescribe particular things, we lose the ability to do other things. I support the clause, and I do not support amendment 58.
Joe Robertson
The clause, and amendment 58, deal with innovation. Although the NHS is responsible for some great healthcare innovations, not only in this country but around the world, unfortunately, it is often an example of a complete failure to innovate, or even to use fairly basic technology that has been around for a long time—I am thinking of using computers for patient records, as paper records have lasted for far too long. Promoting innovation is clearly a good thing—it is essential—so I support the amendment. I will speak about the details in a moment.
Dave Robertson (Lichfield) (Lab)
I think this is the first time we have had a Robertson on Robertson intervention. It is a pleasure to break that duck.
The hon. Gentleman is making a powerful point about the need to change culture to embed innovation across the NHS. There is an example that we always come back to: fax machines. Fax machines were used in the NHS for far too long. It was mandated in 2018 that the use of all fax machines had to be stopped by the end of March 2020, yet in 2023, the NHS still owned 600. That mandation came up against a cultural barrier and it did not work, because 600 of them survived for three years after that.
In amendment 58, I see more mandation and nothing on culture. The problem with the amendment is that, by trying to mandate innovation too closely, we would miss the cultural point. We could undermine the Secretary of State’s power to say that all parts of the system are fair game for them. Would the hon. Gentleman like to respond to that point?
Joe Robertson
I thank my namesake for his intervention. I do not completely understand what he says, because the amendment refers to cultural barriers. He is absolutely right that we have to be careful when we mandate things, but the strength of the amendment is that it has a broad application and does not seek to mandate specific detail. I accept that it has more detail than the Bill, but its strength is that it gives some direction without being overly detailed. I again draw his attention to the fact that it asks the Secretary of State and the Department to identify and remove cultural barriers.
Gregory Stafford
I will not keep the Committee too long. We need to look closely at what the clause is trying to achieve, both on innovation, which I support, and on the prizes. My hon. Friend the Member for Isle of Wight East asked a number of pertinent questions about the prizes, and I want to expand on that before I talk about the amendment in the name of my hon. Friend the Member for Sleaford and North Hykeham.
We have no idea what scale of prize we are talking about. Is it thousands of pounds, tens of thousands of pounds or millions of pounds? Will the prizes be given to individuals or to organisations? Will they be given to NHS bodies? I think not, or at least not exclusively, because the clause suggests that they could be for research. Will they be given to the private sector—I know that Labour Members have antibodies against the private sector—or to university research functions? It is very unclear who the prizes will go to.
Even more interestingly, proposed new section 1CC(3)(b) says that prizes may relate to
“work done at any time (including work before the commencement of this section).”
So they could be given for something that happened prior to the Bill coming into force, but we have no idea how far back that could go. Are we talking months, years or decades? There is no clear outline about who will get the prizes, how much they will be, what innovations or technologies they will be for, or the point in time that is being referred to.
Then the clause says that the Secretary of State may set up a committee. I have been in enough Bill Committees to know that civil servants do not write something into Bills unless they have an idea of what they want to do with it. I would be very interested to hear from the Minister what sort of committee it will be, how many people will be on it, how much remuneration they will receive and how they will establish themselves and fulfil the function that the Secretary of State gives them. If we do not know that, the proposal is so open-ended that I would have real concerns about letting it go forward in the manner in which it is currently written.
My hon. Friend the Member for Isle of Wight East suggested—I do not think he was joking—that the word “prize” made this sound like a game show. That is part of what we need to understand. Will the Secretary of State set up a competition in various areas of healthcare, technology, disease or treatment? Will they say, for example, “We want to find the best technology for dealing with cataracts”? Will a call go out for people to submit bids and say, “We have produced this amazing new laser treatment,” in order to win the prize? Or will it be entirely open-ended? Will people come into the Department of Health and Social Care to this new committee and say, “We have created this amazing piece of innovation—give us some money for having done so”? It is so unclear in the Bill. As I say, I am absolutely certain that the Minister knows the answer to those questions because this clause and subsection would not be in the Bill if she had no idea what she was hoping to achieve by them.
Dr Johnson
My hon. Friend is describing something a little like “Dragons’ Den”, which is a very good TV programme—perhaps it will be televised or livestreamed. How will the Government ensure that there is no conflict of interest?
Gregory Stafford
My hon. Friend’s point is correct. There is so little detail in the clause about how these prizes will be awarded and how the committee that will award them will be set up that we have no idea how conflicts of interest will be dealt with. That is another reason that the Minister needs to explain to the Committee how this is going to work. My hon. Friend mentions “Dragons’ Den”. I see her as the Deborah Meaden of our Committee, so I look forward to seeing that play out—I will not say what that makes me.
What I see from amendment 58, tabled by my hon. Friend the Member for Sleaford and North Hykeham— I hope I am not misrepresenting her—is once again an attempt to codify, clarify and strengthen what is fairly woolly wording within the Bill. In particular, her amendment rightly emphasises the importance of
“timely adoption and spread of clinically effective innovations”.
Timeliness is so important to patients. We need innovation quickly. Again, it worries me that the prizes could be given for innovations that could have happened weeks, months, years or decades ago, according to the wording. We also need to ensure that innovation is not in isolated pockets, either in terms of geography or type of service. We need something that is consistently delivered across the healthcare system.
By highlighting the need to address things such as procurement, the regulatory sector and cultural barriers, my hon. Friend’s amendment would support a more proactive and enabling environment for innovation to flourish, not one that shuts it down, as some Labour Members have suggested. Crucially, paragraph (d) of the amendment represents a significant and commendable commitment to fairness and inclusion by prioritising equal access to new technologies, medicines and models of care regardless of geography or socioeconomic background. It would help to tackle long-standing inequalities and move decisively towards ending the postcode lottery that we often see in care quality.
The focus of the amendment would ensure that innovation benefits all patients, not just those in the most advantaged areas. It would ensure that rural and coastal communities are aligned with the urban. As someone who represents a semi-rural seat, I see those inequalities in service delivery, quality of care and innovation. The large towns in my constituency receive far more money and get far better services than the surrounding villages.
I have many concerns about the clause as it currently stands, and I hope that the Minister will be able to clarify some of the Opposition’s questions. I entirely endorse amendment 58.
Karin Smyth
I am grateful to hon. Members for bringing this discussion to the Committee. We heard about the excitement in our constituencies around innovation—my hon. Friend the Member for Blaydon and Consett mentioned Newcastle University at the start and the hon. Member for Sleaford and North Hykeham mentioned her visit to Imperial College. Those visits are inspiring. Other universities and centres of excellence are available, but they made the case for why this is so important to the Government’s approach to innovation. I will talk about that and then turn to the amendment.
The Government are fully committed to innovation. It is absolutely central to our ambitious priorities to digitise health and care, support prevention and early diagnosis, and enable a shift to neighbourhood care, to growth in our economy, and to regaining our place in the world as a centre for innovation, which was lost under the Conservatives over those 14 years. That is why clause 6 places a clear duty on the Secretary of State to promote innovation in the provision of health services, including in how services are arranged and delivered.
The clause also incorporates the Secretary of State’s existing power to incentivise innovation and research through the payment of prizes, as we have discussed. That is a flexible tool that will allow him to stimulate breakthrough ideas and reward innovation across the life cycle, including an early-stage report.
On some issues that have been raised, the Conservative party knows that Ministers have to act reasonably as this transfers from NHS England, and we would obviously want to tailor a committee to the matter in question, including membership. The clause will allow that flexibility. The equivalent duty was on NHS England; I understand that it has not actually been used over the past five years, but it was previously suggested as a way of promoting innovation.
In practical terms, the Secretary of State already supports innovation in a number of ways, for example through the work of the Health Innovation Network, supporting workforce developments in schemes such as the clinical entrepreneur programme and providing funding support for developing and evaluating promising innovations.
Dr Johnson
The Minister talked about the flexibility of the committee, and my hon. Friend the Member for Farnham and Bordon explained why it is helpful to have some direction. Could the Minister explain why there is no stipulation for the chief medical officer or the chief scientific officer to be part of the committee?
Karin Smyth
I am happy to come back to the hon. Lady if I am not correct in this, or if there is another reason, but in the existing duty and under NHS England, the committee’s membership needs to reflect the matter in the question. If there is anything to add to that, I will certainly come back to her. We are also committed to spending more on innovation, raising the NICE threshold to ensure that patients have access to more innovative medicines on the NHS. That is action, not just words.
The Government commend the intent behind the amendment tabled by the hon. Lady, and she spoke well about that. As a clinician, I recognise her support for innovation, but we recognise that barriers remain to the systematic spread of innovation. That is a long-term problem that existed under previous Governments as well, and we seek to rectify it. The ministerial foreword to the “Life Science Sector Plan” published last year says:
“We are clear-eyed about the challenges. For too long, the journey from discovery to delivery has been too slow, too fragmented, and too often held back by outdated systems.”
That is why we need to remove barriers at every stage of the journey; however, the amendment is the wrong way to do that.
The experience of supporting innovation in the NHS suggests that we need flexibility in our approach to tackle emerging barriers as they arise. Specifying several areas of focus in the Bill would limit that flexibility; those are better set out in published strategies and guidance, which is what we are doing. The amendment could also cause unintended consequences. It would create a one-size-fits-all approach, requiring all of England to have equivalent access to innovations. While tackling unwarranted variation is of course vital, we should continue our focus on providing access to innovation that best meets local needs.
Instead of over-defining what we mean by innovation in legislation, we are taking practical measures to drive it on the ground. We are already building the 10-year health plan and the life sciences sector plan to deliver an ambitious set of actions, which address the areas raised by the amendment including procurement, aligned regulation and the alignment of our NHS innovation policy with sector growth policy. That echoes our approach elsewhere in the Bill of devolving power to local levels and giving more opportunity to systems and organisations to innovate, and more agency to use their resources to do so.
The NHS has a strong record of developing and adopting new treatments, technologies and models of care. The clause will build on that record, signalling the Secretary of State’s clear commitment to promoting innovation, and it will do so in a flexible way that will allow us to respond to challenges as they emerge. For that reason, I ask the hon. Member for Sleaford and North Hykeham to withdraw her amendment, and I commend the clause the Committee.
Question put, That the amendment be made.
Peter Prinsley
I beg to move amendment 33, in clause 7, page 4, line 31, at end insert—
“(2) Training under subsection (1)(a) includes training in general health determinants as defined by section 107ZB of the Local Democracy, Economic Development and Construction Act 2009.”
This amendment would place a duty on the Secretary of State to ensure that the health and care workforce is adequately trained in the wider determinants of health such as housing standards, exposure to air pollution, occupational risk, and use of harmful substances like tobacco.
The Chair
With this it will be convenient to discuss the following:
Amendment 50, in clause 7, page 4, line 32, at end insert—
“(4) After subsection (2) insert—
‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”
This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.
Amendment 54, in clause 7, page 4, line 32, at end insert—
“(4) The Secretary of State must exercise functions under this section with a view to ensuring that managers in the NHS, who have appropriate clinical training, must also undertake clinical care.
(5) The Secretary of State must record the proportion of direct clinical care provided by those with professional qualifications both in terms of the proportion of their areas and full time equivalent by pay grade, and the Secretary of State must increase the proportion.”
This amendment would require the Secretary of State to ensure that NHS managers who are clinically trained must continue to undertake clinical care.
Clause stand part.
New clause 44—Medical training places—
“The Secretary of State must double the number of medical school training places to 15,000 by 2031-32.”
This new clause would put a duty on the Secretary of State to double the number of medical school training places.
New clause 45—Data collection: clinically trained staff—
“(1) The Secretary of State must collect and publish data on the numbers and proportion of NHS staff are qualified to deliver nursing and clinical care who delivering nursing care, or clinical care of any kind, and those who are not.
(2) Information under subsection (1) must be collected according to HCAS pay scales.
(3) Information under subsection (1) must include numbers of nursing and midwifery staff.
(4) Information under subsection (1) must be published quarterly.
(5) The NHS and ICBs are under a duty to comply with any requests from the Secretary of State for data for this purpose.
(6) Information under subsection (1) must include the proportion of time spent delivering clinical care as a proportion of the individual’s total working hours.”
This new clause would require the Secretary of State to collect and publish data on the numbers and proportion of clinically qualified staff who are delivering clinical care, broken down by HCAS pay band.
Peter Prinsley
As the Committee knows, my hon. Friend the Member for Worthing West (Dr Cooper) is one of the five medical doctors in the parliamentary Labour party. It is a great pleasure to move the amendment, which she tabled.
The amendment is about education and training. My hon. Friend would like us to consider whether there should be an additional subsection after proposed new subsection (1)(a), which is about ensuring that
“there are sufficient people with appropriate education and training to meet the workforce needs of the health service”.
My hon. Friend would like to include within that specific training about wider health determinants, which, as we discussed earlier this morning, consist of things like housing, air quality, occupation, and substance abuse—tobacco, alcohol and so on. Her opinion is that that needs to be specifically incorporated into the legislation.
Gregory Stafford
I shall speak briefly to the amendment that was just moved by the hon. Member for Bury St Edmunds and Stowmarket. I do not mean this rudely, but it is a relatively motherhood-and-apple-pie amendment. The onus would be on the Secretary of State to recognise that smoking, exposure to air pollution, occupational risk and harmful substances are bad, but I think we all agree on that. If the Secretary of State, or any future Secretary of State, does not already recognise that, I would be pretty surprised.
I have a number of issues with the amendment, the first of which is that it expands some central duties without clear limits. Potentially, it could be a gateway to what I would describe as interventionism. Perhaps, too, it lacks some of the prioritisation or proportionality that I would like to see in the Bill—as I have said, however, I think that otherwise the training element is pretty good.
Moving to amendment 50, in the name of my hon. Friend the Member for Sleaford and North Hykeham, I entirely support it. This amendment would be extraordinarily useful, because the NHS publishes independently audited forecasts of the workforce every five years, but the amendment would lead to better long-term planning. Regular, independently audited forecasts would help the NHS to anticipate staffing needs, plan training and recruitment, and use resources more effectively and with more efficiency.
Amendment 50 would also increase transparency and trust. One of the key things that we will need to do as a Parliament when the Bill becomes an Act is to convince the public that, when this new world of how the NHS is going to be managed and operated comes in, they can have confidence that the treatment they get is the best that it can be and that those who are being trained and working in the NHS get the training that they require and are being established as some of the best in the world.
Independent audits would make such forecasting more credible and give reassurance to the public and the stakeholders that the workforce planning is evidence-based and not potentially politically influenced, which is one of the big problems about having the Secretary of State in charge of everything throughout the Bill. The key thing must be improved patient care. Accurate workforce predictions will ensure that we have the right number of healthcare professionals available. We will see a reduction in shortages and more consistent, high-quality care.
I support amendment 54, in the name of my hon. Friend the Member for Sleaford and North Hykeham, because it ensures that clinically trained managers maintain patient-facing roles, making better use of scarce clinical expertise and improving workforce efficiency. It strengthens accountability, like amendment 50, by tracking and increasing the proportion of care delivered by qualified professionals, helping to optimise staff deployment and reduce pressure on frontline services. I have some concerns about amendment 33, but amendments 50 and 54 have my support, and clause 7, hopefully amended, will also have my support.
Sojan Joseph (Ashford) (Lab)
I rise to support clause 7 and amendment 33, tabled by my hon. Friend the Member for Worthing West. Having worked in the NHS for many years, I have seen that education and training, especially mandatory training, is absolutely necessary. Some may argue that health staff have too much training, particularly mandatory training, but this amendment specifically concerns training
“in the wider determinants of health such as housing standards, exposure to air pollution, occupational risk, and use of harmful substances like tobacco.”
We may have staff, especially those working in mental health, who have training in some of those areas, but staff in A&E, where patients first present, may not have that training, and may be missing that curiosity. We have heard many incidents involving families living in mouldy houses or people exposed to air pollution. It is important that staff have the curiosity to consider where a patient has come from when they turn up at A&E, or, when planning a discharge, where they are being discharged to.
In the last few years, we have seen many internationally trained healthcare workers join our health sector who may not be familiar with the social and housing situation in this country. Whether this is to be a part of their initial training as nurses or doctors, or through mandatory training at work, the amendment is important because it could help to prevent illnesses and identify them earlier through professional curiosity. I support amendment 33.
Dr Johnson
I declare an interest as a member of the NHS workforce and an NHS consultant paediatrician. In England, around one in every 17 working people is employed by the national health service. That is quite a shocking statistic. It is the largest employer in the country and, indeed, in Europe. It has grown significantly over time, in part because the needs of the population have changed. Life expectancy is longer, which is something to be cherished—that is a good thing—but it brings challenges to the health service, as people are more likely to be living with multiple chronic conditions rather than easily treatable ailments. They require more tests, medicines and clinical care. Demographic change requires a larger NHS workforce, particularly in secondary care.
The previous Conservative Government not only recognised the scale of that challenge but took swift action to increase staffing levels across the board, adding more than 42,000 doctors and 55,000 nurses, health visitors and midwives. Conservative Ministers also supported the pipeline responsible for producing the next generation of medical practitioners. They funded 1,500 additional medical school places and opened five new medical schools, including in Sunderland, Lancashire, Chelmsford and Canterbury, and one just outside my constituency in Lincoln. Emergency care became the fastest-growing specialty, with the number of emergency care doctors doubling. That is what support for the NHS workforce looks like.
Conservative investments in the workforce helped to improve survival rates for cancer, increase the number of GP appointments and deliver the fastest vaccine roll-out in Europe. Under existing legislation, the Secretary of State has a responsibility to ensure that there is an effective system for planning and delivering education and training to current and potential staff. Health Education England has been rolled into NHS England, so it is ultimately NHS England that has the duty to ensure sufficient and appropriately trained staff to meet NHS workforce needs. Now that NHS England is to be abolished, it is right that this duty is to be given to the Secretary of State through clause 7, although to some extent it is a statement of the obvious that that is part of his job.
The job of members of this Committee is to improve the Bill, not just wave it through, and that means recognising that the existing legislation had some inadequacies. Clause 7 states:
“The Secretary of State must exercise functions…with a view to ensuring”
several things about the workforce. It is not a cast-iron requirement; the Secretary of State must just think about it, but actually he should not just think about his job; he should get on with it. I have a bit of a bee in my bonnet about legislation that creates obligations that are easy to proclaim and that are virtuous but are difficult to measure. Such legislation makes legislators feel good about themselves because they are writing nice things into legislation, but they are not really robust. What does
“sufficient people with appropriate education”
mean? What is “sufficient”?
One reason concerns are particularly acute is the Government’s shambolic record on workforce planning. They came to power saying that they had a plan, but their workforce plan has still not been published, almost two years since they came into office. I heard the Minister say “imminently”, but I had a written answer last week, I think, saying “imminently”. I appreciate that “imminently” is probably better than “soon”, but what does it really mean, and how soon can we expect the plan to be published? Does she mean that it is coming this week or next? Can she guarantee that it will be published before the summer recess? Has the Prime Minister’s resignation yesterday put all this up in the air once again?
The Royal College of Radiologists has said that the shortfall in clinical radiologists has grown from 29% to 32% since 2024, and the Royal College of Nursing has released data showing that the growth in the nursing workforce slowed last year to its lowest level in eight years. Newly qualified midwives are finding themselves with no jobs to go to in the health service, despite the fact that there is a maternity staffing crisis in some areas. Will the Minister explain the reason for the delay? She said earlier in this sitting that it was not NHS England, but what is causing the delay?
We were told that stakeholders wanted more time to have conversations, test ideas and work together. One would think that after the many months of deliberation, Ministers would have put together an exceptional workforce plan, but the Royal College of Nursing, the British Medical Association, of which I am a member, Unite the union and several other organisations wrote to the Health Secretary earlier this month to urge for the plan, which they have but which has not been published, to be “paused”, because they are
“concerned that the current direction falls significantly short of the scale of workforce growth required to meet patient need and relies too heavily on assumptions about the current state of NHS services, productivity and technology that are not borne out of frontline experience.”
I recently tabled a question asking who had been given advanced sight of the workforce plan, and I received confirmation that the royal colleges and unions have been involved. As I mentioned, I am a member of the Royal College of Paediatrics and Child Health. We now have a situation where a workforce plan is being delayed, and it has been brought before other organisations for discussion rather than elected Members of this House. It is taking far too long. In the meantime, things are going backwards. It is simply not good enough. Ministers are now about to roll out a plan that has mortified seemingly everyone who has seen it, while expecting members of the Committee to rubber-stamp a rather flimsy legal duty.
In May, the Financial Times reported that plans drawn up under this Government would see recruitment cut back. The article reads:
“A workforce plan being finalised by health officials says the NHS in England will have to use technology to get by with hundreds of thousands fewer staff than envisaged under the previous Conservative government.”
Is that clinical staff? Are we going to have fewer doctors? It is not clear because we have not seen the plan and it has not been published. A draft of the plan seen by the newspaper said that the NHS
“does not need anything like the…numbers…set out in its 2023 workforce plan.’
Will the Minister confirm whether those press reports are accurate? She previously said that her plan
“will ensure that the NHS has the right people in the right places with the right skills for patients when they need them”.—[Official Report, 13 January 2026; Vol. 778, c. 737-738.]
Does that mean fewer people and more AI?
Health Bill (Fifth sitting)
Tuesday 23rd June 2026
(1 week, 2 days ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 23 June 2026 - (23 Jun 2026)
The Committee divided: - Ayes: 4 / Noes: 11 - Question accordingly negatived.
The Committee divided: - Ayes: 3 / Noes: 10 - Question accordingly negatived.
The Committee divided: - Ayes: 3 / Noes: 11 - Question accordingly negatived.
The Chair
Good afternoon, ladies and gentlemen. Members may remove their jackets and, because of the health warning—exceptionally—if Members or civil servants wish to remove their ties, they may do that as well. Please understand that that is not a precedent.
Clause 7
Education and training
Amendment proposed (this day): 33, in clause 7, page 4, line 31, at end insert—
“(2) Training under subsection (1)(a) includes training in general health determinants as defined by section 107ZB of the Local Democracy, Economic Development and Construction Act 2009.”—(Peter Prinsley.)
This amendment would place a duty on the Secretary of State to ensure that the health and care workforce is adequately trained in the wider determinants of health such as housing standards, exposure to air pollution, occupational risk, and use of harmful substances like tobacco.
Question again proposed, That the amendment be made.
The Chair
I remind the Committee that with this we are discussing the following:
Amendment 50, in clause 7, page 4, line 32, at end insert—
“(4) After subsection (2) insert—
‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”
This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.
Amendment 54, in clause 7, page 4, line 32, at end insert—
“(4) The Secretary of State must exercise functions under this section with a view to ensuring that managers in the NHS, who have appropriate clinical training, must also undertake clinical care.
(5) The Secretary of State must record the proportion of direct clinical care provided by those with professional qualifications both in terms of the proportion of their areas and full time equivalent by pay grade, and the Secretary of State must increase the proportion.”
This amendment would require the Secretary of State to ensure that NHS managers who are clinically trained must continue to undertake clinical care.
Clause stand part.
New clause 44—Medical training places—
“The Secretary of State must double the number of medical school training places to 15,000 by 2031-32.”
This new clause would put a duty on the Secretary of State to double the number of medical school training places.
New clause 45—Data collection: clinically trained staff—
“(1) The Secretary of State must collect and publish data on the numbers and proportion of NHS staff are qualified to deliver nursing and clinical care who delivering nursing care, or clinical care of any kind, and those who are not.
(2) Information under subsection (1) must be collected according to HCAS pay scales.
(3) Information under subsection (1) must include numbers of nursing and midwifery staff.
(4) Information under subsection (1) must be published quarterly.
(5) The NHS and ICBs are under a duty to comply with any requests from the Secretary of State for data for this purpose.
(6) Information under subsection (1) must include the proportion of time spent delivering clinical care as a proportion of the individual’s total working hours.”
This new clause would require the Secretary of State to collect and publish data on the numbers and proportion of clinically qualified staff who are delivering clinical care, broken down by HCAS pay band.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
Before the lunch break I was saying that, in essence, clause 7 states what the Secretary of State’s job is. It moves the function of planning the workforce from NHS England to the Secretary of State, which is a reasonable thing to do. I talked about the previous Government’s record on opening new medical schools and how that has helped with the number of clinical staff.
We also talked about workforce planning. The Government are due to produce a workforce plan, but it is not clear when it is due to come out. It was due to come out at the end of last year, but it did not; it was then due to come out in the spring, but now it is the summer. Given the Prime Minister’s resignation, it is not at all clear when it will come out. Will the Minister let us know whether it will come out before the summer recess, this week or whenever?
I quoted some of the concerns of the Royal College of Nursing, the British Medical Association, of which I am a member, and others. Those concerns include the workforce plan. Those organisations have seen what we have not seen, so they have been asked to comment on something that we have yet to see. That brings me to new clause 44, which is in my name.
Before the general election, Labour promised that it would double the number of medical school places. The now Chancellor of the Exchequer promised to double the number of medical school training places, as did the now Secretary of State for Science, Innovation and Technology. Once the general election had passed and Labour was in government, the promise was reiterated. At oral questions in October 2024, the now former Health Secretary said:
“This Government are committed, as we were in opposition, to doubling the number of medical school places”.—[Official Report, 15 October 2024; Vol. 754, c. 683.]—
but there has not really been any progress.
During a debate this year on the junior doctors’ foundation programme, I asked the Minister for Care whether the Government’s intention was still to honour that pledge. He said:
“Yes, that is the Government’s intention.”—[Official Report, 22 April 2026; Vol. 784, c. 133WH.]—
only to later submit a written correction stating that the Government had never committed to doing so. Are they going to, or not? It is not clear.
Labour promised to double the number of medical school places, but now that pledge appears to have been airbrushed out of history. Can the Minister please explain why she and her colleagues deemed the workforce pledge essential before the election but not after it? Can she tell us whether it is Government policy? In essence, my new clause 44 asks Members on the Government Benches to vote for what they promised before the election and have promised since.
New clause 44 is very simple: it stipulates that the Secretary of State must double the number of medical school training places by 2031-32. That is what Labour promised, so it should be fairly easy for Labour Members to vote for it. I hope that the Committee will support the new clause, which only requires Ministers to do what their party promised before it came into government.
If the Government are not keen on committing to clear targets, they can at least commit to full scrutiny of their workforce plans. Of course, there is a risk that the House has been misled. Either the promise was made or it was not. The Minister for Care said that it was promised and then submitted a written correction to say that that was inaccurate and that it was never Government policy, but if it has been stated by the Secretary of State at the Dispatch Box, representing the Government, then it is Government policy. Can the Minister help to clarify that point? If the House has been misled by either her former boss or the Minister for Care, perhaps she can clear that up for us. Perhaps the vote will help.
Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
Does the shadow Minister agree that if we doubled the number of medical students, we would simply not be able to accommodate those people as young doctors unless we also doubled the number of training places? After five or six years, those medical students become young doctors. If we are to correct any problem with the medical workforce, it is insufficient to simply state that we will double the number of medical students.
Dr Johnson
The hon. Gentleman is right. When all the new doctors that the Government have promised have been trained, they will need jobs and postgraduate medical training, and there are issues with that. Nevertheless, the Government asked the public to vote for them on the basis that they would double the number of medical school places. Many of the hon. Gentleman’s colleagues produced little videos to that effect, which can be viewed on Twitter. They toured the newsrooms saying, “Please vote for us, we’re going to double the number of medical school places.” They suggested that there would be a revolution in Government to make sure that there were enough doctors. This is important—more doctors would help.
All new clause 44 does is ask the Government to commit to doing what they have said that they will do—or to say that they will not. Either way, we have had the Secretary of State saying one thing and a Minister saying the opposite and then correcting it, so we need clarity. The public deserve that. The Minister herself said that they would double the number of medical school places so that we have the doctors that our NHS needs. If they do not double the number of medical school places, it follows that they will not have the number of doctors that the NHS needs. Presumably that is in their workforce plan, but it needs to be cleared up.
Amendment 50 would put a duty on the Secretary of State to publish independently audited forecasts of the NHS workforce every five years. The logic is straightforward: if the Government believe that their plans are sufficient, they can be compared to an impartial assessment of the workforce. The previous Government published a workforce plan in 2023, setting out how to tackle existing and future workforce challenges over several years. That included doubling the number of medical school places. Yet three years later, this Government are on course for a new plan that is reportedly far less ambitious—we will find out in a minute.
The workforce affects whether patients can be seen on time, maternity wards are safely staffed and elderly patients get the dignity they deserve. It is the difference between the NHS meeting the challenge of an ageing population or slipping into decline. If Labour Members are confident that the Minister’s workforce planning is robust, I expect that they will support my amendment, which requires an independently audited forecast. If they are not willing to support it, that suggests that they know this Government cannot be trusted to deliver the workforce that patients need.
Amendment 54 and new clause 45 were also tabled in my name. Amendment 54 would require the Secretary of State to look at the amount of clinical work that NHS managers undertake. As a clinician, I have increasingly noticed that highly qualified clinical practitioners come in, become the person on the ward who can be relied on, and then go off because they get promoted to a nine-to-five job that is easier and pays more, but does not deliver clinical care.
The chief medical officer, for example, still delivers clinical care, and the amendment probes the Government to consider how many nurses and clinicians in hospitals are delivering clinical care. I asked that in written questions, and the Government did not know the answer. It is materially important information, particularly when looking at the Dash report, which talks about an explosion in the number of people who are clinically trained but not providing clinical work—instead, they are creating guidelines and monitoring whether other clinicians are doing the work. If more of those people were engaged in clinical activity, that might improve the quality of both the guidelines and care, because more junior staff would have senior staff around to help them.
Sojan Joseph (Ashford) (Lab)
I strongly support the argument that clinical staff, even if they progress into a senior role, should carry out some sort of clinical practice. Does the hon. Lady agree that that is what went wrong over the past few years, especially when NHS England was created? Many senior clinicians who were moved into management posts had no contact with clinical areas. That is what this Government are trying to fix by abolishing NHS England.
Dr Johnson
I am talking predominantly about clinicians working in trusts who are trained and very experienced, but then move to work in the same trust but in a more managerial role that does not involve clinical care. I am not saying that every single person needs to be delivering clinical care—there may be exceptions, of course; people do have career changes—but I encourage the Government to reflect on the number of posts being created that take people away from the clinical arena, and on the effect that that has. When the Minister is presented with the number of nursing or midwifery-qualified staff working in a particular department, that may not reflect the number who are delivering clinical care and, by their own admission, the Government do not know which is which.
Amendment 33 would place a duty on the Secretary of State to ensure that the workforce is trained on the wider determinants of health, such as housing standards, air pollution and the use of harmful substances. In my many years as a paediatrician, I have yet to meet a nurse, doctor, surgeon, porter or care co-ordinator who does not know that damp and mould are bad for people’s health, and I have yet to meet a fellow employee who does not know that air pollution causes asthma, or that tobacco use increases the risk of chronic obstructive pulmonary disease, cancer and a whole host of other ailments.
Considering the many pressures on NHS workers, I do not believe that mandating a new programme on health determinants is a good use of time. I fear that it is rooted in the agenda of creating more and more mandatory training, and I would actually encourage the Minister to look at rationalising mandatory training to that which is absolutely necessary. Control of the curriculum for such staff is dealt with separately, so I object to amendment 33.
Joe Robertson (Isle of Wight East) (Con)
It is a pleasure to serve under your chairmanship, Sir Roger. Clause 7 says—I abbreviate:
“The Secretary of State must exercise functions…with a view to ensuring that…there are sufficient people with appropriate education and training to meet the workforce needs of the health service, and…there is an effective system in place for the planning and delivery of education and training of people to meet those needs.”
That is all very nice—who couldn’t agree with that?—but amendment 50, tabled by the shadow Minister, would add a means by which the public, in the interests of transparency, could make an assessment of that by requiring the Secretary of State to publish independently audited forecasts of the NHS’s workforce needs every five years. That seems entirely sensible, it is something that I am sure any Government would want to do anyway, and it would add meaning, assessment and transparency to what is already in the Bill.
New clauses 44 and 45 would do something similar in relation to the number of medical school places. As the shadow Minister said in response to an intervention, new clause 44 seeks to do only what the Government have already said they want to do. Hopefully, the Minister can give us some clarity on whether that is still the Government’s intention and, if it is, what aversion she has to including it in the Bill.
Separately, new clause 45 seeks to establish a benchmark of data collection. Of course, duties and requirements placed on a Secretary of State, such as those in clause 7, can be delivered only if we start with the proper collection of data and, in the interests of transparency, publish it. For that reason, I also support new clause 45.
The Minister for Secondary Care (Karin Smyth)
I thank hon. Members for bringing this discussion before the Committee. The Government are committed to ensuring that the NHS has the right people in the right place and with the right skills to care for patients when they need it. We will be publishing our 10-year workforce plan imminently. I cannot give the shadow Minister any more details on that at the moment, but it will set out the action to create a workforce that is ready to deliver the transformed service set out in the 10-year health plan. High-quality education and training for the NHS workforce will be fundamental to that, and clause 7 is in keeping with that commitment.
Before turning to the clause, I will address some of the issues raised during the debate and in the amendments. I understand the intention behind amendment 50, but I cannot accept it. The 10-year workforce plan will set out the staffing needs of the NHS for the next 10 years. That goes further than the amendment calls for and will be updated every two years in line with our manifesto commitment to publish regular, independent workforce planning. It is only because the Government have set such a clear direction for the service through the 10-year health plan that we can credibly set out a sustainable approach to staffing the NHS over the long term.
As hon. Members will understand, workforce planning is a complex topic. It is closely related to the wider service planning, which is why we have engaged so widely with independent experts to develop our forthcoming workforce plan. To divorce the process of workforce planning from service planning in the way that is suggested by amendment 50 would not produce a more reliable or useful set of forecasts. However, it would reduce the potential for innovation and reform of the kind that is needed and which the Government have set out so clearly in the 10-year plan for the NHS. I can only conclude from listening to Opposition Members that they really did learn absolutely nothing from their time in office or, indeed, from the problems with their workforce plan, which focused on headcount but notably did not reform care, did not look at new patterns of care, did not look at retention or training, and created some of the bottlenecks and problems that we have had to deal with.
Our commitment will be guided by the workforce plan, which is why we cannot accept new clause 44. Decisions on training numbers must be guided by workforce need, and that will have to be considered as part of the forthcoming plan. Adding to the point made by my hon. Friend the Member for Bury St Edmunds and Stowmarket, whatever the Government’s position on the number of medical school places that will be required in the future, fixing a number in primary legislation would be unhelpful as it would limit our ability to adjust target training numbers subsequently to reflect any changes in workforce need.
I was asked about correcting the record. The last Government did double places in their 2024 workforce plan, and I commend the movement of medical schools across the country. If the former Secretary of State is reported in Hansard as having said something contrary to the correction of the record by my hon. Friend the Minister for Care, we will of course pick that up.
Amendment 54 and new clause 45 look to reduce flexibility and increase bureaucracy for a workforce that is simply trying to deliver what is best for patients. On amendment 54, I think we can all agree that we need strong leadership and management to deliver national priorities, including the 10-year plan’s three shifts. Having a clinical voice in management positions is vital and many of our board-level and senior leaders are also clinicians. While some choose to carry on with clinical practice, others might prioritise their managerial role, and it is right that they should have that flexibility. Prescribing that all NHS managers with clinical experience must also undertake clinical care risks reducing board capacity and expertise, including clinical leadership, and disincentivising opportunities for management experience at a time when the NHS has seen a reduction in the number of managers per NHS staff from 2010 to 2025. We do not think that simply prescribing that requirement would benefit clinicians, managers or, crucially, the wider health service, so we oppose the amendment.
New clause 45 would require the collection of further data on the proportion of time spent on clinical care. Detailed statistics on the number of staff working for NHS provider trusts broken down by profession and pay band are already published by NHS England on a monthly basis. Adding requirements to that is not simple. There is not a centrally held collection of data about NHS staff time, and setting one up would have costs both centrally and for NHS trusts to collect specific data. It is also not easy to separate out clinical care meaningfully. Clinicians spend time in supervision, education, safeguarding, quality improvement and clinical leadership, and the amount of time they spend on different activities can vary from month to month. The new clause risks putting more burdens on NHS staff if they are being asked to record what they are spending time on beyond existing procedures. We therefore cannot accept it.
I turn to amendment 33, which was moved by my hon. Friend the Member for Bury St Edmunds and Stowmarket, on workforce training. It would require the Secretary of State to intervene in the content and design of healthcare programmes. Standards of proficiency, conduct and performance of registered professionals are the statutory responsibility of independent healthcare regulators, although universities and practice partners develop the specific content and design of programmes to meet those standards. It is vital that the independence of regulators and universities is maintained to respect their expertise in designing standards and curricula that ensure public safety.
We have published our 10-year health plan setting out major NHS reforms, including moving from sickness to prevention. Supporting healthcare workers to address the wider determinants of health will be essential to delivering that shift. That is why we are providing the “All Our Health” e-learning on critical public healthcare topics for people working in the health and care sector, and revitalising the “making every contact count” approach to ensure that every contact that a person has with the healthcare system supports a shift to prevention.
I assure colleagues that our upcoming 10-year workforce plan will set out plans for ensuring that we train the staff we need so that we have the brightest people and the right skills to support patients. For those reasons, I ask my hon. Friend to withdraw the amendment.
Finally, I turn to clause 7. The Secretary of State already has an overarching duty in relation to the education and training of the NHS workforce. Currently, that duty is partially delegated to NHS England. NHS England also has a duty to ensure that there are sufficient numbers of appropriately trained healthcare workers across England. Clause 7 will simply merge those existing duties into a single, robust education and training duty on the Secretary of State.
The Secretary of State will be entirely responsible and accountable for exercising relevant functions with a view to ensuring that there is an effective system for the planning and delivery of healthcare education and training, and that we have enough healthcare workers with the right training to meet England’s health service needs. Bringing those duties directly under the responsibility of the Secretary of State will reduce bureaucracy, streamline oversight and enable the Government to provide national strategic leadership across the NHS workforce.
I reassure colleagues that accountability will not be diluted. Bringing these responsibilities into the Department will create clearer, stronger lines of accountability with the education and training of the NHS workforce. Ultimately, the Secretary of State will continue to be accountable to Parliament for the health service in England, including for the planning of education and training and ensuring sufficient numbers of trained healthcare workers. I commend the clause to the Committee.
Peter Prinsley
I am happy with those assurances, so I beg to ask leave to withdraw amendment 33.
Amendment, by leave, withdrawn.
Amendment proposed: 50, in clause 7, page 4, line 32, at end insert—
“(4) After subsection (2) insert—
‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”—(Dr Caroline Johnson.)
This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.
Question put, That the amendment be made.
Karin Smyth
Clause 8 will give the Secretary of State the power to direct integrated care boards to exercise his or her functions. This power, similar to that currently employed by NHS England, will promote subsidiarity by enabling such functions to be delivered at the lowest appropriate level. The clause builds on the existing section 7B of the National Health Service Act 2006, which allows the Secretary of State to direct ICBs but only in respect of public health functions.
With our plans to abolish NHS England, the Secretary of State will again have broad powers and responsibility relating to the health service, and so this power encompasses a wider range of functions. Unlike the delegated frameworks set out under sections 65Z5 and 75 of the 2006 Act, which are entered into voluntarily, any integrated care board directed under this power would be obliged to carry out the stated functions.
I reassure the Committee that, while the ICB will be legally responsible for how it discharges a function, overall accountability will remain with the Secretary of State. Furthermore, the Secretary of State might also use directions to place restrictions on the onward delegation of any functions, preventing delegation where it may be inappropriate. Finally, any directions must be published, ensuring transparency and allowing proper accountability.
This measure will empower the Secretary of State to assign functions to ICBs where most appropriate. It aligns with and facilitates our broader direction of travel towards flexibly planned and delivered local services. I therefore commend the clause to the Committee.
Dr Johnson
Clause 8 is essentially about the control that the Secretary of State has over ICBs. When we discussed the clause abolishing NHS England, we talked a lot about the balance between democratic accountability on the one hand and independence from political interference on the other.
The Government suggest that the Bill is a decentralising Bill. What this clause does is essentially to recentralise by default. As the Minister has just said, the Secretary of State can change what the ICB is doing if they think that it is inappropriate. What does “inappropriate” mean exactly, and how will that power be used? It may be used very infrequently—perhaps the current and previous Secretaries of State think that the power would be used infrequently—but equally it could be used in response to considerable pressure from MPs, lobbyists and campaign groups. Instead of issuing directions sparingly, we may end up in a position where the Secretary of State is issuing day-to-day instructions.
The Government want ICBs to take greater responsibility for commissioning decisions, but then they want to be able to undermine them by direction from the Health Secretary. The Health Secretary will never have as good a grasp of the situation in the local geographic area as local leaders, but he has the power to tell them what to do and issue blanket instructions with different characteristics. That will be inherently inefficient. ICB leaders will be under pressure, knowing that if they make a particular decision they can be removed or be told to do something different. They have the job and they have the power, but they haven’t really—all at the same time.
