Health Bill (Seventh sitting)

Caroline Johnson Excerpts

Committee stage
Thursday 25th June 2026 Public Bill Committees

[Edward Argar]

My hon. Friend comes to this with significant knowledge from his work on the Health and Social Care Committee. He is absolutely right, but that is a tension and a balance that I fear runs as a thread throughout this legislation, between local decision making and tailoring and the genuine need for a Secretary of State to have effective powers. We lobby Secretaries of State; on occasion I have lobbied the Minister, and she has always been very responsive—she does not always agree with me, but she has always been very responsive to me. As Members of Parliament, we do that on behalf of our communities.

My argument is that ICBs need to be more responsive, even when they do consult, to make it clear that the decision is not predetermined by the board and that they are going through the process. In the context of this clause, that also needs to be true of the Secretary of State: it needs to be not simply a formulaic approach but a genuine engagement and consultation. My question for the Minister, in that context, is about how we make sure of what she is seeking to do in the clause. The Secretary of State or those undertaking commissioning on their behalf must pay heed to something, but how do we make sure that that consultation, engagement and feedback genuinely have some teeth in what emerges in the final decision?

[Dr Caroline Johnson (Sleaford and North Hykeham) (Con)]

My right hon. Friend the Member for Melton and Syston and my hon. Friend the Member for Farnham and Bordon have covered my points so effectively that I will be very brief indeed. How do we ensure that the consultation is not just well meaning and ticking the legal boxes, but actually listened to, so that people’s voices are incorporated into the plans? Also, I appreciate that amendment 28 is a well-meaning intervention, but how do we ensure that all voices are heard in a co-production, not just those who are the most articulate or the most able to engage with a process that they see online?

[The Minister for Secondary Care (Karin Smyth)]

Patients and the public have a critical role in shaping our health services. I am grateful to the hon. Member for Oxford West and Abingdon for tabling the amendment, as moved by the hon. Member for North Shropshire. I will discuss the amendment with the wider question of whether the clause should stand part of the Bill.

To be clear, the Government are committed to engaging with patients and the public about the services they use. Services shaped together with the people who rely on them are better services. We want to see deep and collaborative ways of working between patients, public and the NHS. Across the country, there are good examples of that from which we want to learn. That is why the clause requires the Secretary of State to involve patients and the public in the planning of commissioning arrangements, the development and consideration of proposals for service change, and decisions that may affect how services are delivered or the range of services available.

The clause is intended to encourage early engagement and meaningful involvement in service change, thereby helping to build legitimacy, trust and better-informed commissioning decisions. As a duty, it covers the entire end-to-end commissioning cycle. I have been a commissioner myself, so although I will not detain the Committee too much on that, it is indeed part of the job of a commissioner to do that at a very early stage.

I also draw attention to the fact that the clause places a statutory duty on the Secretary of State to make arrangements to ensure the involvement of individuals who use or may use health services, together with carers and representatives, where appropriate, in commissioning activity. That duty is purposely broad, covering both existing service users and those who may reasonably rely on services in future, and will support preventive approaches and enable the consideration of wider population health impacts.

We made the deliberate choice to include specific references to carers and representatives, recognising that some individuals may require support to participate effectively in engagement and decision-making processes. That is particularly important where barriers such as disability, communications needs, sometimes age, vulnerability or unequal access may otherwise limit participation. We are ensuring that involvement is inclusive and meaningful, which I think is what all hon. Members want to see.

Specifically on amendment 28, I gently caution against creating an implication of different approaches to patient involvement for different parts of the system, leading to a two-track approach and unnecessary confusion. Instead, we propose a Government commitment to ensure meaningful consultation. We support co-production and will continue to champion it, but we do not think it necessary to put it on the face of the Bill.

The Government support involving patients and the public at every stage, and we recognise that working closely with the people and communities affected by commissioning decisions brings valuable insight into service quality, accessibility, equity and effectiveness. We will use the duties and powers available to Ministers to ensure that that principle is embedded across the work of the NHS. I hope, therefore, that the hon. Member for North Shropshire has some reassurance and will withdraw her amendment. I commend the clause to the Committee.

