Tuesday 23rd June 2026
(1 week, 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 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 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.
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.
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.
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.