There is also the plan, as the Minister outlined, to make directions something that the Government publish. The clause says that directions must be published by the Secretary of State, but only
“as soon as reasonably practicable”.
The intention behind requiring the prompt publication of directions is to reduce the surface area for back-room pressures, but the lack of a clear timeframe makes it rather a weak measure.
We currently have a Government who seem open to greater use of the private sector, whether in financing projects or in delivering out-patient care. Well, our Prime Minister resigned yesterday, and there is no guarantee that the Government of the right hon. Member for Makerfield (Andy Burnham) will take the same approach. Will the Minister confirm whether the powers in clause 8 could be used by a Health Secretary to instruct ICBs to stop using a specific type of provider?
I would not dispute the idea that the Secretary of State needs to be able to exercise some control over the health service now that NHS England is being abolished, but the clause seems contrary to the Government’s stated vision for health management. I am not sure whether it is in the best interests of patients.
Gregory Stafford (Farnham and Bordon) (Con)
It is a pleasure to serve under your chairmanship, Sir Roger. I agree heartily with the shadow Minister, and a couple of other things concern me about clause 8.
On the one hand, the clause appears to bring more centralisation, but on the other hand it pushes things down to an ICB level at the same time. I am worried that if we have individualisation of ICBs, we will only exacerbate the disparity of services across regions. I would be interested to understand from the Minister how the Secretary of State’s functions will allow the independence of ICBs and, where an ICB understands its local population well, ensure that patients do not end up in a postcode lottery based on which ICB area they happen to live in.
The danger here is that if the Bill does not deal with those problems and close regional gaps, it is not immediately clear from the clause how the Secretary of State could intervene to ensure that ICBs have the autonomy to make decisions based on their local populations and ensure at the same time that patients do not receive a worse service just because they happen to live in one ICB area rather than another.
Karin Smyth
I recognise that this is a subject of some debate; we may discuss it further when we come to the part of the Bill on ICBs. The abolition of NHS England and transferring all its functions to one body has a consequence, which is that the Secretary of State retains that accountability and power. We are keen to have that power clear but flexible in order to empower local systems. That remains the intent.
The power is necessary for the Secretary of State to update national commissioning standards, for example. The ICBs will have wider roles as strategic commissioners. We expect them to take on formal responsibility for a number of services delegated by NHS England. That allows us to issue a common set of commissioning standards, on the point made by the hon. Member for Farnham and Bordon about variability in different places. There need to be common standards across the piece: eligibility criteria, the treatments the provider should use, and national reporting requirements. ICBs having those standards means that there will be a reduction in unwarranted variation in some of these events.
The shadow Minister raised the timetable. The Opposition will recognise that there needs to be flexibility for the Secretary of State and Ministers to respond to unforeseen or changing events. That is why it is purposely broad, because the range of events that can impact the NHS is clearly very broad. We cannot predict the future.
The hon. Member for Farnham and Bordon said that the Bill needs to deal with all these problems. The Bill needs to give enough flexibility to the system and devolve as much power to the system. The Bill needs to make sure that the powers are in the right place, but it is for the local systems to respond to their local needs within that framework. They will be held accountable, for example through the NHS oversight framework and through ICBs’ normal accountability frameworks.
Dr Johnson
The Minister is talking about flexibility. I understand that if a Minister is responding to an unforeseen circumstance, he or she may be very busy, but where a direction has been made, it should not take very long for a member of staff to publish it, because it will already have been written and sent. I understand that a Minister might take a day or so to sign it off because they are so busy, but it should not take months. The addition of a deadline is therefore not an unreasonable request.
Karin Smyth
With due respect to the hon. Lady, it is not a matter of the Minister being busy, whether that is me or anybody else. It is about the operational running of a £200 billion organisation with 1.5 million staff treating millions of people every day. I am sure we all remember from our own experience incidents and unforeseen events that have happened in the local system, and sometimes very tragic events that have required the Secretary of State to take action. We are trying not to increase the number of reports and documentation and to rid the system of bureaucracy by putting something out in that timeline.
Karin Smyth
No, I have finished.
Question put and agreed to.
Clause 8 accordingly ordered to stand part of the Bill.
Clause 9
Secretary of State’s power to provide assistance
Question proposed, That the clause stand part of the Bill.
Karin Smyth
Clause 9, which will insert new section 12DA into the National Health Service Act 2006, will give the Secretary of State a clear statutory duty to provide financial, staffing or other practical assistance in connection with the health service. The power may be used to support persons providing, or proposing to provide, services as part of the health service or which are beneficial to the interests of the health service. It may also be used to support public authorities where the assistance relates to education or training for people employed, or considering becoming employed, in activities connected with the provision of health services. The assistance may include financial assistance, the services of civil servants or other resources of the Secretary of State, and it may be provided on agreed terms, including terms about payments by or to the Secretary of State.
The clause will support the wider purpose of the Bill by enabling a small centre to act in a supportive and enabling way towards the wider system. Where appropriate, the Secretary of State will be able to provide assistance directly to those delivering or supporting health service activity. The clause is needed because the existing statutory framework does not include a clear power that enables the Secretary of State to provide practical support across the full range of health service activity. Relevant support may be financial, practical, staffing-related or connected with education and training.
Without this clear power, there is a genuine risk of confusion about the basis on which such support may be offered, particularly where the Secretary of State is acting to facilitate the delivery of services by others. The power is permissive and facilitative: it does not require the Secretary of State to provide assistance, and it does not require any person or body to accept it. The power is also limited by its connection to the health service and matters relevant to education, training or activities considered beneficial to the health service. Its exercise remains subject to ordinary public law principles and public financial controls. For those reasons, I commend the clause to the Committee.
Dr Johnson
In a system as large as the NHS, covering an area as diverse as England, it is necessary that the Government be able to deal with unexpected situations. The pandemic may be half a decade behind us already, but the Committee will remember that the previous Government had to act quickly and part with a lot of money in a short time. In such instances, it is essential that Ministers have the power to provide financial assistance. It is not only about crises, however; ordinarily, there are occasions when a Government will want to roll out a new prevention programme or address deficiencies in care in particular areas. I know that health policy is always evolving, and the case for flexibility is clear. The Health Secretary may need to be able to provide financial assistance in pursuit of supporting the health service.
I am sure that hon. Members are familiar with the existing legislation. Section 12D of the National Health Service Act 2006 gives the Secretary of State, NHS England, an ICB or the local authority the ability to make direct financial payments as an assistance to persons or bodies. Clause 9 would new section 12DA of the Act, under which the Secretary of State would be empowered to provide assistance to any person or body carrying out, or proposing to carry out, activities that they deem beneficial to the service.
This is where semantics are important. The existing legislation allows the Secretary of State to make payments, but clause 9 is different: it would allow the Secretary of State to provide financial assistance and to make available persons employed by the civil service or any other resources that the Secretary of State has. This is a remarkably open-ended power that would allow the Secretary of State to spend taxpayers’ money while bypassing standard scrutiny. When NHS England spends money, there is transparency: the public can see how much has been spent on different types of care, ranging from hospitals to public health programmes. The public can see how much money has gone into trusts, into the independent sector and into procurement.
Transparency builds trust in the system and disincentivises wasteful spending. Where will parliamentarians or the public be able to see the financial expense of civil servants, or literally any other resource that the Secretary of State may offer in support? For the first time, the Health Secretary will have the power to insert politically directed civil servants into elements of the health service that are not under public ownership.
As clause 9 is drafted, the Secretary of State could provide civil service labour to private or mutual health providers that work within the NHS. Will the Minister elaborate on how that would be used, and how it would be beneficial to the taxpayer and the health service? The number of civil servants taking home more than six figures has increased under this Government. Their time should be focused on delivering public services, not propping up providers, especially ones that are private businesses.
It is also unclear where the legal liability lies under such arrangements. If something goes wrong and the human resources provided by the Secretary of State are responsible, is the Secretary of State responsible or the entity into which those staff have been inserted? Can the Minister clarify that?
It may be politically beneficial in the short term to provide state support, but it can be costly to the public purse and damaging to markets in the long term. By allowing the Health Secretary to issue assistance in the form of free civil servant labour, clause 9 effectively creates a new type of off-the-books subsidy. How can Members of the House or NHS providers tell whether assistance is operational support or a de facto subsidy? It could undermine the idea of a level playing field for firms contracted to deliver NHS services.
There is also the question of when assistance crosses from operational support into running a provider or firm. We do not necessarily want to be in a position where the Bill is used to bail out failing private firms with NHS contracts. I return to the phrase
“any other resources of the Secretary of State”.
It is difficult to understand why the legislation was written in this way, allowing financial assistance, the provision of labour, and then the use of absolutely any other resource at the Health Secretary’s disposal. As with several other provisions in the Bill, it seems another sign that the legislation was rushed. Instead of circumscribing power tightly where it is needed, the Bill gives huge sweeping powers while claiming that it decentralises.
The Minister has described clause 9 as a discretionary power intended to support the effective functioning of the health service and its workforce. Although that may be what she sought to achieve, that is not the reality. The clause paves the way for arbitrary and unaccountable deployments of state resources, and that should concern all hon. Members.
Gregory Stafford
I endorse the comments made by my hon. Friend the Member for Sleaford and North Hykeham.
I am particularly concerned about subsection (2)(a) of proposed new section 12DA. On examination, this provision raises significant concerns about the control of public expenditure and the efficient use of resources within the health service, and I find it rather vague. There is no definition of the terms used, no indication of scope and no express limitation on how the power is to be exercised.
When read together with subsection (1) of proposed new section 12DA, the effect, as I read it, is to allow the Secretary of State to provide funding to an extremely wide category of recipients. That includes not only public bodies and established NHS providers but, as my hon. Friend the Member for Sleaford and North Hykeham has said, private entities, charities, individuals and any person engaged in activities that the Secretary of State considers to be beneficial to the health service.
That breadth is not accompanied by a corresponding statutory safeguard. The clause does not set out criteria for eligibility, priorities for funding or principles to guide decision making. It does not impose limits on the sums that may be disbursed, nor does it require any structured process for allocating funds. There is no express provision for transparency, such as publication of decisions or reporting obligations to another body such as Parliament. That absence is significant.
Control over public expenditure ultimately lies with Parliament, yet the clause delegates a wide and flexible spending power to the Executive with little direction as to how that power is to be exercised. While it may be said that Treasury rules, audit requirements and general public law principles continue to apply, those are external controls and they do not substitute for clear statutory discipline within the provision itself.
The practical consequences of such a broad power need to be considered. The NHS is already under considerable financial strain; as we all know, demand is rising and resources are constrained, and there is a continuing need to ensure that funding is allocated in a way that delivers measurable improvements in outcomes. In that context, certainty, prioritisation and efficiency are essential. By framing this power in such open terms, the clause risks undermining those objectives. It will create the possibility of fragmented funding decisions, with resources distributed across a wide range of initiatives without clear and consistent frameworks, and it may lead to duplication of effort or to supporting projects with benefits that are uncertain or difficult to evaluate. Without clear criteria or structured oversight, it will become more difficult to ensure that funding is directed to the areas of greatest need.
Karin Smyth
In concluding the debate on this part of the Bill, the Opposition have helpfully made most of my arguments for me. The hon. Member for Sleaford and North Hykeham opened with reference to the pandemic and the unusual circumstances in which we have found ourselves. It is obviously important that this Government learn the lessons from that pandemic in the round, that we are prepared and that, as NHS England is abolished, those powers come back to the Secretary of State so that we can respond to any eventuality that comes before us.
As the hon. Member for Farnham and Bordon said, there are existing standards and rules of procurement. Any spending that happens through the Department and the NHS will be publicly recorded and published in the Department of Health’s consolidated accounts. Those come before Parliament, so there is direct transparency through the parliamentary process in the usual way and, as we all know and as the hon. Member for Farnham and Bordon said, Treasury rules apply.
The point about the use of civil servants has been made. Again, it is really important that we recognise that we are bringing together NHS England, NHS staff and civil servants in the Department. It is right that the Secretary of State, in whatever eventuality comes before him or her, is able to deploy the right person for the right job, be they a civil servant or someone currently under NHS staff terms and conditions, to support that work going forward. The clause is necessarily flexible and broad to provide for those eventualities, and to enable the necessary assistance to be deployed. I commend clause 9 to the Committee.
Question put and agreed to.
Clause 9 ordered to stand part of the Bill.
Clause 10
Secretary of State’s duty as respects variation in provision of health services
Dr Johnson
I beg to move amendment 53, in clause 10, page 6, line 21, leave out from “interests” to end of line and insert “of patients”.
This amendment would only allow the Secretary of State to vary the balance between the public and private sectors in the NHS where it is in the interests of patients to do so.
Dr Johnson
This is perhaps the oddest provision in the Bill. Since time immemorial, the Labour party has accused its political rivals of wanting to privatise the health service. In the early 2010s, the then shadow Ministers indulged the idea that the Health and Social Care Act 2012 was a Trojan horse for privatisation. Several years later, after the Minister had herself joined the House, claims continued. The then leader of the Labour party urged the previous Government to
“undo the very damaging privatisation of so much of our NHS”. —[Official Report, 23 October 2019; Vol. 666, c. 960.]
In the 2019 election, the public were even presented with a dodgy dossier—not Labour’s first—that purported to show that the NHS was on the table in negotiations for a trade deal. We now have a trade deal and the NHS is still intact.
Even though Members know full well that no sensible opposition party is advocating for abandoning our NHS system, they keep saying that Governments have been selling off the health service through the back door. Today, private providers deliver only about 10% of NHS care and the system continues to be free at the point of use.
That brings us to the deep irony of today’s debate. After years of peddling the NHS privatisation myth, the Labour party has introduced legislation to make privatisation possible. The Health and Social Care Act 2012 inserted a safeguard against privatisation, section 12E, into the NHS Act 2006. That section prohibits the Secretary of State from exercising his functions for the purpose of “causing a variation” in the proportion of services provided by the public or the private sector.
Clause 10 substitutes the text in that section and makes two small but significant changes. The first change is to expand the type of providers beyond public and private to
“different kinds of legal entity”.
That is probably a good change, because it encompasses the mutual and voluntary sectors, which do have an important role to play in health provision going forward.
The second change is what has caused alarm. The Secretary of State cannot alter the provider mix unless they deem it to be
“in the interests of the health service.”
Could the Minister set out some scenarios when it would be deliberately beneficial to privatise provision or, indeed, when it would be beneficial to deliberately nationalise provision? I cannot recall an instance where Ministers needed to privatise an entire service to ensure patients did not lose access to care.
In February, the Minister of State for Secondary Care told the House that lessons had been learned from private finance initiatives. Yet the Government announced that 80% of neighbourhood health centres will be privatised through public private partnerships. The Government are able to use these partnerships to loan money outside their limits, but it tends to be more costly than public sector borrowing. Essentially, it is borrowing, but not borrowing on the balance sheet.
What is the effect of these private initiatives? I remember receiving my own office on being promoted as a doctor to consultant. It is quite an exciting moment; before that, resident doctors share an office. I had my own space, my own desk, my own computer and a big whiteboard for notes. When I asked whether I could place the whiteboard on the wall, I was told I could not—it was £800 to stick it on the wall under the private finance initiative contract.
So my great big whiteboard sat there, propped against the wall. Periodically, I would move a piece of paper, knock the bottom of the whiteboard and it would tip and fall on me when I was sat at my desk. I did suggest putting it up myself, but that would also incur a charge through the PFI contract—for modifying things without getting them to do the modifications—so I just had to sit there with it propped up against the wall, ad infinitum.
The Government are on the hook for more than £100 billion of payouts, simply for the use and maintenance of PFI facilities. The Labour scheme was a shambolic waste of taxpayers’ money that could have been spent on improving care. When my hon. Friend the Member for Hinckley and Bosworth (Dr Evans) asked the Minister about public private partnerships, she told him she was
“very proud of the capital investment under the last Labour Government”.—[Official Report, 4 March 2026; Vol. 781, c. 386WH.]
But is clause 10 simply a mechanism for Ministers to develop further private finance initiatives? If Government spending is under pressure, may Ministers seek to shift provision even if it proves more costly in the long run?
There is another side to the conundrum of clause 10. Instead of a Health Secretary intent on privatisation, what if we get one intent on squeezing out private sector provision? Who our new Prime Minister will be, we do not know, but one of the candidates has called for the country to abandon 40 years of neoliberalism. Perhaps the Minister could elaborate on what that means, since the tax take as a percentage of GDP is the highest it has been in 40 years. To me, it signals a potential hostility towards choice and competition. We do not want to be in a situation in which the decision is made to alter the provider mix in service of ideology, rather than in the best interests of patients.
I am aware of several private firms that provide services to the NHS and are concerned that clause 10 could be wielded against them. If a future Health Secretary decided to reduce private provision on the basis of ideology, what would happen to the 10% of planned activity that is currently delivered by for-profit entities? NHS providers could not feasibly handle such a surge in demand, waiting lists would increase further, and patient choice would suffer. It would also be expensive. If private providers fear that the NHS is no longer a reliable customer, and that they may suddenly lose their contract if this clause is invoked, they will charge a risk premium on their services—that is what firms do when they face shifting regulatory goalposts. That would only damage the public purse.
Under clause 10, it would be legally possible for the Health Secretary to alter the provider mix. As a result, it would be worth it for several types of providers and ideologically motivated groups to spend vast sums of money hiring lobbyists to convince Ministers that their sector deserves favourable treatment and that they serve the interests of the NHS. Organisations would invest less in resources and more in influencing the rules, which is not a good outcome either.
All those issues are compounded by the fact that clause 10 is imprecise. What does the Minister define as
“the interests of the health service”?
I am not trying to catch the Minister out; I just want to illustrate the problem with legislation drafted in such terms. It is difficult to prove that the Health Secretary has not acted in what they thought were the best interests of the health service. What could that refer to? It could refer to the interests of patients, to the interests of NHS staff or to the financial stability of the health service—it is entirely subjective. What is the health service there for? It is there for patients, which is why I tabled amendment 53.
Amendment 53 would revise clause 10 to specify that the Secretary of State must not alter the provider mix unless doing so is in the interests of patients. I would like to place patients at the centre of the Bill’s changes, in recognition that we do not have the numbers on the Committee to change the clause altogether. My revision would make it harder for the Health Secretary to justify altering the provider mix if it harms patient access or reduces their choice. It would make NHS providers less fearful to know that the Health Secretary would be subjected to a better defined legal threshold.
Gregory Stafford
The shadow Minister has outlined a couple of hypotheticals for the future, when we have a different Prime Minister and a different Secretary of State. One might go down a route of more privatisation, another down a route of removing the private sector from health service provision. My concern is more practical and for the here and now: if the clause stands part of the Bill, it must be because the Government have some desire to do one of those two things now. Would it not be a good idea to hear from the Minister which of those two options it is?
Dr Johnson
It does raise questions about the point of new section 12E. That provision was not there before; there must be a reason for adding it. Either the Government want ideologically to reduce the amount of private provision in the NHS, or they want to increase it. The clause gives them the power to do both.
Labour politicians very often tell the public that the NHS is being privatised. Data has shown that that is not happening, but that did not matter; they found the myth politically advantageous and repeated it ad nauseam. Now, the Minister and her colleagues are in office—they have the levers of power—and are proposing to change the law to make it easier to change the provider mix. That is not only ironic but deeply misguided.
I tabled amendment 53 to require any changes to the provider mix to be in the interests of patients. If the Minister is unwilling to support that, will she offer a compelling explanation why? Clause 10 has alarmed stakeholders across the health sector and the political spectrum. That really ought to tell us something. I look forward to her response.
Helen Morgan (North Shropshire) (LD)
It is a pleasure to serve with you in the Chair, Sir Roger. I have concerns similar to those of the shadow Minister about clause 10. Proposed new section 12E allows Ministers to vary the proportion of activity by provider, and I am interested in the rationale behind that. The powers to retain the provider mix were put in place because of concerns that the NHS would be privatised by the back door, so the requirement to maintain the mix is there for a reason.
As we heard earlier when discussing ophthalmology, there are risks to using private provision for certain NHS activities, as there can be unintended consequences—a bit like the deregulation of buses. In ophthalmology, private providers do thousands of cataract operations very efficiently, but the less exciting and more critical work of preventing people from going blind, which is done in NHS hospitals, is under threat because so many people want to work in easy and profitable areas. I am concerned that that will occur in more areas of the NHS if the Bill allows more privatisation. Although I do not have an ideological problem with the NHS contracting out to private providers—that has worked well to bring down elective waiting lists, for example—the provisions to protect the mix are important.
I am not sure that amendment 53 really moves us forward; it just requires the Secretary of State to consider who benefits from the change in mix.
Peter Prinsley
It is true that the situation in ophthalmology is now quite serious, but is the hon. Lady aware of the problems in radiology and pathology? Some hospitals are unable to recruit histopathologists or significant numbers of radiologists, who provide key services, because the personnel necessary to run those services have been attracted into a private system, although they are contracted to the NHS. That jeopardises the ongoing services for urgent and emergency care.
Helen Morgan
The hon. Gentleman outlines an unintended consequence of the NHS contracting out to private providers. There are ways to get the pricing of those services right, but the clause could introduce that unintended consequence.
Why is this proposal included in the Bill, and what does the Minister see it being used for? Is there a risk that a future Government might use it to bring much more privatisation into the NHS? The general public consensus is that that would be a bad thing. What safeguards can she put in place to ensure that does not happen?
Karin Smyth
I will respond to that question before picking up the other comments. If I do not address all the Committee’s comments, I will come back to Members.
Everyone would expect this, but let me be clear: this Government are absolutely committed to a free-at-the-point-of-use, taxpayer-funded service. We also think that unless it is reformed and changed, it is an existential problem for the British public, who will not continue to support the service. As Members know, one Parliament can never bind another one, so I cannot predict what a future Government will do. There is talk from some of our Reform colleagues about an insurance-based system. There are people who were in the Conservative party but have moved over who think that, so obviously I cannot—
Karin Smyth
I will make some points, and then I will be happy take the hon. Lady’s intervention if I do not address what she was going to say.
The hon. Member for North Shropshire outlined some of the history. This clause seeks to strike a balance. The governing principle behind it is that the decisions of the Secretary of State must not vary the proportion of providers by the type of legal entity that they are. Decisions must be taken according to what serves the health service and the people who depend on it. The clause permits, by way of exception, the balance between sectors to be varied purposefully, but only where doing so would be in the interests of the health service. That would, for example, prevent the Secretary of State from deliberately choosing to grow the proportion of NHS services delivered by private providers for solely ideological reasons.
I understand the concern that drives the amendment. It is that the exception might be relied on to support the convenience of those already providing the service, without taking into account what is best for patients, as the hon. Member for Sleaford and North Hykeham said. That is not the Government’s position, and the clause does not lead to that outcome. The test that it creates is whether the interests of the health services are served.
As the hon. Member for Sleaford and North Hykeham also said, the definition of the health service—as defined under section 1 of the National Health Service Act 2006—is not separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness. A decision to rely on the exception must be justified by reference to that duty; one taken merely because it was easier or more convenient for existing providers or any other group, with no such justification, would be unlawful. The protection that she seeks is, in substance, already secured by the clause.
The amendment would also create another difficulty. Section 1 of the 2006 Act reaches the entire population and includes the prevention of illness before anyone becomes a patient at all. The “interests of patients” reaches only those already receiving care, which is a narrower test than I think the hon. Lady intended, and would allow a Secretary of State who was so minded to provide a landscape that ignores vital preventive health and wellbeing concerns. I hope that she will take from my remarks an assurance that the clause already meets her concerns.
The hon. Lady also highlighted the example of PFI—a subject of much discussion over many years—and of being unable to change her whiteboard. That is absolutely one of the lessons that needs to be learned from the way in which some past PFIs were procured and dealt with. For example, as a new Government, we outlined proposals for a new model of public-private partnerships for neighbourhood health centres, among other things. The previous Government could also have learned the lessons and done something about that, but they chose instead to completely halt the building of any kind of facilities. That is one reason why we are in such a shocking state at the moment. The new proposal outlines, as I think the Opposition know, an 80:20 funding route, exactly to make the point about which is the most efficient way forward. That will absolutely drive measures for growth and create more jobs in the sector.
Gregory Stafford
I want to take the Minister back to her rejection of the amendment of my hon. Friend the Member for Sleaford and North Hykeham on the basis that—I paraphrase—she felt the definition of “patients” was too limiting because it would not count people who had not entered the health system at that point. The clause itself, however, refers to the benefit for the health service. Is the Minister suggesting that the health service, as defined in the Bill, includes what happens before people enter what I would describe as the health service? Is it something before that point? She seems to be saying that our definition is too narrow, but her definition in the Bill must apply to those who have entered some kind of formal setting. Or is the health service wider than that?
Karin Smyth
I refer the hon. Gentleman back to my comments. The health service is defined under section 1 of the NHS Act 2006 as not being separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness—so, yes.
At this juncture, I will explain a number of other features of the clause. In particular, I draw the Committee’s attention to the fact that it builds on section 12E of the 2006 Act to cover the Secretary of State’s health functions, powers and duties. It recognises that, with the abolition of NHS England, the Secretary of State has a far more substantial role to play—as a commissioner of services, for example—than previously. I also put on the record that whenever the Secretary of State takes a decision in this space, the general NHS procurement requirements and other statutory duties will continue to apply.
Finally, the NHS relies on privately owned providers, as well as charities and community organisations, to provide a range of important NHS-funded services across the country. As such, it is important to ensure that, where there is a mixed-market provision between public and private for providers of a particular service, the Government’s powers are not used to distort the provision and potentially discourage important investment from outside the NHS. Conversely, they should not be used purposefully to favour independent providers over NHS providers for reasons unrelated to the quality or efficiency of NHS-funded healthcare.
Dr Johnson
If I heard the Minister right, she said that the clause did not provide for changes on the basis of ideology. However, it says that changes are not to be made
“unless the Secretary of State considers that to do so is in the interests of the health service.”
A Secretary of State whose ideology is that the private sector is bad, good or whatever else could well believe that it is in the interests of the health service to be private or not private. How does the clause prevent an ideologically driven Secretary of State from changing the health service on the basis simply of his ideology, rather than of patient or clinical need?
Karin Smyth
The hon. Lady tempts me to delve into the politics of future Secretaries of State. They will respond according to the manifesto on which they are elected by the British public. That is the point of a democratically accountable public service. I think that the clause strikes that balance, as I have said. For those reasons, I hope that the hon. Lady will withdraw her amendment. I commend the clause to the Committee.
Question put, That the amendment be made.
Dr Johnson
I beg to move amendment 47, in clause 11, page 8, leave out lines 15 to 30.
This amendment prevents the Secretary of State from removing the Chief Executive of an integrated care board.
Dr Johnson
Clause 11 is particularly interesting. In August 2025, Alan Milburn was asked about the abolition of NHS England on the Health Foundation podcast. He said that the Government wanted to see a model that was “more delegated…more devolved” and “more diverse”, which necessitated the centre being smaller. Considering that he is a former Labour Health Secretary and a non-executive director at the Department of Health and Social Care, I do not doubt his understanding of what the Government wanted to achieve.
When the former Health Secretary, the right hon. Member for Ilford North (Wes Streeting), announced the 10-year plan to the House, he also talked about dissolving power. He spoke of a
“brave new world of devolution of power, resources and control”.—[Official Report, 3 July 2025; Vol. 770, c. 469.]
That was repeated in the Government publications that accompanied the Bill:
“Empowering ICBs as strategic commissioners will support putting patients at the centre of care by devolving decisions to a local level where different services can better integrate… Reforms to the NHS FT model will give providers more flexibility to design and deliver healthcare around local needs.”
Between the announcement of the abolition of NHS England and the publication of the Bill, Ministers articulated a vision for a more decentralised system. There is expert consensus that decentralisation boosts performance, reduces health disparities and fosters innovation. After listening to remarks this morning, I have no doubt that Members are clued up on the importance of innovation to the health service, but a problem—a philosophical contradiction—at the heart of the Government’s reform programme and the Bill is that Ministers talk about decentralisation while these provisions constitute a recentralisation of power.
Helen Morgan
I mentioned in Committee last Thursday that the Liberal Democrats are worried about the risk in the Bill of political capture and the Secretary of State’s ability to meddle in day-to-day operations. As I am sure the Minister is aware, speaking at the NHS ConfedExpo this month, Sir Jim Mackey, the chief executive officer of NHS England, warned that the Bill may give Ministers too much control and that there has to be operational freedom; otherwise we will grind to a halt.
I want to probe the process by which we got to this point. Originally, there was discussion about whether the seven NHS regional teams should become independent arm’s length bodies to mitigate such a risk. NHS leaders argued that this would mitigate the risk of direct political control of the service and pointed out that the 10 regional strategic health authorities had played a useful role in running the service efficiently before the creation of NHSE. That proposal was rejected by Ministers, and it is not entirely clear why. I am interested to hear the Minister’s view on that.
It is now being reported that a fresh attempt is being made to argue that regional teams should be hosted by an NHS organisation—probably an ICB—to protect their employment terms and, as staff would remain public rather than civil servants, provide some brake on political control. Can the Minister shed any light on all this? Does she recognise the importance of maintaining operational freedom in NHS decision making?
We have discussed the reality that current Parliaments cannot bind future ones, and I take that point on board. However, current Parliaments do set precedents and establish the legal frameworks within which future Governments initially operate until they change the law. With the potential for more extreme Governments, there is a risk of discrimination and political considerations entering what should be clinical decision making—for example, decisions on whether to place a trust into special measures or what services are offered, such as sexual health, IVF, outreach to migrant communities and so on.
We are concerned not about the current Secretary of State, or indeed the shadow Secretary of State, but about the risk of those sweeping powers being placed in the hands of an extreme Government. If we imagine for a moment that an incoming Government decided that they did not approve of diversity on an NHS board, for example, and replaced an executive with their own candidate, that would be a horrifying situation. I think we would all agree on that. It would be useful to include safeguards now and set a precedent that such action would not be acceptable under this Bill. Notwithstanding the fact that a future Government could come along and change that, they would have to be transparent about their reasons for doing so.
The former Health Secretary, the right hon. Member for Ilford North, claimed that he was taking powers back into DHSC in order to give them away to the system, but this Bill has a lot on taking those powers and very little on giving them to the system. How can we be sure that that will actually happen on the ground, and that ICBs, hospital trusts and other health trusts will have the opportunity to flex their local muscle and ensure that services are best shaped for the local population? The NHS Alliance has called for an operationally independent regulatory function in DHSC to oversee NHS organisations, or for an independent panel to make appointments. Will the Minister consider such practical changes to ensure that political capture is not an unintended consequence of the Bill?
Gregory Stafford
I rise to support amendment 47, tabled by my hon. Friend the Member for Sleaford and North Hykeham, and to ask a few questions about clause 11. I completely understand the thinking behind the clause. The Secretary of State for Health and Social Care is probably the most politically impotent of all Secretaries of State: as my hon. Friend said, they pull levers and not much seems to happen, because they do not have the control over the health service that the public think they do—or indeed, that Members of Parliament think they do, judging by the number of us who stand up and demand that the Secretary of State do things in our local areas.
I understand the Government and the Secretary of State’s desire to change some of that, but there is concern about the potential politicisation of NHS leadership. Integrated care boards were established in various forms under the Health and Social Care Act 2012 precisely to remove politicisation to ensure that decisions in our healthcare service were made for the benefit of patients on the basis of clinical evidence and the needs of the local population, not on the whim of any Secretary of State or Minister. More importantly, ICBs were brought in to make sure that local health systems, local authorities, clinicians and communities made decisions based on local need.
Those politically independent ICB chief executives were expected to exercise professional judgment, make difficult decisions about priorities and resources and sometimes deliver messages that Ministers, and indeed local Members of Parliament, found uncomfortable. If those leaders know that their continued employment ultimately depends on the confidence of the Secretary of State, there is a real risk that the independence of their judgment will be weakened and that patient safety will diminish.
The amendment tabled by my hon. Friend the Member for Sleaford and North Hykeham tackles a core question: should an ICB chief executive focus solely on what is best for patients and the local health economy, or should they have to consider whether their decisions may attract ministerial displeasure? Even if the power is rarely used, and even if, as my hon. Friend said, there are currently some guardrails in the clause, its existence will change behaviour—it must do. Leaders will become more cautious, perhaps more risk-averse and potentially less willing to challenge national policy when local evidence points in a different direction.
ICBs have benefited from the ability to speak truth to power. A system in which senior NHS leaders fear dismissal by Ministers risks discouraging precisely that kind of honesty. Do not get me wrong: there are good ICB chief executives and bad ICB chief executives, ones who understand their role well and ones who feel that they do not need to engage at all with their local communities. I have a very good ICB in what is currently Surrey Heartlands, soon to be a larger organisation, and an ICB that does not do the job as well—I will not name it, but any student of geography will be able to work out which one it is.
Secondly, excessive ministerial power blurs the lines of accountability. The Minister, in her defence, has argued that Ministers need powers because Ministers are accountable. I get that argument, but one of the most important principles of effective public administration is clarity of responsibility. If the Secretary of State gains extensive powers to appoint and dismiss local NHS leaders, it will become increasingly difficult to know who is actually responsible for outcomes. When performance improves, Ministers will claim credit; when performance deteriorates, local leaders may be blamed. If Ministers possess the power to select and remove those leaders, they will inevitably become more directly responsible for those management decisions, so far from increasing accountability, this might dilute it by creating uncertainty about where true authority lies.
Thirdly, there is a constitutional concern. Whether one likes it or not, the previous Act created a balance between democratic accountability and operational independence. Parliament rightly determines the funding, priorities and legislative frameworks, and Ministers rightly set national policy, but operational decisions have been made by healthcare professionals and the statutory bodies established for that purpose. That distinction exists for a good reason. No Secretary of State, regardless of ability or commitment, or indeed their own background in the health service, can personally manage every NHS organisation in England, and I do not think they should. The more powers we concentrate at the centre, the greater the temptation for Ministers to become involved in operational matters that are better addressed through professional expertise and local knowledge. My hon. Friend’s amendment seeks to preserve that distinction in a singular and precise way. It recognises that Ministers should govern the NHS and be held accountable at the top by us as Members of Parliament and our constituents, but should not seek to manage every aspect of it.
Fourthly, there is a practical problem. Supporters of ministerial intervention often point to examples of failure and ask what should happen when an ICB is underperforming. That is a fair question, but the answer is not that the Secretary of State must personally possess dismissal powers. A range of mechanisms already exist: ICB boards have governance responsibilities; NHS England has oversight powers; professional regulators oversee the conduct of clinicians; there are provisions in employment law for procedures when it comes to misconduct and capability issues; and auditors and inspectors can identify failings. It would be far better if the Bill strengthened those provisions to ensure that accountability was brought forward, rather than giving the Secretary of State the ability to fire and hire as he or she sees fit.
Of course, none of those mechanisms of accountability will disappear if amendment 47 is adopted. The amendment would not create any kind of immunity from accountability; it would simply ensure that accountability is exercised through the established governance structures, rather than through direct ministerial intervention on a chief executive. Indeed, one might ask whether a Secretary of State is really the best person to assess the performance of an individual ICB chief executive. Such judgments often require detailed understanding of local service pressures, workforce challenges, demographic factors, financial constraints and so on. Those are matters better evaluated by individual organisations with operational expertise than by politicians operating at national level.
Fifthly, I think the clause as drafted would present a risk to recruitment and retention. The NHS already faces significant leadership challenges. Senior leaders are expected to manage enormous budgets, oversee complex organisations and make difficult decisions under intense public scrutiny. If we create a system in which their tenure can ultimately depend upon ministerial whim, we may deter talented individuals from seeking those positions. As my hon. Friend said, the NHS needs leaders who are willing to innovate, take calculated risks and make difficult long-term decisions. It does not need a culture in which leaders are constantly looking over their shoulder, wondering whether a politically controversial but clinically necessary decision could threaten their position. Strong organisations attract strong leaders when governance arrangements are stable, predictable and professionally driven. They do not attract them through uncertainty and political intervention.
Sixthly, we need to consider the precedent being established. Powers granted to one Secretary of State are inherited by the next, as the hon. Member for North Shropshire said. Members may trust the intentions of the current Minister—I certainly do. They may also believe that these powers would be exercised responsibly—and at the moment I think they would be. However, legislation must be judged not on how it is going to be used by one individual, but on how it could be used by any future holder of the office. Therefore, the question is not whether the current Secretary of State or Minister would misuse the power, but whether Parliament wishes to establish a framework in which future Secretaries of State possess the ability to remove local NHS leaders whose decisions, views or priorities may conflict with their political objectives. That is a much more serious question.
Finally, we must remember what ICBs were trying to achieve, even if we do not think that they have achieved it or performed in the way that we wanted them to. If we go back to the principle of why they were set up, they were designed to encourage collaboration rather than some sort of command-and-control structure. They were intended to bring decision making closer to patients and communities. They were established to support long-term planning across local health systems. Those objectives, I am afraid, are very difficult to reconcile with a model in which local leaders remain subject to direct ministerial dismissal. Partnership working flourishes when organisations have confidence in their independence and responsibilities. It is weakened when authority is increasingly concentrated at the centre.
For all those reasons, I believe that amendment 47 in the name my hon. Friend the Member for Sleaford and North Hykeham raises an important principle. It is not about protecting poor performance or shielding individuals from accountability; it is about ensuring that accountability is exercised through proper governance structures rather than political control. Expanding ministerial powers to hire and fire local NHS leaders risks undermining all of those principles.
Karin Smyth
We have a clear political and—as I think the hon. Member for Sleaford and North Hykeham said—philosophical division here. This Government believe in democratic accountability, in politics and in good government. I understand that both Opposition parties were architects of the 2012 Act, which created this huge, independent body to run what has become a £200 billion service that clearly has not worked, and that they want to hold on to some of that, despite not opposing the Bill on Second Reading and, actually, not really opposing the abolition of NHS England—I think we will keep returning to that—but we believe that, ultimately, the Secretary of State needs to be accountable for the service, which is not working as the British public deserve or expect.
The hon. Lady asked me to go into good variation and bad variation. Our drive has been to understand the variation. I know from Members of Parliament who have come to me in the past two years, and we understand from looking in detail at the variation across the service, that there is often no rationale for the variation. Local people do not understand why services work better in one part of their county, even, than in another. The hon. Member for Farnham and Bordon alluded to that when he mentioned some places in his area that are working better than others. That is why—and I personally wanted to drive this very strongly—we are getting more information out, releasing the outcomes framework and releasing information to all Members of Parliament about where and how the current data shows their local systems are performing. That is what local people need, and in my view good local parliamentarians, of whom there are very many, should be able to go back to talk to their local systems and chief executives about why that is—not to berate them, but to understand it. There might be a very good cause for the variation; there might be structural reasons or geographical reasons, and they might be long-standing reasons. That is what we seek to do in order to regain the trust and confidence of the British public, and that is why we are publishing those documents.
I stand by my comments that my approach is more local than centralised. This is about changing the culture, which we seek to do by making that happen more locally. I absolutely get the points about operational freedom and the balance that we will seek when we release the operating model, which is being worked on in the Department, as we bring the new system into being, alongside the Bill.
However, we want to be very clear that when an ICB has failed or is at risk of failure, and that failure is significant, it is right that the Secretary of State has the tools to minimise the impact on patients and the public and to act swiftly to put things right. The public rightly expect that, in such circumstances, Ministers will take the necessary steps to protect patients, taxpayers and the public. In some cases of significant failure, that may include directing an ICB and removing the chief executive.
I am sure that all Members here today will agree that effective performance management of ICBs will continue to be essential once NHS England is abolished, not only to support the provision of a quality service, but to reassure the people served by ICBs that when things go wrong, they will be put right.
Helen Morgan
I could not agree more with the Minister that when there is an obvious failure, either in a local system or in a trust, we would hope that the Secretary of State will intervene. She will know from our experience in Shropshire that, when a system is failing or underperforming, that intervention is welcome. But the Bill gives the Secretary of State power to intervene even when things are going well, which is quite an extension of power. Will the Minister comment on that?
Karin Smyth
I thank the hon. Lady for that intervention, and I will come on to the power.
As hon. Members are aware, NHS England currently holds similar powers, so it makes sense for these powers to be held by the Secretary of State once NHS England is abolished. I want to be clear—I hope that this will address the hon. Lady’s point—that our intention is to use these significant failure powers rarely and not as a first port of call. It is far better to work closely with ICBs and their leaders to spot issues and work collaboratively to resolve them before they have the opportunity to become significant, but it would be irresponsible not to have the power to intervene as a last resort.
