Tuesday 16th June 2026
(2 weeks, 2 days ago)
Public Bill CommitteesHealth Bill 2026-27 View all Health Bill 2026-27 Debates Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 16 June 2026 - (16 Jun 2026)
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.
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?
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.
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.
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.
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.
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.