Helen Morgan (North Shropshire) (LD)
I am a vice-president of the Local Government Association.
The Minister for Secondary Care (Karin Smyth)
I am a member of the Managers in Partnership trade union, which is giving evidence this afternoon.
Liz Twist (Blaydon and Consett) (Lab)
I am co-chair of the Unison group of MPs, which is linked to Managers in Partnership.
Dr Johnson
Q
Dr Dash: I do not see a conflict. I think they are complementary and this is all about improving the regulatory landscape in the healthcare system.
Karin Smyth
Q
Dr Dash: One of the things that I observed when I was doing the review, and that I have observed even more so now that I am in post, is that we do not have effective mechanisms of really learning from patients and patient experience. If I compare how the NHS works with how other large organisations in our country work, we are not systematically collecting patient information, we are not looking at that in detail, we are not segmenting it into different groups of people, and we are not systematically bringing it into board meetings, which is where it should be in order to drive improvement. We are hoping, or expecting, that the new director of patient experience will take a real leadership role in this and will improve the way in which the centre works but, more importantly, will be working with organisations right across the NHS to build those skills and capabilities, and to put patient experience feedback and improvement in patient experience right at the centre of every discussion on improvement.
Helen Morgan
Q
Dr Dash: The CQC is an independent regulatory body as well. The hope and expectation is that we have a high-calibre, independent regulatory body that is the prime regulatory body for looking at how well health and care services are delivered and, as well as observing how well they are currently performing, is able to carry out specific, focused investigations when it spots systematic problems across the healthcare system, or indeed when particular problems are identified.
In terms of safe space, clearly, confidentiality is important. Confidentiality is important right across the board; staff need to feel able to report within NHS organisations and to the CQC where they have concerns. I have to say that I was concerned in that Health Committee session to hear an example given by Jeremy Hunt, who said that if a midwife is concerned about quality of care in their maternity unit, they need to be able to go somewhere and report that, and to know that HSSIB would not tell anyone else about it. I looked at Duncan, our chief nursing officer, who was there with me, and we were shocked to hear that. How can that possibly be right? We need to have a mechanism whereby if there are concerns about quality of care, they are properly investigated, and mechanisms to deal with those problems and improve services. Yes, we need confidentiality, but I was not convinced by what I heard then—that we needed a completely separate organisation that was duplicating the work of others.
Dr Johnson
Q
Jacob Lant: There are a few points on that. The narrative around the Bill is that Healthwatch is being abolished and its functions lifted and shifted across to local authorities and ICBs. That is not the case. We lose a number of important functions.
For example, the signposting support that Healthwatch provides will disappear so patients and care users will not have that to help them to understand how to navigate local services. I mentioned the unsolicited feedback that is gathered; that function will disappear. The outreach into communities, particularly marginalised communities, will disappear. The voice for patients and communities on health and wellbeing boards disappears, so there is no feed into those local decision-making bodies. There are several places where there is not a direct lift and shift across. That is a concern, and the Committee should probe it further.
On the resourcing point, at least local authorities will get part of the existing funding for Healthwatch to support their functions in that space. Under the Department’s impact assessment, ICBs will not get any funding from the current pot. That represents a 50% cut in the resourcing for listening to patients and communities, which is a concern.
Karin Smyth
Q
Sarah Woolnough: As an organisation, we have taken the view that we would not necessarily relitigate the decision. I think you can argue it both ways. I understand the desire to reduce duplication and to have clearer lines of accountability. Our concern has been the opportunity cost and everything that you are not doing at the time that you are spending so much energy and resource driving the abolition through.
Jacob Lant: I would echo everything Sarah says. From the work that we do, we see that decision making is taking longer, programmes are taking longer and it is taking longer to secure an impact on things. That is very frustrating, and underpinned by the massive change that is ongoing. Let us take as an example a programme exploring the experience of waiting for hospital care—of being stuck on waiting lists. Jim Mackey spoke about that at the NHS ConfedExpo last week. It is a major focus for the NHS and new guidance is expected by the end of the month. We have been waiting for that since 2021. The most recent effort towards it has been about 18 months. I can only think that drags on because we have so much other change going on in the system. I wish we focused more on doing things directly for patient care.