I want to address the other elements of clause 11. The first part of the clause establishes a general power for the Secretary of State to direct integrated care boards about the exercise of their functions. Using that power, the Secretary of State could direct a singular ICB, a group of ICBs or all ICBs, depending on the scope of the direction. This power is a necessary step in restoring democratic control over the NHS. The public rightly expect Ministers to be able to set priorities, drive improvements and set out how they expect the NHS to operate. For example, we expect to use the power to set up and update national commissioning standards.
The power is particularly relevant given the wider commissioning responsibilities ICBs will have in their role as strategic commissioners following the abolition of NHS England. By setting standards for all ICBs, the power will help reduce the unwarranted variation in the way that ICBs discharge their functions. It is also an important tool for enabling Ministers to respond to changing events. The lack of such a power has slowed the ability of NHS England to respond to unforeseen challenges within the health system.
I can also give the Committee an assurance that the clause includes a considered set of limits on the scope of the power. The Secretary of State will not be able to direct ICBs to appoint a particular individual, issue a direction about the services to be provided to an individual, or direct the use of a drug treatment or diagnostic technique where that is inconsistent with NICE guidance or recommendations. Equally, to maintain transparency in the health system, directions made under the general power to direct ICBs as to the exercise of their functions will be required to be made in writing and to be published as soon as reasonably practical. The power will enable the Secretary of State to uphold the standards that patients expect and deserve, while also protecting the principles of fairness and impartiality at the heart of the NHS.
We have already addressed much of the second part of the clause, but I should note that we have purposely placed the powers to intervene in cases of significant failure outside the general power of direction over ICBs. That is because it is important to be clear that those powers are expected to be used only rarely and in situations where an ICB is failing or at risk of failing.
I hope the hon. Member for Sleaford and North Hykeham feels able to withdraw her amendment. I commend the clause to the Committee.
Question put, That the amendment be made.
Health Bill (Sixth sitting)
Thursday 25th June 2026
(1 week ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 25 June 2026 - (25 Jun 2026)
The Committee divided: - Ayes: 3 / Noes: 10 - Question accordingly negatived.
The Chair
Before we begin, I remind Members to switch all electronic devices to silent. Tea and coffee are not allowed during sittings. As Members will have noticed, I have taken my jacket off, so please feel free to take yours off—it is hot in here.
Clause 12
Commissioning functions: responsibility
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
I beg to move amendment 57, in clause 12, page 10, line 10, at end insert—
“(4A) Before making regulations under subsection (1)(b) that would alter the range of services or facilities which the Secretary of State is required to commission nationally, the Secretary of State must—
(a) prepare and publish a commissioning transition plan in accordance with subsection (4B),
(b) consult in accordance with subsection (4C), and
(c) lay the commissioning transition plan before Parliament.
(4B) The commissioning transition plan must set out—
(a) a description of each service or facility that the Secretary of State proposes to add to, or remove from, national commissioning responsibility under section 3B(1)(b), and the reasons for each proposed change;
(b) a description of the body or bodies to which commissioning responsibility for each such service or facility would transfer and the basis on which that body is considered capable of commissioning that service or facility effectively;
(c) an assessment of the impact of each proposed change on patients who rely on the affected services or facilities, including—
(i) patients with rare diseases or conditions,
(ii) patients whose needs cannot be met by a single integrated care board area, and
(iii) patients who may face differential impacts on account of a protected characteristic within the meaning of the Equality Act 2010;
(d) the transitional arrangements to be put in place to ensure continuity of service for patients during any transfer of commissioning responsibility;
(e) the workforce and capacity implications for the bodies to which commissioning responsibility would transfer;
(f) the financial arrangements for the transfer of commissioning responsibility, including the funding to be allocated to receiving bodies; and
(g) the proposed timetable for implementation of each change.
(4C) Consultation under this subsection must include—
(a) integrated care boards that would assume commissioning responsibility under the proposed changes;
(b) NHS trusts and NHS foundation trusts providing the services or facilities affected by the proposed changes;
(c) patient groups and representative organisations for patients likely to be affected by the proposed changes;
(d) clinicians with expertise in the services or facilities affected; and
(e) such other persons as the Secretary of State considers appropriate.
(4D) Consultation under subsection (4C) must—
(a) run for a period of not less than twelve weeks, and
(b) begin no earlier than the date on which the specialised commissioning transition plan is published under subsection (4A)(a).
(4E) Following the consultation period, the Secretary of State must publish a response to the consultation that—
(a) summarises the representations received,
(b) sets out the Secretary of State's response to the key issues raised, and
(c) describes any amendments made to the specialised commissioning transition plan in light of consultation responses.
(4F) No regulations under section 3B(1)(b) that alter the range of nationally commissioned services or facilities may be made until at least 60 days have elapsed after the consultation response required by subsection (4E) has been published.”
This amendment requires the Secretary of State to publish and consult on a commissioning transition plan before making any regulations under the new section 3B of the National Health Service Act 2006 (inserted by Clause 12) that would alter which services are commissioned nationally.
The Chair
With this it will be convenient to discuss the following:
Clause stand part.
Clause 13 stand part.
Dr Johnson
In essence, the clause confers the commissioning duties of NHS England on to the Secretary of State, because NHS England is being abolished. In that respect, it is quite straightforward. In the existing National Health Service Act 2006, which is to be amended, section 3 sets out the duties of integrated care boards as to commissioning health services, and section 3A similarly. Section 4 is about NHS England’s responsibility for the provision of high-security psychiatric services. In essence, clause 12 replaces the references to “NHS England” in sections 3 and 3A with “the Secretary of State”. The ICBs now must act consistently with the discharge by the Secretary of State of the section 1 duty to promote a comprehensive health service. That is consistent with the aims of the Bill. I have concerns, which I have expressed previously, about how the Government ensure that the Secretary of State can make those decisions fairly, on the basis of clinical need, rather than because of pressure from a lobby group, a celebrity campaign or such like, but again, that seems consistent.
The clause also replaces entirely section 3B of the 2006 Act. Under the previous section 3B, the Secretary of State could direct NHS England to commission the service nationally; the proposed new section 3B confers a regulation-making power to require the Secretary of State to arrange nationally services for members of the armed forces and their families specifically, as well as such services or facilities as may be prescribed. Perhaps the Minister will comment on what sort of services or facilities might be prescribed under that proposed new section.
In doing that, the Secretary of State must have regard to the number of people needing the service, the cost and the number of possible providers. That reflects a balance. Some services, such as hip replacements, are very common. They occur in all areas of the country, perhaps at different rates, but they are broadly a common service. Accident and emergency is another common service. Some people, however, have the misfortune to have a condition that is rare and requires specialist care, in small numbers. That needs to be commissioned on a more national basis, because of the need for specific expertise among commissioners and health professionals.
In subsection (4), proposed new section 3B(5) modifies section 4 of the 2006 Act so that the duty to arrange high-security psychiatric services transfers from NHS England to the Secretary of State, and the Secretary of State gains a new power to direct the providers of those bodies—but only non-public bodies—if he is satisfied that the provider is already licensed under the Health and Social Care Act 2012 and would be required by its licence to obey the direction.
In one respect, as I said, it is necessary to transfer powers to Secretary of State, now that NHS England is to be abolished, but I have a couple of questions. NHS England published a direct commissioning update on 2 March, which describes a new commissioning structure. At the moment, NHS England commissions regional NHS England bodies and the ICBs at a more local level. The update suggests that we will have the ICBs commissioning services, and the Secretary of State instead of NHS England, but that each of the seven regions will have an office for pan-ICB commissioning, known as an OPIC, to support ICB commissioning services—both standard commissioning and at-scale commissioning in some instances.
How is that more efficient than the old structure? Are we just going to see the people working in the regions of NHS England get made redundant, at a huge cost to the state, only to be re-employed by the OPIC? What is the estimated cost of that? Is that the intention? We are going to either lose the expertise of the regional advisers in NHS England or end up re-employing them having paid them redundancy. Can the Minister explain which she thinks it is?
There is a hugely long list of specialist nationally commissioned services. Can the Minister guarantee that those services will not be moved locally? The ICBs only have so much capacity. It will be a challenge for an ICB to deal with conditions that may affect only one or two people in its area in a given year, particularly given the 50% budget cut; obviously, it will prioritise things that affect more of its population. People who have the rare conditions that are currently commissioned nationally may be worried that they will not get the same level of service that they are getting at the moment.
The direct commissioning update talks about prisoners and the justice system. At the moment, NHS England works directly with the Ministry of Justice to commission healthcare for those in the justice system. That includes adults in the custodial system, children in secure children’s homes, non-custodial care, sexual assault and abuse centres, and abuse referral centres.
There are eight high-security category A prisons in England. Instead of being specially commissioned as one batch, they are going to be commissioned specially by their local ICBs. Where are the ICBs going to get the advice and expertise to do that? Dealing with category A prisoners is about not only managing the prisoner and providing them with healthcare, but keeping the people providing that healthcare safe while they are working. This is a specialist area. I am interested to understand why the Minister thinks it will be managed best locally. If, under her new system, it is to be managed locally and the prisoner’s home address ICB is different from the prison address ICB, where will the funding move from and to? Will the prison’s ICB be reimbursed by the prisoner’s home ICB or will it bear the brunt locally?
What will happen to the sexual abuse referral centres? It is perfectly possible, particularly in some areas of the country, that an individual is sexually assaulted in one ICB area, lives in another and reports a crime in a third. Will local commissioning have an impact on where the individual needs to go for their pretty intimate examination and assessment? Has the Minister considered that? What is her view?
What happens to healthcare for migrants? That is another area that is dealt with partly by the justice system at the moment. Can the Minister update us on that? There are over 100,000 people in asylum accommodation, including 30,000 in hotels, and many members of her party are keen to welcome even more. Who will be responsible for commissioning their care?
The Government are also delegating the child health information services, which are the record of whether children have been vaccinated and such like. Given that they are planning to have a single patient record and the electronic red book, why do they want the services to be commissioned locally rather than nationally? Do they expect commissioning for a uniform service, such as a screening service, to lead to differential outcomes—and if it does not, what is the rationale for it?
A particular example is blood spot screening. The Minister will be aware that there was a Westminster Hall debate earlier in the week on spinal muscular atrophy, in which blood spot screening was mentioned. Metachromatic leukodystrophy is another condition for which people want blood spot screening. If blood spot screening is to be commissioned on a local ICB level, will ICBs be required to do it in line with Government guidelines, or will they be able to vary the service they provide to those patients?
By delegating more to ICBs, Ministers are creating variation. On one hand, they want local differentiation and variation; on the other hand, they have put in a clause that requires the Secretary of State to limit local variation. Again, there is a tension there. Will the Minister talk about that?
Moving to some technical points, I noticed that “hospital premises” is defined in section 4 of the 2006 Act, but I cannot find it defined in the Bill. Under the original section 3B of that Act, the Secretary of State had to obtain appropriate advice before making regulations about commissioning services; when services were commissioned locally or nationally, the Secretary of State had to take expert advice. That seems like a sensible thing that we want the Secretary of State to do. One would hope that if the Secretary of State were doing his job properly, he would do that, but it seems a little odd that that requirement has been taken out, as though there is an intention for the Secretary of State not to do that. I would appreciate the Minister’s comments on that.
Proposed new section 3B provides that a direction can be given to a person other than a public authority regarding high-security psychiatric services. The Minister knows that high-security psychiatric services are currently provided at Broadmoor, Ashworth and Rampton, which are still stand-alone units run by NHS providers. Does she plan to ask a private provider—someone other than a public authority—to run those facilities? If not, what is the purpose of the clause? There is a secure children’s unit in Sleaford in my constituency. What will happen to those children if it is commissioned locally, and where will the money flow from?
We asked in a previous sitting whether the Minister thought that the new Prime Minister will want to continue with this Bill. When it comes to the OPICs, in essence the Government will be firing staff from one job, paying them redundancy, and rehiring them, potentially on different terms and conditions, to do a similar job in the OPICs. Is the Minister aware that the right hon. Member for Makerfield (Andy Burnham) used to speak out against firing and rehiring staff, and abolishing and recreating organisations? That is essentially what is happening, so will she have to abandon these changes?
Dave Robertson (Lichfield) (Lab)
We have heard a few times about Conservative fears about redundancy payments and so on. Why did they not add NHS England to the list of organisations covered by the modification order when they had the opportunity to do so? Is the hon. Lady aware of a reason why that did not happen when the Conservatives were in government?
Dr Johnson
I am afraid I do not know the answer to that question. The key point is that it is not logical to abolish a three-tier structure and recreate it with taxpayers’ money to do exactly the same thing. If NHS England is replaced by the Secretary of State, the regional NHS England is replaced by the OPICs and the ICBs are at the bottom—the more local tier—what has changed? The middle tier will be doing the same thing.
Dave Robertson
The modification order is a piece of legislation that is often used in the public sector. It means that when people from a lot of public sector organisations are made redundant and find alternative employment at another state-funded organisation, they are not entitled to a redundancy payment. During their 14 years in power, it would have been entirely possible for the Conservatives to add NHS England to the list of organisations covered by the modification order. That would have prevented the costs that the hon. Lady has mentioned several times. It just seems like they did not take the opportunity to do that, and now they are saying that they should have done that when they were in government.
Dr Johnson
But we were not planning to abolish NHS England, so we had no reason to worry about redundancy. We were not planning a large-scale abolition—the largest that has ever happened in this country.
Amendment 57 would require the Secretary of State to publish and consult on commissioning transition plans before making regulations under proposed new section 3B that alter which services are commissioned nationally. It is a very reasonable amendment that would just mean that people get answers. It would mean that vulnerable people with unusually rare or highly complex conditions requiring regional or even national treatment could understand any changes the Government planned to make. We know that some services are delivered in only three or four centres in the UK. If a patient lives far from a centre, and suddenly that centre is closed, that can have huge travel and service implications, which can create huge distress and worry and make care worse.
Helen Morgan (North Shropshire) (LD)
It is a pleasure to serve with you in the Chair, Ms Lewell. In general, the Liberal Democrats support clauses 12 and 13. We think that local decision making and community empowerment in the NHS, including on commissioning decisions, is the right thing to be doing.
However, I echo some of the concerns of the shadow Minister, the hon. Member for Sleaford and North Hykeham, particularly on specialist commissioning. I declare an interest as vice-chair of the spinal cord injury all-party parliamentary group. We are concerned that expertise in low-volume, very specialist concerns will be lost if the commissioning is pushed out to multiple ICBs. My understanding is that specialist commissioning sat with NHS England in the first place because of concern that multiple commissioning groups would struggle to deal with low-volume, complex issues.
The president of the Royal College of Psychiatrists warned earlier this month that the new commissioning structure lacks mental health experts, with only one senior mental health lead across the seven new regional commissioning hubs taking specialised services from NHS England. Equally, the chief executive of the Derby and Derbyshire, Lincolnshire, and Nottingham and Nottinghamshire ICB cluster has said that it does not look like there will be a requirement for senior mental health expertise in reorganising ICBs. Will the Minister reassure us that when the Department designs which specialist services will be pushed back down to ICBs and which will be retained centrally, it will be minded to listen to representations from experts in the sector?
There are excellent services located geographically by accident—for example, the orthopaedic hospital in my constituency and the veterans service that goes with it. Both are highly valued, but they need specialist commissioning at national level to be utilised properly and to provide the best outcomes for patients. I would be grateful for the Minister’s reassurance on those points.
Dr Johnson
I agree with much of what the hon. Lady has said. Does she therefore support amendment 57, which would ensure that such a consultation takes place?
Helen Morgan
Yes, we would support the amendment, which is a reasonable way to get there, but an assurance from the Minister that the Department will consider specialist commissioning and really think that through properly before the powers are delegated to ICBs would be sufficient.
Gregory Stafford (Farnham and Bordon) (Con)
It is a pleasure to serve under your chairmanship this morning, Ms Lewell.
It is right that Ministers are ultimately responsible to the House for the performance of the health service and subjected to the scrutiny of Parliament for its execution, but there is an important distinction between accountability and operational control, which I fear the clause risks eroding in some cases. The national health service has over many years developed a structure that seeks to balance political accountability with operational independence, and that balance exists for a reason. Decisions on what services are commissioned, where they are delivered and how resources are allocated are not purely political judgments; they are complex, technical decisions that ought to be guided—primarily, in my view—by clinical evidence, patient need and professional expertise. Transferring commissioning functions directly to the Secretary of State, as the clause will do, risks drawing those operational decisions more directly into the political sphere, even if that would not happen in every case.
The more that Ministers are involved in determining which services are commissioned nationally and which are not, the greater the risk that over time those decisions will be influenced by short-term considerations and short-term pressures rather than long-term patient outcomes. Even when no such influence is intended, the perception that that could occur will be damaging. As I said in discussions on previous clauses, the NHS depends heavily on public trust, and that trust rests in part on the belief that decisions are being made in the best interests of patients and on the basis of evidence, rather than political expediency. We should therefore be cautious about any measure that threatens to blur that line.
Despite the Minister saying that the stated intent in the Bill is to decrease centralisation, the clause appears to move some parts of the system closer towards centralisation, rather than maintain that balance. I do not believe that the Committee should take that step without careful consideration of the potential consequences.
There is also a practical dimension to this issue. Under the clause, the Secretary of State potentially assumes direct responsibility for any and all decisions currently exercised at arm’s length. That raises legitimate questions about capacity and focus. As I said previously, the health service, as we all know, is vast, complex and complicated, and decisions, especially about specialised commissions, are technical and require detailed expertise and understanding. What is not immediately clear from the clause is that such decisions are best taken by the Secretary of State rather than by bodies with dedicated expertise and a degree of operational independence.
Both my hon. Friend the Member for Sleaford and North Hykeham and the Liberal Democrat spokesman, the hon. Member for North Shropshire, spoke about highly specialised services, where essentially there is a capacity issue and a need to be able to look at the demand as a whole. They both raised the danger that, if those commissioning decisions are taken at local level, those at that level may not have the expertise, the finances or indeed the capacity to truly understand those highly complex, low volume specific needs.
I have some sympathy for the Minister, because the danger that we have seen in the NHS is that everything becomes more and more specialised and the ICBs push it away. I understand why the Government are proposing some of these changes, but we must not throw the baby out with the bathwater. We must ensure that services continue to be commissioned by experts at the national level if they need to be; and that if they need to be commissioned by experts at ICB level or even more locally, it is done through the neighbourhood health schemes that the Government are pushing, which I support in principle.
For those reasons, if the Committee is minded to support the shift in responsibility, I suggest that we put in place some robust safeguards to ensure we have transparency, consultation and evidence-based justifications for decisions. Without those safeguards, there is a risk that the centralisation of power on the one hand and the devolution of specialist services on the other will unintentionally make a system that is less transparent and less robust.
That is why I support amendment 57 in the name of my hon. Friend the Member for Sleaford and North Hykeham. The powers in clause 12 need to be bounded by checks and balances, because these are not minor administrative changes, but a significant shift in responsibility. We must ensure that decisions to move service commissioning are made as transparently as possible. In those circumstances, it is entirely right that Parliament should be able to scrutinise those decisions.
The amendment would achieve that. Subsection (4A) would require the Secretary of State, before making regulations, to prepare and publish a commissioning transition plan and to lay that before Parliament. Subsection (4B) would require the plan to set out, in detail, the services being changed and the reasons for the changes. It would also require clarity on which bodies will assume the responsibility and why they are considered capable of doing so. That level of transparency is essential if Parliament is to exercise meaningful oversight. Subsection (4C) would establish a formal consultation requirement, and subsection (4E) would require the Secretary of State to publish a response to that consultation, setting out how concerns have been addressed. That is vital, because there is no point having a consultation if the Government just ignore it. Finally, subsection (4F) would ensure that no regulations can be made until a defined period has elapsed after that response, thereby providing a time for proper parliamentary and public scrutiny.
Those of us who sit on Select Committees, especially the Health and Social Care Committee, often receive responses to our recommendations from the Department that, as my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) said in evidence, give the veneer of acceptance, but then no meaningful action is taken. The amendment would allow meaningful scrutiny and ensure that the Government actually respond to that request.
Taken together, the provisions would ensure that decisions are not only made, but made openly, transparently and accountably to those who are elected in this place to represent our constituents.
Liz Twist (Blaydon and Consett) (Lab)
I wish to speak on clause 12 in the context of specialised commissioning. In my parliamentary work, I deal with a great number of rare disease communities and other specialised groups. Specialised commissioning is important to them to ensure that they get the service they need and deserve. Will the Minister explain how we can ensure that there is patient involvement in a more dispersed system of commissioning, and that there is national oversight and clinical leadership for all these things? How will she ensure that specialised commissioning groups are monitored and that effective services are being provided to those in the communities who need them?
The Minister for Secondary Care (Karin Smyth)
Clause 12 inserts new section 3B into the National Health Service Act 2006, re-establishing the responsibility of the Secretary of State to commission services. Although we intend ICBs to commission the vast majority of services, as we discussed this morning, we will use this regulation-making power to set out the small number of specialised services that the Secretary of State will be responsible for. That may include, for example, proton beam therapy, alongside a small number of other specialist services not currently suitable for ICB commissioning, such as gender dysphoria services and clinical genomics. By their nature, those are services to which national commissioning is appropriate because, for example, they have fewer patients or providers, greater or changeable costs, or they require specialist clinical expertise and input. Having a regulation-making power allows us to future-proof the system and update the regulations when new services or treatments emerge, or when services become cheaper or mainstream and therefore sit better with ICBs.
I now turn to amendment 57, which was tabled in the name of the hon. Member for Sleaford and North Hykeham. I recognise that any change to the way these services are commissioned matters enormously to the patients who depend on them. The hon. Lady used the word “worried”, and I understand that. Any change must be made with the greatest of care. However, the amendment would require the Secretary of State, before any regulations are made that alter the range of nationally commissioned services and regardless of the scale of the change, to publish a transition plan covering seven prescribed matters, to consult five prescribed categories of persons for a minimum of 12 weeks, to publish a response to that consultation and then to wait a minimum of 60 days before the regulations can be made.
As I have said, I understand and share the concern about continuity of care and the careful allocation of responsibility that lies behind it, but the proposals in amendment 57 are not the right way to address that concern. It proposes a fixed sequence of steps with minimum time periods that would apply to every change without exception. Taken together, the prescribed steps would add the better part of half a year to any change, including changes that are minor or technical, or that, for reasons of clinical safety, need to be expedited. That would create delays for patients and uncertainty for the wider system over where commissioning responsibility sits.
I would like to offer assurance on some of the concerns raised today. I commend my hon. Friend the Member for Blaydon and Consett, who has spoken to me regularly about her concerns, for the work that she does in this area. I also commend the Lib Dem spokesperson, the hon. Member for North Shropshire, for her work on spinal cord injuries. I have met the chair of the APPG on spinal cord injury to discuss this topic. I would like to thank Bristol Councillor Kelvin Blake, who has a spinal cord injury and who for many years has impressed on me the difficulties faced by people with spinal cord injuries who are wheelchair dependent. I commend the work of people with these conditions who, as the hon. Member for Sleaford and North Hykeham said, struggle through a system that they should not have to struggle through. We want to make sure that these changes are assured, and I commit to working with hon. Members to do that as the Bill goes through.
I can assure the Committee that any significant change to nationally commissioned services will be accompanied by proportionate and appropriate engagement with patients, clinicians and the bodies affected. Change will always proceed according to appropriate transition arrangements. Each service, as hon. Members know, has very different patient needs and commissioning requirements, and demands different skills to commission effectively. The framework the Government are proposing will enable the Department to manage these processes flexibly and proportionately.
The hon. Member for Sleaford and North Hykeham asked about arrangements for new organisations. In a changing organisation where people are coming forward for redundancy and in a new organisation that is taking shape, it is important that the executive looks at all redundancy requests and changing needs with regard for critical business infrastructure and the retention of skills. That is what we are currently doing.
The hon. Lady also asked about funding. The Bill allows the Secretary of State to set out which ICB pays for whom, and there are clear rules for people in prisons and those not registered with a GP currently under the guidance of court, which is called “Who Pays?” There are also long-standing processes for ICBs to pay each other as needed. The hon. Lady also asked about high security mental health services; I can assure her that we have no plans to ask the private sector to provide services. The power to direct has been updated to ensure that directions would bite on non-NHS providers if that changes in future.
Clause 13, which is part of this group, is a technical clause that permits the Secretary of State or an integrated care board to confer on a person discretion in relation to anything that is to be provided under the commissioning arrangement. In practice, this means that they could undertake some activities traditionally carried out by a commissioner, such as reviewing how services are provided for a population and designing the way that those services will be delivered within the parameters set by the commissioner. These activities would be clearly set out and measured under the contract, and the commissioner would retain overall responsibility for the delivery of their functions. Currently, integrated care boards are already permitted to do this, and with the transfer of NHS England’s commissioning powers to the Secretary of State, we propose a similar approach for services that are commissioned nationally.
I hope that I have been able to reassure the hon. Member for Sleaford and North Hykeham, and that she will withdraw her amendment. I commend clauses 12 and 13 to the Committee.
Dr Johnson
Unfortunately, the Minister’s reassurances have not convinced me. In relation to change, “significant” means various things to different people. As for “proportionate”, what is “proportionate” to one person is not necessarily “proportionate” to another.
Amendment 57 makes reasonable provision for a situation in which there is a change from national to local commissioning, or from local to—mostly, it is from national to local commissioning. Therefore, I would like to push it to a vote.
Question put, That the amendment be made.
The Chair
With this it will be convenient to discuss the following:
Clause stand part.
Government amendments 14 to 18.
Schedule 1.
New clause 2—Right to a GP appointment—
“(1) The Secretary of State must by regulations, within six months of the passing of this Act, establish a scheme to provide every patient with the right to a GP appointment within seven days of seeking one.
(2) The scheme should include a right contained in the NHS constitution for a patient to receive a GP appointment within seven days, or 24 hours if urgent.
(3) The Secretary of State may review the scheme every three years from the day on which this Act is passed and amend it through regulations made by statutory instrument.
(4) A statutory instrument under this section may not be made unless a draft has been laid before and approved by a resolution of each House of Parliament.”
This new clause requires the Secretary of State to introduce a scheme to ensure that patients have the right to see a GP within seven days.
Government new clause 21—Dispensing medical practitioners etc.
Government new clause 22—Inadequate provision of pharmaceutical services.
Government new clause 23—Pharmaceutical services: appeals etc.
New clause 30—General Ophthalmic Services: national framework, tariff and protected funding—
“(1) The Secretary of State must by regulations establish and maintain a national service specification for the primary ophthalmic services referred to in section 115 of the National Health Service Act 2006 (in this section referred to as general ophthalmic services, "GOS"), setting out the minimum standards of access and provision that integrated care boards are required to secure.
(2) Regulations under subsection (1) must establish and maintain a national tariff for GOS, setting out the prices at which GOS must be commissioned by integrated care boards.
(3) An integrated care board must commission GOS in accordance with the national service specification and national tariff established under subsections (1) and (2), and may not exercise any discretion to vary, restrict or reduce provision below the standards so specified.
(4) The Secretary of State must ensure that funding for GOS is allocated to integrated care boards as a ring-fenced, protected funding stream, which—
(a) may not be applied by an integrated care board to purposes other than GOS; and
(b) may not be reduced by an integrated care board in order to meet expenditure requirements in respect of other services.
(5) In determining any expenditure limits or resource allocations for integrated care boards under the National Health Service Act 2006, the Secretary of State must calculate and separately identify the GOS component of each board's allocation.
(6) The Secretary of State must lay before Parliament a report in each calendar year assessing the extent to which integrated care boards have complied with their obligations under this section.”
Government new schedule 1—Pharmaceutical services: appeals etc.
New clause 52—Access to dental provision: Dental deserts—
“(1) Within six months beginning on the day on which this Act is passed, the Secretary of State must establish a scheme to improve access to dental provision (“the Scheme”).
(2) The purpose of the scheme is to end dental deserts.
(3) A dental desert is defined as any local authority area with fewer than ten active dental practices per 100,000 people.
(4) The scheme must make provision to support integrated care boards to—
(a) guarantee emergency access to an NHS dentist,
(b) provide free dental checks up for—
(i) children,
(ii) mothers within one year of having given birth,
(iii) pregnant women, and
(iv) low-income households, and
(c) guarantee dental appointments for persons commencing—
(i) surgery,
(ii) chemotherapy, or
(iii) transplant procedures.
(5) The Secretary of State must, before publishing the scheme, issue a reformed dental contract.
(6) The Secretary of State must, within six months of the establishment of the scheme, publish a dental workforce plan to support delivery of the scheme.”
This new clause would establish a scheme to support integrated care boards to end dental deserts.
Karin Smyth
Primary care is the front door to the NHS and is critical to delivering our neighbourhood health agenda. The neighbourhood health service will bring care into local communities, ending fragmentation and preventing unnecessary hospital admissions. To support that, alongside clause 14, which I will discuss shortly, we have tabled new clauses 22 and 23 and new schedule 1, to strengthen action in the event of local pharmacy challenges and streamline the appeals process.
On new clause 22, many hon. Members will know how the closure of a local pharmacy can significantly affect a community. Pharmacies close for a range of reasons: voluntary closure, business failure or emergencies affecting the premises or surrounding area. Even where a pharmacy remains open, unforeseen or unexpected events can disrupt access for local people.
The NHS Act 2006 sets out how ICBs should commission pharmaceutical services in normal circumstances and what can be done if those arrangements fail. Section 133 of the Act is intended to deal with exceptional situations where standard commissioning processes are too slow and rapid action is needed to restore provision while long-term solutions are put in place, if required. However, the current wording of section 133 is widely interpreted as applying only to large-scale national emergencies, as it refers to inadequate provision affecting a significant number of people. It is unclear whether that would cover more localised situations, such as a village cut off by flooding following a bridge collapse, or where the only pharmacy serving an area closes unexpectedly, creating an urgent unmet need, as we have seen happen. It is also unclear how the Secretary of State would authorise alternative arrangements.
To address those issues, new clause 22 ensures that ICBs can respond swiftly to exceptional circumstances, regardless of scale. It removes the unnecessary provision for the Secretary of State to make arrangements himself and clarifies that authorisation to ICBs should be given through directions. The directions will be limited to six months, with the possibility to extend further if required. This change maintains appropriate national oversight while preventing misuse of the powers. It is a sensible and proportionate amendment that gives the system the flexibility it needs in exceptional circumstances while retaining proper safeguards.
New clause 23 and new schedule 1 simplify the appeal framework for NHS pharmaceutical services by allowing appeals that are currently split between different routes to be heard by a single appeal authority. At present, where concerns arise about a pharmacy contractor, different appeal routes may apply depending on whether a case is characterised as one of fitness or of performance. In practice, however, that distinction is not always clear and the current system can create unnecessary complexity and duplication.
New clause 23 and new schedule 1 address that problem, providing for such appeals to be heard through a single route, which we intend to designate in regulations as NHS Resolution. It is a practical and proportionate change; NHS Resolution already has substantial experience in handling disputes involving NHS pharmaceutical services and is well placed to provide a clear, consistent and independent route of appeal. Importantly, this measure does not change the position in relation to the fitness to practise of individual pharmacy professions. Cases concerning individual practitioners will continue to be dealt with separately by the General Pharmaceutical Council.
By simplifying the framework, this measure will help to ensure that related issues can be considered more coherently, reduce fragmentation in decision making and support the effective oversight of NHS pharmaceutical services. In short, it aligns the appeal system more closely with operational practice, reduces unnecessary complexity and preserves the appropriate safeguards for individual practitioners.
The remaining Government amendments are consequential on those changes, or are technical changes that have emerged as necessary following drafting of the wider Bill. I will speak to new clause 21 in particular, as it updates section 132 of the 2006 Act so that the legislation reflects current commissioning arrangements for pharmaceutical services. Section 132 currently allows, in addition to retail pharmacy business, arrangements to be made with individual doctors and dentists for the provision of pharmaceutical services.
That wording reflects an early model of care. In practice today, arrangements for primacy medical services are made with GP practices, not individual general practitioners, and patient lists are held at practice level. New clause 21 therefore brings the legislation into line with the way services are already commissioned and delivered. It will mean that, where such arrangements are made with dispensing doctors, they are made with GP practices rather than individual GPs. It also removes provision to make such arrangements with dentists, to reflect the fact that that provision is redundant.
In summary, new clause 21 is a technical amendment, which does not change current practice but simply updates the statute book to reflect modern NHS arrangements. Patients in rural areas eligible to receive medicines from the dispensing doctors will continue to receive that service as they do now.
Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
I have received representations from rural dispensing practices in my constituency about the provision of vaccination services. I understand that dispensing general practitioners are having difficulty securing the funding to provide vaccinations, particularly the new meningitis vaccination for young people. Does the Minister envisage that the change being proposed will have any effect on that arrangement?
Karin Smyth
The changes here, as I have outlined, are bringing practices in line in terms of the regulation. I think the issue my hon. Friend really addresses is the arrangement between those local practices and the ICB as the commissioner on where the service is provided. Ordinarily a commissioner would seek to make sure that a rural area had provision from somewhere in particular; I am happy to talk to my hon. Friend outside the Committee if there is a problem in his local area.
Dr Johnson
Clause 14 is very straightforward: it states that schedule 1
“confers functions on integrated care boards in relation to commissioning primary care services…transfers related functions from NHS England to the Secretary of State, and”—
perhaps most interestingly—
“contains other amendments relating to primary care services.”
Schedule 1 essentially makes the following changes to the NHS Act 2006: it makes ICBs responsible for commissioning pharmacy services instead of NHS England; it amends section 99 to make ICBs responsible for commissioning dental services instead of NHS England; it amends section 83 to make ICBs responsible for commissioning primary medical services such as general practice instead of NHS England; and it amends section 115 to make ICBs responsible for commissioning ophthalmic services.
Largely, this change is formalising existing delegation and the risk of disruption is therefore relatively low. Local commissioners can tailor decisions to local need, and it is better if decisions are taken closer to users. However, there are a few other things in there as well. Paragraph 12(2) amends section 97 of the 2006 Act containing local medical committees, which are statutory committees. The way it is phrased,
“the whole or part of the ICB’s area”,
does not allow for overlap. Is that the Government’s intention? The Government, in a broader sense, talk about the strategic authorities and having the mayoral authority level involved in the ICB. But in Lincolnshire, for example, an area that I represent part of, the local medical committee could not work in conjunction with the mayoral authority under this legislation, as far as I read it, because it essentially covers two ICB areas and two regions.
The mayoral authority is the Greater Lincolnshire mayoral authority. That includes Lincolnshire’s upper-tier area, the Lincolnshire county council area. It also includes the areas around Scunthorpe, Grimsby and Immingham, which fall into the Yorkshire region as opposed to the midlands region, and therefore not a whole or part of any given ICB area. I wonder whether the Minister has any comment on whether that was the intention, because it is also the case with paragraph 24(2) of schedule 1, which amends section 113 of the 2006 Act on local dental committees. Again, although the ambition stated and discussed in the Health and Social Care Committee yesterday by the Minister for Care, who is responsible for primary care, was that ICBs were to be covered at strategic level, that would not be possible for local medical committees or local dental committees under my reading of paragraph 12(2).
Gregory Stafford
Does my hon. Friend agree that this Bill would have been the perfect time to align health commissioning services with local government structures and that the fact that these structures are being created totally without the new local government structures is not just an oversight, but a potential problem with the whole Bill? Does she also agree—I think that she was outlining this already, but I want to ensure that the Minister is clear on it—that the Government still have a chance to amend the Bill to ensure that the commissioning structures and commissioning areas outlined in the Bill neatly map out to the new local government areas? In relation to, for example, the current Hampshire and Isle of Wight ICB, Hampshire is potentially being split up into a number of local government areas. I am against the way it is being split up, but if the Government are pressing ahead with it, this would have been the perfect opportunity to align commissioning with those areas. The problem is that we will now have a situation in which they do not match up, and the problems that my hon. Friend has outlined in her speech thus far will come to the fore.
Dr Johnson
Of course, my hon. Friend is right. One challenge with the Bill is that although not all the measures are a problem individually, the way they are being brought in is a problem. The planning and organisation that has gone into it has not been coherent. A 50% cut has been made to the budgets of ICBs, which has required many of them to merge, but that has been done before the local government reorganisation has been finished, which means that ICBs have been melded together in a way that is not the same as the local government reorganisation.
Let me again give the example of Lincolnshire. Lincolnshire had an excellent ICB, run by chief executive John Turner. That has now merged with Nottinghamshire and Derbyshire. Nottinghamshire and Derbyshire form the East Midlands mayoralty, but Lincolnshire ICB, as was, forms part but not all of the Lincolnshire mayoralty—which, as I said, also includes part of what was the Yorkshire region. Because the cuts were done before the local authority reorganisation, and the left hand does not know what the right hand is doing, we have ended up with an incoherent pattern, which does not help, particularly for social care services that are delivered by local authorities. We will come back to that when we talk about who is on the ICB. The risk is that we end up spending money doing this twice—being forced to do it at short notice, because of the 50% cuts brought in overnight by Government, and then doing it again to try to sort out the mess and bring things back into line with the new local authorities as and when it is decided what they will be.
Going on to the pharmaceutical arrangements—I should probably declare at this point that my brother is a rural dispensing GP—I share the concerns raised by the hon. Member for Bury St Edmunds and Stowmarket in relation to rural dispensing GPs. Let me give the Minister an example from my constituency. The Cliff Villages medical practice was an excellent medical practice. However, there was a doctor retirement and the illness of a doctor, and as a result the service reduced in quality quite substantially.
The ICB was working alongside the surgery and the one remaining practice doctor—not swiftly enough, it must be said. What happened in the end was that the Care Quality Commission came in, found that the service was really not good enough and closed the surgery down overnight, in the middle of the week. It was closed with immediate effect and there were no appointments for any patients in my constituency. Then, because the surgery had been closed, the ICB worked very hard to get a new practice in straightaway, and it got that opened on the Monday, which was pretty quick in the circumstances; but people lost their dispensing GP.
Living in a rural area—I have a dispensing GP myself, living in a rural area—people can go to the doctor’s, see the doctor and, if the doctor perhaps says, “You need some antibiotics,” they can go back to the waiting room and sit there for 10 minutes, be given the antibiotics and then leave. That is significantly more helpful to a rural constituent than having to drive eight or nine miles into the centre of town, park the car, find somewhere to get the prescription and then go all the way home again, which would take much longer. People really value that service—I saw how much when I held a public meeting with the ICB and the new provider to talk about what had happened at the surgery, and 250 people turned up to an evening event in the village hall at short notice. It is hugely important to people.
Will the changes allow the Secretary of State to step in in such circumstances, where the medical contract has been lost due to that cut-off by the CQC? Will that sudden loss of service be able to be replaced with a new dispensing service? Could Ministers have therefore given dispensing rights to the new provider? At the moment, those rights are not transferable, and it means that the only way that my constituents who live in that area and attend that practice can maintain dispensing rights is either to move house—perhaps to next door and back again, but they have to move house—or to change practice immediately, that same day, to another dispensing practice. To be honest, that seems ridiculous. Could the Minister make any comment on how the provisions in the Bill will help that situation and what her views are?
I am confused by new clause 23 and new schedule 1; the Minister has introduced them later than the rest of the Bill, but they seem quite significant. They would move pharmacy appeals from the first-tier tribunal to an NHS body specified by regulations made by the Secretary of State. I presume the regulations are not yet written, so we do not know what form that would take, but the first-tier tribunal is part of an independent judicial system and the appeals will now be under political control, within the Department.
Could the Minister explain why they think that is fair? Why do the Government want to do that? Is it just about saving money? How will the judgments made by that new authority be properly enforceable and give people confidence, given the change from the first-tier tribunal in the judicial system to something more politically controlled?
I move on to new clause 2, which would require the Secretary of State to establish within six months a scheme to give patients the right to a GP appointment within seven days of seeking one, or 24 hours if urgent. I would be interested to hear the Minister’s comments on that and how she thinks it could be achieved.
Modelling by the Health Foundation suggests that 6,500 full-time equivalent GPs—37,800 in total—will be needed by 2030-31 to meet greater clinical need. We have already talked about the doubling of medical school places; I presume the Minister has sought correction since we last spoke on whether the Government have a plan to double those places or not, but the Government are not on track to have that number of GPs. Is it simply that they do not have the resources to deliver it? I would be interested to hear the Minister’s comments.
Helen Morgan
With permission, I will explain to the shadow Minister our votes on amendment 57, which she pressed to a vote. I was reassured by the commitment the Minister made to consult widely on those commissioning changes, so the Liberal Democrats switched our vote from support to abstain.
I move on to new clause 2, our amendment in this group, which the shadow Minister was just discussing. It would require the Secretary of State to introduce a scheme to ensure patients have the right to see a GP or another appropriate clinician within their GP practice within seven days.