Karin Smyth
Q
Sarah Woolnough: It is a major opportunity. If they feel they have trust in the system, patients are generally supportive of a single patient record or joined-up records—they often assume one already exists. Of course, we have a patchwork across the country, and certain places are further ahead than others. The idea of having more national co-ordination and more infrastructure to drive progress in that area could be, and hopefully will be, transformative. I know from my previous work just how frustrating it is for so many people to experience fragmented care and to have to tell their story endlessly.
We must be a little careful, because telling your medical history is often part of a good consultation, but the idea of care being more streamlined and patients and staff having better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. Previous attempts to drive progress in this area have so often fallen down. Ensuring the right balance of progress, and building trust and sufficient safeguards, will hopefully lead to the most progress.
Jacob Lant: I have been working in patient and public engagement and involvement for about 15 years, and the most consistent theme in that time has been the frustration about constantly having to retell your story, and the fact that notes and information are not available for the care that people need in different settings.
There is a golden opportunity with the Bill to get the single patient record right and meet a long-standing patient need for that join-up of information. We are very supportive of the single patient record, and the debate needs to move on from whether we need one to what the safeguards are and how we build public trust. I have two things to say on that. First, you cannot legislate for everything on this, but it is important to have a commitment to an ongoing public conversation around the risks and benefits of data sharing. The Department has done some really good work in this space, on its public deliberative on use of data—that should continue—but we understand that cannot all be put into the Bill.
However, we know that the safeguards and red lines that we already have could be put into the Bill. For example, using patient data or non-consented data for insurance and marketing purposes is a red line that has been clearly talked about in policy for many year—we will not use data for that purpose. Why can’t we put that in the Bill to help build public trust? It would really help to be clear on red lines and what will not be included.
Karin Smyth
Q
Jacob Lant: There are three things there. First, we need transparency about what is being heard by the system. Wherever we put patient voice functions, it is really important that what they hear from communities is clear and made available publicly, in terms of themes and demographics, so that we understand who is being heard and who is not. That is really important for the transparency of what is being heard and how it is being interpreted by the system. What has it understood from the feedback it has received, and does that resonate with what people are actually trying to say?
The second thing is accountability. Can people see those voices leading to change—not just commitments to change, but following through? It is about evaluating where policy changes implemented as a result of patient feedback have improved patient experience, and drawing that golden thread through for people so they can understand how their feedback is making a difference. That is missing from the system at the moment.
The last point is around equity. My big concern is that we might design a system that hears from more people, but whether it hears from the right people and there is equity of voice is a real concern. The resourcing and support need to be put in, particularly at a local level, so that they can engage communities who are marginalised and make sure we are hearing from the people who are basically getting the worst experiences and outcomes at the moment.
If we can deliver on those three things—transparency, accountability and equity—we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it has had available. It works out that less than 0.01% of the health and care spend is on Healthwatch, and that generates about 1.4 million interactions every year, either by gathering people’s experiences or by supporting them to navigate the health and care system. That is a really good return on investment, and it will be hard to find something more efficient. The challenge is in the system being more culturally open to listening and changing as a result of what people say, regardless of the way the evidence comes through.
Helen Morgan
Q
Sarah Woolnough: There are probably two concerns in a couple of different areas: appointments and the power of direction, which is very broad. We think it would be helpful to probe the detail and understand the intention a little more to see whether the legislation could do with amendment.
There is more general point. If the narrative is that this is a straight transfer, of course, you cannot legislate for culture and how those powers will be used. Our concern is that, while the narrative is about a straight transfer, empowering local systems and earned autonomy, the legislation pulls a lot of power back to the Secretary of State, and you cannot legislate for how a future Secretary of State may enact those powers.
Dr Johnson
The question is, how do you find it within the way it is structured?
Karin Smyth
Q
Dr Dickson: Part of it has been touched on by the previous panel, regarding patient experience. Patients come in, they give the same story again and again to different healthcare professionals in different settings, and that frustrates them. Patients are human. I forget what I did last week; patients forget what they did last week, let alone what they did 10 or 20 years ago, although that is still relevant, increasingly. If you go on holiday to Whitby, fall over and break something, have tests done and come back to your house in central London, you cannot see information about that; you cannot share that information.