The NHS constitution currently confers rights on patients when they are considered really important. There are, for example, rights within the NHS constitution around receiving cancer diagnoses and treatment. We felt that there was a gap on access to GPs. Given the Government’s stated aim of transferring more care into the community, which we fully support, and given the observation in the Darzi report that more and more money is being spent on secondary rather than primary care, we think it is really important to confer the right on patients to be able to access primary care when they need to.
As the hon. Member for Sleaford and North Hykeham pointed out, this measure would require a large number of additional GPs and would therefore not be achievable overnight, but over the course of a Parliament. The Liberal Democrat plan includes recruiting and retaining an extra 8,000 GPs, relieving pressure on the rest of the health service and enabling that shift into the community. When patients—
Sojan Joseph (Ashford) (Lab)
New clause 2 clearly states that everybody should have a legal right to an appointment with their GP “within seven days”, while the current provision is that patients are entitled to see a GP or other professional within 24 hours or two days for urgent care. Would creating this legal burden on GP practices not reduce their ability to prioritise, meaning that the people who need urgent treatment will be delayed further?
Helen Morgan
We do not consider the right to achieve a cancer diagnosis and treatment to be burdensome on the secondary care providers of those treatments; we consider that important enough to enshrine that right within the NHS constitution, and this would be a similar level of right. I would not imagine that a GP would be worrying about somebody taking them to court, but it would confer upon the Secretary of State the duty to ensure that primary care is adequately resourced in order to be able to meet that commitment.
Edward Argar (Melton and Syston) (Con)
I am very grateful to the hon. Lady for giving way; she is typically generous with her time. Can I just seek a little clarification in terms of the right to a GP appointment in new clause 2? Is her intention that that is an appointment with the practice—be that any clinically qualified individual within it—or an appointment with a GP, not with a practice nurse? Would, for example, a telephone appointment constitute an “appointment”, rather than specifically an in-person appointment? I just want to understand a little more about what is expected here.
Helen Morgan
The right hon. Gentleman asks an extremely important question, and I am happy to clarify. It would be an appropriate clinician within the GP practice, and it could obviously be a telephone appointment, because that might be more convenient for the patient. Lots of patients are really happy with telephone appointments and we should be using them wherever that is the patient’s choice, because we want—I think we all do—to see an NHS that is patient-led and not politician-led.
Helen Morgan
I am going to make some progress, actually, because I think I am going to be asked the same questions.
Helen Morgan
Well, I will just move on a little bit. The important question is: can this be achieved this overnight? Clearly not; we need additional clinicians in the service. The Liberal Democrat view is that the extra—I think 1,000 or 1,500—GPs that the Government have recruited so far is a welcome step forward, but that does not go far enough over the course of a Parliament.
As I was saying earlier, when patients cannot access their GP surgery, they end up, more often than not, in accident and emergency departments. That is no good for anybody. It overburdens the A&E department, leaves people who genuinely need urgent care getting a substandard level of care, and costs the NHS far more. We think it is really important that we put the resource in the right place.
Dr Danny Chambers (Winchester) (LD)
Just to reiterate what my hon. Friend is saying, in Winchester we are now putting an urgent treatment centre in front of the A&E, staffed by GPs to do the triage, because so many people who turn up are only there because they cannot get a GP appointment. So we now have hospital trusts paying for GPs to provide same-day GP appointments, and that is coming out of the secondary care budget instead of the primary care budget. That is obviously the most expensive place to treat patients for routine things.
Dr Johnson
We Conservatives share the hon. Lady’s desire to ensure that patients get their appointments as soon as they need them to be had, but she is talking about a difference between urgent appointments, within 24 hours, and non-urgent appointments, within a week. Who is going to make the decision about whether the appointment is urgent? Will it be the clinician? Will it be the patient themselves? Has she thought about where that responsibility lies?
Helen Morgan
Yes, I have thought about where that responsibility lies. It clearly lies with the triaging process within the GP surgery. I do not think any of us envisage somebody phoning up about a child with a cold and saying, “I consider this to be urgent,” and getting an appointment within 24 hours, but I would imagine somebody from the surgery saying, “Please describe the symptoms to me,” and then, if they detected something more serious, saying, “That is urgent and you do need to come in within 24 hours.” The point of new clause 2 is to clarify in the NHS constitution that some services require parity with others. We have already established legal rights under the NHS constitution for certain types of treatment, and this puts GP access on the same level. We think that that is important.
I am conscious of time, so I will move on to new clause 52, which is about dental deserts. Everyone is horrified by dental deserts and by “DIY dentistry”, a phrase that means—let us face it—people using pliers to extract their teeth and super glue to reattach crowns, and cavities filled with household adhesives. More than 5 million children did not see a dentist at all in 2025. That is a stark failure. Dental care is as important as care for other parts of the body, in particular when most of what goes wrong in dentistry is preventable. We should absolutely focus on prevention, and that is in line with the Government’s aims to move from sickness to prevention.
New clause 52 is about our £750 million dental rescue plan to guarantee access to an NHS dentist for anyone needing an urgent or emergency appointment, which I hope would end that awful DIY dentistry. The plan needs to be achieved through bringing dentists back from the private sector, fixing the contract, using flexible commissioning wherever necessary and introducing an emergency scheme. For example, the emergency dental scheme in Shropshire, operated by the community dental practice, enables people who have urgent need and cannot register with an NHS dentist to get the care that they need when they need it. I urge the Minister to take our new clauses on board and to ensure that people get the care they need when they need it.
Gregory Stafford
I will start where the Liberal Democrat spokesman, left off, with new clause 52 on dental provision. I have a lot of sympathy for what she is trying to achieve with the new clause. In my own constituency, as far as I can tell, looking earlier today, not a single dental practice is taking new NHS patients for dentistry, whether that be children or adults, and that is extraordinarily concerning.
Even more concerning—this somewhat relates to the changes that the Government are making in the clause through bringing the commissioning of dental services to ICBs—I have a fully equipped and fully functional dental surgery in Haslemere hospital in my constituency, but it has remained entirely unused for a number of years, because it sits within the hospital, which is run by the Royal Surrey NHS trust, but is commissioned by the ICB. That seems like an utter waste of resources. That is something that could be clarified through new clause 52 and, I hope, through the clauses tabled by the Government.
On new clause 2, about GP practices, I am disappointed that the hon. Member for North Shropshire did not want to take my intervention because she will not be able to answer my questions, unless she intervenes on me now, which I hope she will. Again, I sympathise entirely with what she is trying to achieve. We want to ensure that people have timely access to their GPs. I am sure that, like me, she has constituents who cannot get a GP appointment in any reasonable time. They can wait numerous weeks, upwards of five or six weeks, for something that they should be seen about.
A lot of questions are unanswered by new clause 2, however. I will not repeat the questions asked by my right hon. Friend the Member for Melton and Syston and by my hon. Friend the Member for Sleaford and North Hykeham, but I have some others. For example, the new clause states that the Government must
“establish a scheme to provide every patient with the right to a GP appointment”.
Although the hon. Lady clarified that that could be a telephone consultation, what is not clear is whether that is an appointment at the named GP practice at which the patient is registered, or is just with any GP, through something such as the NHS 111 service.
Helen Morgan
I would like to clarify that point. We envisage that being at the GP with whom the patient is registered. Our broader policy, which is not included in new clause 2, is to have named GPs for people with complex conditions and complex comorbidities. Absolutely, we would envisage that as being a part of the continuity of care, which is so crucial.
Gregory Stafford
That is a helpful clarification, but it raises a number of other questions. I entirely agree with the hon. Lady that named GPs are most appropriate; all the clinical evidence suggests that even for people with non-complex needs, having a named GP whom they can see regularly improves patient outcomes. I therefore support her on that, but does she believe that we currently have sufficient GPs for that to go ahead? Even the six-month lag in her new clause would not be enough time to recruit thousands more GPs. If she does not believe that there are enough GPs at the moment, when does she envisage that they would be in post? How much would that cost? Where would she get the money to fund those extra GPs? Rather than just expressing what I would call “motherhood and apple pie” statements about things that we all want, we in this House have a duty to be honest with our constituents about how we would achieve them—and, if we have to achieve them within six months, what funding and impetus will have to be put in place.
Helen Morgan
Let me clarify. The new clause is about conferring a duty on the Secretary of State to provide that level of care. It would require a significant number of additional GPs, and that would cost a lot of money. The Liberal Democrats’ 2024 manifesto had a fully costed pledge to recruit and retain an additional 8,000 GPs within the course of a Parliament. I think we can all agree that the world has moved on since then, but the hon. Gentleman will be aware that this week we proposed a significantly closer relationship with the European Union, which would grow our economy, increase our tax base and pay for a number of these things without having to subject people to additional, onerous tax hikes.
Gregory Stafford
I think that clarifies that there is no real concrete plan for how to fund this new clause. I do not mean in any way to demean what the hon. Lady is trying to achieve, because she is trying to achieve something important, and which we all want, but we have to be honest with our constituents about how we can do that, and some ethereal money to come through some ethereal plan at some point in the future—
Gregory Stafford
Let me finish this point. I am not in the mind of the current Prime Minister, and I am certainly not in the mind of the potential next Prime Minister, but even if the hon. Lady is right my understanding is that he—either is probably a he—is unlikely to have changed our relationship with Europe within six months.
The Chair
Order. We are straying slightly into a debate about European matters. Can we stick to the amendments before us, please?
Gregory Stafford
Thank you, Ms Lewell. You have certainly saved me from myself, if not anybody else. I think I have belaboured the point; I will leave it there. I sympathise with and indeed support the ambition of new clause 2, but I have a real problem with the lack of detail on how it would be achieved.
I turn quickly to clause 14. As my hon. Friend the Member for Sleaford and North Hykeham said, it has bits that we welcome, but there are some concerns about how the ICB structures fit over the local government structures, and cutting ICB administrative budgets by 50%, while asking them to take on more power and responsibility for commissioning services and many other things, is a real problem.
Likewise, we have welcomed, and I think both sides of the Committee agree, having neighbourhood health—however we want to describe it—and care closer to home, and having commissioning closer to home. It is therefore strange that my best performing ICB, Frimley ICB, has been abolished or merged with a number of other ICBs that have been performing far less well.
If the Government want to have the principle of place-based, locally responsive commissioning, they have to have a real focus on, actually look at, what fits with the current structures and to ensure that those ICBs that are performing best are encouraged and kept and that those that are not are dealt with. I have real concerns about, for example, the superstructure of the new Surrey and Sussex ICB. It is huge and, essentially, entirely antithetical to what the Government were trying to achieve by making stuff local—closer to home.
Dr Johnson
One thing that my hon. Friend mentions is the Government’s stated intention to bring things closer to home, as opposed to the reality of the Bill as drafted. Does he agree with me that the document that explains what will happen to the commissioning of specialist services, and that talks about seven regions and how ICBs could collaborate within those regions, might imply that the Government are looking forward to having seven areas in which most commissioning takes place? These are even larger areas than have been described in the mergers so far.
Gregory Stafford
It is for the Minister to clarify that point, but I share my hon. Friend’s concern. It is ironic that we seem to be heading back towards the strategic health authorities of an earlier age. Things in the NHS are neither created nor destroyed; they just go round and round and round. I think we may end up being back where we were 15 or 20 years ago, in an ever decreasing cycle of spending money on changes that are perhaps not wanted or needed.
I have touched on dental services, so I will not go any further on that. On pharmaceutical services, I agree entirely with what my hon. Friend said about dispensing GPs. That is a big issue. And I have touched on the Liberal Democrat new clauses. In conclusion, although Conservative Members support a number of the ambitions in relation to the group that we are debating, the questions that my colleagues and I have raised require more clarification from the Minister.
Edward Argar
It is a pleasure to serve under your chairmanship, Ms Lewell. My hon. Friends have addressed at some length the Government new clauses and amendments, so the Minister may get a slightly easy ride from me this time, but I want to pick up on new clause 2 and some of the points that my hon. Friend the Member for Farnham and Bordon raised.
The hon. Member for North Shropshire knows that I have huge respect for her. I have worked with her, across the health and social care space in this House, on a number of issues, so I can entirely appreciate where she is coming from on this. She raises an issue that is very important to all our constituents, which is access to primary care when people need it. For example, in Melton Mowbray in my constituency, there have been real concerns in recent months about very long waiting times to access primary care services. That has on occasion caused considerable distress for some patients, who have become more and more concerned.
I have to say that the practice has sought to do a lot to address that. It has brought on board a new annexe and additional services and been recruiting more GPs, but the challenges remain and the concerns are very real and would, I suspect, be shared by all our constituents. One of the key things in how the practice has been seeking to address the issue and how other practices locally, both rural ones and ones in some of the towns in my patch, have sought to address it has been a degree of flexibility and of clinical triage as to what is the most appropriate access point to primary care services for the individual, based on their symptoms and needs.
For me, despite the work being done in Melton Mowbray at the moment to improve waiting times, it remains a very significant concern that despite the integrated care board having a few years ago acknowledged publicly the need for additional GP provision in the town, whether a second GP practice or a new satellite service, it said a few months ago—despite the fact that in the intervening period there has been considerable housing development in the town—that it considers that there is no need at the present time for additional GP provision, and so it does not appear to have a plan to expand that provision. That is obviously concerning. All of us in this House will from time to time have these issues in our constituencies and, I suspect, sometimes get frustrated by the fact that ultimately we can press our ICBs and ask questions of the Minister—who, I have to say, always responds in a courteous and measured fashion—but ultimately the decision maker is the integrated care board’s board and it will do what it wishes to do when it comes to commissioning those services. There is a disconnect there.
My challenge with regard to new clause 2, despite my being in agreement with the need to improve access to services, is that there is a lack of clarity about how that will be done and there is the fear that it may raise expectations that are not necessarily deliverable on in the current context. The Liberal Democrat five-year plan for GPs is in their 2024 manifesto, and the hon. Member for North Shropshire alluded to the commitment to 8,000 additional GPs. It is not my usual habit, but I have read the Liberal Democrat website, which sets out the background. I appreciate that this is from 2024 and the hon. Lady may have moved things forward a little bit since then, but it states that the five-year plan
“gives patients the legal right to see a GP within a week or 24 hours if needed urgently”.
The hon. Lady may wish to respond on that.
Helen Morgan
I am sure the right hon. Member has enjoyed reading the Liberal Democrat website. If he had delved a little further into the policy paper that sits behind that manifesto commitment, he would see that that is with an appropriate clinician and not with a GP. I appreciate that the wording of the new clause says a GP, but it does indicate a GP practice, and would require the Secretary of State to establish a scheme that would achieve that. I expect that clarification could be made at that point.
Edward Argar
I am grateful for that, and the hon. Lady has that on the record. As we all know with political campaigning, the headline on the front page of the website may sometimes, although not always, contain the “conditions apply” caveat in the small print. The hon. Lady has read her explanation into the record of the House, and I, as always, take her at her word and accept that explanation.
My concern is how this measure would be paid for—8,000 GPs, of which half were to be new recruits and half were either through retention or by encouraging returners to the profession, with a costing of about £1 billion. That works out at about £125,000 a head, so it is not outside the realms of possibility. That was not going to be paid for through closer ties with the European Union; if I recall correctly, I think it was tagged against hikes in capital gains tax with three new bandings, rather than EU links.
Helen Morgan
I am happy to clarify. Clearly, the world has moved on since July 2024 when we put together our manifesto, but this was a fully costed plan with a number of different changes to tax regimes, including a tweak to capital gains tax and changes to the way that banks were taxed and digital services tax. Since then, we have proposed a number of other alternatives, but the principle of changes to capital gains tax, to the way that windfall profits of the big banks are taxed and to digital services taxes still stands. Plus, we also have a fully fleshed-out plan to actually grow our economy and deal with this problem in the long term.
Edward Argar
I am grateful for that clarification. I am conscious that we have to finish at 1 pm, so I will bring my remarks to a conclusion.
We can all see the intent behind new clause 2; we can all feel that intent in correspondence we get from constituents. Having taken legislation through the House, my concern is that often the challenge is in the drafting of such clauses: while the objective may be honourable, the opacity of them, or the lack of some detail, can risk creating an expectation while not actually setting out how that can realistically be met. My worry here is about the practicalities, in an era where expectations are being set and dashed and that is causing challenges for our democracy.
Dr Chambers
Even when the right hon. Gentleman criticises, he does so in a charming way.
None of this is moving the discussion to how we keep people healthy and treat them early. He may criticise our funding models and challenge the detail for achieving this measure, but if we flip that round, the previous Government promised 40 new hospitals, which were not hospitals and did not materialise. The entire focus of healthcare has been on treating people once they are sick, while people cannot get GP appointments.
I hope that the right hon. Gentleman would agree that the thrust of the argument is to try to keep people healthy and treat them early, before they end up needing hospital treatment, and that that is what we should all be focusing on. If he wants to help with the details in order to get 8,000 GPs by the end of this Parliament, he can submit his suggestions to the Liberal Democrat website.
Edward Argar
The hon. Gentleman makes his point in a typically reasonable way. Of course, he is right to talk about the need to shift, where we can, from acute settings to either community settings or, ideally, a preventive setting or focus. The Minister may well disagree with me, but I think that is a desire or thread that, however well implemented or otherwise, runs consistently through Governments. It ran through the Blair-Brown Government, the previous Liberal Democrat and Conservative coalition, the Conservative Government and into what the previous Secretary of State announced and what the Minister today is seeking to achieve. I do not think that anyone would disagree with that. We will always need those acute settings for particular treatments and cases, as well as for those very specialist pieces of work or for people with significant illnesses.
There has always been a desire to push the care into the local community. GPS are a central part of that, as are—to address the points raised by my hon. Friends earlier—our community pharmacists and other pharmacists. Pharmacies remain an improving but underused resource as part of that preventive picture. I do not disagree with the hon. Member for Winchester in that, but one can agree with the objective, but nonetheless gently push a little on the detail. As we know, the devil is in the detail, and people will want to see a deliverable plan.
That is one of the challenges that I have had in Melton Mowbray, where the ICB says it will do one thing and then says, “Actually, no, we can’t do that anymore.” Expectations go up and down and people are understandably frustrated. When we put such proposals forward we need to be robust in how we are going to achieve them and in their practicalities. The Minister may wish to make further observations.
Karin Smyth
I have enjoyed the “back to the good old days” of the Lib Dem-Tories. They tell us we live in fractured political parties, but I quite like the old days.
On new clause 2, I understand the intention that GP provision is important to us all and to our constituents. We have recruited over 2,000 more GPs since 2024—the highest number of qualified GPs since 2015—and there is provision to ringfence money for even more. We all know the importance of timely access to general practice, and patients need to be confident that they can get that care urgently and receive it promptly.
We are seeing improving signs. According to the ONS, the number of people who say it is now easy to contact their GP practice is up 14% since 2024, and that satisfaction is rising. Importantly, 69% of patients are seen within seven days and 44% are seen within the one day that they have requested an appointment, irrespective of urgency. That is the progress that we are encouraging, but we are not complacent; we recognise that there is more to do.
We also recognise that not everyone not seen within seven days is experiencing an unnecessary delay. Not every patient requires an appointment within seven days, and many people book appointments in advance for routine reviews, medication checks, to ensure that they see their preferred clinician or to fit around work and other life responsibilities. The new clause would cut across that flexibility by imposing a more rigid approach to appointment allocation, weakening both clinical judgment and patient preference. We do not believe that would be the best for patients or safe care. We must protect both clinical judgment and patient choice. We therefore cannot support the new clause.
We are clear that if someone is unwell and a doctor needs to see them urgently, they should be seen that same day. NHS England’s medium-term planning framework, which was published in October 2025, sets out an ambition for all clinically urgent appointments to be delivered on the same day, ensuring that patients assessed as needing urgent care are prioritised appropriately. We have made changes to regulations to require clinically urgent requests to be dealt with on the same day to support that ambition within the 2026-27 GP contract. We will publish data on that progress soon.
On new clause 52, we know that dentistry is broken and that we need to rebuild it. That includes ensuring an urgent care safety net across the country by reforming the dental contract and developing the 10-year workforce plan This new clause is unnecessary; we have delivered 1.8 million more dental treatments, and from April we began introducing a package of reforms to address some of the pressing issues that dentists and dental teams have been experiencing. Those reforms will prioritise those with the greatest need, shifting care away from clinically unnecessary check-ups. We are also including dental school places, and we will make more provision in our upcoming workforce plan.
The Government are committed to more fundamental contract reform by the end of this Parliament, which will include publicly consulting on future proposals. I make no apologies for taking the time to get that right. The issues are complex; this has not been done for a long time and there is no consensus on the perfect approach. On that basis, I commend clause 14 to the Committee.
Question put and agreed to.
Clause 14 accordingly ordered to stand part of the Bill.
Schedule 1
Conferral of primary care functions on integrated care boards etc
Amendments made: 14, in schedule 1, page 60, line 19, leave out sub-paragraph (2).
This is consequential on NC21.
Amendment 15, in schedule 1, page 60, line 26, leave out “(a), (b), (c) and”.
This is consequential on NC21.
Amendment 16, in schedule 1, page 60, line 36, leave out paragraph 46.
This is consequential on NC22.
Amendment 17, in schedule 1, page 65, line 5, leave out paragraph 65.
This is consequential on NS1.
Amendment 18, in schedule 1, page 75, line 1, at end insert—
“(4) In subsection (5), in the definition of ‘relevant area’, after paragraph (b) insert—
‘(ba) in relation to an integrated care board, in a case where a person has at any time provided or performed services by arrangement or contract with the board, means the prescribed area (at the prescribed time).’”—(Karin Smyth.)
This adds an amendment to section 259 of the NHS Act 2006 that is consequential on the transfer to integrated care boards of NHS England’s commissioning functions in respect of primary care.
Schedule 1, as amended, agreed to.
Ordered, That further consideration be now adjourned.—(Emma Foody.)
Health Bill (Seventh sitting)
Thursday 25th June 2026
(1 week ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 25 June 2026 - (25 Jun 2026)
The Committee divided: - Ayes: 3 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 4 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Chair
Before we begin, I remind Members to switch electronic devices to silent. Tea and coffee are not allowed during sittings, but there are copious amounts of water—blue is still and silver is fizzy.
Clause 15
Public involvement in commissioning by Secretary of State
Helen Morgan (North Shropshire) (LD)
I beg to move amendment 28, in clause 15, page 11, line 26, at end insert—
“(d) in the design of service and arrangement for service delivery (co-production).”
The amendment would explicitly require the Secretary of State to make arrangements for the co-production of any health service commissioned by the Secretary of State.
Helen Morgan
It is a pleasure to serve with you in the Chair, Dr Huq. I am moving this amendment on behalf of my hon. Friend the Member for Oxford West and Abingdon (Layla Moran), who is the Chair of the Health and Social Care Committee. She designed the amendment to explicitly require the Secretary of State to make arrangements for the co-production of any health service commissioned by the Secretary of State.
The Liberal Democrats support clause 15 more broadly, and particularly the plans to involve affected patients, carers and representatives in planning and commissioning arrangements. Carers are a priority for our party, so it is really important to us that they have a meaningful say in the design and delivery of their care. I would be grateful if the Minister could elaborate on what that might look like in practice.
The amendment would tighten up the clause to make some of its provisions more explicit, so that we can be confident that anyone involved in an individual’s care has the ability to influence it in an appropriate way.
Gregory Stafford (Farnham and Bordon) (Con)
It is a pleasure to serve under your chairmanship, Dr Huq. I will speak briefly about clause 15 and amendment 28, tabled in the name of the hon. Member for Oxford West and Abingdon, the Chair of the Health and Social Care Committee, of which I am a member.
The amendment is clearly positively intended. We all want the co-production of services, and we have discussed it quite a lot on the Health and Social Care Committee. A number of amendments were tabled in the name of the hon. Member for Oxford West and Abingdon but were agreed on by the Select Committee. I think it is fair to say that there are a number of areas that the Committee could not agree on and that are obviously not in front of it, given its political make-up, but we all agreed on the ones she has tabled.
That being said, cross-party agreement often necessitates fairly non-partisan and perhaps non-specific wording, so while I agree with the intention behind the amendment, and while it is clearly important to have co-production when designing services, I am not entirely comfortable with the way the amendment has been drafted. This goes back to comments I made on the Liberal Democrat new clause 2 about how the requirement would operate in practice or how such an approach would be applied consistently across different commissioning functions. Although I am very keen on the principle, I am concerned about the intention.
Edward Argar (Melton and Syston) (Con)
I will not detain the Committee for long, and I will speak primarily to clause 15. I am broadly supportive of what the Minister seeks to achieve, as I understand it, with the clause. It is absolutely right that service users and communities are engaged by their integrated care boards—those commissioning services—in the design of services as well in individual care.
As I alluded to before we adjourned for lunch, however diligent an ICB may be in doing formal consultations or conducting surveys, it is all too easy for that to appear to the actual users of the service as a box-ticking exercise, with the board none the less determined to follow through with the strategic plan that it conceived and consulted on in the first place. We have seen that challenge on a number of occasions in my Melton and Syston constituency, with the recent closure of St Mary’s birth centre in Melton Mowbray. There was a consultation and engagement with the public, but we always feared that, ultimately, a decision to close was what the ICB wanted and, lo and behold, that is what happened. Similarly, the ICB decided to pull away from accepting the need for a second GP practice or enhanced GP services in Melton Mowbray. There was a consultation and discussion, but ultimately the conclusion that we feared at the outset of the process was indeed what was reached at the end of it.
The clause will not necessarily address all that, but it is a step forward in putting pressure on an ICB, or on those commissioning services, whoever they may be, to engage with local communities in a meaningful way.
Gregory Stafford
My right hon. Friend is making an absolutely correct point, which I made when we were talking about the Secretary of State’s ability to remove, by sacking or otherwise, the chief executives of ICBs. There is a tension between us as Members of Parliament trying to lobby the Secretary of State for changes in our constituencies when he currently has no power to actually make those changes. The clause will potentially give him the power to make those changes, but being able to sack a chief executive is probably a step too far. How does my right hon. Friend see the powers in the clause, which are probably correct, balancing with the local decision-making process and clinical expertise? There will clearly be a tension between the two.
Edward Argar
My hon. Friend comes to this with significant knowledge from his work on the Health and Social Care Committee. He is absolutely right, but that is a tension and a balance that I fear runs as a thread throughout this legislation, between local decision making and tailoring and the genuine need for a Secretary of State to have effective powers. We lobby Secretaries of State; on occasion I have lobbied the Minister, and she has always been very responsive—she does not always agree with me, but she has always been very responsive to me. As Members of Parliament, we do that on behalf of our communities.
My argument is that ICBs need to be more responsive, even when they do consult, to make it clear that the decision is not predetermined by the board and that they are going through the process. In the context of this clause, that also needs to be true of the Secretary of State: it needs to be not simply a formulaic approach but a genuine engagement and consultation. My question for the Minister, in that context, is about how we make sure of what she is seeking to do in the clause. The Secretary of State or those undertaking commissioning on their behalf must pay heed to something, but how do we make sure that that consultation, engagement and feedback genuinely have some teeth in what emerges in the final decision?
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
My right hon. Friend the Member for Melton and Syston and my hon. Friend the Member for Farnham and Bordon have covered my points so effectively that I will be very brief indeed. How do we ensure that the consultation is not just well meaning and ticking the legal boxes, but actually listened to, so that people’s voices are incorporated into the plans? Also, I appreciate that amendment 28 is a well-meaning intervention, but how do we ensure that all voices are heard in a co-production, not just those who are the most articulate or the most able to engage with a process that they see online?
The Minister for Secondary Care (Karin Smyth)
Patients and the public have a critical role in shaping our health services. I am grateful to the hon. Member for Oxford West and Abingdon for tabling the amendment, as moved by the hon. Member for North Shropshire. I will discuss the amendment with the wider question of whether the clause should stand part of the Bill.
To be clear, the Government are committed to engaging with patients and the public about the services they use. Services shaped together with the people who rely on them are better services. We want to see deep and collaborative ways of working between patients, public and the NHS. Across the country, there are good examples of that from which we want to learn. That is why the clause requires the Secretary of State to involve patients and the public in the planning of commissioning arrangements, the development and consideration of proposals for service change, and decisions that may affect how services are delivered or the range of services available.
The clause is intended to encourage early engagement and meaningful involvement in service change, thereby helping to build legitimacy, trust and better-informed commissioning decisions. As a duty, it covers the entire end-to-end commissioning cycle. I have been a commissioner myself, so although I will not detain the Committee too much on that, it is indeed part of the job of a commissioner to do that at a very early stage.
I also draw attention to the fact that the clause places a statutory duty on the Secretary of State to make arrangements to ensure the involvement of individuals who use or may use health services, together with carers and representatives, where appropriate, in commissioning activity. That duty is purposely broad, covering both existing service users and those who may reasonably rely on services in future, and will support preventive approaches and enable the consideration of wider population health impacts.
We made the deliberate choice to include specific references to carers and representatives, recognising that some individuals may require support to participate effectively in engagement and decision-making processes. That is particularly important where barriers such as disability, communications needs, sometimes age, vulnerability or unequal access may otherwise limit participation. We are ensuring that involvement is inclusive and meaningful, which I think is what all hon. Members want to see.
Specifically on amendment 28, I gently caution against creating an implication of different approaches to patient involvement for different parts of the system, leading to a two-track approach and unnecessary confusion. Instead, we propose a Government commitment to ensure meaningful consultation. We support co-production and will continue to champion it, but we do not think it necessary to put it on the face of the Bill.
The Government support involving patients and the public at every stage, and we recognise that working closely with the people and communities affected by commissioning decisions brings valuable insight into service quality, accessibility, equity and effectiveness. We will use the duties and powers available to Ministers to ensure that that principle is embedded across the work of the NHS. I hope, therefore, that the hon. Member for North Shropshire has some reassurance and will withdraw her amendment. I commend the clause to the Committee.
Helen Morgan
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 15 ordered to stand part of the Bill.
Clause 16
Regulations about commissioning by integrated care boards
Dr Johnson
I beg to move amendment 51, in clause 16, page 12, line 10, at end insert—
“(3) The regulations must ensure that integrated care boards may not impose operational policies requiring patients to wait a minimum number of weeks before they may access treatment.”
This amendment would prevent minimum waiting times for NHS treatment.
The Chair
With this it will be convenient to discuss the following:
Amendment 35, in clause 16, page 12, line 10, at end insert—
“(3) Regulations under this section must make provision requiring integrated care boards to make arrangements which ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services.
(4) For the purposes of subsection (3)—
‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure-relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”
This amendment would require the Secretary of State to make regulations which would require integrated care boards to ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services.
Amendment 63, in clause 16, page 12, line 10, at end insert—
“(2A) Regulations under subsection (2) must make provision requiring integrated care boards to—
(a) assess whether sufficient capacity exists to meet current and projected patient demand for cancer treatment, including radiotherapy treatment,
(b) maintain plans to ensure that workforce, equipment and estates capacity are sufficient to reduce waiting times for cancer treatment and improve access to treatment, and
(c) monitor and address geographical variations in access to cancer treatment, including radiotherapy treatment, with a view to reducing inequalities in patient outcomes the provision of satellite units.”
Amendment 52, clause 16, page 12, line 10, at end insert—
“(3) The regulations must include a requirement for the Secretary of State to publish the number of patients validated off of treatment waiting lists each month, and the reason for which they have been removed.”
This amendment would require publication of the number of patients validated off waiting lists each month and the reason for their removal.
Amendment 32, clause 16, page 12, line 22, at end insert—
“14Z45BA Patient choice: community services substituting for consultant-led elective care
(1) The Secretary of State must by regulations make provision to enable patients to make choices in respect of non-consultant-led community services where those services are commissioned as a direct substitute for, or to prevent a referral to, consultant-led elective services.
(2) For the purposes of subsection (1), a service is to be regarded as a direct substitute for, or intended to prevent a referral to, consultant-led elective services if it—
(a) provides assessment, treatment or management for a condition that would otherwise be referred to a secondary care specialist; or
(b) is commissioned by an integrated care board for the purpose of reducing or managing demand on secondary or elective care.
(3) Services to which this section applies include, but are not limited to—
(a) community audiology services;
(b) community glaucoma management and monitoring services; and
(c) Minor eye conditions services.
(4) Regulations made by virtue of this section must ensure that—
(a) patients are offered a choice of any clinically appropriate provider commissioned under a qualifying NHS contract for the relevant service;
(b) no limitation on the number of providers from which a patient may choose is imposed solely on grounds of cost or demand management; and
(c) patients are provided with information enabling them to make an informed choice, including information about waiting times and quality.
(5) An integrated care board must not commission a community service of a kind falling within subsection (2) in a manner which has the effect of restricting patient choice below the standard that would apply to an equivalent consultant-led elective service.”
Clause stand part.
Schedule 2.
New clause 35—Community equipment and wheelchair services: standards, performance and outcomes—
“(1) Each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services.
(2) Each integrated care board must monitor its performance against the standards under subsection (1).
(3) Each integrated care board must publish an annual report including—
(a) its performance against the standards under subsection (1),
(b) waiting times for the assessment for and supply of community equipment and wheelchair services,
(c) the number and proportion of people waiting longer than 18 weeks for such equipment or services,
(d) outcomes achieved for people by the provision of community equipment and wheelchair services, and
(e) steps taken by the integrated care board to improve the assessment for, and supply of, community equipment and wheelchair services.
(4) For the purposes of this section—
‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure-relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”
This new clause would require each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services and publish an annual report on their adherence to these standards.
Dr Johnson
The Government say they are firmly committed to cutting waiting times and meeting the NHS’ 18-week target. It seems odd that, despite that, it is necessary for me to table an amendment to prevent systems from forcing patients to wait artificially longer for their care through the imposition of minimum waiting times.
Last year, The Times reported that at least eight local ICBs had introduced policies to pay healthcare providers for treatments only once patients have waited 12 weeks or more. I cannot think of any clinical reason why someone should wait for 12 weeks before having any treatment. At the time, the Minister said that while there was
“no formal national policy supporting minimum waits”,
local areas may
“choose to include minimum waiting times in Activity Planning Assumptions to ensure delivery of targets within agreed financial allocations…to support commissioners in managing activity to ensure they can sustainably manage within their budgets”.
I do not understand why we would want to make people wait longer than necessary.
The Royal College of Surgeons has expressed concerns and made clear that minimum waits prolong “pain and anxiety” for those made to wait longer, saying that it is
“counterintuitive…to give commissioners the green light to impose 18-week waits, while simultaneously working to ensure patients begin treatment within 18 weeks.”
Age UK deemed it a “rationing approach” that is
“potentially harmful to the health and wellbeing of older people.”
NHS England has made it clear that ICBs cannot introduce minimum waits of more than 18 weeks—that is longer than the target, so that makes sense—but waits between 12 and 18 weeks are permissible. Will the Minister explain why that is a good idea?
Amendment 51 seeks to ban ICBs from introducing any operational policies requiring patients to wait a minimum number of weeks before they may access treatment. There are safety risks involved in introducing minimum waiting times. They distort clinical priorities and may make patients wait in unnecessary pain and anxiety. Treatment should be delivered when possible, based on clinical needs. If a patient has a high level of clinical need, they might need to be treated earlier than the minimum waiting time because of the suffering they are experiencing.
Minimum waits are not only detrimental to patient experience by forcing people to live in greater pain and discomfort; in some cases, the delay may make the patient’s condition worse, and the treatment they need may be more extensive and even more expensive. Their condition may even become life-limiting or life-threatening as a result of the delay. The introduction of arbitrary minimum waiting times that do not have any relevance to patient clinical need raises worrying issues, clinically, professionally and ethically.
Minimum waits will also hinder the NHS’ ability to cut waiting lists and get waits to within 18 weeks. Some providers will have a list of people who can be available at short notice for a procedure, who they can call on if there is a cancellation on the day. If that person has not waited the minimum, that may be left as a gap, and that operation or appointment may not happen. That is wasted NHS resource.
Each month that goes by, many people are added to the waiting list, and some are removed from it. We are aware that there seem to be a lot of unexplained removals from the waiting list, and that has spiked recently. Among the people treated by NHS providers in April, around 600,000 were treated within eight weeks of referral, versus 74,000 who were treated between 14 and 18 weeks. The introduction of a minimum waiting time will therefore push back many people’s treatment by as much as 10 weeks.
Minimum waits also worsen and entrench postcode lotteries, because patients who have differential waits, based on whether their ICB has decided to implement minimum waiting times, may experience differential levels of care because of where they live. They are also another way of undermining patient choice, because patients may want to be treated in one area or one hospital because of the waiting time. If they all have different minimum waiting times, that distorts patients’ ability to choose.
Minimum waits are also completely contrary to the 10-year plan for health, in which choice and productivity were considered central features, along with the Government’s wider commitment to keep people healthy. I hope the Minister will agree with amendment 51, which would ensure that minimum waiting times cannot be instituted.
Amendment 52 also concerns waiting times. You will no doubt have seen, Dr Huq, the many newspapers articles about the Government fiddling the figures on waiting times, and there has been a spike in removals from waiting lists. People have found themselves removed from lists or going back on lists, or have suddenly found out that their waiting time started more recently than they thought. Amendment 52 would require the Secretary of State to publish the number of patients who are taken off treatment waiting lists each month and why they were removed. It is important that we are able to explain to our constituents why the Government have decided to remove them.
Helen Morgan
I want to speak to amendment 63, tabled by my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron). As hon. Members know, he has campaigned passionately and for a long time on the provision of radiotherapy. His amendment seeks to ensure that there is sufficient and equitable access to radiotherapy. Radiotherapy is required by half of all cancer patients, and it is incredibly cost-effective, but England has fewer radiotherapy machines than comparable European countries, and thousands of people have to travel long distances and over 45 minutes for their treatment, particularly in my hon. Friend’s Cumbria constituency, as he has noted on many occasions.
The Darzi review noted that radiotherapy services are on their knees. They have some of the longest waiting times for treatment and vast parts of the country are classed as radiotherapy deserts, because of lack of accessibility. Radiotherapy currently has the worst 62-day performance of all main cancer treatments, and if we are serious about ensuring that all cancer targets are met by 2029, then we need the infrastructure, people and equipment to deliver them.
Cancer cases are expected to rise 30% by 2040, meaning that radiotherapy centres must be able to keep pace. Importantly, radiotherapy can also be used at an earlier stage in treatment, potentially saving lives, saving money and meeting important waiting time targets. We really ought to be leading the way on this and keeping pace with our European counterparts so that no one is left without the treatment they so desperately need. I add my support to amendment 52, because we do need to build confidence in the reduction of waiting lists, and more transparency around reductions would be helpful.
Gregory Stafford
Amendment 35 has not been moved, but it is very similar to new clause 35, which may be moved and concerns equipment. I will address both together. I think all in this Committee would agree that ensuring timely access to community equipment and wheelchair services is vital for patient independence, dignity and recovery. I have a number of constituents who believe that they are not getting access to that equipment in the time they would expect.
We also need to ensure that we give proper consideration to the efficiency and management of resources. In particular, we should look more closely at what happens after that equipment has been distributed. Too often, items such as crutches, wheelchairs or Zimmer frames are not reviewed after issue or returned when they are no longer needed. We are already seeing a massive financial consequence of that. It was reported last year that the Royal Berkshire NHS foundation trust is losing around £70,000 a year due to patients retaining unused mobility equipment. That might seem like a drop in the ocean for the NHS, but £70,000 could fund another nurse, if we include the on-costs. These things do have consequences.
Despite distributing thousands of items, only 38% of crutches and just 15% of Zimmer frames were returned in 2024. That represents a significant loss of reusable equipment and considerable pressure on NHS resources. It also gets into the mindset of how patients use and value those pieces of equipment and how NHS users think about resources. While I think that we all agree in this Committee that the NHS should be free at the point of use, one of the downsides of that is that patients rarely think about what the cost of their care contributes. I personally think that if people understood how much crutches or medicines cost, they would use them much more usefully. Plenty of times I have spoken to pharmacists in my constituency who tell me that once a patient has unfortunately died, their family then comes to the pharmacy with a sackload of drugs that have never been used. I think that if people understood the cost of those things, they would use them more effectively and with more caution.
This is not an isolated issue but indicative of a wider problem across the system. If we were to introduce firm timelines for provision, we would need to ensure that there is a robust process for recovery, reuse and proper management of that equipment. Therefore, while I am not supportive of amendment 35 or new clause 35, I ask the Government to consider how those proposals could be strengthened by embedding clear expectations about the return and reuse of that equipment so that public funds are used as effectively as possible.
I will now turn to the two amendments in the name of my hon. Friend the Member for Sleaford and North Hykeham. Amendment 51 is important because, while I understand the Government’s intention in clause 16, as my hon. Friend has mentioned, her amendment will prevent any artificial delays in treatment by ensuring patients are seen as soon as clinically appropriate, rather than being required to wait a minimum period. It simply protects the principle that care should be based on medical need—which I think we would all agree on—rather than some administrative target. It helps avoid situations where waiting times are managed on paper rather than reduced in reality. That ultimately safeguards patient outcomes and timely access to care.
Moving on to amendment 52, I add my strong support to this amendment, because it goes to the heart of trust, transparency and patient safety in the health system. I have been speaking to constituents and individuals from across the country who have contacted me after a video I posted on my social media that contributed to the exposure of the removal of 351,000 patients from waiting lists in March of this year. The stories I have heard are deeply troubling. Those include patients who have waited years for potentially life-changing treatment only to receive notification late—or in some cases not at all—that they have been removed from the list. For many it came as a shock, while for some it came after months or years of uncertainty. This is not some trivial administrative matter. I would sum up the Minister, when responding to questions on this point, as: “Nothing to see here, this is what always happens.”
There has been such a significant jump over a period of two months that there has to be something going on here. The experiences of patients who have spoken to me about this suggest that that is happening. For those patients it is the difference between treatment and deterioration, between hope and abandonment. It is also undoubtedly affecting more vulnerable and less technologically savvy pockets of society, such as the elderly.
Dr Johnson
I should say that I am on a waiting list for treatment myself. The validation process seems to involve phoning people to check if they still need treatment, which after a long period is perhaps not an unreasonable thing to do. However, if they then say yes, they are phoned again a few weeks later; and if they say yes again, they are again phoned a few weeks after that. That puts pressure on people to say, “Okay”. If they are then asked, for example: “Would you be happy to see the consultant so that he can check that you are still listed for the right procedure, given that your condition may have changed and you may want to do something else?” it feels entirely unreasonable to say anything other than “Yes” to that. Would my hon. Friend be surprised to hear that when some people do that they find that they do indeed need the same procedure, but that their waiting time has now gone back down to zero?
Gregory Stafford
My hon. Friend makes two important points. First, of course there has to be a validation process. There has been for a long time, and I do not think that anyone is objecting to that. However, it is a question of how it is being articulated and the people it is focused on. It is being focused on vulnerable people. I have anecdotal evidence from conversations with a significant number of people since I posted that social media video that they feel pressured into coming off the lists. It does not help that trusts have financial incentives to take people off lists. Earlier this month, the Health Service Journal said that three trusts are earning more than £1 million in having people taken off lists. There is no problem with giving trusts a financial reward to do due diligence and validate the lists, but there is potentially a perverse incentive for trusts to try to knock people off them.
Dr Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
I am not entirely clear why there is a problem with the financial incentive. People coming off lists that they have been on for a long, long time may well have a clinical condition that is changing. In my practice, I deal with the management of children with glue ear, who need to have grommets. From time to time, the condition fluctuates and the glue ear goes away.
Equally, the reason that we do a tonsillectomy is that people get recurrent acute tonsilitis, but it is actually quite a good idea for people to wait some time because often the recurrent acute tonsilitis simply settles down and they do not need their operation. Sometimes, when a patient comes into hospital for an operation on their tonsils and I ask them, “When did you last have an attack of tonsilitis?” they say, “I can’t remember.” We have to take account of the fact that the condition of the patient may fluctuate.
Gregory Stafford
The hon. Gentleman is entirely correct, and I think I said some moments ago that I am not against a validation of the list—I think I even said that I am not against some sort of financial incentive to clear the list. My concern is the extraordinary jump in the baseline in the last month or so: 351,000 people have been removed from the list for no apparent reason.
While I have been having anecdotal discussions with patients, my hon. Friend the Member for Sleaford and North Hykeham has been doing something a little more robust. It would be interesting to see the outcome of her endeavours and researches and to find out exactly what is happening in those areas. Anyone with a modicum of inquiry and common sense would say that the significant jump that we have seen in a single month deserves at least a level of interrogation, which the hon. Member for Bury St Edmunds and Stowmarket is not allowing in his comments.
Dr Johnson
Does my hon. Friend agree that when somebody—particularly a vulnerable person—receives a call asking them whether they would be prepared to see a consultant to see whether they still need treatment, they are aware of all the noise in the media? They are aware that other people are waiting. People do not want to waste NHS resources. The first time, they may think it is a routine process but, when they receive the second or third call, they may start to think to themselves, “They are trying to tell me that they want to do something else. Maybe I don’t need it as much as other people.” They feel obliged and pressurised into saying they do not need the procedure when they do.
Gregory Stafford
My hon. Friend is absolutely right. The danger in this process—especially the multiple instances of chasing within a period of weeks, which sometimes happens—is that pressure is put on patients. Again, I know anecdotally from patients who have been speaking to me that those who are most compliant—if I can put it like that—and do not want to make a fuss are generally older and vulnerable people, who feel that they are perhaps causing an inconvenience to the system. They see people with, in their view, more serious conditions or a greater need. We need to be very careful about creating perverse incentives, financial or otherwise, to try to take some of those people off the list. As I say, the significant jump that we have seen deserves more scrutiny and inquiry, and that is why I am very supportive of my hon. Friend’s amendment.
We need to understand whether patients are being removed because they no longer require treatment, as the hon. Member for Bury St Edmunds and Stowmarket said—which is, of course, entirely appropriate—or just to improve targets, present an improved picture of waiting lists, and unlock the financial benefits tied to performance metrics. There is a troubling echo here. We saw similar practices in the 2000s when patients were removed or reclassified in ways that reduced waiting list numbers without genuinely improving access to care; it damaged confidence in the system then and it risks doing so now. What concerns me most is that we may be repeating that pattern. If the Government find they cannot meet their waiting list targets, there is a real danger that the pressure to do so will translate into decisions that, intentionally or not, compromise patient safety and fairness.
Sojan Joseph (Ashford) (Lab)
We are in 2026. Social media and the media scrutinise everything that we do. Will the hon. Member confirm if there has been any report in the media that somebody, anywhere in the country, has had their condition made worse, or died, or did not get treatment?
Gregory Stafford
There have been a number of reports of situations where people have not received care and have died because of that, so I do not see the hon. Member’s point. I think that, with amendment 52, my hon. Friend the Member for Sleaford and North Hykeham is trying to ensure that when the statistics are published, we can scrutinise the reasons behind them. The hon. Member for Ashford may be entirely right; let us imagine that is the case, and there is no gamifying or pressure going on. Why not allow the public to see that? Why not put to bed the HSJ stories that say there is something fishy going on? He should welcome that level of transparency and scrutiny to back up his argument if he is correct.
Dr Johnson
The hon. Member for Ashford talks about social media and social media comments. I wonder if, where the DHSC or the Government have put that waiting lists are falling, my hon. Friend has read any of the comments that come in from the general public below such proclamations.
Gregory Stafford
My hon. Friend tempts me to be political; I will rise to that briefly. Yes, I have seen them and she is right. There is a clear concern that when the Government make all these proclamations about how brilliant the NHS has suddenly become, the reality on the ground does not meet that for many patients. However—I am being gentle now—that is probably not exclusively a problem with this Government. My right hon. Friend the Member for Melton and Syston might kill me, but I am sure other Governments have done something similar.
I will go back to amendment 52 because I think it is really important. Let me be clear: it would not prevent people being removed where appropriate; it would simply require the Government to be honest about why. It requires the Secretary of State to publish the number of patients removed from waiting lists each month and, crucially, the reasons why. If everything is being done properly there should be nothing to fear from such transparency, but if there are problems, sunlight is the best disinfectant and the amendment is exactly what we need. We owe it to our constituents and to every patient in the country to ensure that waiting lists are not improved just on paper, or in a press release, or in a social media tweet, or at the expense of the care of real people but actually improved.
If we are to strengthen patient choice, particularly in relation to community services that substitute for or prevent hospital admission and treatment, there are some good measures in clause 16. However, as my hon. Friend the Member for Sleaford and North Hykeham said, there are concerns, so I hope the Minister will be able to pick those up in her comments when she winds up.
Karin Smyth
There are a number of amendments in the group. Amendment 35 was not moved but as the hon. Member for Farnham and Bordon spoke to it, I will comment on that amendment, which is in the name of my hon. Friend the Member for Bexleyheath and Crayford (Daniel Francis). Community equipment and wheelchair services are really important to us and—to allay the concerns of the hon. Member for Farnham and Bordon—that is why the medium-term planning framework requires that, from this year, all ICBs and community health services must actively manage and reduce waits over 18 weeks and develop a plan to eliminate all 52-week waits. I assure the Committee that we will hold the ICBs for their performance. The community health services situation report has a specific monitoring line, covering children and young people and covering adults, for the wheelchair, orthotics, prosthetics and equipment category. We intend to continue that work following NHS England’s abolition. Consistent national standards will help us to identify the best and the weakest-performing areas, to identify what improvements need to be made and to tackle the longest waits.
Amendment 52 was tabled by the hon. Member for Sleaford and North Hykeham. We are committed to ensuring that all patients receive the NHS care they need in a timely manner, and I recognise the importance that Committee members have placed on that matter. The NHS constitution sets out that patients should start consultant-led treatment within 18 weeks of referral, and it is imperative that the system continues to work towards returning to and then upholding that standard.
I listened with great care to the comments from Members on the Opposition Benches, but I was here—as were you, Dr Huq—during the last couple of Parliaments; I was here as waiting lists rose and rose after 2012, under the previous Government’s stewardship, until they reached 4 million people, all waiting an inordinate amount of time. That Government had no kind of approach to reducing the numbers; they were quite content to have 4 million people on waiting lists, and to never bring forward measures to change that. They were quite content not to challenge NHS England or trust boards about why people across the country in all our constituencies were languishing on those lists. We are determined to resolve that situation.
Karin Smyth
I will move on. It is absolutely right that integrated care boards, as local commissioners, retain the ability to manage their services and waiting lists effectively, given the shocking numbers that they have inherited. This is complicated, difficult work: commissioners have to balance demand, capacity and clinical need, and a prohibition such as the one set out in the amendment would threaten to remove legitimate flexibilities that are required at the local level to ensure that services are delivered safely and efficiently.
We are clear that systems should not be setting minimum wait times that exceed the 18-week constitutional standard, but hon. Members will appreciate that not all elements of waiting are inappropriate. In many cases, they reflect clinical pathways, sequencing of care or the need to prioritise the most urgent patients. It is imperative that clinical judgment and urgency remain the key drivers of prioritisation, which is something the amendment threatens to remove.
Turning to amendment 52, I recognise that Members across the House are committed to ensuring that all patients receive the NHS care they need in a timely manner. Validation is a routine and long-standing part of waiting list management by providers. It ensures that patient records are accurate, that patients are on the best pathway to meet their needs and that they still need their appointments. Routinely validated waiting lists will support a return to the 18-week NHS constitutional standard.
Reasons for removal as a result of validation include a patient no longer needing their appointment or there being a duplicate appointment. The previous Government left behind some systems and trusts in such a poor condition that they give out duplicate appointments, and we need to resolve that as part of our work. Other reasons for removal include a patient’s record not being properly updated following treatment or a clinical decision—another sign of the inefficiency that the previous Government left behind.
Dr Prinsley
I am interested to hear what the Minister has to say, but does she agree that this is yet another reason why we must go full speed ahead to get the single patient record sorted out?
Karin Smyth
Once again, my hon. Friend is absolutely right. He is expert on this issue and has outlined to us some excellent clinical examples. I look forward to debating the single patient record further in Committee.
Importantly, any patient removed from a waiting list should be notified alongside their GP. Data on the total number of removals from waiting lists is published by NHS England. That data includes, but cannot separately identify, patient pathways removed as a result of validation. The Department remains committed to the transparent publication of official waiting list statistics following the abolition of NHS England, although there are no plans to publish more detailed breakdowns. NHS staff are delivering record levels of elective activity, which has enabled us to meet our interim target of 65% of patients being seen within 18 weeks.
Dr Johnson
If a person has been waiting more than 18 weeks, the trust calls them and asks them to see a consultant to check whether they still need the appointment or whether they need a different treatment. If, after having that appointment, they are told that they still need the treatment, that same day they go back on the waiting list as if it were day one. Therefore, they have not waited less than 18 weeks, even though the Minister’s statistics might suggest they have. Does she accept that?
Karin Smyth
The hon. Lady outlines a particular case, and if she wants to raise that separately, I am happy to come back to her with a fuller answer. As she knows, and as the hon. Member for Farnham and Bordon also knows from his work with Getting It Right First Time, there are complications in some of this. I do not accept the hon. Lady’s point, but if there are particular or anecdotal examples of what she referred to, I am absolutely prepared to look at them.
Patients, with their GP, need to understand what is happening. That is a key part of our elective reform plan. If patients are on the list for a long time, they should be told why, and what alternative provision can be made for them. We are taking an active approach to supporting and empowering patients with information and knowledge, and being transparent about how we get down the shocking lists that the Conservatives left us, which stood at 4 million people before the pandemic.
Karin Smyth
We know that in some areas of Scotland and Wales that are near the border with England, the way that health services are planned and commissioned in England can have implications for the people who live in Scotland or Wales. That is why clause 17 inserts new section 14Z45E into the 2006 Act, to place a duty on integrated care boards, when exercising their commissioning functions, to
“have regard to the likely impact of those decisions on the provision of health services”
to persons in Scotland and Wales living near the English border.
I assure the Committee that the clause will operate solely in relation to the exercise of ICB commissioning functions in England. It will neither confer functions on ICBs in relation to the commissioning or provision of services outside England, nor affect the responsibilities of devolved Administrations for the organisation and delivery of health services in Wales and Scotland. I commend the clause to the Committee.
Helen Morgan
I want to draw the Minister’s attention to some of the difficulties relating to cross-border healthcare in a border area. I represent an area on a border. North Shropshire has a very wiggly, for want of a better word, border with Wales, which means that some English constituents are registered with a GP surgery in Wales but receive their secondary care in England. That causes significant difficulties for them because of the lack of joined-up communication between the two Administrations. I seek assurance from the Minister that as ICBs in England will have to pay regard to people who live near the border in Wales, conversations are going on with the commissioners in Wales to ensure that that process is as smooth as possible.
Edward Argar
The hon. Member for North Shropshire makes the point very well. Back when I was a Minister, and subsequently shadow Secretary of State, she raised that point with me. The clause is sensible. The Minister articulated concisely and reasonably why it is necessary. It is the nature of any devolution arrangements that a little bit of cross-border co-operation is required along the border to make sure that services work effectively for people. This may have changed, but in my experience the majority of those crossing the border were people from Wales coming for secondary care services in a hospital on the English side of the border, so I think the clause is entirely reasonable.
I echo the hon. Lady’s request: I would be grateful if the Minister updated the Committee on what conversations she has had, particularly with the Welsh Government, but also with the Scottish Government, to ensure that there is reciprocity and that they will put an equivalent provision into their laws to ensure that patients in England are taken into consideration in their healthcare planning.
Dr Johnson
The clause imposes a duty on ICBs to have regard to the likely impact of their commissioning decisions on areas of Wales and Scotland close to the border. In some respects, this is like other parts of the Bill—a statement of the obvious regarding a person’s job. Are we suggesting that the Secretary of State, and in particular ICBs, would not consider the effect of their decisions? I hope that they would, but, given that the clause is there, what teeth does it have? What if they do not? Is there any consequence in the Bill if they do not? As others have said, will the Minister confirm whether there is a reciprocal agreement with Wales and Scotland? If there is not, what negotiations has she entered into and what progress are they making?
Karin Smyth
As an MP in Bristol, which is not quite on the border, but is pretty close, I absolutely understand. We have relationships with our Welsh colleagues and I have been involved in debates on this matter. The clause ensures that, with the abolition of NHS England, regard is had to to arrangements with our colleagues across the border. We all understand that devolution means that different arrangements will be made in the constituent parts of the United Kingdom. It is not for the UK Government to determine what those are, because they are devolved. However, I assure members of the Committee that across the piece in the Department, and indeed across the Government, regular meetings and conversations on these and other matters with regard to the devolved functions are a regular part of the work that we do.
Question put and agreed to.
Clause 17 accordingly ordered to stand part of the Bill.
Clause 18
Transfer schemes in connection with integrated care boards
Question proposed, That the clause stand part of the Bill.
Karin Smyth
The clause gives the Secretary of State the powers to make transfer schemes where an ICB is being abolished or established, or where the area covered by an ICB is being amended. A transfer scheme ensures that all the staff, property rights, responsibilities and liabilities, other than criminal liabilities, of the ICB being abolished are transferred to another ICB. That ensures that the ICB taking over has the appropriate information and resources to continue to arrange healthcare services for their population. In the past, that has been used to support the restructuring of ICBs to achieve geographical boundary alignment with strategic authorities, as set out in the 10-year health plan. The power also allows transfers to the Secretary of State and, when a new ICB is established, allows the transfer of staff from an NHS trust or foundation trust or from a special health authority.
Following the abolition of NHS England, we expect that Ministers will continue to need to be able to make transfers between ICBs. The clause allows that as needed. I therefore commend the clause to the Committee.
Dr Johnson
I have one question for the Minister. Which ICBs does she envisage being abolished, or is this just a precaution for the future?
Karin Smyth
It is precautionary to give the power in the event—future-proofing the Bill.
Question put and agreed to.
Clause 18 accordingly ordered to stand part of the Bill.
Clause 19
Integrated care boards: power to provide assistance
Question proposed, That the clause stand part of the Bill.
Karin Smyth
The clause relates to the power for integrated care boards to provide assistance and support in relation to the health service. It replaces section 14Z48 and, in part, section 12ZA of the National Health Service Act 2006 with a clearer and more flexible power. At present, the various ICB assistance powers are narrower and more confusing. Section 12ZA provides for certain forms of practical assistance in connection with ICBs’ commissioning functions, while section 14Z48 provides a more limited power to make grants or loans. Other specific assistance powers sit elsewhere in the legislation, including in sections 96, 112, 124 and 147, which allow assistance and support for primary medical services, dental, ophthalmic and pharmaceutical services.
Clause 19 replaces all those separate powers with a general power for ICBs to provide assistance or support. The clause will make it clearer when an ICB may support providers, prospective providers or other activity connected with the health service. It will allow an ICB to provide assistance or support to a person who is providing or proposing to provide services as part of the health service. It will also enable an ICB to support a person who is carrying out or proposing to carry out activities that the ICB considers to be conducive to the health service. The assistance may include financial assistance, making available the services of ICB staff, or making available any other ICB resources. The clause also allows assistance to be provided on agreed terms, including terms about payments by or to the integrated care board.
The clause supports ICBs in their role as strategic commissioners. ICBs need to be able to support the development, improvement and resilience of services for their populations. They need to be able to cultivate their provider sector to meet the needs of the people they are responsible for, and they need to be able to do so in innovative and flexible ways. The clause gives them a clearer statutory basis for doing so. This is only an enabling power; it does not require an integrated care board to provide assistance and it does not create any entitlement for a person to receive assistance, nor does it disapply the ordinary legal and financial controls that apply to integrated care boards, or any other element of the usual way in which NHS bodies are overseen and regulated.
The clause should be read alongside clause 9, which creates a broadly analogous assistance power for the Secretary of State. In combination, the clauses support the move to a simpler, more flexible statutory framework that enables everybody, from the centre to ICBs, to discharge their responsibilities in ways that can be adapted to the complexity and multiplicity of circumstances they will inevitably encounter. I commend clause 19 to the Committee.
Dr Johnson
The Government’s explanatory notes state that the clause is intended to give ICBs the ability to provide a broad range of support to those involved in providing or administering the health service. The flexibility there aligns with the Government’s stated vision for more autonomy across the system. I have a couple of questions. If the ICB were to provide support in a way that was out of line with good practice or what is expected by the Department, what would be the recourse? Where will it be possible for right hon. and hon. Members to see the financial expenditure that ICBs make in any such circumstance?
Karin Smyth
I thank the shadow Minister for her questions. ICBs are part of the accountability outcomes framework, so they will be monitored in the usual way, and any expenditure by the ICB—and, indeed, by the Department—is recorded in the departmental accounts.
Question put and agreed to.
Clause 19 accordingly ordered to stand part of the Bill.
Clause 20
Performance assessments of integrated care boards
Question proposed, That the clause stand part of the Bill.
Karin Smyth
The clause transfers the requirement to conduct annual assessments of integrated care boards from NHS England to the Secretary of State and focuses the assessment on the statutory functions of the organisations. To do that, it removes a prescriptive list of duties to be assessed that was inserted by the Health and Care Act 2022.
ICBs are essential to delivering our health mission. They are responsible not only for arranging healthcare services, but for planning how those services will focus more on prevention, digital innovation and delivery in the community. It is therefore entirely appropriate that the Secretary of State should hold ICBs to account and undertake a meaningful assessment of their performance.
Currently, NHS England assesses the performance of ICBs annually, reviewing how well they have performed against a list of duties prescribed by the current legislation. The process for those assessments is set out in guidance each year and is driven by both publicly available performance data and local insight. The results are published online and form part of the ongoing performance conversation between NHS England and each ICB.
Although NHS England can choose to assess more than those statutory duties as part of that process, the duties form a static list of requirements that are already expected as part of the ICBs’ statutory functions. Having such a list may inadvertently skew attention away from other priorities in the 10-year health plan and our mission. As we reform the NHS, the ICB performance assessment will need to adapt to the evolving role of ICBs as strategic commissioners and reflect new models of commissioning. The list of duties will therefore become too prescriptive to provide the accountability intended. The clause allows a more nimble and flexible approach, ensuring meaningful assessment of ICB performance.
Edward Argar
The Minister has saved me from having to give a speech on this clause, so I will ask her a couple of questions instead. Does the Secretary of State intend to publish the list of criteria against which he will require assessment to take place, so that it is transparent what is being considered? Notwithstanding the Minister’s point about the 2022 legislation, the Secretary of State will define the list, so will he publish those criteria? Within what period following the end of the financial year will the Secretary of State commit that the results will be published?
Karin Smyth
I recognise the right hon. Gentleman’s expertise as a former Minister in this role. I do not want to mislead him, so I will come back to him in writing on both those points, if that is acceptable. He tempts me to be more prescriptive than I think we intend to be at this point, but I will ensure that he gets a proper answer to both questions. I commend the clause to the Committee.
Dr Johnson
As has been said, the clause replaces the part of the NHS Act that requires NHS England to carry out performance assessments of the ICBs and rewrites it so that the Secretary of State has to carry out those assessments. That makes some sense, but, as the Minister said, it takes out the criteria against which the ICBs will be assessed.
I accept what the Minister says—she wants those criteria to be set out more flexibly than can be done in primary legislation—but it is not reasonable or fair to assess people against criteria that they do not know in advance. It will be important, will it not, that ICBs know in advance what those criteria will be? Given what she said to my right hon. Friend the Member for Melton and Syston about writing to him, will she commit to writing to us to say not only what the criteria will be at the moment, but how far in advance ICBs can expect to receive them before they are expected to work to them and then be assessed against them?
Will variation be a factor in whether an ICB is deemed to have been performing well or not? We know that there is a tension in the Bill between the Secretary of State’s need to equalise provision and the ICBs’ desire and intention to vary it and innovate. Given that the Secretary of State is a political individual, how will the assessment process be conducted in a way that gives ICBs and their leaders confidence that there will not be political interference in it?
Karin Smyth
Of course ICBs will know how they are going to be assessed; that will be in guidance in the usual way. In the last two years, in planning terms, we have brought forward all that work for the system—including on the finances—in order that the system works more efficiently, and we will continue to seek to do that.
The hon. Member, as she has several times in the Committee, returned to the question of variation. When there is devolution and local systems are different, there will be a degree of variation, as I have said. In performance management terms, where there is unwarranted variation, we will seek justification and understanding of that. Sometimes, there is variation for geographical reasons. There may also be historical structural reasons in a local system, or temporary reasons why performance is variable. We would look at that as part of that general work.
Question put and agreed to.
Clause 20 accordingly ordered to stand part of the Bill.
Clause 21
Membership of integrated care boards
Dr Johnson
I beg to move amendment 46, in clause 21, page 15, leave out from line 33 to line 6 on page 16 and insert—
“(2) The constitution must provide for the ordinary members appointed as mentioned in sub-paragraph (1)(b) to include—
(a) at least one person nominated by one or more NHS trusts or NHS foundation trusts which provide services under arrangements made by the integrated care board, in accordance with regulations made under sub-paragraph (2A);
(b) at least one person nominated by a body representative of providers of primary medical services whose area falls wholly or mainly within the area of the integrated care board, in accordance with regulations made under sub-paragraph (2A);
(c) at least one person appointed by a local authority whose area falls wholly or partly within the area of the integrated care board; and
(d) at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with, or includes the whole or any part of, the integrated care board's area (if any).
(2A) The Secretary of State may by regulations make provision about the nomination of ordinary members under sub-paragraph (2)(a) and (b), including provision about which NHS trusts, NHS foundation trusts or representative bodies are entitled to make nominations.
(3) The constitution must set out the process for making nominations under sub-paragraph (2).
(4) A person making a nomination under sub-paragraph (2) must have regard to any guidance published by the Secretary of State as to the selection of candidates.”
This amendment modifies Clause 21 so that, rather than replacing the existing mandatory membership requirements in Schedule 1B to the National Health Service Act 2006 with a requirement for mayoral representation alone, the new sub-paragraph (2) reinstates and consolidates the full range of required ordinary members.
The Chair
With this it will be convenient to discuss the following:
Amendment 25 in clause 21, page 15, line 38, at end insert—
“(2A) The constitution must also provide for the ordinary members appointed as mentioned in sub-paragraph (1)(b) to include at least one member nominated jointly by the local authorities whose areas coincide with, or include the whole or any part of, the integrated care board's area.”
This amendment would require integrated care boards to have a member jointly nominated by local authorities from within the board's area, as is currently the case but would otherwise be removed by clause 21.
Amendment 45, in clause 21, page 15, line 38, at end insert—
“(2A) The constitution must provide for the ordinary members as mentioned in sub-paragraph (1)(b) to include at least one member nominated by local primary care providers.”
This amendment would ensure that ICBs have to have representation from primary care providers.
Amendment 26, in clause 21, page 16, line 3, leave out from “mayor” to “sub-paragraph (2)” on line 4 and insert
“or local authority nominating an ordinary member as mentioned in sub-paragraphs (2) and (2A).”.
This amendment is consequential on amendment 25 and would require a local authority involved in nominating a member of an integrated care board to have regard to guidance published by the Secretary of State.
Amendment 27, in clause 21, page 16, line 9, at end insert—
“‘local authority’ has the meaning given by section 2B(5);”.
This amendment is consequential on amendments 25 and 26 and defines the term “local authority”.
Clause stand part.
Dr Johnson
At present, integrated care boards will have a chair, a chief executive and at least three further ordinary members. Those three ordinary members will include a representative of the NHS trusts and NHS foundation trusts in the area, someone from the primary medical services in the area and someone nominated by the local authority areas within the ICB area. Under the clause, the requirement for those individuals is replaced with a requirement to have someone from each of the mayoral authorities.
Because of the order in which the Government have done this—removing half the budget from the ICBs, which has caused them to merge in a way that is not coherent with the Government’s not-yet-complete local government reorganisation—we have a situation where representation is not even. For example, in my ICB area the Mayor of Greater Lincolnshire and the Mayor of the East Midlands will each be able to choose someone to represent them on the board, but the proportions of the population are not even. Lincolnshire will be over-represented, which is not an issue for my constituents, but it may be for those from Nottinghamshire and Derbyshire. Likewise, the northern part of Greater Lincolnshire, which is in a different region, has a small population relative to its ICB. Some mayors will therefore have representation that is not proportionate to their population size.
There is surely a risk that the next step will be for the Government to say they want to make things more even, with ICBs working in relation to mayoral authority areas. Yesterday, the Minister for Care suggested at his appearance before the Health and Social Care Committee that the ICBs should be aligned with strategic authorities, but the only way in which that can happen once the Government have decided where the strategic authorities will be is if things are changed once again.
That brings ongoing costs—financial costs, opportunity cost for service development, and cost to the people delivering these services. The people working hard to try to deliver the Government’s plan find themselves and their jobs threatened and chopped and changed all the time. We heard evidence that the concentration on reorganisation rather than service delivery, provision and development is causing distress to those people.
We also heard about the effect on social care, which, certainly in Lincolnshire and in other places, is delivered by the upper-tier local authority, but not all mayors have any responsibility for health—our mayor does not. We will therefore have someone who is not responsible for health on the ICB while someone responsible for delivering social care will have their seat on the ICB removed. I am afraid that I simply do not understand that. I watched through several times the Minister for Care’s Select Committee appearance, and I still do not understand the rationale. I will be grateful if the Minister for Secondary Care could explain that.
Dr Danny Chambers (Winchester) (LD)
We have a few concerns about the clause in general, especially about the removal of local authority and primary care representation on the ICB. Some ICBs are already stepping back from joint commissioning arrangements with social care and the health and wellbeing boards, and it is vital that social care has a seat at the table. We have talked about this extensively in many Committees and in the Chamber, but the Liberal Democrats have been emphatic that we cannot solve any of the problems in the NHS without solving social care. At any given point, our hospital in Winchester certainly has 160 people in it who are well enough or would be better cared for in the community with a social care package; instead, they are stuck in a hospital, obviously affecting flow through the whole hospital and even affecting A&E waiting times.
Combined with the changes to the pooled budgets that will affect the better care fund, we are seriously concerned that the Bill is increasingly separating the NHS and social care just at a time when the service and experts are screaming out for greater integration and collaborative working. We discussed GPs this morning. They have long-standing concerns about getting their voice heard, given their unique place in the health system. They are the front gate to the NHS and they have the most patient contact of any NHS service. Removing the duty seems to be a step in the wrong direction in that regard.
Finally, the change will leave in limbo areas such as Hampshire that do not yet have a fully functional mayoral authority—our elections will be in the next couple of years. There has not yet been sufficient clarity about what the interim arrangements will be.
Gregory Stafford
The clause will replace the constitutional requirements contained in paragraph 8(2) to (4) of schedule 1B to the 2006 Act so that “ordinary members” must now include at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with or includes the whole or any part of the ICB’s area. The ICB’s constitution must set out a process for making such a nomination, and a mayor nominating an ordinary member must have regard to any guidance published by the Secretary of State, following the abolition of NHS England, as to the selection of candidates.
The definition of a local authority in paragraph 8(7) of schedule 1B to the 2006 Act will be replaced with the definition of a mayoral strategic authority. Sub-paragraph (1), outlining the process to determine the appointment of an ordinary member, and sub-paragraph (6), specifying that one ordinary member must have knowledge and experience in mental health services, are both retained. The clause therefore represents a clear shift in the structure of integrated care boards and, in my view, an unwelcome one, by removing the requirement for representation of GPs, local authorities and NHS trusts, while introducing a requirement for representation from mayoral authorities.
Those are not minor features of the system. The inclusion of local authorities in particular was designed to ensure that decision making reflected local needs and supported genuine integration between health and social care.
For as long as I can remember, Governments of all colours have talked about bringing health and social care together. Some have been more successful at that than others, but there should be agreement across the House that much more needs to be done. With this clause, the Government seem to be taking at least one step back—I would say numerous steps—from trying to bring health and social care together. Like my hon. Friend the Member for Sleaford and North Hykeham, I watched the Health and Social Care Committee’s discussions with the Minister for Care yesterday, and I too cannot fathom why the Government are doing it. I hope that it is an oversight and that, once the Minister goes away and reflects on it, she will look to table some amendments further down the line—I am sure that she will vote against ours today—so that we can bring these matters back.
I am especially concerned about the removal of local authority representation. We are effectively asking local authorities to continue to deliver vital services while removing their voice in the room where strategic decisions about health and social care are made. That raises a fundamental question about how the integration is intended to work in practice. There is also a broader concern about the direction of travel. We are moving away from place-based representation towards a model that places greater emphasis on these mayoral structures, yet the legislation is not prescriptive about who the mayors appoint, and colleagues within and without this Committee have already raised concerns that there is a gap in the understanding at the centre about how local authorities operate in practice.
That brings me to the point raised by my hon. Friend the Member for Sleaford and North Hykeham and the hon. Member for Winchester. I apologise; the Minister said that she did not want a geographic tour of our constituencies, but I am afraid that she will get one now. Part of my constituency sits in Hampshire in the Hampshire and Isle of Wight ICB, and as the hon. Member for Winchester said, we may or may not have mayoral elections in a year’s time. Hampshire county council has launched a judicial review against the proposed local government reorganisation; if that is successful, or even if it delays the process, this Bill will come into effect without our having a mayor, and there will be no representation for anybody on this board. We need clarity from the Minister on who will represent the people on the board if there is no mayoral authority. I would say that local authorities—Hampshire county council in this case—should remain on that board, at least until there is a mayoral authority.
Dr Johnson
Where a mayor is from one political party and local authorities are run by different political parties, the mayor, as part of the ICB, will be able to make decisions about spending done by authorities that are run by different parties. That will surely create a political conflict, or at least the potential for one.
Gregory Stafford
My hon. Friend makes an interesting point that I had not considered before, but she is absolutely right. The upper-tier authorities and strategic mayors might be from different parties, and, where the mayor does not have an actual responsibility for health, there essentially could be democratic deficit there that I had not thought about. My hon. Friend makes an interesting point.
That democratic deficit will potentially be exacerbated in the other half of my constituency, which is in Surrey. As I have already alluded to, the Surrey ICB has taken on Frimley but is also now merging with Sussex. As far as I can tell, the Government have absolutely no plans to introduce a mayoral authority in Surrey; however, my quick googling suggests that there will be a mayoral authority in Sussex in 2028, so the mayor of Sussex could be sitting on a board where there is no representation from the Surrey side. That is a complete democratic deficit. There would be the Surrey and Sussex ICB, with representatives for the people of Sussex but not for the people of Surrey. That must be an unfairness. I hope the Minister, if she cannot answer now, will at least go away and think about how that democratic deficit will be avoided. I suggest that she dumps the whole idea and goes back to having the people who actually run health and social care in our country on the board.
That is why I am very supportive of amendments 45 and 46, tabled by my hon. Friend the Member for Sleaford and North Hykeham. Reducing the representation to a single mayoral representative is a problem. Reinstating and consolidating the full range of required members and thereby giving the breadth of representation within ICBs that we have all talked about, is essential. It would strengthen the legislative framework, ensuring decision making remains multidisciplinary and balanced and that it incorporates both the clinical expertise, which we are going to lose, and the local authority political input, rather than having a one-sized, over-politicised mayor in charge.
By maintaining that membership, the amendments would help safeguard overdominance by a single actor, support a much more informed and locally responsive decision-making process and, crucially, reinforce the collaborative foundation between health and social care that I thought was a given among all parties in this House. I urge the Minister to reconsider what she is proposing in this clause. She should, at least, give us some clarity on what will happen in the interim period or, at best, go back to the drawing board and ensure proper representation of the people who are actually delivering health and social care in our constituencies.
Edward Argar
I agree entirely with my hon. Friend the Member for Farnham and Bordon. At risk to my political career, such as it is, I also agree entirely with the hon. Member for Winchester, who made a very good point in drawing the Committee’s attention to something that should not need to be said, which is that the provision of healthcare and social care go hand in hand, and if either part of that equation does not function, the other part will not. He highlighted a good example, and I visited Winchester hospital when I was a Minister.
If we do not have a functioning social care system, or a social care system that is closely integrated in and working closely with the NHS, we see the knock-on effects pretty swiftly in terms of the large numbers of people medically fit for discharge who are unable to be discharged, which then impacts on the flow through an acute hospital setting. That is one of the big factors we see in A&E backing up, because people cannot be discharged, people cannot get into beds because the beds are full and then the ambulances are queuing up outside. The hon. Gentleman illustrated that point extremely well.
Dr Chambers
On the economics, it costs around £850 a night to keep someone in a hospital bed and a fraction of that for a social care package. This is an absolute false economy, even if we ignore patient experience and patient recovery.
Edward Argar
The hon. Gentleman is absolutely right from the financial perspective. As he mentioned, there is, of course, the human perspective and the impact on someone’s recovery and their health, as well as their psychological health, if they are in hospital when they simply want to get home, because they have no medical need to be in hospital.
My worry about clause 21 is that it essentially seeks to undermine the whole concept that ICBs rest upon. ICBs were conceived to bring together all the NHS services in a particular area, but also, as my hon. Friend the Member for Farnham and Bordon highlighted, to make sure that the NHS footprint mapped on to the geographical footprint of the upper-tier local authority delivering social care, so that the ICB is looking at the same geographical area for the two key parts of the system and they neatly map on to one another.
With changes, mergers and acquisitions—as well as a whole range of other changes—that link is already breaking and weakening, as ICBs start covering larger areas and look in different directions. As my hon. Friend the Member for Farnham and Bordon set out, and as I think the hon. Member for Winchester highlighted in an earlier sitting, because we do not know what local government reorganisation will look like in the years to come, we increasingly run the risk of creating something that again will not map on to a geographical footprint and may have to change.
In a number of areas—take my area, Leicestershire—we do not have a mayoral authority. At present, there is no plan or proposal before us for one. Yet the ICB is merged with Northamptonshire, which does not have one either. We will see a real gap in representation.
We are moving away from what we sought to do with ICBs. During the passage of the 2022 legislation, I always used the phrase—the Minister probably heard it until she wished to hear it no more—that we were seeking to be permissive, not prescriptive, where we could be. However, this was one area where it was not just us in the then Government who were trying to put a bit of a guardrail around the membership of ICBs. We were pushed by the now Government, then Opposition MPs, to go further in what we prescribed for the membership of an ICB.
Dr Prinsley
I am listening carefully to what the right hon. Member has to say. I wonder whether he could present us with a concrete example of where precisely elected local government involvement in the commissioning of services in ICBs has been essential, because it seems to me that what an ICB needs is expertise in commissioning. We need people who know how to commission services. Although I understand the importance of representation, I think that what we really need is expertise in commissioning.
Edward Argar
I take the hon. Gentleman’s point to a degree, but I would refute a chunk of it. We need within the organisation people who have those technical skills and know how to commission, draw up a specification, put it out to tender, or work out what is needed and ensure that what is delivered reflects what was commissioned and that the performance is what is sought to meet the needs of the local area. At board level, we need representation from local authorities and others, because it sets the strategic direction.
The board members are not the people who are going to sit there and write the commissioning document. They will probably approve it, but they are not the experts who will be drafting it. We are talking about two different functions, and I argue that when a board-level decision is being made, we want those voices in the room to ensure that those different perspectives are reflected and there is that critical challenge to what is proposed by the executive directors. We essentially have non-executive directors who are there to challenge, to question—perhaps to agree, but perhaps to push back on things. That is how many boards operate.
In what is proposed, we lose some powerful voices from round the table. They may not carry the day, but those voices should be heard. Having sat where the Minister is sitting now, I appreciate that she may not be willing or in a position to accept the amendments, but I hope that she will take away and reflect further on the challenges of representation.
Karin Smyth
I absolutely recognise that this is an area of huge interest to hon. Members across the piece. I assure colleagues that officials and I have been working with representatives of the Local Government Association and mayors throughout the development of the Bill and the future architecture, and we will continue to do so. We will continue to have discussions and to make sure we get this right, because it is complex and complicated. Given that we are all politicians, we understand. Many of us have been councillors and local representatives, and have spent a lot of our time—sadly, for officials—knocking on doors, going out and persuading individuals to vote for these people. We understand that it is quite personal and we want to get it right.
If I may, I will not take any interventions so that I can address the amendments and our approach to ICB membership. As my hon. Friend the Member for Bury St Edmunds and Stowmarket said, ICBs are commissioners. This is a fundamental shift, which I will come on to, and it is different from the 2022 work. I now want to outline the board membership set out in clause 21, but I think we will be discussing this for some time.
Lord Darzi’s review found inconsistency in the roles being undertaken by ICBs and concluded that the health and care system would work better if each organisation had greater clarity and focus on its particular role. That is our starting point, and we set out to do that in the 10-year health plan. In future, all ICBs will discharge their common statutory duties through best-practice approaches, getting better at allocating their budgets to meet the population’s needs and securing the best outcomes. The new focus for ICBs is strategic commissioning. All ICBs will, in future, operate at a minimum efficient scale, with a population of around 1.5 million people covering multiple partner local authorities.
Effective partnership working is core to strategic commissioning and is aided, rather than diminished, by replacing ambiguity in roles with clarity and focus. That is why we are altering the membership requirements for ICBs. We are adding a requirement for strategic authority mayors, or a nominated representative, to be appointed to ICBs operating within their footprint. Strategic authorities will increasingly become key bodies for growth and prosperity in their localities. Mayors, or their nominated representatives, will highlight opportunities to improve health outcomes through a joined-up approach to their other devolved responsibilities, such as transport, housing and employment.
Although we recognise that the coverage of mayors and strategic authorities varies across the country, we will provide guidance to ensure that no area is disadvantaged, regardless of how advanced its local devolution arrangements are. In all cases, ICBs will have an obligation to ensure that their boards have a suitable membership to discharge those functions properly.