The opportunity to see everything on a patient across primary care, secondary care and social care is a huge benefit to them in terms of their view of seamless care, but also in terms of safety. I have a chronic health condition; part of my care is delivered by general practice and part by a hospital. At the start of the pandemic I was exceptionally clinically vulnerable; it took the NHS six weeks to tell me that. That is not safe.
Helen Morgan
Q
Dr Dickson: I am not a general practitioner. The key thing for data control and data sharing is the trust that patients have in us to share and to hold their data in a way that is beneficial for them as individuals, and potentially sometimes beneficial for the population, but not to share it for what you might call retail use.
One issue with data control is that most general practices are small businesses with a small number of staff working flat out. That legal obligation of a data controller looms large for them, whereas it does not loom as large for large NHS organisations—although, technically, the impact is as hard. I do not mind who controls the data; what we need to do is to find a way to enable that data to be shared safely and with a belief that it is done for patient benefit. I do not think it matters whether GPs maintain data control, with something else happening to support them, or whether it is taken away from them; it is about how we enable that to happen. But I do think that general practice struggles more with resilience.
Kay Keane: I think that is true, in that we are generalists, not experts in a lot of areas. Certainly, we can be very good data controllers of our own data—the stuff that we produce, and that we write and code about our patients. We have to code things to be able to respond to our contract, so we have to be good at that. Things fall down when information comes from other providers, which we have no control of. That would be an area of real concern—that such information would be part of our property and our jurisdiction.
I guess it is about the detail of how that record will be structured. If it is a brand-new thing and we all feed into it, that is very different from all the data coming to the current healthcare record that we hold. I think the detail is not there yet to enable us to describe who should be the data controller, but certainly I do not think that any practice manager would want to control data generated by someone other than themselves.
Dr Johnson
Q
Dr Benneyworth: There is no doubt that it helps to improve safety. That is something we have learned from 100 years of the air accidents investigation branch, which has had an immense impact on aviation safety, the rail accident investigation branch, and many others. Safe space, or protected disclosures, means that people can talk freely to us about things that have gone wrong without fear of sanctions, being told off by their line manager or losing their jobs.
We hear all the time about people who have ended up losing their jobs or getting into trouble because they have raised concerns. We see in our investigations that we are still working in a culture of fear. In an ideal world, that would not be the case and people would feel able to speak up openly about what has gone wrong, but we are working in a culture where people are not in that place.
This enables staff working in the service and patients to talk to us freely about what they see on a daily basis that they think needs to change. Patients sometimes worry that they will be treated differently and not get the same care after they raise things. This enables patients to talk to us in the knowledge that they will not be named. The patients we work with who have been harmed from healthcare tell us, “We don’t want this happening to other families. We’ve been through this awful, terrible time, and we want to change the system.” This enables them to talk to us.
We do not name individuals in our reports and do not name organisations. We are now in a stage where we are growing that trust. We are coming up to being three years old as an organisation, and we are growing that trust with the system. When we launch an investigation, organisations right across the country say, “Please come and see what’s happening here. Please come and talk to us.” I worry that that might be impacted by the changes ahead.
Karin Smyth
Q
Dr Benneyworth: The two key things have been touched on already. The first is the independence to choose what we investigate and make recommendations to any part of the system. The second area is around protected disclosure. The legislation needs to be much clearer around the protection of protected disclosure materials, to give the system confidence in our ability to hold and not share confidential information.
At the moment, the legislation talks about connected individuals having access to the protected materials. The clauses outlining connected individuals mean that anyone working in the CQC could potentially have access to protected materials. That is a very large number of people, and it will create risk. There needs to be a legal duty on the CQC to protect the safe space. There is also something about maintaining an identity that gives people confidence that when they are talking to us, their information will not automatically go into the CQC regulatory functions.
Some of that may be about perception rather than the reality of what is happening, but as we know, perception is very important. People will perceive that we are part of the regulatory system even if we have the same email address, for example.
Karin Smyth
Q
You talked about the culture of fear, which I think we have recognised over time. We are all constituency MPs, so we recognise that. Can you say something about the opportunities for learning that could arise from working with the CQC, which is in that regulatory space?
Dr Benneyworth: We already work very closely with the CQC. In fact, we meet with them on a very regular basis. They share their learning and concerns with us already. Some of our investigations have come from the learning that they have seen on inspection, so we have a very good relationship with the CQC.