Given the larger geographical footprint of ICBs in the future, we are also removing the requirement for ICBs to have at least one member jointly nominated by local authorities. At present, local authorities collaborate with ICBs by sitting on health and wellbeing boards and local integrated care partnerships. The multitude of plans, committees and measures have resulted in confusion, siloed working and, too often, inaction. I think many of us would recognise that in our own areas.
I emphasise that we want to ensure a strong voice for local government in the work of the NHS. Our preferred approach is for local authorities to work with the NHS through health and wellbeing boards, co-commissioning and local authority health scrutiny. Those are likely to be more fruitful forums in which to resolve issues, agree joint approaches and tackle the needs of a local area.
As ICBs become more focused on effective commissioning, it is right that we remove any potential conflicts of interest. That is why the 10-year health plan and the Bill propose removing the requirement for one member jointly nominated by primary medical care providers and one member jointly nominated by NHS trusts and foundation trusts. The clause will provide ICBs with memberships that are best equipped to fulfil their commissioning responsibilities and role in health planning.
On amendment 45, which was tabled by the hon. Member for Sleaford and North Hykeham, I assure her that the Government fully appreciate the importance of general practice and primary care more broadly, and the role that they play in informing ICB decisions. However, as I have said, health and wellbeing boards should be the key forum for resolving local issues and making planning decisions for their neighbourhoods. GPs are well placed to contribute to those discussions and also vital to them. We expect health and wellbeing boards to ensure that they involve relevant stakeholders, including GP practices and primary healthcare providers, in their work.
There is an opportunity for health and wellbeing boards to play a much more proactive and important role in the local economy. To respond to the point made by the hon. Member for Winchester, we absolutely recognise that place is important in those arrangements. Although I agree that the experience of primary care is important, I hope that I have reassured the Committee that having a member nominated by primary care on the board of an ICB is not necessary.
A similar argument applies to amendment 46, which would require a local government representative on the ICB. I should start by saying that I wholeheartedly recognise the important role that local authorities play in the health and care system. As we have discussed, their work in social care and public health, and their influence on the wider determinants of health such as housing and employment, mean that they have a fundamental role in supporting the delivery of our ambitions to improve the health and wellbeing of the population and implement the three shifts identified in our 10-year health plan.
Rather than one local authority attempting to represent the interests of many on an ICB board, however, we think that it is more effective for local government to use health and wellbeing boards to address local barriers to joint working and support the development of neighbourhood health plans, which will shape the commissioning plans of the ICBs. I assure the Committee that we expect ICBs to work effectively with every one of their partner local authorities in the local authority footprint to deliver the neighbourhood health service and progress the integration of health and care services at that level.
I should stress that our changes are not designed to weaken democratic accountability in the NHS. ICBs are NHS statutory bodies that are governed by a unitary board that is jointly responsible for ensuring that the ICB discharges its legal duties. Given that specific role, the ICB board is not the forum in which democratic leaders hold the NHS to account; rather, that is conducted through the local authority health scrutiny functions and Parliament. Again, this is a good opportunity for those health scrutiny functions to be much more robust and proactive at local authority level.
Amendment 46 also proposes retaining provider representatives on the ICB board. As I said earlier, we think that an ICB should have a core focus on commissioning, so it is right to remove the requirement to have providers on them. That will also support the avoidance of potential conflicts of interest.
We debated these issues many times—the right hon. Member for Melton and Syston referred to it—in this Committee Room, or one very similar to it that was not quite as hot, during the passage of the Bill that became the Health and Care Act 2022. These are difficult and complex issues. I mean no disrespect to him—he had a difficult job to do at the time—but the architecture has not worked. It is confusing, and I do not know any area that particularly thinks it has worked. We think that clarifying the roles will make the system much more effective.
I think we agree that adding requirements for strategic authority mayors to make nominations to their ICB boards is a good thing. It will be an effective tool to harness the benefits of joint planning between an ICB and strategic commissioners and strategic authorities, who will have increasingly significant roles in shaping their areas. I ask hon. Members not to press their amendments, and I commend clause 21 to the Committee.
Question put, That the amendment be made.
Health Bill (Eighth sitting)
Tuesday 30th June 2026
(2 days, 6 hours ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 30 June 2026 - (30 Jun 2026)
The Committee divided: - Ayes: 9 / Noes: 6 - Question accordingly agreed to.
The Minister for Secondary Care (Karin Smyth)
The clause updates the National Health Service Act 2006 to abolish the requirement for integrated care boards and their partner NHS trusts to prepare and publish a joint forward plan and a joint capital resource use plan. The 10-year health plan aims to simplify local healthcare planning, and the Bill delivers that objective by removing legal requirements for integrated care partnerships, integrated care strategies, joint forward plans and joint capital resource use plans. Planning will now begin with the joint strategic needs assessment, developed by health and wellbeing boards. The assessment will inform a new neighbourhood health plan, replacing the joint local health and wellbeing strategy. ICBs will produce population health improvement plans, aligning multiple joint strategic needs assessments, neighbourhood health plans and local priorities across their wider populations. As a result, the planning process will be streamlined and less bureaucratic, and will deliver healthcare for local people based on local planning and strategy. I commend the clause to the Committee.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
As the Minister said, the clause removes the need for ICBs and their partner trusts to produce a joint forward plan. The existing legislation requires ICBs and their partner trusts to prepare a plan setting out how they propose to exercise their functions over five years, which is reviewed and/or revised each financial year.
Joint forward plans address objectives in the Government mandate regarding the ambitions in the NHS long-term plan and planning guidance. Section 14Z52 of the 2006 Act sets out that an ICB and its partner trusts have to prepare such a plan before the start of each financial year and specifies what the plan must give regard to, including the ICB’s discharge of its duties—general duties and financial duties—under other sections of the Act. The plan must also cover steps that will be taken to implement the local health and wellbeing strategy, the particular needs of young people, and the particular needs of victims of abuse. ICBs and their partner trusts must publish the plan and give it to a set of specified authorities, and NHS England may give directions for that. Section 14Z54 sets out that an ICB and its partner trusts must consult people when developing such plans and that health and wellbeing boards must be involved. Section 14Z55 sets out that the relevant health and wellbeing board may give an opinion, and that when it does so, it must provide it to the ICB and its partner trusts.
Section 14Z56 sets out that an ICB and its partner trusts must prepare a joint capital resource use plan before the start of each financial year, and that the period may be determined by direction from the Secretary of State. Section 14Z57 sets out that an ICB and its partner trusts may revise the joint capital resource use plan, but if it is revised significantly, it must be published and given to the list of specified authorities.
Section 14Z58 sets out that an ICB must produce an annual report on how it has discharged its functions. It must explain how it has discharged its duties under other specified sections of the Act, review the extent to which it has exercised its functions in accordance with the forward plan and its capital resource use plan, review the extent to which it has exercised its functions consistently with NHS England’s views, and review steps it has taken to implement any joint local health and wellbeing strategy. The report must include details of expenditure and be given to NHS England by a specified date and then published.
In essence, the clause deletes sections 14Z52 to 14Z57. In some respects, it is legislative plumbing, to remove plans that are no longer necessary. The Government’s impact assessment notes that
“there is some duplication across planning documents. For example, the Joint Forward Plan covered the integration of services, which the Better Care Fund plan also considers, as does the Joint Local Health and Wellbeing Strategy.”
It goes on to note that duplication delivers an administrative burden, as staff
“complete parallel planning returns and fulfil competing data requests,”
so that is a positive aspect of the clause.
Will the Minister please address the following points? Section 14Z52 contains specific requirements to address the particular needs of young people and of victims of abuse. Where do they fall now? The NHS has a large maintenance backlog. What is the new mechanism for transparency of capital prioritisation decisions between the ICBs and the trusts? Can the Minister remind me and the Committee of other areas in which local democracy will be able to input into ICB planning once these planning documents are no longer required?
Under the Government’s strategic commissioning framework, ICBs have to develop population health improvement plans. Essex ICB published a document that is 148 pages long, with a particular focus on inequality. Is the Minister concerned about the length of some of the plans, the time it takes to produce them and the amount of bureaucracy involved, or does she think this is an improvement? What is the key objective in delivering these plans? Do the Government plan to introduce population health improvement plans through legislation? If they do not, Parliament will have scrutiny of the bureaucracy being removed but not of the bureaucracy that the Government replace it with. As the Minister once said:
“Local taxpayers deserve to know how their money is being spent.”—[Official Report, 13 June 2023; Vol. 734, c. 122WH.]
Karin Smyth
I thank the shadow Minister for her comments. I largely agree about legislative plumbing—that is a nice phrase. As she rightly highlights, and as is clear in the explanatory notes and so on, the duplication and administrative burden on all these bodies is considerable. On her question about objectives, we certainly want to streamline that so that ultimately, as well as organisations knowing the objectives they are pursuing, the local population—importantly to her concluding point—can readily see and address that, follow it through and hold people to account. I do think that 150-page documents are not always the easiest to see.
Young people will obviously be part of the joint strategic needs assessment, and ICBs will be mindful of the Government’s wider policy objectives, as we have discussed previously. With regard to maintenance and prioritisation of capital schemes, since coming into office we have already done a huge amount of work to streamline the relationship between NHS England and the Department of Health and Social Care—and, indeed, our friends over at His Majesty’s Treasury—in respect of the approvals process, making better use of capital and making that more transparent at local level so that individual organisations are involved in the prioritisation that comes forward to the ICBs.
Question put and agreed to.
Clause 22 accordingly ordered to stand part of the Bill.
Clause 23
Abolition of integrated care partnerships and strategies
Question proposed, That the clause stand part of the Bill.
Karin Smyth
The clause abolishes the requirement for ICBs and their partner local authorities to form an integrated care partnership. It also abolishes the related requirement for that partnership to prepare and publish an integrated care strategy.
These abolitions address the policy objectives of the 10-year health plan by streamlining the number of plans that must be created by local health systems and supporting key local stakeholders to work together more flexibly and effectively. The changes recognise that in many areas, integrated care partnerships have not had a positive impact on local health outcomes and have come with significant opportunity costs. Alternative planning approaches proposed elsewhere in the Bill and more broadly will enable local health bodies to plan for their patients in a way that is tailored to their strengths. However, I can reassure the Committee that where existing arrangements are working well, nothing in the Bill will prevent local areas from coming together to consider how best to integrate services and plan their approach to tackling the challenges they face. I commend the clause to the Committee.
Dr Johnson
In essence, the clause abolishes integrated care partnerships and strategies, which are where ICBs come together with local authorities to discuss how they can make their services more integrated. We know that many of the challenges facing the NHS are caused by difficulties in social care provision and some of the difficulties in social care provision are caused by issues with health provision, and that if those commissioning services in those two areas work together, we can see an improvement in both.
The Local Government and Public Involvement in Health Act 2007 made changes to local government structures and enhanced public involvement in health services. Section 116 requires local authorities to produce joint strategic needs assessments for the local authority and its partner ICB. When preparing the assessment, the local authority and its partner ICB must
“co-operate with one another…have regard to any guidance issued by the Secretary of State…involve the Local Healthwatch organisation”,
and involve local people and the relevant district councils. I note that later in the Bill we will also come to the abolition of Healthwatch.
Section 116 of the 2007 Act has been modified by the Health and Social Care Act 2012 and the Health and Care Act 2022 to ensure that references match the current NHS structure. For instance, in 2008 there were primary care trusts, rather than ICBs. Section 116ZA of the 2007 Act requires ICBs and local authorities whose areas coincide or overlap to create integrated care partnerships, which consist of a member appointed by the ICB, one from each responsible local authority and any other members that they choose to add; to some extent, they can determine their own procedures.
Section 116ZB of the 2007 Act requires ICBs to prepare an integrated care strategy
“setting out how the assessed needs in relation to its area are to be met by the exercise of functions of…the integrated care board…NHS England, or…the responsible local authorities”.
When developing that integrated care strategy, the integrated care partnerships must have regard to NHS England’s mandate and any guidance issued by the Secretary of State. Clearly, that would now apply only to guidance issued by the Secretary of the State, because NHS England is also being abolished. An integrated care partnership must publish its integrated care strategy and give it to each local authority and partner ICB. Integrated care partnerships must reconsider and, where necessary, revise the strategy each time they receive a new needs assessment.
Clause 23 deletes section 116(5A) of the Local Government and Public Involvement in Health Act 2007. That subsection required the local authorities to give a copy of the needs assessments to the ICBs, which is of course no longer necessary because they are being abolished. Clause 23 also deletes sections 116ZA and 116ZB of the same Act, which established ICBs and defined integrated care strategies respectively.
As Conservatives, we believe that streamlining bureaucracy is sensible, and I am sure that this is a well-intentioned reform. However, a survey conducted by the NHS Alliance in November indicated that a quarter of integrated care system leaders are likely to keep the integrated care partnerships anyway on a non-statutory basis, and 40% plan to fold them into health and wellbeing boards and working partnerships with the authorities. It is not really a ringing endorsement of the policy if a sizeable number of people intend to keep it anyway.
Like many other elements of the Bill, these changes are uncosted—if we read the impact assessment, it says “N/A” for the cost. Clearly, there will be a cost incurred by the abolition of the process, but there will also be an opportunity cost to services if ICBs and commissioners are not working together in the provision of social care as effectively as they were before. That will cost people in social care, and it will cost people in healthcare.
As recognised by the impact assessment that the Government have produced themselves, there is a risk of reduced focus on the wider determinants of health at system level. Committee members on both sides of the House have already stressed the impact that other health determinants can have on the health service and social care, and we have previously considered amendments to that effect.
Overall, it is regrettable that local government does not have the direct feed into ICBs that the design of those integrated care partnerships provided. Whether or not I agree, I can follow the theory or principle behind making the area covered more local, in line with the strategic authority. However, if the Government wanted to do that, I do not understand why they did not decide the mayoral areas first. At the moment, we do not know where the mayors will be, and where they are now is not where the ICBs are. The Government have decided to cut ICB budgets and force mergers before they have decided where the mayoral authorities will be in some cases. Even where there are mayoral authorities already, the Government have not mandated that the ICBs be coherent with them, and, therefore, in many cases, they are not. We have a very confusing pattern emerging, which may require further reorganisation of ICBs to line them up, with a further cost down the line.
Joe Robertson (Isle of Wight East) (Con)
Will my hon. Friend reflect on the fact that, even if the Government get through the combined mayoral authorities they are trying to in this Parliament, there are still great swathes of England where there are no active plans for a mayoral authority at all. Even if the Government get their own way, some areas will not have a mayor for many years—if they get one at all.
Dr Johnson
My hon. Friend is, as ever, correct. The mayors are also not all responsible for health and social care—the local authorities are, in most cases. There could therefore be a mayor directing proceedings with the ICB who is a political opponent of those actually democratically elected to look after social care. ICBs are supposed to be apolitical commissioners accountable to the Secretary of State, but now, instead of working with social care directors, they will work with an elected mayor instead.
I can see a positive to that in terms of democratic accountability, but what happens if they all disagree? There is some incoherence about who is in charge. We have the local authority tasked with delivering social care, which may be led by one political party; the mayor directing the ICB, who may be of a different political party; and the Secretary of State who can also direct the ICB, who may again be of a different political persuasion. How does it work if they disagree? Does the mayor actually have authority, given that the Secretary of State can override them anyway? How does the Minister see that working in practice? It feels like some people will be in power without responsibility and others will have responsibility without the power to exercise it.
Helen Morgan (North Shropshire) (LD)
I will raise some similar concerns about the abolition of integrated care partnerships and integrated care strategies, which clause 23 brings about. Before I do, I should declare my interest as a vice-president of the Local Government Association.
The removal of integrated care partnerships, as well as the extension of ICBs to cover multiple local authorities, raises unanswered questions about the future of social care planning, which is very important to the Liberal Democrats, as the Minister knows. We feel that it removes the voice of charities and others in the voluntary sector who are crucial to meeting the range of needs in health and social care.
Throughout the Bill there is a theme of separating social care and the NHS, at a time when greater integration and closer working are clearly needed. We heard Sir Andrew Dilnot say in evidence that we cannot deal with some of the challenges that arise in the NHS—particularly around flow through hospitals and long waits in corridor care in accident and emergency—without improving the discharge of patients into social care. Separating the organisations that deliver those things is clearly problematic. If we think about it, as the shadow Minister just outlined, we have lost the local authority representative on ICBs. The Bill also changes the way the better care fund is administered. With those changes, we are really concerned about the separation of these two responsibilities.
I want to draw the Minister’s attention to an example in Shropshire. Shropshire council spends almost 80% of its budget on social care. It is an extremely challenged council because of those funding pressures. Shropshire, Telford and Wrekin ICB has also been one of the most financially challenged ICBs. That is partly because of its small scale and its merging with Staffordshire—which, for the record, is unlikely to be the combined mayoral authority that Shropshire ends up in, as is my current understanding, although we are a long way off resolving that problem.
Edward Argar (Melton and Syston) (Con)
Does the hon. Member share my concern that what often gets billed as simply streamlining or efficiencies is in fact slimming down, decoupling and weakening?
Helen Morgan
We cannot see the resources allocated, so we cannot confirm that, but it is clearly a concern. We are not yet discussing the part of the Bill that deals with Healthwatch, so I should keep my powder dry, but we know that local authorities will get some additional funding to deal with their elements of Healthwatch, while ICBs will not. There is a concern that that streamlining is, in fact, slimming down.
Gregory Stafford (Farnham and Bordon) (Con)
It is a pleasure to serve under your chairmanship, Sir Jeremy. I want to pick up where the shadow Minister left off. Essentially, she said that the cart is being put before the horse in terms of mayoral authorities.
As my hon. Friend the Member for Isle of Wight East outlined, many areas have no plans for a mayoral authority; our area of Hampshire and the Isle of Wight is some way down the track. As I expressed last week in Committee, we have a strange anomaly in the new Surrey and Sussex ICB, because Sussex will get a mayor and Surrey will not, so Sussex residents will have representation on the ICB whereas Surrey residents will not. I hope that the Minister has had a chance to reflect on that strange paradox over the weekend and that she will now be able to answer specifically, as she did not last week, how that lack of representation for Surrey residents will work locally.
The abolition of the integrated care partnerships and their allied strategies continues a theme whereby the Government, under the veneer of slimming down, are actually decoupling—or weakening or whatever terminology Members wish to use—health and social care. For many years, all parties have regarded the bringing together of health and social care as essential, but the Bill not only looks like it is not trying to encourage that bringing together, but in fact is doing the opposite of that—it seems to be looking to pull them apart and decouple them. That is strange, because it does not appear to be the expressed policy of the Government, but it is the only logical explanation for many parts of the Bill, including the abolition in clause 23.
The shadow Minister pointed out that a number of areas will keep the ICPs in some form or other. I ask the Minister, does the Government support that feature? Was it the Government’s intention to remove the statutory footing of the ICPs and strategies in the hope and expectation that they would continue on a non-statutory footing? If so, we come to the paradox: if the Government support local authorities and health services continuing to work together in informal ICPs, why is the Minister trying to get rid of them? If they do not support that, is it now stated Government policy to separate social care and health services?
Joe Robertson
It is a pleasure to serve under your chairmanship, Sir Jeremy. There is a consensus—not just in this room, but within Parliament and going back several decades—that we want more integration and partnership working, particularly to bring together health and social care services, but this clause drives a coach and horses through that, and does so in a way that weakens rather than strengthens the Government’s plans to replace the system.
Local authorities bear responsibility for social care and public health in their areas, but they will no longer have a direct voice when it comes to integrated care boards. What we have seen to date is not an ideal system, or even a system that works particularly well, so I understand that the Government want to strengthen it, but we should not do that by removing the local government voice or making it indirect via a mayor who does not have the direct responsibility for delivering social care locally. Mayors may have some strategic oversight, but that is different.
Just last week, the Minister of State for Care appeared before the Health and Social Care Committee and was questioned on this very issue by me and others. His view was that the mayoral strategic partnership would be more than sufficient to make up for the local authorities losing their seat, but he faced particular scrutiny from the hon. Member for Chelsea and Fulham (Ben Coleman), who made some excellent points, which I will not repeat or paraphrase as they are on public record.
The gist of his argument was that local authorities have been ignored for too long when it comes to joining up health and social care services. This measure puts local authorities in an even weaker position and threatens what the Government are trying to achieve with social care, particularly for areas such as mine that have an older population and a relatively small unitary authority with so much responsibility to deliver on.
As my hon. Friend the Member for Farnham and Bordon has already said, the combined area of Hampshire and the Isle of Wight—or the Solent, as the Government like to call the Isle of Wight, despite the fact that fish cannot vote—is not set to get a mayor for a couple of years, but it will be at the vanguard of the Government’s plans. What about those areas for which there is no date, or even no plan for a mayor at all? It seems extraordinary that the Government would do away with the current set-up, imperfect as it is, and replace it with something that does not yet exist.
The Government have time deal with this problem. I am sure they quietly understand that there could be a problem. It is now on their shoulders to deal with it. I welcome the Minister’s reflections.
Karin Smyth
There has been a wide-ranging discussion on this clause. I remind Members that the abolition of ICPs is about reducing that complex legal framework, allowing for local decisions and putting partnership work in place in the most effective way. That is what the measure seeks to do. I do not think anyone has disagreed with the notion that the landscape is complex, and that people are producing a lot of reports. In future, health and wellbeing boards will be the focal point for the collaboration between ICBs and local authorities. They are statutory committees that bring together the NHS, local government and relevant community partners; set the strategic direction for health and care services; and oversee joint working in their area, which we are of course committed to making work in local areas. I do not think many people will disagree with that; I hope that is clear.
There is also an enhanced role, not only for the health and wellbeing boards—as I said last week, I think they have been underutilised in most areas; again, I do not think people generally disagree with that point—but for health scrutiny. Again, across the country, that has not been pursued to the greatest extent to create links with elected councillors in local areas.
We are clear that the role of local authorities is crucial at a local level—as the name describes—and particularly in working on our commitment for neighbourhood partnerships and developing the neighbourhood plan; most of that was covered in our sittings last week. I accept that there are a number of concerns about how that will work in different geographies. I think the Opposition said last week that a survey suggested a quarter of areas will keep those partnerships, which is absolutely fine. That is up to them.
On the one hand, the Opposition say that there is centralisation and a power grab in this Bill; on the other, they complain—I should not say complain, because it is their right and their job to do so—about the move to devolution and the freedom to allow, or indeed encourage, local leaders to work together across authorities on behalf of the populations they serve, even where some of them are politically divided, because the populations they serve voted for different people. It is incumbent on all of us as individual elected politicians to work with people—whoever the population around us voted for. These provisions provide for that.
Edward Argar
Can the Minister set out how she envisages health scrutiny committees having genuine teeth? Our cross-party health scrutiny committee in Leicestershire universally condemned a decision by the ICB—totally disagreed with it—and the ICB basically said, “Thank you; noted,” and carried on anyway.
Karin Smyth
We all have examples of decisions that are made in our constituencies that we do not like. Again, that is part of the democratic process, but I go back to my earlier point: either there is a centralised unaccountable body like NHS England making decisions, or the Secretary of State devolves those responsibilities.
It is incumbent on people and elected leaders locally, and the ICB, which is not elected, to work with local leaders on these decisions. ICBs will be held accountable through mechanisms in the Department of Health and Social Care. There will be decisions that people do not like—that is a consequence of some of these things—but the clause simplifies the landscape.
Karin Smyth
I will not; we need to move on from this point. Of course, if people want to keep the partnerships, they are totally able to do so. That will be up to local leaders to decide.
Question put, That the clause stand part of the Bill.
The Chair
With this it will be convenient to discuss new clause 70—Duty to engage primary care providers in integrated care boards—
“(1) An integrated care board must take all reasonable steps to secure the meaningful involvement of primary care providers in the exercise of its functions relating to—
(a) service redesign,
(b) integration of health services,
(c) development of neighbourhood health services, and
(d) population health planning.
(2) In this section, ‘primary care providers’ includes—
(a) providers of primary medical services,
(b) community pharmacy contractors,
(c) providers of primary dental services, and
(d) providers of ophthalmic services.
(3) Under subsection (1), ‘meaningful involvement’ includes—
(a) involvement at an early stage in the development of ICB proposals,
(b) provision of sufficient information to enable informed participation of primary care providers in ICB functions,
(c) opportunities for primary care providers to influence ICB decision-making, and
(d) opportunities for primary care providers to deliver feedback on how their views have been taken into account in the delivery of ICB functions.
(4) An integrated care board must publish an annual statement describing—
(a) how it has complied with this section, and
(b) the impact of primary care providers’ involvement on decisions taken by the ICB.
(5) The Secretary of State may issue guidance about the application of this section to which integrated care boards must have regard.”
This new clause ensures a certain range of primary care providers are consulted by integrated care boards in the development of their healthcare plans.
Karin Smyth
Clause 24 abolishes the requirement for health and wellbeing boards to prepare and publish a joint local health and wellbeing strategy. Instead ICBs, local authorities and their partners must work together through the health and wellbeing board to develop a neighbourhood health plan, in line with this Government’s commitment in the 10-year health plan. The neighbourhood health plan should be updated regularly to reflect the needs of the local population, unless all partners consider the existing plan is sufficient.
In developing their neighbourhood health plans, responsible local authorities and partner ICBs must involve the people who live or work in the area of the responsible local authority. The neighbourhood health plan will cover most of the topics previously considered by joint local health and wellbeing strategies, but will also encourage a deep focus on tackling the challenges facing individual neighbourhoods. That may mean applying different geographical focuses to different elements of the plan, to ensure that planners are addressing the real and different needs of the diverse communities they serve.
These plans will outline how the NHS, local government and local partners intend to improve the health of people in their locality and reduce health inequalities through a joined-up neighbourhood health approach. The plans will consider how local services can help realise national NHS priorities, further public service reforms, and improve performance against the adult social care outcomes framework and the local outcomes framework metrics. To support this work, the Government also intend to provide local areas with guidance and we will work with systems to ensure this addresses the needs of local planners and local communities.
Dr Johnson
Clause 24 puts neighbourhood health plans on a statutory basis. Currently, section 116A of the Local Government and Public Involvement in Health Act 2007 requires local authorities and partner ICBs to prepare a joint local health and wellbeing strategy once they have received their integrated care strategy. Essentially, that means that the ICBs and local authorities produce their overall strategy, then it devolves down, and then the joint health and wellbeing strategy looks at how it will be delivered. The local authority and its partners must give regard to the integrated care strategy, the NHS England mandate and any guidance issued by the Secretary of State. The strategy must be published and local people and the local Healthwatch must be involved in its development.
Section 116B of the 2007 Act places a duty on local authorities and partner ICBs to have regard to various strategies when exercising their function, specifically, a joint strategic needs assessment, an integrated care strategy and a joint local health and wellbeing strategy. NHS England also has regard to these when providing healthcare for a specific area.
Clause 24 changes the JLHWS to a neighbourhood health plan. In many ways, that aligns with the shift in the Government’s 10-year health plan from hospital to community. As they have described it, more care in the neighbourhood will allow hospitals to focus on the more specialist care that may be needed, so more people can be cared for closer to home, which seems a reasonable aim.
However, if local authorities and partner ICBs have to give regard to what the centre is doing when developing neighbourhood health plans, to what extent does the Minister envisage that being directed? Local authorities and partner ICBs giving regard to the centre could mean there being a very loose requirement from the centre to provide for the local population, and then they get on with it; it could also be very prescriptive—my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) has talked about the pros and cons of having targets—with a whole litany of targets in the plans. Whether that squares with the Government’s claim to be devolving power, or whether it strikes as a centralising power, depends on how that is done and to what extent the Secretary of State plans to direct it. I would appreciate it if the Minister could talk about that.
As has been said, Sir Andrew Dilnot told the Committee that
“we cannot really address many of the fundamental problems facing the NHS if we do not sort out social care.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 84, Q131.]
The Government have asked Baroness Casey to review social care, but they have developed this measure in the meantime. Is that because they have been talking to her and know that it is the sort of thing that she will recommend—or are they putting the cart before the horse, as my hon. Friend the Member for Farnham and Bordon suggested?
Later in the Committee’s considerations, we will come to Healthwatch, its benefits and the concerns that I and, I am sure, many other Committee members have about its abolition. What mechanisms does the Minister envisage there being for local people—local patients—to contribute to the neighbourhood health plans? A local Healthwatch currently contributes to the equivalent, the joint local health and wellbeing strategy, as a way of ensuring that it captures patient and community voices. How will that be done otherwise?
Some 80% of the Government’s new neighbourhood health centres that will deliver these plans are expected to be funded through public-private partnerships. Does the Minister have any comments on that, particularly in the light of the expensive private finance initiative that the last Labour Government entered into and left us stuck with?
In March 2026, the Government produced a neighbourhood health framework policy paper, which identified the goal of reducing non-elective admissions for those with severe frailty. Given that goal, why are the Government not on track to deliver the fracture liaison service improvements that they promised?
The policy paper also commits to what it calls
“a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties”.
What is a “diversion rate”? It essentially requires more GP referrals to be rejected, so let us be clear about what that means. When someone, either hon. Members or constituents, goes to see their GP, they are referred to a consultant for care; I should declare an interest as a consultant in the NHS. The consultant will then review that referral and decide whether they think it is clinically appropriate to see the patient, whether a different specialty may be more appropriate, or whether they can give advice or make suggestions about treatment that could be given in primary care instead.
When a patient is given an appointment in secondary care, it essentially means that the GP has decided that they clinically need it, and the consultant has decided that they clinically need it too. If the Government want a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties, are they suggesting that patients who the GP and consultant agree clinically need an appointment should not get one? If so, why?
Dr Danny Chambers (Winchester) (LD)
It is an honour to serve under your chairship, Sir Jeremy. I have been itching to speak on this new clause, tabled in the name of my hon. Friend the Member for Epsom and Ewell (Helen Maguire)—I am not sure how to pronounce that, but I am sure it is a very beautiful place; I have never been. It would ensure that a certain range of primary care providers were consulted by integrated care boards in the development of the healthcare plans.
The recent King’s Fund report, as well as many others, showed that over 90% of NHS contact with patients is in primary care in all its forms. New clause 70 relates to new clause 60, also tabled by my hon. Friend, which is about having GP representation on integrated care boards. This is an extension of that, so that dentists, pharmacy contractors and providers of ophthalmic services can all feed into integrated care boards’ healthcare plans. That is how most people come into contact with the NHS, which means that those providers have a close and deep understanding of the healthcare issues facing the demographics in their communities.
Dr Johnson
New clause 70 talks about a certain range of primary care providers being consulted by the ICB. Can the hon. Member clarify whether it is his intention for all providers of those services in a defined area to be consulted, or would it be a representative selection? If it is the latter, how would they be chosen?
Dr Chambers
The hon. Lady makes a good point. The purpose is to ensure that those who are deeply embedded in community care are consulted by the ICBs, so that they do not miss obvious localised issues in their demographics when developing care plans.
Just to give a brief example from a surgery I held recently, Joanne Cook is an occupational therapist who is campaigning for occupational therapists who have received specific training to be able to prescribe, and crucially de-prescribe, medications, in the same way that trained paramedics can. Often, occupational therapists see patients on a daily basis. They give them intimate and regular care, and are even better placed than GPs to notice small changes and adjust medications to keep people out of hospital.
If integrated care boards are not drawing on the experience, knowledge and data from primary care providers in all their forms, any healthcare plans they come up with will not be relevant to those demographics. We will not be keeping people out of hospital or treating them as effectively in the community, and the whole system will not be as efficient or as targeted as it could be. I would appreciate it if the Minister considered accepting the new clause.
Gregory Stafford
I am not convinced that clause 24 delivers the transformation that the Minister claims. At its core, it appears to be little more than a rebranding exercise. It replaces joint local health and wellbeing strategies with neighbourhood health plans, but does remarkably little to strengthen the underlying duties on local authorities or integrated care boards. Merely changing the name of a document does not improve patient outcomes, reduce waiting lists or deliver more integrated care.
The duty created by the clause is also remarkably weak. Local authorities and ICBs need only prepare a plan and then “have regard” to it when exercising their functions. That is one of the least demanding obligations available in legislation. It requires consideration, not compliance. An ICB could acknowledge the plan, but decide to depart from it and still satisfy the legal test. If neighbourhood plans are genuinely intended to drive local health policy, the Bill should do a lot more to require decision makers to act in accordance with them, or at the very least to explain publicly why they have chosen not to.
I am also concerned that the clause creates additional bureaucracy without any clear accountability. It requires the production of another planning document, another consultation exercise and another set of reporting expectations, but provides for no—for want of a better phrase—enforcement mechanism or measurable outcomes against which success can be judged. There is a risk that local systems will spend their time drafting plans rather than delivering services. Public involvement is of course essential, and indeed welcome, as we have heard, but the clause offers no detail about what meaningful involvement looks like and contains nothing to prevent a token consultation from satisfying the statutory requirement. If the objective is genuine neighbourhood-led healthcare, the legislation needs to be drafted much more tightly.
Moving on to new clause 70, I do my absolute best not to be flippant when it comes to Lib Dem amendments and new clauses, but once again we have an idea that is fine in principle—in fact, I think we would all support it in principle—yet the hon. Member for Winchester could hardly articulate how the new clause would work and whom it would involve.
Helen Morgan
The hon. Member will be aware that the new clause is a probing amendment. It is designed to push the Minister to describe how we will ensure that this range of expertise is taken into account when the plans are put together. We will not press the new clause to a vote, but we want to use it as a discussion point to probe how the range of expertise in the health service will be fully utilised, so that the plans are the best they can be.
Gregory Stafford
I thank the hon. Lady for that clarification. It is helpful to understand that the Liberal Democrats will not press the new clause to a vote, but if we are to use probing amendments effectively, they need to be drawn much more tightly, so that a Minister does not have the opportunity—I am sure that today’s Minister would not do this—to wriggle out of it because it is so poorly drafted.
Dr Chambers
What we are desperately trying to do is ensure that we are drawing on the expertise of primary care providers. The hon. Member seems not to understand that talking about 40 new hospitals the whole time with no plan to deliver them is looking at the wrong end of the health service. We need to try to keep people healthy and in the community. The new clause is an attempt to refocus thoughts on keeping people healthy in the community, rather than talking about hospitals that never existed.
Gregory Stafford
We can go back to the record in Hansard, but I do not remember mentioning anything to do with hospitals in what I just said; I may have had some sort of amnesia at that point. If the hon. Member is referring to the plan of the last Government, which was fully costed, for 40 new hospitals, then I am afraid I did not mention that. On his wider point, Conservative Members want to understand how local authorities and deliverers of primary care—dental services and so on—will be included and can have influence over the plans and strategies that ICBs draw up. I fully support that ambition; I just feel that, if we are to have that ambition, we need to table amendments and new clauses that the Minister might actually accept, so that we can go forward.
Karin Smyth
I thank hon. Members for their comments. I accept those made by the hon. Members for Winchester and for North Shropshire. I offer the Liberal Democrats the assurance that the Government fully appreciate the important role that primary care plays in informing ICB decisions, which is why we have retained the requirement that ICBs engage with their system partners, including primary care services, in the exercise of their planning and commissioning activities.
It is universally recognised that full engagement with providers, including primary care, is fundamental to good commissioning, and this is reflected in the strategic commissioning framework. The neighbourhood health framework sets out how neighbourhood health plans should be developed through health and wellbeing boards and with the involvement of system partners. We expect primary care to be fully involved in the process.
In addition, ICBs will continue to engage local representative primary care committees, such as the local medical committees. ICBs must comply with their duty to obtain appropriate advice from persons who have broad professional expertise in prevention, diagnosis or treatment of illness and the protection or improvement of public health. Primary care practitioners will remain key sources of such advice. Although I agree that experience of general practice is fundamental—as a commissioner, I worked very closely with general practitioners, who deal with 90% of patient contacts—I do not believe that placing an additional requirement on ICBs to engage specifically with primary care providers is necessary.
I will take this opportunity to clarify matters. We are moving between the roles of ICBs and local authority health and wellbeing boards. I know this is a subject of great interest and will continue to be debated in relation to those bodies’ commissioning and providing functions. The planning structure will be improved under clause 24, reflecting our commitment to neighbourhood health and making it a reality.
Planning begins with a joint strategic needs assessment developed by health and wellbeing boards; that assessment informs the new neighbourhood health plan, replacing the joint local health and wellbeing strategy. Meanwhile, ICBs will produce population health improvement plans, aligning multiple joint strategic needs assessments, neighbourhood health plans and local priorities. Patient and local voices must, of course, be embedded in ICB decision making and in the planning process. ICBs are being supported to do that. The strategic commissioning framework published on 4 November 2025 clearly set out that user involvement is key to strategic commissioning.
Having proper plans that address the needs of neighbourhoods will help the NHS to deliver for every community in our country. That is where the patient focus is and where people experience healthcare the most, and it is why we have made these commitments in neighbourhood health plans. I commend clause 24 to the Committee as the means to make that a reality.
Question put and agreed to.
Clause 24 accordingly ordered to stand part of the Bill.
Clause 25
NHS trust accounts
Question proposed, That the clause stand part of the Bill.
Karin Smyth
Clause 25 makes focused but important changes to the accounting and audit arrangements for NHS trusts by amending schedule 4 to the National Health Service Act 2006. It does not put additional burdens on NHS trusts; instead, the aim of the clause is to align the requirements for trusts with the updated accounting arrangements for foundation trusts made elsewhere in the Bill. The changes are needed as a consequence of the abolition of NHS England and the removal of the requirement for foundation trusts to have councils of governors and members.
The amendments the clause makes replicate trusts’ existing duties to keep proper accounts and records about those accounts, and to prepare annual accounts for each financial year. The clause also replicates the Secretary of State’s current power to direct an NHS trust regarding the form of its annual accounts, but extends that power of direction so the Secretary of State may also direct a trust to prepare accounts for a specified period—for example, when part-period accounts are needed. That will help to ensure a consistent approach to financial reporting while retaining the flexibility to keep requirements up to date.
The clause also sets out and strengthens how the audit arrangements for NHS trusts should operate, mirroring the approach for foundation trusts and integrated care boards. It provides that NHS trust annual accounts are audited under the Local Audit and Accountability Act 2014, as is the case currently, but it also provides that part-period accounts may be audited in accordance with that Act where the Secretary of State so directs.
The clause also enables the Comptroller and Auditor General to examine the accounts and related auditor reports, as is currently the case. To reflect the fact that the Secretary of State will have oversight of providers once NHS England is abolished, it requires the accounts and audit reports to be sent to the Secretary of State.
Taken together, these measures support transparency, consistency and robust financial assurance. They will help to reduce unnecessary divergence in accounting requirements across different types of NHS provider, while maintaining clear oversight of public funds. That is consistent with the Bill’s broader intent to support effective governance and clear accountability for providers.
Clause 26 makes minor technical amendments to ensure that the statute book remains clear and coherent as the Bill aligns the approach to audit and accounts across NHS trusts and foundation trusts. It sits alongside the provisions in the Bill that update the arrangements for the audit of foundation trusts following the abolition of NHS England and the removal of the requirement for NHS foundation trusts to have councils of governors and members.
The clause does that by amending or removing outdated transitory provisions relating to the audit of NHS trust accounts in two places: the NHS Act 2006 and the Local Audit and Accountability Act 2014. Clause 26 therefore supports the effective implementation of the wider measures in this part of the Bill by ensuring that the legislation is up to date, accurate and internally consistent. I commend clauses 25 and 26 to the Committee.
Dr Johnson
As has been said, clause 25 specifies how NHS trusts should handle their accounting. Paragraph 11A of schedule 4 to the NHS Act 2006 sets out the current obligations, which are that the trust must keep proper accounts, that the Secretary of State may give directions about how the accounts are held, and that the accounts must be prepared annually, may be examined by the Comptroller and Auditor General, and must be submitted to NHS England.
Clause 25 replaces paragraph 11A entirely. Under the new provisions, the reporting goes to the Secretary of State, instead of NHS England—which seems sensible, because the Government are abolishing NHS England—and the Secretary of State may give directions about “methods and principles”, as well as the “form and content”. The Secretary of State may also give directions about specified periods in which accounts are to be prepared.
Will the Minister explain why those provisions are felt to be necessary? There will be suspicion among some more cynical people that the power to specify periods could be used to be more flattering for the Government, or that methods and principles could be used to change the perception of the position. Can the Minister give an example of where she thinks such periods would be useful, and also say why she thinks it is necessary to enable the Secretary of State to give directions about methods and principles, and form and content, in a way that is not done at the moment?
The exception for charitable trusts of which the NHS is a trustee is being removed. Will the Minister explain why she thinks that is important, and in what situation she thinks that power would be used? Finally, will she say whether the financial directors of NHS trusts have been consulted about these changes? If so, what was their feedback?
Clause 26 tidies up relevant provisions in two pieces of legislation, as the Minister has described.
Karin Smyth
If there are specific examples that are helpful, I will write to the hon. Lady—I am not entirely sure I got the point about charities, but we will pick that up in Hansard.
As I outlined in my opening remarks, these clauses are about standardising the key requirements across the NHS provider landscape in relation to annual and other accounts and records in relation to those, and audit and reporting requirements, including keeping those up to date and having a consistent approach across all NHS provider types. Of course, we worked closely with NHS England colleagues and directors of finance in seeking to bring forward those provisions.
Question put and agreed to.
Clause 25 accordingly ordered to stand part of the Bill.
Clause 26 ordered to stand part of the Bill.
Clause 27
Special Health Authorities: establishment and exercise of functions
Karin Smyth
Clauses 27 and 28 make amendments to the legal framework around special health authorities to give the Secretary of State the flexibility to best manage the reliable delivery of healthcare for patients and the public. As the Committee knows, special health authorities are independent bodies established by the Secretary of State, by order, to perform specific functions. They play a key national role in the health system, carrying out specific functions on behalf of the Secretary of State.
Clause 27 does two key things to the special health authority legal framework. First, it amends section 28 of the NHS Act 2006 to increase the scope of functions that a special health authority could be established to deliver. Currently, the Secretary of State can create a special health authority only for the purpose of exercising functions under the 2006 Act. The clause allows a special health authority to be established to exercise functions under any other Act as well.
Secondly, the clause amends section 29 of the 2006 Act, which currently enables regulations to provide for the functions of a special health authority to be carried out flexibly, by another special health authority or jointly with one or more other special health authorities. That applies only to functions that the Secretary of State has directed the special health authority to exercise under section 7 of the 2006 Act. The clause removes that limitation, so that those arrangements can be made for any functions of the special health authority, not just those that it is directed to carry out under section 7.
These changes are needed because the health and care system is underpinned by a range of statutory functions that do not sit exclusively within the 2006 Act. The Secretary of State needs to be able to establish special health authorities to carry out those wider functions, and to give those functions to existing special health authorities. The clause ensures that the Secretary of State has the modern, adaptable tools required to place specialist functions in the right national body, with the appropriate governance and accountability. Equally, special health authorities need to be able to work with other special health authorities across all their functions in a way that best serves the needs of the wider health and care system.
On occasion, it is necessary for Ministers to merge, alter or abolish special health authorities, either because of changing circumstances or to ensure the smooth and effective running of the system. Clause 28 provides the flexibility to transfer and redeploy staff. It allows regulations to be made to enable staff to be transferred to an integrated care board or another special health authority. These changes ensure that staff can be transferred where they may be needed most, allowing for flexibility to direct resources in the health system.
The clause also allows for arrangements to be made for a special health authority’s staff to be made available to another special health authority, a local authority, the Secretary of State or an integrated care board. That may be necessary during an emergency or to provide specialist support to help an organisation achieve a particular outcome. The clause also allows the Secretary of State to give directions to a special health authority to make staff available to another special health authority or integrated care board or the Secretary of State.
Clause 28 also amends the existing power to make regulations about the sharing of information with other bodies, to allow information to be shared with integrated care boards in addition to the Secretary of State and other special health authorities. That allows for information to be shared across the system so that national and local functions can be successfully fulfilled and supports a more joined-up health system.
Clauses 27 and 28 provide for future-facing updates that will support effective administration and ensure the more reliable delivery of healthcare for patients and the public. I commend them to the Committee.
Dr Johnson
Special health authorities are, in essence, specialist health authorities set up by the Secretary of State, usually to provide an England-wide service of some form. Examples include NHS Blood and Transplant, and the NHS Business Services Authority, which provides NHS pensions—I should declare that I have an NHS pension—admin for prescription exemptions and other such business-type functions. We also have NHS Resolution, which deals with clinical negligence claims, and the NHS Counter Fraud Authority.
In principle, special health authorities are useful in some cases, but they are effectively a form of quango. Can the Minister explain when she thinks the Government might want to set up a special health authority, rather than using a department within the DHSC to deliver the same thing? There are plenty of other nationally delivered services, and although the Government have suggested that some services, such as screening, will become localised as part of the Bill, some things will remain national. Can the Minister give some examples of what the new provision will be used for?
I can see there is provision for flexibility, but the special health authorities would require setting up, and there are set-up costs and costs associated with branding and those sorts of things. How does the Minister envisage those costs being provided for, and when will it be necessary for the Government to use them rather than just using the Department?
Special health authorities have been created, reconfigured and shelved many times. For example, the National Treatment Agency for Substance Misuse became part of Public Health England in 2013, and the NHS Institute for Innovation and Improvement was closed in the same year. The functions of the National Patient Safety Agency went to the NHS Commissioning Board Special Health Authority, later known as NHS England, in 2012 and then to NHS Improvement in 2016. Widening the scope could leave us with more quangos than are necessary.
Which specific functions do the Government plan to move into special health authorities under this widened power? Have the Government just decided that they need this power and are increasing the scope because they are abolishing NHS England without a proper plan? Is this power just to cover themselves in the event that, as they start to make a plan, they find out they need it?
Clause 28 enables the Secretary of State to make regulations for the transfer of staff from one special health authority to another, or to an ICB. Paragraph 3(8) of schedule 6 to the National Health Service Act 2006 states:
“Regulations may provide for the transfer of officers from one Special Health Authority to another”,
or to NHS England,
“and for arrangements under which the services of an officer…are placed at the disposal of another Special Health Authority”,
or NHS England, or a local authority. Paragraph 3(12)(a) states that the Secretary of State may give directions
“to place the services of any of its officers at the disposal of another Special Health Authority”,
or NHS England. Paragraph 13 states:
“Provision may be made by regulations with respect to the recording of information by a Special Health Authority, and the furnishing of information by a Special Health Authority to the Secretary of State, another Special Health Authority”,
or NHS England.
Clause 28 modifies that paragraph such that regulations can now provide for the transfer of an officer to an ICB—that is a new power—as well as a special health authority and a local health authority, but no longer to NHS England because NHS England is being abolished. Regulations can now provide for an officer’s services to be placed at the disposal of the ICB and the Secretary of State, which is a new power, as well as the special health authority or local authority, but no longer NHS England. The clause modifies paragraph 3(12)(a) of schedule 6, so that directions may be given about placing the services of officers at the disposal of the special health authority and, newly, the Secretary of State or an ICB, but not NHS England. As the Minister said, the clause also modifies paragraph 13 of schedule 6, so that a special health authority can be required by regulations to pass information to integrated care boards, which is a new power, but no longer to NHS England.
NHS England is to be abolished, so it is sensible to say that staff can no longer be placed there—that seems an entirely reasonable exercise—but the legislation providing for special health authorities essentially contains open-ended spending power. Remuneration of the special health authority chairman and staff can be determined by the Secretary of State, with the approval of the Treasury. Does the Minister foresee an upper limit to those sorts of salaries?
People will essentially be able to transfer from one special health authority to another, or to an ICB—or be placed at the disposal of another special health authority, an ICB, a local authority or the Secretary of State. Will the Minister talk about the location, pension and salary of those individuals? We heard yesterday that the future Prime Minister, the right hon. Member for Makerfield (Andy Burnham), may want to move a whole load of civil servants from London up to Manchester. That will clearly be within his gift if he becomes Prime Minister, but for individuals who work in one location to be asked to move to another is disruptive to their family and social lives, and involves significant relocation costs. If people are moved in the way that clause 28 describes, particularly by transfer, what choice will they have? What will happen to their pension, salary and other terms and conditions, and will they have a choice of location or not?
Gregory Stafford
Very briefly, on clauses 27 and 28, I am sure the Committee is aware that special health authorities were initially established under the National Health Service Act 1977. Since then the number of special health authorities has expanded and contracted a number of times over the years to leave us with, currently, NHS Blood and Transplant, and the Business Services Authority, which covers pensions, as my hon. Friend the Member for Sleaford and North Hykeham mentioned—I should declare that I have an NHS pension, albeit a very small one—as well as the NHS Litigation Authority, also known as NHS Resolution, and the NHS Counter Fraud Authority.
The mood music and the direction of travel, certainly since 2006, has been to reduce the number of special health authorities. On my reading, clauses 27 and 28 suggest that the Government are potentially looking to expand the number of special health authorities, given the Secretary of State’s direction under clause 27 and the practical steps for staff transfers in clause 28. Is the Minister looking at, for example, a special health authority to deal with artificial intelligence? Clearly that is something the NHS will have to embrace—or deal with, depending on which end of the AI argument one is on—rapidly over the coming years. Is that a potential area for a special health authority? Perhaps the Minister could outline where she sees the special health authorities acting and what their remits might be.
Karin Smyth
To be clear, in response to the comments of the Opposition spokesperson, the hon. Member for Sleaford and North Hykeham, it is not currently our intention to set up any new special authorities to deliver any specific functions. We are taking this opportunity to update the legislative framework and ensure that in future the functions that a special health authority could carry out are less limited. The current legislative framework limits the remit of such authorities to their functions under the NHS Act 2006, which is outdated and does not reflect changes since that time. There are functions of the Secretary of State under the Health and Social Care Act 2012 that we may want special authorities to carry out in future. I agree with the Opposition spokesperson that the situation is complex. We have had a lot of changes over many years, as both she and the hon. Member for Farnham and Bordon said. I agree that we need flexibility for future provision, and that is what the clauses provide.
We have no immediate intention to delegate specific functions of the Secretary of State. However, following the abolition of NHS England, a range of functions may need to be established, as the hon. Member for Farnham and Bordon outlined. Those functions could, as an example, include the data and information functions in part 9 of the Health and Social Care Act 2012, which currently sit with the Secretary of State.
I assure the Committee that the clauses do not change the existing processes or scrutiny that exist around setting up a special health authority. They are, as I think the Opposition spokesperson said, about future-proofing. I commend the clauses to the Committee.
Question put and agreed to.
Clause 27 accordingly ordered to stand part of the Bill.
Clause 28 ordered to stand part of the Bill.
Clause 29
Constitution of NHS foundation trusts
The Chair
We now come to group 24, and amendment 73 to clause 29 tabled by Charlie Maynard. Does any Member wish to move amendment 73? With that not being so, the question becomes that clause 29 stand part of the Bill.
The Chair
With this it will be convenient to discuss the following:
Amendment 74, in schedule 3, page 80, leave out paragraphs 5 to 8.
This amendment would retain the requirement for NHS Trusts to have a Council of Governors.
Amendment 75, in schedule 3, page 80, leave out paragraph 14.
This amendment would retain the requirement for NHS Trusts to have a Council of Governors.
Government amendment 19.
Amendment 36, in schedule 3, page 82, line 3, at end insert—
“(1A) The function under sub-paragraph (1) must be exercised by a person employed in the civil service of the State, and a Minister of the Crown or a special adviser must not be involved in any decision relating to such an appointment, suspension or removal.”
This amendment would ensure that civil servants are responsible for the decision making and appointment processes for trust and ICB leaders, rather than Ministers or Special Advisers.
Schedule 3.
Clause 30 stand part.
New clause 59—Independence of appointments—
“The Secretary of State must make provision to ensure that operational decisions regarding the appointment, suspension or removal of—
(a) chairs and directors of NHS trusts and NHS foundation trusts, and
(b) chief executives of integrated care boards,
are made exclusively by persons employed in the civil service.”
Karin Smyth
Amendment 19 reinstates in primary legislation the requirement in schedule 7 to the National Health Service Act 2006 for an NHS foundation trust board to include one executive director who is a medical or dental practitioner, and another who is a registered nurse or midwife.
I want to be clear to the Committee from the outset that there was never any intention to change the policy on the clinical membership of NHS foundation trust boards. Foundation trusts would still have been expected to have appropriate clinical leadership on their boards, but we had heard from ambulance foundation trusts that the current framing of the requirement for clinicians is not always helpful, and greater flexibility was therefore required. However, we also heard from important stakeholders, including the Royal College of Nursing, that removing the requirement from primary legislation has been perceived as deprioritising clinicians, which is absolutely not the case. We have therefore tabled amendment 19 to remove any doubt.
These roles provide valuable clinical oversight of board governance in decision making in foundation trusts, and are essential to ensuring the safety and quality of patient-facing services in the NHS. At the same time, some providers may need different clinical expertise at board level. For example, in ambulance trusts, an experienced paramedic may be better placed to provide the relevant clinical guidance and oversight. The amendment therefore gives the Secretary of State a regulation-making power to create exceptions to the requirement following engagement with relevant stakeholders. That preserves the current position in primary legislation while allowing for targeted flexibility for ambulance or patient transport-focused foundation trusts where appropriate. I commend amendment 19 to the Committee.
Clause 29 introduces schedule 3, which makes changes to the governance and constitution of NHS foundation trusts. It removes the various statutory roles of foundation trust members and councils of governors, and repeals the requirement for FTs to have them. Amendment 73 to 75 look to oppose that, but I do not think that we are discussing those.
The Chair
Order. Forgive me; let me interrupt to explain. I asked if anyone wished to move amendment 73, and no one did. We will come to amendments 74 and 75, so the Minister is welcome to speak to those amendments now or at the end of the debate if she wants to. Other members of the Committee may wish to move those amendments subsequently.
Karin Smyth
Thank you for the clarification, Sir Jeremy. I will come to amendment 75 at the end of the debate.
The Bill’s removal of councils of governors from NHS foundation trusts is part of delivering the 10-year health plan goal of hospitals putting patient experiences and outcomes at the heart of their decision making. That is not because we want to rid the system of local voices in democratic accountability—far from it. Although governors have provided helpful advice and oversight for some foundation trusts, we expect the next generation of NHS foundation trusts to put in place more responsive and flexible arrangements for drawing on patient, staff and stakeholder insight.
Rather than a one-size-fits-all model, providers should develop engagement arrangements that reflect their local populations, geographies and healthcare needs. Foundation trusts will have the option to retain aspects of their engagement model where it is working well, but can take a different approach if needed. Following Royal Assent, foundation trusts will be expected to have those arrangements in place and will be assessed as part of the non-statutory advanced foundation trust process.
Schedule 3 makes related changes to governance and decision making, in line with the Government’s policy to streamline oversight of providers and reduce duplication in the system. For example, the legal powers to appoint chairs and non-executive directors of foundation trusts and NHS trusts will, in future, both sit with the Secretary of State while supporting the effective use of talent across the NHS. Other functions of the council of governors, such as reviewing plans and major transactions, currently duplicate existing NHS England responsibilities, which will transfer to the Secretary of State through this Bill. Removing those requirements will therefore reduce duplication in the system.
Schedule 3 will also give the Secretary of State responsibility for approving changes to foundation trust constitutions and material changes to private patient income, and deciding chair and non-executive remuneration. The Secretary of State will take on the oversight role currently exercised by NHS England, and previously Monitor, including monitoring foundation trust performance, use of resources and governance. That will support system alignment and ensure that appropriate accountability arrangements are in place. Can I seek clarification, Sir Jeremy, that I can speak to clause 30 at this point?
The Chair
Yes, we are debating all the provisions in this group together, so the Minister is welcome to speak to clause 30 now or later, when she winds up.
Karin Smyth
Thank you, Sir Jeremy. Clause 30 clarifies how NHS foundation trust status will be applied for and granted following the abolition of NHS England and the removal of the council of governors model. The Government are committed to reinvigorating the foundation trust sector by granting high-performing providers greater freedoms and autonomy. The power to authorise foundation trusts originally sat with Monitor and passed to NHS England in 2022. The clause, alongside schedules 3 and 11, sets out how that power will operate when it transfers to the Secretary of State. It also makes consequential amendments to the authorisation process, including removing requirements linked to recruiting members and electing governors. The Secretary of State will also set the criteria for becoming a foundation trust. I commend the clauses and the schedule to the Committee.
Dr Johnson
This is quite a large group. First, clause 29 introduces schedule 3, which will make changes to the constitution of NHS foundation trusts. Currently, chapter 5 of the National Health Service Act 2006 establishes NHS foundation trusts as public benefit corporations in accordance with schedule 7 to the Act. That schedule, “Constitution of public benefit corporations”, sets out, among other things, the requirements for a constitution, the eligibility for membership, and the council of governors.
Schedule 3 to the Bill, introduced by clause 29, has a number of functions. First, it modifies the 2006 Act so that a foundation trust will no longer be a public benefit corporation, but will now be a body corporate—I would be interested in the Minister’s explanation of that change. It also modifies section 33(4) of the 2006 Act to remove reference to councils of governors, so that trusts no longer need to set those up, and modifies section 37 so that an NHS foundation trust can amend its constitution with the approval of the Secretary of State, where previously, that would have required a vote of more than half the members of the board of directors and more than half the members of the council of governors.
The schedule also deletes section 39A of the 2006 Act, “Panel for advising governors”, because one presumes if there are no governors, they do not need advice. It modifies section 43, “Provision of goods and services”, so that if a foundation trust wishes to raise its non-NHS income by 5% or more, the Secretary of State must approve it—previously that would have required local decision making from more than half of the members of the council of governors. It also deletes section 51A, “Significant transactions”, which states that an NHS foundation trust may enter into significant transactions, as defined in its constitution, only if more than half the members of the council of governors voted to approve it.
The schedule also deletes sections 56(1A), 56A(2), 56B(2) and 57A(2) of the 2006 Act. That means that governors will no longer have to approve a trust merging, being acquired, splitting or being dissolved. The Bill’s explanatory notes say that the Secretary of State will take on those approvals via schedule 11. Schedule 3 also deletes section 59, “Conduct of elections”, section 60, “Voting and standing for election” and section 61, “Representative membership” of the 2006 Act, which set out the democratic machinery for foundation trusts.
Schedule 3 also substitutes schedule 7 to the 2006 Act with an entirely new version. Elements of that new schedule 7 are as follows: the Secretary of State will now be able to appoint, suspend or remove the chair and non-executive directors—previously that was a governor’s role—and they can set the pay, allowances and terms of non-executive directors, and may regulate their tenure. The chief executive will be appointed by the non-executive directors, and the other executives will be appointed by a committee of the chair, the chief executive and non-executive directors, but the Secretary of State may set when those powers may be used. As the council of governors and its membership will be abolished, there are no members, elections or constituencies anywhere in the new schedule. Constitutional amendments will need the Secretary of State’s approval, not the approval of members and governors. The Secretary of State may make regulations on director eligibility, beyond the standard disqualifications. Directors owe a duty to promote the trust’s success, to maximise benefits for the public, with respective interests, duties and registers of interest. Board meetings must be open to the public. Accounts and audits are aligned with NHS trusts and ICBs. The Secretary of State may direct the form, content and timing as we have talked about before. Annual reports and forward financial plans go to the Secretary of State in the form that the Secretary of State decides, and trusts must publish their constitution, register, accounts and annual reports and hold a public meeting on them.
The council of governors was intended to feed in democratic input. Does the Minister have any comment on where democratic input will be held? Will it be solely through the Secretary of State, or is there any intent for local patient voice, now Healthwatch is being abolished too? How will local decision making be informed, and how will they understand their local area, particularly if it is to be directed largely by the Secretary of State?
Removing the council of governors will save money on administration, as noted in the impact assessment. The impact assessment also notes the Secretary of State does not have the ability to intervene in serious instances of foundation trust failure. Could the Minister comment on that?
Foundation trusts were intended to be independent. If the council of governors is removed and many things, as I have listed, are put under the control of the Secretary of State, they become increasingly more like an ordinary NHS trust, pre-foundation. Will they be independent in name only?
Non-executive directors are meant to be there to hold the leaders of the trust to account, but the Secretary of State can now appoint, pay and fire every non-executive director so a foundation trust’s internal watchdog can now be controlled by an elected politician who is potentially quite remote from that area. Does the Minister have any comment on how she sees that working?
Foundation trusts may have failed to increase democratic involvement in so far as there has not been huge interest in some of these elections for chairs of governors. But the answer to that would be a better version of local involvement rather than removing local input entirely.
The theme right across the schedule and the changes I listed is that foundation trusts are looking up to the Minister rather than out to local communities. Many NHS inquiries have reported back that frontline concerns did not reach the highest tiers of leadership. The Government are now closing an independent channel for sounding the alarm. Will the Minister comment on that?
I welcome Government amendment 19 because the idea that you need medical expertise on the board of a trust that delivers medical care seems to me fairly obvious, because otherwise you will get decisions that are not grounded in medical knowledge. I do recognise what the Minister says about it was not having been her intention to demote the voice of clinicians, but that was the effect. This amendment will go some way to correcting that, by having an executive director who is registered medical practitioner or a dentist, and another who is a registered nurse or midwife. Could the Minister be clear if a foundation trust wanted a nurse and a midwife, perhaps because they had a specific issue with the midwifery area, or a medical practitioner and a registered dentist, could they have both?
The Minister suggested that an exemption would be ambulance care, but there are medical practitioners, consultants, with expertise in out of hospital care. Does the Minister feel their expertise is not useful in some way?
I will speak to amendment 36 once it is moved. On clause 30 stand part, that clause removes the requirement for NHS England to consult prospective members or governors of a prospective foundation trust before its authorisation. Getting a new foundation trust without NHS England because it has been abolished is a consequence of earlier clauses that we have already voted on. Therefore, I will not go further on that issue.
Helen Morgan
I wish to speak to amendment 36 and new clause 59, which are different ways of seeking to do the same thing. They are aimed at ensuring that “civil servants are responsible for the decision making and appointment processes for trust and ICB leaders, rather than Ministers or Special Advisers.”
In earlier sessions, we spoke about the risk of political capture; the amendment and new clause intend to deal with that. The Government’s intention is to give providers more freedom to design services around local needs, but we are worried that giving the Secretary of State the powers to appoint trust chairs and non-executive directors will undermine that local flexibility and agency. It risks creating a bottleneck in the Department for Health and Social Care, leaving foundation trusts waiting for approval to make their arrangements. In theory, the Secretary of State will be responsible for the appointment of 143 foundation trust chairs and roughly 1,000 foundation trust non-executives, who themselves will appoint the executive directors. Clearly, there is the potential for a bottleneck there.
We also think that in the hands of the wrong Secretary of State—I cast no aspersions about the current one—there is potential for mass manipulation of the make-up of future NHS leadership. I think everybody here would agree that NHS leaders should be the best possible people for the job, not those who best fit the political agenda of the Secretary of State of the day. We are worried that future Secretary of States could abuse their power, intervening unnecessarily and for non-clinical reasons in hiring and firing decisions. Their political views could heavily influence the make-up of trust and ICB non-executives across the country—who are themselves responsible for appointing the chief executive— and lead to the firing and hiring of those who suit their personal vision of what a leader should look like.
From speaking to chief executives and other senior NHS leaders, I know that many already feel that chief executives are subject to the political whims of the day and are too easily scapegoated for wider failures. Holding poorly performing leaders to account is extremely important when there are failures, but sometimes those concerns and the blame culture that can exist in those organisations stops capable, impressive NHS leaders from taking the next step up the ladder to becoming a chief executive. We think a safeguard is necessary there.
We recognise that someone has to hold that power and appoint those people now that NHS England has gone. That is why amendment 36 proposes that in order to ensure there is not political capture of those decisions, they are taken by impartial civil servants who are given a set criteria of what a good leader looks like, rather than by Ministers or their special advisers.
As I mentioned, new clause 59 broadly seeks to do the same thing, but uses a different mechanism for getting that into the Bill.
Helen Morgan
I had finished speaking, but I will give way and think of something else to say.
Dr Johnson
The civil servants will be under the direction of the Minister, so how does the hon. Lady envisage it working? Presumably, civil servants are there to deliver for their Ministers or Secretary of State? Is she suggesting that makes the decision more impartial? Can she give us some detail on how that will work?
Helen Morgan
As I mentioned in my previous remarks, one imagines that a Secretary of State would set out criteria to ensure that the best people for the job are appointed. We are in a situation where a current Parliament cannot bind a future one, but we do need to set a precedent that political capture of these important leadership roles is not an unintentional consequence of this legislation. I accept that it is unintentional; I think the Secretary of State and the Minister have drafted this legislation with the best of intentions, but this is something we should guard against.
Gregory Stafford
On clause 29 and the relevant amendments, the membership model and the council of governors were originally introduced to give patients, staff and local communities a formal voice in the governance of NHS organisations. I worry that by removing them the clause concentrates power in the hands of the trust board at a local level and, potentially, the Secretary of State at a national level, while reducing opportunities for local scrutiny and public participation. As my hon. Friend the Member for Sleaford and North Hykeham said, there is a real danger that organisations will be independent in name only.
That brings us back to the never-ending tension in the Bill between the centralisation of power in the Secretary of State, through the abolition of NHS England and all the other bodies we have talked about, and the Government’s stated desire to have more accountability for decision making at a local level.
Dr Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)
I am aware of the role of governors in some of our NHS trusts and the way in which they are appointed, but governors have said to me that they are sometimes disappointed by the level of influence they can in fact have in their trust. Can the hon. Member think of examples of where governors have particularly influenced the activities of individual trusts? I have not found that to be the case in my experience.
Gregory Stafford
The hon. Gentleman’s intervention neatly brings me to my next point. I have some sympathy for his viewpoint—and apparently the viewpoint expressed to him by governors—that in many cases, if not most, governors do not have the teeth, the influence or the ability to change things in the way they would like. My argument is very similar to the one we will expand on later regarding the abolition of the Healthcare Services Safety Investigations Branch and Healthwatch: the Government’s response to something not working as effectively as it could is to abolish it, but why not give those organisations the teeth—the powers—to achieve the things they were set up to do, unless the hon. Gentleman and the Government feel that there is no need, in Healthwatch’s case, for that level of independent scrutiny or, in governors’ case, that level of independent influence on boards?
There is a fundamental difference here: the Conservatives would take something imperfect and make it better; the Government’s response is to take something imperfect and abolish it. That is the wrong way round.
Dr Johnson
Does my hon. Friend think that this leaves a bit of a gap? The Secretary of State will not have the level of local oversight that the governors had, so how will that local oversight feed into the Secretary of State so that he or she can make the decisions instead?
Gregory Stafford
My hon. Friend is right that there will be a gap in local decision making on these issues. It goes back to that tension I described some moments ago: the Government’s stated intention is to devolve powers locally, but they seem to be pulling so much power up to the Secretary of State that we will lose the ability to make local decisions for the benefit of local populations where appropriate. We have a stated ambition for neighbourhood health, but those neighbourhoods are rapidly expanding in this legislation to become areas of millions of people. Local people who are interested in their local health delivery or local hospital trust would not see that as local decision making, and there is the gap that my hon. Friend describes.
I do not think that amendments 74 and 75 have been moved, so I will not talk about them. Government amendment 19 will require
“NHS foundation trusts to have at least one executive director who is a registered medical practitioner or a registered dentist and another who is a registered nurse or a registered midwife.”
As also stated in the explanatory note, and as the Minister mentioned, regulations may create exception—for example, for ambulance trusts. That is the right decision, and it is important that we have medical experience on foundation trust boards. I am interested in understanding from the Minister, first, why she has chosen a medical practitioner or registered dentist. Does she see some equivalence in their expertise that could be substituted? I have great respect for doctors and for dentists, but they have potentially different clinical expertise. If a foundation trust does no oral healthcare or maxillofacial reconstruction, and does no dentistry or allied specialties, would it really satisfy requirements to have a dentist on the board? Likewise, given that the amendment also refers to a registered nurse or midwife, if a trust has no maternity services, would having a midwife on the board really satisfy the requirement of that trust to have nursing care input? I ask those questions, and I would be interested in the answers.
Likewise, there is the exemption for ambulance trusts. Like my hon. Friend the Member for Sleaford and North Hykeham, I would be interested to understand from the Minister why she thinks ambulance trusts do not need a medical practitioner on their boards, given that they are doing medicine. Plenty of consultants work alongside paramedics and in ambulances, so again I am not quite sure why she is making that exemption. I would be interested to hear from her on that.
I understand the intention behind Liberal Democrat amendment 36. Once again, it is trying to soften the Secretary of State’s power grab over decision making—like the hon. Member for North Shropshire, I am not saying anything against the current Secretary of State, but a future Secretary of State could be different. The aim is to try to temper that in some way. Unfortunately for the hon. Member—I have sympathy for the amendment—the stated intention of the Bill is to pull more power to the Secretary of State. The Minister may surprise me, but I fear that the amendment will not find favour with the Government, because the whole Bill is about pulling more power to the centre, certainly when it comes to appointments, and to the Secretary of State.
However, the Minister should think about how future Secretaries of State may have to go through some process whereby their decisions are checked and justified, especially at local level. If we want local people to have influence and say over their local health systems and trusts, there needs to be some sort of bridging legislation or bridging process to ensure that whatever a Secretary of State decides, it has the confidence and support of local people and local service providers.
Karin Smyth
I think I am almost going to agree with the hon. Gentleman on his final point. It is important that local people have confidence in how their local systems are run and managed and, clearly, in the outcomes.
I will come first to the issue of governors and boards and then move to the amendments. I think we have all had emails, as is quite right, from local board members. Let me say, as I did earlier, that that is with good intent; they are very good people, who have given public service to be part of their local health system. As I said, this provision is no judgment on them; it is, as we heard, about effectively making the really important patient voice and patient experience central to the functions of the organisations delivering our healthcare. As I said in previous sittings, a debate will continue to be had about where we most effectively have that, but our intention throughout the 10-year health plan and this Bill is about devolution to providers and to ICBs and about making boards, as I also said in a previous sitting, responsible and accountable for the outcomes.
Let me outline broadly, because I think this is of interest to people, the impact on governance and the role that governors had. Just to be clear, since the creation of foundation trusts in 2004, NHS England—and, before it, NHS Improvement and Monitor—has had a statutory role to oversee the governance of NHS foundation trusts, including holding the whole board to account and taking steps where it identifies weaknesses in how foundation trusts are being run. The regulatory function is underpinned by the NHS provider licence, which will continue when NHS England’s functions pass to the Secretary of State. That is why we do not consider that the removal of the council of governors will have a negative impact on the governance of FTs, as some hon. Members have suggested.
Karin Smyth
I will move on, if I may. I think my response will the cover the issues raised in the debate.
On amendment 36 and new clause 59, I note the concern that the Secretary of State could act inappropriately when making appointments to the boards of ICBs and NHS trusts and foundation trusts. We discussed democratic accountability in a previous sitting, and at the end of the day it is up to the British public whom they elect to Parliament and as the governing party.
Transparency and democratic accountability are at the heart of our reforms. It would not be right for the civil service to be given sole legislative responsibility for appointments to NHS trusts, foundation trusts or integrated care boards. Ministers are democratically accountable to Parliament, and civil servants act on their behalf under the Carltona principle. Civil servants serve and advise the Government, and act on behalf of Ministers, but it is for Ministers to take decisions and to be held accountable to Parliament for the performance of the NHS. The civil service will run fair, open and equitable campaigns to fulfil these roles and will recommend appropriate candidates to Ministers.
Ministers are under a duty to comply with public law principles and to act reasonably, and will adhere to the Nolan principles, including objectivity, transparency and integrity, in discharging this function. The practical arrangements for appointments are being developed as part of the transition planning for the integration of NHS England’s functions into the Department, and will be based on these principles. It would therefore be inappropriate to exclude Ministers entirely from the appointments process. I urge hon. Members not to push the amendments to a vote.
The Chair
I think the Minister has finished.
Question put and agreed to.
Clause 29 accordingly ordered to stand part of the Bill.
Amendment made: 19, in schedule 3, page 81, line 10, at end insert—
“(1A) Unless or except to the extent that regulations provide otherwise, the executive directors must include—
(a) at least one person who is a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984), and
(b) at least one other person who is a registered nurse or a registered midwife.”—(Karin Smyth.)
This requires NHS foundation trusts to have at least one executive director who is a registered medical practitioner or a registered dentist and another who is a registered nurse or a registered midwife. Regulations may create exceptions (for example, an exception could be created for ambulance foundation trusts).
Schedule 3, as amended, agreed to.
Clause 30 ordered to stand part of the Bill.
Clause 31
NHS foundation trusts etc: audit of accounts
Question proposed, That the clause stand part of the Bill.
The Chair
With this it will be convenient to discuss the following:
Schedule 4.
Clauses 32 to 34 stand part.
Karin Smyth
I will address clauses 31 to 34 and schedule 4 together. Clause 31 ensures that NHS foundation trusts are subject to the same robust, transparent audit regimes as other NHS bodies. Together with schedule 4, clause 31 makes provision about the audit of NHS foundation trust accounts, which is needed as a consequence of the abolition of NHS England and the removal of the requirement for NHS foundation trusts to have councils of governors and members. Schedule 4 does that by removing the current bespoke provisions related to the auditing arrangements for the accounts of foundation trusts and amends the Local Audit and Accountability Act 2014 so that foundation trusts are subject to the auditing regime under that Act. This means that foundation trusts will in future be subject to the same auditing requirements as trusts and integrated care boards, ensuring a clear, consistent and transparent framework for local audit across NHS provider organisations. Taken together, these measures strengthen consistency in financial reporting and audit assurance across the NHS provider sector, while preserving the independence of the local audit process.
Clause 32 repeals provisions of the NHS Act 2006, requiring NHS England to maintain a register of NHS foundation trusts and a power to charge fees related to maintaining the register. The register formed a repository of documents that related to how foundation trusts were governed and regulated. However, removing the requirements does not mean there will be no transparency. NHS foundation trusts are already required to publish the information provided on this register, and where a foundation trust is placed into special administration the administrator is required to publish its report. As a result, the additional requirement to maintain a register is unnecessary, burdensome and duplicative, providing the public with no new information. For those reasons we are removing that bureaucratic duty in the Bill.
On clause 33 stand part, the Department of Health and Social Care, like all Departments of State, has a responsibility to diligently and responsibly steward taxpayer’s money in delivering services to the public. Clause 33 updates and strengthens existing legislation to make sure we have the statutory tools we need in order to effectively manage and oversee the finances of the NHS. It does that by updating sections 42B and 42C of the NHS Act 2006 so that the existing last-resort statutory capital spending limit for foundation trusts can also apply to revenue expenditure for a given year.
Foundation trusts account for a substantial proportion of NHS revenue spending, at around 40%, and continue to benefit from significant operational autonomy, including the freedom to retain and reinvest surpluses. We remain committed to seeing those freedoms expanded further through our advanced foundation trust programme. However, this strengthened power ensures we have a financial framework that makes it easier to consider additional freedoms. The Department must therefore ensure it has in place robust tools to oversee the finances of the health service, to reassure taxpayers and Parliament that public money is being managed effectively and to ensure that the Department can meet its financial obligations.
The power will remain subject to strong safeguards, including a mandatory consultation period with the foundation trust before any order is made, the requirement for any order made to be published, and detailed statutory guidance setting out the circumstances in which the power would be used and how limits would be determined. Crucially, this is a last-resort measure. This power would be used only in exceptional circumstances—for example, when the Secretary State thinks there is a risk of breaching a departmental delegated expenditure limit. I should note that the existing capital backstop on which it builds has never been used. The purpose here is not routine financial management, but assurance. By ensuring that foundation trust freedoms operate within a viable and sustainable framework, the clause helps protect those freedoms rather than undermine them.
Finally, clause 34 makes straightforward but important provision about financial accountability when NHS organisations change legal form. It requires an NHS foundation trust that has been newly authorised, or that has recently acquired an NHS trust or another NHS foundation trust, to prepare the final accounts for its predecessor organisation. As the Committee will appreciate, organisational change, whether through authorisation to foundation trust status or through acquisition, can bring real benefits for local services, but it can also create a practical issue at financial year end. The predecessor body will have ceased to exist in its previous form and so will not be in a position to complete and sign off its final set of accounts. Clause 34 addresses that gap by making clear where responsibility sits—
Health Bill (Ninth sitting)
Tuesday 30th June 2026
(2 days, 6 hours ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 30 June 2026 - (30 Jun 2026)
The Chair
I remind the Committee that with this we are considering the following:
Schedule 4.
Clauses 32 to 34 stand part.
The Minister for Secondary Care (Karin Smyth)
I will start where I left off. Clause 34 addresses the gap by making it clear where responsibility sits, so that there is no doubt about who must produce the final accounts and ensure that they are completed properly, and about how those accounts should be audited. We think this is a proportionate provision to ensure continuity and clarity on how NHS money has been managed during organisational transition. I commend the clauses to the Committee.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
Clause 31 introduces schedule 4, which essentially makes series of amendments to other Acts. It amends the Public Finance and Accountability (Scotland) Act 2000 to remove a cross-reference to other categories, and it amends the Audit and Accountability (Northern Ireland) Order 2003 and the Public Audit (Wales) Act 2004 for similar purposes. It also amends the National Health Service Act 2006 by deleting section 62 and schedule 10, relating to the audit of accounts of NHS foundation trusts, to end the old audit scheme.
Schedule 4 amends section 3 of the Local Audit and Accountability Act 2014 so that foundation trusts are now included in the list of bodies that must keep accounts in the standard way, it amends section 4 to specify which documents count as accounts of foundation trusts for the purpose of auditing, and it amends sections 8 and 10 so that the auditor appointment procedure and the auditor panel’s role now cover foundation trusts.
In addition, schedule 4 rewrites section 13 of the 2014 Act so that if a trust fails to appoint a local auditor, it is the Secretary of State’s job to step in. Previously, that was NHS England’s job; clearly, that needs to change, because NHS England is being abolished. The schedule also amends section 21 so that the auditors’ general duties now apply to foundation trusts too, and it amends section 30, relating to unlawful expenditure and activity, and section 32B, relating to the independence requirement, to remove a now-redundant item from the list.
Schedule 4 also amends schedule 2 to the 2014 Act to formally add foundation trusts to the official list of audited bodies; schedule 5 so that the rules on who can be a local auditor now cover foundation trusts too; schedule 6 to remove an outdated segment from the audit practice code rules; schedule 7 to tidy the reporting rules and extend them to foundation trusts; schedule 9 to realign data matching rules that apply to foundation trusts in the new system; and schedule 11, relating to the disclosure of information, to remove a reference to NHS England, which is no longer necessary because NHS England is being abolished. In general, clause 31 aligns the audit process for accounts of foundation trusts with those of standard trusts and integrated care boards.
Clause 32 removes the need for NHS England to maintain a register of foundation trusts and the fees associated with maintaining it. Section 39 of the NHS Act 2006 requires NHS England to maintain a current register of NHS foundation trusts and specifies what must be in that register. Section 50 states that an NHS foundation trust must pay NHS England a fee that NHS England may determine in respect of exercising its functions under section 39, which relates to keeping the register, and section 39A, relating to a panel for advising governors. Clause 32 deletes sections 39 and 50. The explanatory notes say that the requirement to maintain a register does not need to be transferred to the Secretary of State when NHS England is abolished because, the Government argue, the information will already be available centrally, and there is no need for a fee to keep that in place. That seems sensible to me.
Clause 33 enables the Secretary of State to impose limits on a foundation trust’s annual capital or revenue expenditure. Section 42B of the 2006 Act allows NHS England to make an order imposing a limit on the capital expenditure of a foundation trust in a single year. Section 42C sets out that NHS England must publish guidance about the exercise of its power under section 42B, including about the circumstances in which it is likely to make an order and the method it will use to determine the capital expenditure limit. Clause 33 entirely replaces sections 42B and 42C with rewritten sections, with some notable changes. The wording is changed from “capital expenditure” to “expenditure”. The power is therefore widened from capital expenditure limits to limits on any expenditure—capital and revenue. The Secretary of State replaces NHS England as the entity with the power to impose limits, which makes sense, and the subsection requiring an order to specify the trust, the financial year and so on has been removed in full.
The change gives the Government financial control to stop overspending by NHS foundation trusts. I note that in financial year 2023-24, NHS trusts overspent by £1.2 billion, so presumably this is the Secretary of State getting a tighter grip on spending. In some respects that is sensible, but overspending is often due to staffing costs and day-to-day pressures, not capital expenditure, so there is an argument that the capital limits themselves are not sufficient to deal with the problem. Under the new governance model, the Secretary of State has oversight and responsibility for the health service, and financial control aligns with those changes. The new power could prevent one organisation’s failures from undermining the health service’s wider financial position or impacting other providers.
However, the purpose of foundation trusts is supposed to be that they have greater independence over spending, and the Government have stated that their aim is to create a more devolved and autonomous health system. How does broadening the Secretary of State’s ability to interfere in expenditure devolve power or make foundation trusts more independent? Imposing expenditure limits may control overspending on paper, but it does not address the reasons why it is happening, so limits could lead to a deterioration in the health services delivered by some trusts. What plans does the Minister have to deal with that?
Because the power moves from an arm’s length body to the Secretary of State, interventions could be politically motivated, rather than in the best interests of the NHS. How does the Minister consider that that will be managed?