There are significant opportunities for the whole patient safety landscape. We are a tiny part of the patient safety landscape. We need to all work much more collaboratively right across the regulatory space—ourselves, the investigatory bodies and the wider system. The National Quality Board will have a significant role to play in that to share learning and identify key patient safety risks. That is already happening in our work with the CQC. This legislation will not significantly change that.
Helen Morgan
Q
Dr Benneyworth: First, we do not replace local investigations. If something goes wrong, the local teams are very much responsible for investigating their work. Dr Dash talked about the new processes around PSIRF and the new investigation processes, which we fully support. In fact, our education team have had 40,000 people enrolled over the last three years, free of charge in the NHS, to support them in developing those investigation skills, really supporting that excellence in local investigation. We have a long way to go there, because they are variable in quality.
We do not replace that immediate, “There has been an incident and it needs investigation.” We know that, quite often, the things that need to change are not sitting within one provider. We know that the same things are happening in Cornwall and Cumbria and everywhere in between, and that they often need national solutions to change.
As a recent example, we published a report a few weeks ago looking at the care of people in mental health crisis in emergency departments. That showed that the legislation around the care of mental health patients is not supporting people in emergency departments to look after these people properly. That is not something that can be changed by a regulator. The CQC going to look at that emergency department will not impact that. It is not something that the individual provider can change, but we can make national recommendations about it to change the national system to enable people on the ground working in health and care to do their job properly. We can make sure that the systems and processes really consider how things work, and really change them so that providers and systems locally can do their job.
Karin Smyth
Q
Sir Jeremy Hunt: I would just like this to have teeth, because I think people are fed up, as I say, with Governments of all colours receiving recommendations and then nothing happening. I would like the Bill to place a legal obligation on the Government, for a certain category of recommendation, that within a period of time a proper decision will be made with a timescale. If the decision is no, because the money is not available, that is fine, and the Government should say so, but people would prefer to have a decision than for Governments to continually say, “We are reviewing this.” Frankly, I am worried that inertia in the system, and the fact that it is always easier for Ministers to kick things into the long grass rather than give a yes or a no, means that a vague commitment that the NQB will do this job will not be enough. If it is the NQB, I would like there to be a legal obligation that, within six months of recommendations being made by public inquiries, Select Committees and HSSIB, the Government will give a proper yes or no, with a timescale if it is yes.
Karin Smyth
Q
Sir Jeremy Hunt: I set up NHS England, following the Lansley reforms, and it may surprise you that I have not opposed the Government’s decision to abolish it, for this reason. When it was set up, it did have a very valuable function, which is that it depoliticised a lot of very contentious issues. Typically, those were things such as the closure or downgrading of an A&E that was clinically advised as important, but very difficult politically, or, for example, which drugs are made available through the NHS and which are not. I felt that putting those decisions at arm’s length from Ministers was helpful. However, I think it became too big.
My real problem is that I think the NHS has become the world’s largest health bureaucracy, in which it is very hard to get anything done because 1.5 million people are accountable to one person. The way the DHSC does this, as you know just as well as me, is through the ruthless imposition of targets, so every hospital has 18 monthly operational targets. That makes it very difficult to have any kind of local innovation or local autonomy, because everyone is performance-managed with incredible strictness—their whole career depends on it—by these targets. I felt NHS England was beginning to embody that targets system, so when the former Heath Secretary said he was planning to scrap it, I said, “That’s absolutely fine, as long as this is a decentralising move, and you don’t simply transfer that ruthless central control from NHS England to DHSC.” I have to say I am concerned that that is, in fact, happening—or that we are just getting all those targets recreated by DHSC, rather than NHS England, as I think former Health Secretary Patricia Hewitt has also gone on record as saying.
Helen Morgan
Q
Sir Jeremy Hunt: Ideally, when something goes wrong, what you want is for there to be an investigation and for lessons to be learned, so that grieving families can say, “Well, at least we are confident that this wouldn’t happen again.” What happens in the health world is that families still think the only way they can get real change is through a public inquiry, so there is endless demand for more inquiries, rather than for things to actually change. If HSSIB was allowed to flourish, and there was confidence that its recommendations really would be acted on quickly, I think that would reduce the demand for public inquiries. They are very expensive, and the fact that they often take five, six or even seven years also means that there is enormous delay before anything changes.