The power for the Secretary of State to impose expenditure limits at any time during or before the financial year could create uncertainty among trust leadership and undermine long-term planning. If a trust is given a budget for the year, it knows what it has to work with, but if somebody says halfway through the year, “Actually, you are going to have to work with less money than that,” it is very difficult for the board to plan its expenditure, because it is always looking the other way. Why does the Secretary of State need that power? Can the Minister clarify that, if there is a change in the expenditure limit during the year, it will always be revised upwards, and never downwards?
Gregory Stafford (Farnham and Bordon) (Con)
My hon. Friend is making a prescient point. Has she thought about the word “limits”? To me, it is not clear from the clause as drafted—perhaps it is clearer to her—whether that is an overall limit on capital and revenue expenditure, or whether the clause is saying that the Secretary of State could impose limits on individual line items or departments. The word “limits”—plural—suggests that he or she may be able to do that.
Dr Johnson
I do not think the Bill is very clear on that. It says that the Secretary of State
“may by order impose limits on the expenditure that may be incurred by an NHS foundation trust in respect of a single financial year.”
However, it does not say whether that is an overall limit, whether it is for capital or revenue or whether it is a limit on a specific item, so the degree to which the Secretary of State has control is not clear. I presume it is an overall limit and that it is for dealing with budgets, but perhaps the Minister can provide some clarity for my hon. Friend.
Clause 34 requires foundation trusts that have been newly authorised, or that have recently acquired another trust or another foundation trust, to prepare the final accounts for their predecessor trust or foundation trust. It does that by modifying section 36 of the NHS Act 2006 to add new provisions that require foundation trusts to prepare accounts for the final period for which they were an NHS trust, establish that part of schedule 7 and part of the Local Audit and Accountability Act 2014 apply in relation to those accounts, and define the final accounting period. It does the same for section 56AA of the 2006 Act.
Karin Smyth
I thank the shadow Minister for in general, I think, agreeing that the alignment of many of these processes is quite sensible.
The shadow Minister talked in general terms about financial controls. The Government take financial controls and our responsibility for taxpayers’ money very seriously. As I said last week, from very early on, we were very keen to ensure that there is a grip on NHS finances in order to properly deliver the sort of healthcare that all our constituents deserve. We take that very seriously. There has not been that sort of grip at board level and through the system in recent years. As a result of the measures that we have taken, I think this is the first year in six or more years that the NHS has not gone back to the Department for additional funds to get through the year. The Committee can be assured that financial control is important.
The shadow Minister referred to limits. Of course they are overall limits; the Secretary of State does not go line by line through what a trust spends. I understand the point that people are trying to make to conflate some situations, but of course it is an overall limit.
The safeguards in these provisions are designed to protect foundation trusts’ freedoms and not constrain them, but a foundation trust can enjoy such freedoms only if it is in a well-overseen and stable NHS financial system. By including a backstop for use in exceptional circumstances, clause 33 helps to safeguard public funds and will help the Department to meet its financial obligations, which I think hon. Members understand. It is a usual process for the Department to go through, as anyone who has sat on the Public Accounts Committee will know. Adherence to the departmental expenditure limit creates and maintains the necessary environment for the foundation trust to exist.
Question put and agreed to.
Clause 31 accordingly ordered to stand part of the Bill.
Schedule 4 agreed to.
Clauses 32 to 34 ordered to stand part of the Bill.
Clause 35
Conversion of failing NHS foundation trust into NHS trust
Question proposed, That the clause stand part of the Bill.
The Chair
With this it will be convenient to discuss the following:
Schedule 5.
Clauses 36 to 38 stand part.
Schedule 6.
Karin Smyth
During the process of producing our 10-year plan, we were clear that, as much as we will reward the best performing providers with new freedoms to innovate, we will not hesitate to act on poor performance, and this group of measures deal with just that: action in the event of a failing provider.
Clause 35 and schedule 5 insert new provisions into the NHS Act 2006 to enable the Secretary of State to, by order, convert a failing foundation trust to an NHS trust. This is intended to take place only in the most critical circumstances, and where it is in the public’s best interest for the Secretary of State to be able to direct the trust about how it should exercise its functions, to address safety or other issues at the trust. Foundation trust status should be a mark of good performance, and there must be a mechanism to remove it when performance is seriously deficient. This deauthorisation power will help to maintain the integrity of the reinvigorated foundation trust status and provide an additional incentive for challenged foundation trusts to improve.
The power to make a conversion order can be used where the foundation trust has failed to comply with a condition of its provider licence or with another legislative requirement. In deciding whether to make a conversion order, the Secretary of State must consider various factors, including the seriousness of the failure, the health and safety of patients, the quality of the provision by the trust of goods and services, the financial position of the trust, and the way the trust is being run.
The conversion power is also subject to two additional requirements. First, the Secretary of State must publish guidance about the matters they will consider in deciding whether to exercise the conversion power, including the factors I just outlined. They must consult on any such guidance before its publication. Secondly, where the Secretary of State proposes to use the power, they must first consult the foundation trust in question, any integrated care boards in the areas in which the trust operates, and any other person to whom the trust provides goods and services, and whom the Secretary of State considers it appropriate to consult.
Clause 35, together with schedule 5, also inserts new schedule 9A into the NHS Act 2006, which sets out the immediate consequences of a conversion order. Deauthorising a foundation trust has no impact on the property it holds, the contracts it has with commissioners and other groups, or the terms of employment of employees. These powers set clear organisational consequences for significant underperformance and allow the Secretary of State the freedom to take action to protect patients in extreme circumstances.
Clause 36 contains another critical power to allow action in the case of a failing foundation trust. It allows the Secretary of State to add conditions to an NHS foundation trust’s provider licence where they consider that the trust will breach its licence conditions due to issues with its governance. The clause is a consequence of abolishing NHS England and makes changes to the powers currently held by NHS England under section 111 of the Health and Social Care Act 2012, to confer them on the Secretary of State, with additional consequential changes reflecting the abolition of councils of governors.
The clause sets clear expectations for a foundation trust through the licence conditions and provides the Secretary of State with a transparent mechanism to take more urgent, targeted enforcement action to address failures of governance. Should the foundation trust breach any conditions imposed via section 111, the Secretary of State may require it to make changes to the executive directors of its board as necessary, including removing or suspending executive directors, replacing executive directors with interims, and preventing the trust from appointing specific individuals. If the foundation trust fails to take those actions, the Secretary of State may implement the changes.
To reassure the Committee, there are clear safeguards underpinning the clause, which can be used only where there is evidence that failures of governance in the foundation trust will cause it to breach the conditions of its licence. Further, acting under section 111 does not preclude the Secretary of State from using their other regulatory powers, including to require the foundation trust to take steps to address a breach of any condition of the licence, or to accept undertakings from the trust to address the breach.
Finally, the section 111 power was originally granted to Monitor in 2012 under transitional arrangements, as it was anticipated that the power could be withdrawn once governors had transitioned into their roles and could hold boards to account without outside intervention. Over 13 years on, that has proven not to be the case. With the abolition of the foundation trust councils of governors, it makes sense to repeal the provisions under sections 112 to 114 of the same Act that made it transitional.
Clause 37 makes changes to the special administration framework to ensure that it continues to function coherently after the abolition of NHS England. The clause makes focused, technical amendments to the Health and Social Care Act 2012 to amend the framework for establishing a mechanism for financial assistance in cases where a provider is subject to a health special administration order under chapter 5 of that Act. It also amends the Act to remove the duty to establish a mechanism for financial assistance to foundation trusts to which a trust special administrator has been appointed. The duty no longer needs to apply to foundation trusts, because the Secretary of State already has the power under provisions in the NHS Act 2006 to provide financial assistance to NHS foundation trusts if needed.
With the abolition of NHS England, the duty to establish a mechanism for financial assistance for independent providers will be retained and conferred on the Secretary of State. It is worth noting that the provisions related to financial assistance in special administration cases, and chapter 5 of the Health and Social Care Act 2012, which sets out the powers and processes for the making of health special administration orders, have not yet been commenced. However, the amendments made by the clause ensure that the special administration regime can operate smoothly if it is ever needed.
The clause does not create new financial support mechanisms, but ensures that existing ones can be used appropriately in the reformed system. In short, clause 37 ensures that the legal framework reflects the new institutional landscape while retaining the ability to act swiftly to safeguard continuity of services during special administration.
Clause 38 makes changes to the trust special administration framework to ensure that it continues to function coherently after the abolition of NHS England. This clause, together with schedule 6, make targeted changes to the trust special administration process set out in the NHS Act 2006 for NHS trusts and NHS foundation trusts as a consequence of the abolition of NHS England. It also aligns more closely the processes between NHS trusts and foundation trusts.
Trust special administration is, and will remain, a last resort mechanism used only in cases of serious failure. It is used to protect patients, stabilise services and put the organisation back on a sustainable footing. Where deemed necessary, a trust special administrator would be appointed to manage the trust and work with relevant key stakeholders to develop recommendations regarding the organisation and its services.
The amendments made by schedule 6 remove functions that currently sit with NHS England and confer the key decision-making functions on the Secretary of State, who will provide clearer lines of accountability and faster decision making when rapid intervention is required. The amendments also simplify the steps involved in the TSA process, with the aim of improving the speed of intervention and providing transparency. They align more closely the processes for trusts and foundation trusts, and set out a simpler process in relation to the administrator’s draft report, consultation and final report. They also require, as is the case now, that key documents and decisions are published and laid before Parliament. That will help ensure proper and meaningful scrutiny of the TSA process and outcomes. It also helps ensure that affected patients, staff and local partners have the opportunity to engage during the process, while maintaining the balance with the need to deliver timely intervention and secure continuity of safe services.
In addition, the amendments in schedule 6 make changes to the role of the Care Quality Commission in trust special administration. The CQC will be able to recommend that a trust special administrator should be appointed. The Secretary of State is also required to consult the CQC before making an order, ensuring that independent expertise on quality and safety informs decisions and that intelligence on service performance is co-ordinated.
The provisions in the Bill ensure that the process remains fit for purpose, proportionate, and aligned across NHS trusts and foundation trusts. They support faster, more coherent decision making in the most serious cases, with the aim of protecting patients and securing sustainable, high-quality services for the future. Taken together, the clauses provide the necessary tools for the Secretary of State to take proportionate, swift and decisive action in the event of provider failure. I therefore commend these clauses to the Committee.
Dr Johnson
Clause 35 essentially establishes the right of the Secretary of State to convert a foundation trust into an NHS trust in certain circumstances. Currently, section 25 of the NHS Act 2006 establishes trusts and introduces schedule 4 of the same Act, which makes provision about NHS trusts. Section 56AA sets out how additional requirements concerning acquisitions of a trust or foundation trust are to work. Clause 35 deletes section 25(2), which specifies that an order in this context is referred to as “an NHS trust order”, and amends subsection (3), so that no order under section 25—previously no “NHS trust order”—can be made until any consultation that has been prescribed is complete.
Clause 35 introduces proposed new section 57B into the 2006 Act, “Conversion of failing NHS foundation trust into NHS trust”, which provides the Secretary of State with the power to convert if the foundation trust breaches its licence or other legal duties. The trigger is broad and includes non-compliance with any statutory requirement. The proposed new section requires an order to specify when it takes effect and also requires the Secretary of State, when deciding to issue an order, to consider among other things
“the seriousness of the failure…the health and safety of patients…the quality of the provision by the trust of goods and services…the financial position of the trust, and…the way that the trust is being run.”
Before making an order, the Secretary of State will be required to consult the trust, any ICB where the trust has facilities and
“any other person to whom the trust provides goods or services…whom the Secretary of State considers it appropriate to consult.”
The proposed new section also provides the Secretary of State with the power, when the conversion order is made, to
“terminate the appointment of the chair or any executive or non-executive director”,
and to
“appoint a person to be the chair or an executive or non-executive director”.
It also time-limits the powers to intervene with management to one year after the order is made.
Clause 35 also introduces proposed new section 57C into the 2006 Act, “Guidance about conversion”, which requires the Secretary of State to publish guidance about matters to be considered when deciding to make an order and requires them to consult persons considered appropriate before publishing or revising guidance. The clause removes “NHS trust order” from section 276 of the 2006 Act, “Index of defined expressions”, and updates schedule 4, so that an NHS trust may be established by an ordinary order under section 25 or a conversion order under proposed new section 57B.
Schedule 5 to the Bill inserts proposed new schedule 9A to the 2006 Act, “Conversion of failing NHS foundation trusts”, which provides that, on conversion, the foundation trust’s chair and directors become the initial chair and directors of the new NHS trust, unless they are removed by the Secretary of State under the procedures we have just talked about. The proposed new schedule initially keeps the board the same size, until new arrangements are made. It provides that the foundation trust’s public dividend capital carries over to the NHS trust and that the conversion does not affect continuity of the body —it will remain the same organisation, just with NHS trust status.
The proposed new schedule provides that the trust’s property and liabilities, including criminal liabilities, continue unaffected. It also provides that existing contracts continue and that the trust remains party to them. It clarifies that those contracts do not automatically become NHS contracts under section 9(1) of the 2006 Act, provides that the trust keeps any corporate memberships that it held before the conversion, and clarifies that the continuity provisions do not affect the Secretary of State’s wider powers to make directions.
The Secretary of State will have a direct power to act where the foundation trust has failed—for instance, where there have been patient safety lapses—and there are clear benefits to that. There are also transparency requirements built in: the Secretary of State must publish guidance and consult before issuing guidance or undertaking conversion, and the power to change the management is limited to a year.
However, the last Labour Government said that independence was central to the success of foundation trusts. In 2005, the then Secretary of State, Patricia Hewitt, said:
“We know that independence from central Government control and greater freedoms are giving NHS foundation trusts the opportunity to innovate new approaches to healthcare and healthcare services, for the benefit of NHS patients.”—[Official Report, 7 November 2005; Vol. 439, c. 5WS.]
The challenge with innovations is that, even with the very best intentions and the very best advice, some will work and some will not. If any failure at all is a reason for trusts to be taken over, will that cause them to be shy about innovating, for fear of their independence being undermined as a result? There is a balance to strike, so I wonder whether the Minister will comment on that.
The change also makes it easy for the Secretary of State to convert a foundation trust for political reasons—for instance, because of pressure from local Members of Parliament. That is a positive in some ways and a negative in others. Again, it could have a chilling effect on the very autonomy and innovation that Ministers want to see, so the question is how they think they will balance that.
Edward Argar (Melton and Syston) (Con)
I will endeavour to be relatively brief in my reflections, and I will address, particularly, clauses 35 and 38. I can see a logic to what the Minister proposes in them. On clause 35, we know that foundation trusts face challenges. We saw that writ large with the scandal at Mid Staffs, and in my time as a Minister, several foundation trusts required intervention—maybe not on that scale—or required improvement. I pick on them just because they are in my head—I do not know the situation today. I am looking across at the hon. Member for Ashford, because going back some years to when I was a Minister, East Kent hospitals NHS foundation trust faced some considerable challenges. I am not necessarily saying that that meets the bar for intervention, but foundation trusts have challenges from time to time.
I should also declare an interest: I was born in the forerunner of the William Harvey hospital—the old Willesborough hospital—in the hon. Member’s constituency. I recognise that on occasions foundation trusts get into serious, or less serious but still challenging, circumstances. So I can see where the Minister is coming from, but I have a few questions for her.
First, we recognise that although foundation trusts can get into bother, so too can NHS trusts. NHS trusts can underperform, have safety issues or have financial or other performance issues. I am interested to hear the Minister’s reflections on why she believes that removing foundation status and the organisation becoming an NHS trust will necessarily solve those problems, when many NHS trusts can have equally significant challenges. I would welcome the Minister’s reflections on that.
In terms of whether a conversion was to take place—if the Secretary of State determined that that was expedient and it met the criteria—what would the timescales and process be if, further down the line, a foundation trust wished to reapply for its old status, having previously converted to an NHS trust? Would that be possible, and how would it work? I suspect that there would be a significant number of hurdles to get over to prove that it had achieved that status. I would welcome the Minister’s reflections on that point.
Finally, on clause 38, what the shadow Minister, my hon. Friend the Member for Sleaford and North Hykeham, touched on gives me a little cause for concern. Essentially, this appears to be a further centralisation of powers in the Secretary of State’s hands, particularly with the changes to the role of the CQC. It effectively downgrades the CQC’s power as the independent regulator in these matters. Instead of the CQC being able to initiate the appointment of a TSA where, on safety grounds, they consider it to be necessary and the criteria met, that power will sit with the Secretary of State, who will be required to consult the CQC, but it will seemingly lose its ability to take that initiating step irrespective of what they have seen in any inspections. I would be grateful if the Minister addressed and potentially reassured me on those points.
Karin Smyth
As people who have been listening will know, this is a chunky set of clauses on some technical details. Let me broadly pick up some of the key points.
I want to be very clear about deauthorisation and our seeking to establish, essentially, a more dynamic model. As I said, the coalition Government repealed the legislation on deauthorisation in the 2012 Act. Although other regulatory levers exist to manage poor performance, we are using two core arguments. First, converting foundation trusts into NHS trusts will enable the Secretary of State, if needed, to intervene further through their power of direction over NHS trusts. The Secretary of State will therefore be able to focus on the patient and public interest over preservation of providers’ statutory freedoms in cases of serious failure. I hope that that addresses some of the points that have been raised. Secondly, having a more dynamic environment with the potential for deauthorisation in such cases, and the consequent loss of statutory autonomy, may act as an incentive for challenged foundation trusts to improve, and it would show that there are consequences.
As I think the hon. Member for Sleaford and North Hykeham knows, the usual processes exist for managing performance across various aspects of the provider. They will continue. This is for exceptional circumstances. As I said, this is about maintaining a more dynamic model than the one we have. The purpose behind her questions about continuous service—the purpose of having a range of failure powers—is to ensure continuity of care for patients and the public. The analogy with general practice does not hold; this is a very different set of circumstances. But, obviously, she raises an important point about public concern relating to the service’s provision, and I assure her on that. We need to make sure that we diagnose the situation, provide the trust with support and assess which toolbox is most applicable.
The CQC can recommend that a trust special administrator should be appointed where it is satisfied that there is a serious failure to provide services of a sufficient quality, and it must provide a report on the safety and quality of services following the appointment of an administrator. The Secretary of State must also consult the CQC before making an order to appoint a trust special administrator.
Question put and agreed to.
Clause 35 accordingly ordered to stand part of the Bill.
Schedule 5 agreed to.
Clauses 36 to 38 ordered to stand part of the Bill.
Schedule 6 agreed to.
Clause 39
Joint working and delegation arrangements
The Chair
With this it will be convenient to discuss the following:
Government new clause 20.
New clause 26—Arrangements between NHS bodies and local authorities: duty to review—
“(1) The Secretary of State must conduct a review of the effectiveness of arrangements entered into by NHS bodies and local authorities under section 75 of the National Health Service Act 2006 (arrangements between NHS bodies and local authorities).
(2) In conducting the review, the Secretary of State must consult—
(a) NHS bodies,
(b) local authorities, and
(c) any another person that the Secretary of State considers it appropriate to consult.
(3) Having conducted the review, the Secretary of State must consider whether the power to make regulations in section 75(1) or the power to issue guidance in section 75(6) of the National Health Service Act 2006 should be exercised in order to improve the effectiveness of arrangements under that section.
(4) The Secretary of State must lay before Parliament, and publish, a report of the review.
(5) The report of the review must explain whether the Secretary of State decided to exercise the powers in section 75(1) and (6) of the National Health Service Act 2006 and the reasons for that decision.
(6) The Secretary of State must comply with the requirements of this section before the end of the 12-month period beginning with the day on which this Act is passed.”
This new clause requires the Secretary of State to conduct a review into arrangements under section 75 of the National Health Service Act 2006, and to consider whether to require NHS bodies and local authorities to enter into arrangements with each other if this is likely to lead to an improvement in how their functions are exercised.
Karin Smyth
Government new clause 20 and clause 39 both look to strengthen joint working arrangements across the health system. Clause 39 is part of the architecture of the Bill that allows the delegation of functions from the Secretary of State to NHS bodies, local authorities or other relevant organisations. The clause builds on the existing delegation powers in section 65Z5 of the National Health Service Act 2006, which already allow NHS bodies to delegate functions and pool resources with one another and with local authorities or other relevant bodies on a voluntary basis. It is a well-used voluntary power that enables systems to develop joint working and ensure that health functions are carried out by the most appropriate body or groups of bodies. The result is stronger integration, with better joint working between NHS and local government, and services better tailored to meet local needs.
With the abolition of NHS England and the new functions of the Secretary of State, it is right that the Secretary of State should have the flexibility to delegate their health functions appropriately and efficiently under a voluntary arrangement, as and when necessary. We would not want to exclude the Secretary of State from joint working arrangements, if joint working would bring benefits to patients and the public. The power is therefore purposefully broad to allow that, including allowing the Secretary of State to delegate to a range of public bodies, establish joint committees and pool funds. It also allows the Secretary of State to issue guidance to relevant bodies about the use of their powers under sections 65Z5 and 65Z6.
This proposal is not, however, a means to avoid accountability. Accountability for any function delegated through this power remains with the person delegating it whereas liability rests with the person to whom the function is delegated. Accountability, as opposed to liability, means that the body delegating a function must provide oversight for how their functions are carried out and ensure that any issues are dealt with. Ultimately, the Secretary of State will continue to be accountable to Parliament for the health service in England, including any delegated powers. I am sure that Parliament will relish holding all Ministers to account.
Building on our ambition to support greater local partnership working, as set out in our 10-year plan, we have tabled Government new clause 20 to strengthen section 75 of the NHS Act 2006 by providing much greater scope for combined authorities, combined county authorities and the Greater London Authority to use these arrangements. Section 75 currently supports flexible voluntary partnership arrangements, including the pooling of budgets between NHS bodies and local authorities. These arrangements are a critical tool in supporting local collaboration and ensuring more joined-up working within systems.
The new clause looks to strengthen the section 75 guidance-making power. At present, that power only covers consultation and applications for consent on section 75 arrangements. The Government’s new clause will extend the guidance power so that it can cover all aspects of section 75, helping us to support the wider and more effective use of partnership arrangements. For those reasons, I commend new clause 20 and clause 39 to the Committee.
The Chair
I do not think that the Minister addressed new clause 26, so does she wish to do so now? [Interruption.] She need not worry about it, I am told.
Dr Johnson
Clause 39 broadens the Secretary of State’s ability to delegate or jointly exercise health service functions with NHS bodies and local government. Currently, section 7A of the National Health Service Act 2006 enables the Secretary of State to arrange for any of their public health functions to be exercised by relevant bodies, such as NHS England, ICBs and local authorities. Section 65Z5 sets out how relevant bodies may jointly exercise delegated functions, and section 65Z6 sets out how funds may be pooled for such purposes. Section 65Z7 sets out that NHS England may issue guidance for exercising functions under those two sections and that relevant bodies must have regard to any guidance. Section 75 then sets out that the Secretary of State can make regulations to enable NHS bodies and local authorities to enter into arrangements related to the delivery of health functions.
Clause 39 deletes section 7A, removing the separate power for the Secretary of State to delegate public health functions. It amends section 65Z5 to create a wider power that allows the Secretary of State to arrange for any health service-related function in England to be exercised by or jointly with relevant bodies, local authorities, combined authorities, combined county authorities or other prescribed persons. It removes outdated references in section 65Z5 linked to NHS England and updates the wording so that arrangements can be made with a wider range of persons and not just bodies.
Clause 39 also replaces section 65Z6 so that where functions are exercised jointly, the parties can use joint committees and pooled funds. It provides that pooled funds can include payments from relevant bodies and the Secretary of State, and can be used for expenditure connected to jointly exercised functions. It amends section 65Z7 so that guidance on joint working and delegation is issued by the Secretary of State rather than NHS England. It makes consequential amendments to provisions on directors of public health and local authority public health functions, reflecting the removal of section 7A. It also makes consequential amendments to section 75 partnership arrangements and the Local Government Act 1974, again removing references to section 7A.
Once again, it is necessary to move functions to the Secretary of State when NHS England is abolished—somebody else needs to do the work. The changes introduce more flexibility for joined-up working between the Secretary of State and other entities in the health system, which could support integration and the shift to place-based care, with localised approaches to prevention, integration and service planning in line with the Government’s 10-year plan.
However, the power is very broad, relating to any function in the health service. The Secretary of State could arrange for functions to be exercised by or jointly with any person prescribed, which could mean anyone. How will it be possible to determine who is responsible for things that have gone wrong when joint committees are established and funds are pooled? The Minister has spoken a number of times during our sittings about the importance of clear accountability. In the event that the work, funds and activities are pooled, how will it be made clear who is responsible and therefore accountable for the activity that occurs?
Melanie Williams, the then president of the Association of Directors of Adult Social Services, told the Health and Social Care Committee that we spend
“a lot of time debating about who pays, rather than having a conversation about how, in the longer term, we can invest in people’s outcomes to enable better health and wellbeing.”
Is it the Government’s intention to decide the allocation of money for social care and health providers, or that whoever they decide will work together?
The Government have said that this is all about the devolution of power. This morning, we discussed the abolition of integrated care partnerships, on which ICBs and local authorities work together on projects that they choose locally. The Government are now introducing another power that will enable the Secretary of State to direct them to work together on things that he or she chooses. That does not sound terribly like the devolution of power. Could the Minister explain that to me?
I shall leave new clause 26 to the Liberal Democrats. Government new clause 20 ensures that there is a complete list of authorities that may be included. I think some were missing from the first iteration. I just make the point that the more actors there are in the mix, the harder it may be to see who is responsible overall. We also need to discuss how to maintain the balance between clinical need and political priorities in the choice of what healthcare is provided.
Dr Danny Chambers (Winchester) (LD)
New clause 26, tabled by my hon. Friend the Member for Oxford West and Abingdon (Layla Moran) and the hon. Member for Worthing West (Dr Cooper), who both sit on the Health and Social Care Committee, would require the Secretary of State to review the arrangements under section 75 of the National Health Service Act 2006 and consider whether to require NHS bodies and local authorities to enter into new arrangements with one another if that is likely to lead to an improvement in how their functions are exercised.
A recurring theme of Health and Social Care Committee inquiries is the impact of financial flows and how they frustrate attempts to deliver truly integrated care—an issue we discussed in earlier sittings. We all recognise that closer arrangements are needed to properly address discharge delays, which directly lead to corridor care or even unnecessary admissions to hospital. It seems that a consensus has been reached, yet the action to back that up is not there. We feel that, through this Bill, the Government are moving away from closer integration.
Melanie Williams, the then president of the Association of Directors of Adult Social Services, told the Health and Social Care Committee that the NHS and local authorities
“spend a lot of time debating about who pays, rather than having a conversation about how, in the longer term, we can invest in people’s outcomes to enable better health and wellbeing.”
She highlighted concerns about the funding of intermediate care and community health services through aftercare under section 117 of the Mental Health Act 1983 and NHS continuing healthcare.
Section 75 of the 2006 Act provides a legal mechanism for NHS bodies and local authorities to pool budgets and jointly commission health and social care services. The Select Committee has heard evidence of positive examples of such arrangements being used to commission integrated services. It also heard that the use of section 75 arrangements is inconsistent.
In October 2023, the Government launched a call for evidence to explore how section 75 could be better utilised to support integration. A summary of responses published in December 2024 identified several areas for improvement, including the need for stronger inter-organisation relationships, clearer governance and financial structures, and better data sharing. The Health and Social Care Committee recommended that the Government expand the use of section 75, including the range of services that it will be used to support.
This Bill is a missed opportunity for the Government to reform or promote the use of section 75 arrangements, or to provide an alternative mechanism that they believe would be more effective in addressing the challenges that funding flows present to the integration of health and care services. That is why the Select Committee suggested this new clause to prompt a review of section 72 and the introduction of guidance to support pooled budgets and jointly commissioned health and social care services.
Gregory Stafford
I want to touch briefly on clause 39, Government new clause 20, and new clause 26, tabled by the hon. Member for Oxford West and Abingdon in her role as Chair of the Health and Social Care Committee.
I recognise the intention behind clause 39. Greater collaboration between the NHS, local authorities and other public bodies has the potential to improve the co-ordination of services and deliver a more integrated approach to population health, which I think we all welcome. However, it sits slightly uncomfortably with other clauses we have debated that appear to draw local authorities and the NHS further apart. In this case, it looks like they may be brought together.
As the clause expands delegation and joint working powers, I would be interested to understand from the Minister where the oversight and safeguards for accountability for spending the joint budgets would sit. Would it be with the NHS, local authorities or somewhere else? We hope that everything goes well, but if services fail or financial problems emerge, the public deserve to know who precisely is accountable for those budgets. As I have said in debates on numerous other clauses, I continue to be concerned by the broad powers that the Bill gives to the Secretary of State. I have the same concerns about this clause.
On Government new clause 20, bringing health services and wider local government functions together is really important, particularly where combined authorities have responsibilities that affect the wider determinants of health. However, once again, I am concerned about the fact that the new clause further complicates an already crowded accountability landscape. As more functions are delivered through pooled budgets and joint arrangements, it becomes harder to identify who is responsible for outcomes, spending decisions and—hopefully not, but potentially—service failures. I welcome the flexibility, which I think has value, but it must be balanced with transparency and democratic accountability. I am not convinced that the new clause gets that right.
On new clause 26, as I have said before concerning amendments and new clauses that have come from the Health and Social Care Committee, it is often difficult to get entire agreement on these things because of the cross-party nature of the Committee. Therefore, new clauses and amendments that come out of the Committee are in some ways aspirational, rather than ones that hit the nail on the head.
The new clause suggests that the Secretary of State carry out a review of how effective section 75 arrangements are—the hon. Member for Winchester outlined evidence that in some cases, the use of section 75 arrangements has not always been effective—consult NHS bodies, local authorities and anyone else considered appropriate; consider whether existing powers should be used to improve those arrangements; publish a report and lay it before Parliament; explain whether the Government intend to use their powers to change regulations or guidance and why; and complete all that within 12 months of the Bill passing, which I think is a reasonable timeframe.
Section 75 arrangements already play an important role in bringing together health and social care. It is reasonable to ask, as the hon. Member for Winchester did, whether they are delivering the benefits in the most effective way possible. I would potentially say that this proposal does not go far enough. The new clause would require a review, a consultation and a report, but would not require any action to follow that. The Secretary of State need only “consider” whether existing powers should be exercised and explain the reasons for any decision. If the review identified significant weaknesses, there is no obligation in the new clause, as far as I understand it, to implement those changes.
I agree that the new clause is well-meaning. It has some good recommendations, and I hope the Minister takes on board its sentiment, but it probably does not have the teeth and the power to make it an effective part of the Bill.
Karin Smyth
I got a little confused at the end, but I think the Opposition generally accept the power in this clause. The hon. Member for Farnham and Bordon contended that this Bill and previous amendments to it will drive local authorities and the NHS further apart; just to have it on the record, I do not accept that that is true at all. Section 75 of the National Health Service Act 2006 and the work that we are doing on this further highlights the effect of some of the things that we are trying to do.
The hon. Member for Winchester raised new clause 26. I have sympathy for the intention behind the new clause. We all want health and care services to work closer together, as I have said repeatedly, and we agree that the partnership framework under section 75 of the National Health Service Act 2006 is a useful tool for doing so. While I understand the new clause, it is not necessary. The Department can review the section 75 framework without needing legislation, and indeed it has already done so. The Department carried out a review of section 75 in 2023, as has been said. Since then, we have continued to consider how these partnership arrangements can best support health and care integration.
The new clause would risk duplicating ongoing work. Furthermore, that work is not a one-off exercise but an ongoing process of learning and improvement across the country, and we want something that is responsive and flexible enough to respond to changes in health and care services and to the changing needs of people who use them. For that reason, I do not consider requiring a single statutory review to be the most effective approach.
Hon. Members raised important issues about clarity of accountability and responsibility. To reiterate, the legislation is clear: the legal responsibility or liability for a function being carried out properly rests with the receiving party; however, the delegating party is accountable for that function being carried out, and they must know how it is being carried out and make sure that any issues are addressed. The hon. Member for Sleaford and North Hykeham rightly alluded to one of the examples that we are exploring around section 75, which is how it might support key priorities in delivering neighbourhood health, to make absolutely clear and sure that we bring services closer together.
Both spokespeople outlined a quote from Melanie Williams of ADASS. Although I do not know the whole context of the quote, I understand the frustration of colleagues in social services and this whole area as it is one that I worked in myself. I understand the issue, but it is slightly different because it concerns the what, rather than the how, of what is being discussed. Section 75 is part of the how. We want to make this easier for people who are trying to do the right thing, and these provisions, which I commend to the Committee, do just that.
Question put and agreed to.
Clause 39 accordingly ordered to stand part of the Bill.
Clause 40
Consolidated accounts
Question proposed, That the clause stand part of the Bill.
Karin Smyth
We know that robust finances are an essential part of the health service. The financial accounts related to the NHS are of keen interest to His Majesty’s Treasury and indeed to Parliament. The Government are especially mindful of the keen interest of the Public Accounts Committee in this area. Under current arrangements, NHS England prepares a set of financial accounts for all NHS trusts and foundation trusts, and that is audited by the National Audit Office. That is the point at which the National Audit Office conducts its oversight of NHS providers, with that feeding into the National Audit Office’s assurance over the Department of Health and Social Care group.
The financial accounts for integrated care boards are currently included in the NHS England group accounts, which are presented separately and audited by the National Audit Office. With the abolition of NHS England, the Government intend to reduce central administration costs, so financial reporting needs to be proportionate while balancing stakeholders’ keen interest in financial information related specifically to the NHS. Clause 40 therefore replaces the current consolidated accounts of NHS providers with a single set of consolidated accounts for the NHS covering its trusts, foundation trusts and integrated care boards. That consolidated account will continue to be audited by the National Audit Office.
We believe that bringing the accounts together in this way will assist the public, Parliament and the National Audit Office in scrutinising NHS expenditure. Although it is not covered by the clause, it is important for the Committee to be aware that there will be no change to the current requirement for the Department to publish a Department of Health and Social Care group annual report and accounts that will consolidate the NHS accounts with the core Department and other group bodies—for example, its arm’s length bodies.
However, the Government recognise that only reporting figures for the NHS in the overall Department group would reduce transparency compared with the current structure of NHS financial accounts. The clause therefore seeks to prioritise high quality audited financial accounts information being made available while balancing against administrative costs, both of which are important to the Government.
Clause 41 amends the Secretary of State’s existing power to create a scheme allowing NHS bodies to pool funds to cover property losses and legal claims arising from their healthcare activities. They ensure that when liabilities arise, whether from damage to property, negligence or other claims, there is a clear and consistent mechanism through which those liabilities can be managed and resolved. In doing so, they protect the financial stability of the NHS. The clause updates the legislation for the new landscape by removing NHS England from the arrangements and ensuring that responsibility for administrating the schemes rests appropriately with the Secretary of State.
Although the clause is targeted and technical, its effect is essential in that it ensures continuity and legal clarity and continued effective operation of arrangements that underpin confidence and functionality across the health service. Clause 42 is a necessary technical and structural change that supports the new statutory framework following the abolition of NHS England. It removes provisions in the NHS Act 2006 and the Health and Care Act 2022 that relate specifically to NHS England’s funding and financial responsibilities, which will no longer be required once NHS England ceases to exist. The clause avoids duplication and confusion and ensures that financial accountability is clearly defined in the post NHS England system. Under the reformed framework, the Department is responsible for the overall funding of the NHS and for national financial assurance, while integrated care boards and providers continue to operate within defined statutory financial duties and controls.
Clause 42 plays an important housekeeping role, providing legal clarity and underpinning a more transparent and coherent financial framework that is fit for the NHS future operating model. I therefore commend the clause to the Committee.
Dr Johnson
Clause 40 prepares for the preparation of the annual accounts of NHS trusts and integrated care boards. Existing legislation in section 65Z4 of the NHS Act 2006, “Consolidated accounts for NHS trusts and NHS foundation trusts”, requires NHS England to prepare a set of accounts every financial year and consolidate the accounts of all the trusts and NHS foundation trusts. The Secretary of State can give directions about the content for methods and principles, and the accounts must be accompanied by reports or other information as directed by the Secretary of State. A copy may be sent by NHS England to the Secretary of State and the Comptroller and Auditor General. The latter must then examine and certify those accounts before sending a copy to the Secretary of State and NHS England, and NHS England must then lay a copy of the consolidated accounts and the Comptroller and Auditor General’s report before Parliament. That is how it works at the moment.
Clause 40 rewrites section 65Z4 and the duty to prepare the consolidated accounts every financial year moves to the Secretary of State, and the list of what gets consolidated now includes the ICB accounts. The power to give directions to NHS England about accounts is removed, which is fair enough because there would be no need for it, as the Secretary of State is now preparing them and NHS England will cease to exist. The requirement for the accounts to be accompanied by such reports or other information as the Secretary of State may direct has been removed. The accounts go straight to the Comptroller and Auditor General, who reports back only to the Secretary of State. At the end, the Secretary of State lays the accounts before Parliament. The changes are necessary owing to the abolition of NHS England.
I want to ask about the consolidation, including the ICB accounts, which was not there before, and what impact that will have. Will the accounts be sufficiently detailed so that it is possible to disaggregate that information if people are interested in doing so?
Clause 41 changes which NHS companies can be covered by the scheme that meets certain losses, legal claims and liabilities. Currently, section 71, “Schemes for meeting losses and liabilities etc of certain health service bodies”, of the NHS Act 2006 enables the Secretary of State to establish schemes to meet the losses of NHS England, ICBs, trusts, the National Institute for Health and Care Excellence, the CQC and several other bodies. The list of bodies includes
“(ha) a company formed under section 223 and wholly or partly owned by the Secretary of State or NHS England”.
In the new legislation, clause 41 rewrites paragraph (ha) so that it is
“a company formed under section 223 other than by an integrated care board by virtue of section 223A”.
That narrows the scope of the liability scheme by preventing ICB-created companies from automatically gaining protection, presumably to encourage ICBs to manage risk responsibly.
Edward Argar
I will be relatively brief, turning just to clause 40. I hope the Minister may be able to clarify something for me. I take the opportunity to thank the Minister for the letter that I received this morning, which was a very prompt response to her promise to write to me last week.
In respect of clause 40 and subsequent clauses, I can see the logic of updating the legislation to reflect the abolition of NHS England and the changes that come with that. I can also see the logic of a consolidated set of accounts so that one can see the national, or overall, picture. In the interests of transparency, I would be grateful if the Minister could confirm that that will be in addition to, and in no way replace, every individual trust having to produce granular public accounts that anyone can inspect, so that we can see not only the overall operation and financial health of the system but that of each of its individual component parts sitting beneath.
Gregory Stafford
I wish to carry on the point that my right hon. Friend the Member for Melton and Syston has just raised. He rightly says that there is a transparency element to this, so that the public and any other interested party can look at the individual accounts of an ICB or a trust. Going further than that on the technical elements, my understanding is that NHS England’s own guidance notes suggest that consolidation does not just bring accounting under one set of accounts, one umbrella or one document. Within that accounting, however, adjustments and eliminations of transactions between NHS bodies can happen. Therefore, the aggregated figures do not necessarily reflect the financial reality of individual organisations.
I understand why that might be entirely appropriate from an accounting point of view, but it can make it harder for external observers to understand exactly where the pressures are coming from, where they are concentrated and, in a world where we want accountability, who should be held responsible for addressing them. That is all I need to say on that point.
Karin Smyth
I am pleased that, in an outbreak of cross-party agreement at 3.20 pm on a Tuesday, I completely agree with the comments made by the hon. Member for Farnham and Bordon and the right hon. Member for Melton and Syston. It is a point that I made myself: the ability of Members of Parliament and the public to understand the granularity relating to their local providers and ICBs is very important for transparency and accountability. I hope Committee members recognise that I have tried to drive much more transparency in that system. They are absolutely right that that is separate from this clause, and we will continue to expect providers and ICBs to do that; I hope that addresses that point.
To add further clarity on the wider point the clause deals with, the consolidated accounts we prepare include some analysis by different types of body. That will mean separate information about NHS providers being included in the document, such as a summary of income and expenditure. Separately, providers and ICBs will continue to publish accounts so that people can look at those. The Government will listen to any feedback from users to adapt the nature of this content in future years after the initial publication, recognising that this is a new development following the abolition of NHS England. We are also mindful that too many separate publications add to administrative costs and risk losing focus. The intention is to have transparency at the local level, building that up to do something more sensible and cost-effective that is also transparent at national level. I commend the clauses to the Committee.
Question put and agreed to.
Clause 40 accordingly ordered to stand part of the Bill.
Clauses 41 and 42 accordingly ordered to stand part of the Bill.
Ordered, That further consideration be now adjourned. —(Emma Foody.)