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[Dr Johnson]

I beg to move amendment 51, in clause 16, page 12, line 10, at end insert—

“(3) The regulations must ensure that integrated care boards may not impose operational policies requiring patients to wait a minimum number of weeks before they may access treatment.”

This amendment would prevent minimum waiting times for NHS treatment.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 35, in clause 16, page 12, line 10, at end insert—

“(3) Regulations under this section must make provision requiring integrated care boards to make arrangements which ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services.

(4) For the purposes of subsection (3)—

‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure-relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”

This amendment would require the Secretary of State to make regulations which would require integrated care boards to ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services.

Amendment 63, in clause 16, page 12, line 10, at end insert—

“(2A) Regulations under subsection (2) must make provision requiring integrated care boards to—

(a) assess whether sufficient capacity exists to meet current and projected patient demand for cancer treatment, including radiotherapy treatment,

(b) maintain plans to ensure that workforce, equipment and estates capacity are sufficient to reduce waiting times for cancer treatment and improve access to treatment, and

(c) monitor and address geographical variations in access to cancer treatment, including radiotherapy treatment, with a view to reducing inequalities in patient outcomes the provision of satellite units.”

Amendment 52, clause 16, page 12, line 10, at end insert—

“(3) The regulations must include a requirement for the Secretary of State to publish the number of patients validated off of treatment waiting lists each month, and the reason for which they have been removed.”

This amendment would require publication of the number of patients validated off waiting lists each month and the reason for their removal.

Amendment 32, clause 16, page 12, line 22, at end insert—

“14Z45BA Patient choice: community services substituting for consultant-led elective care

(1) The Secretary of State must by regulations make provision to enable patients to make choices in respect of non-consultant-led community services where those services are commissioned as a direct substitute for, or to prevent a referral to, consultant-led elective services.

(2) For the purposes of subsection (1), a service is to be regarded as a direct substitute for, or intended to prevent a referral to, consultant-led elective services if it—

(a) provides assessment, treatment or management for a condition that would otherwise be referred to a secondary care specialist; or

(b) is commissioned by an integrated care board for the purpose of reducing or managing demand on secondary or elective care.

(3) Services to which this section applies include, but are not limited to—

(a) community audiology services;

(b) community glaucoma management and monitoring services; and

(c) Minor eye conditions services.

(4) Regulations made by virtue of this section must ensure that—

(a) patients are offered a choice of any clinically appropriate provider commissioned under a qualifying NHS contract for the relevant service;

(b) no limitation on the number of providers from which a patient may choose is imposed solely on grounds of cost or demand management; and

(c) patients are provided with information enabling them to make an informed choice, including information about waiting times and quality.

(5) An integrated care board must not commission a community service of a kind falling within subsection (2) in a manner which has the effect of restricting patient choice below the standard that would apply to an equivalent consultant-led elective service.”

Clause stand part.

Schedule 2.

New clause 35—Community equipment and wheelchair services: standards, performance and outcomes—

“(1) Each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services.

(2) Each integrated care board must monitor its performance against the standards under subsection (1).

(3) Each integrated care board must publish an annual report including—

(a) its performance against the standards under subsection (1),

(b) waiting times for the assessment for and supply of community equipment and wheelchair services,

(c) the number and proportion of people waiting longer than 18 weeks for such equipment or services,

(d) outcomes achieved for people by the provision of community equipment and wheelchair services, and

(e) steps taken by the integrated care board to improve the assessment for, and supply of, community equipment and wheelchair services.

(4) For the purposes of this section—

‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure-relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”

This new clause would require each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services and publish an annual report on their adherence to these standards.

[Dr Johnson]

The Government say they are firmly committed to cutting waiting times and meeting the NHS’ 18-week target. It seems odd that, despite that, it is necessary for me to table an amendment to prevent systems from forcing patients to wait artificially longer for their care through the imposition of minimum waiting times.

Last year, The Times reported that at least eight local ICBs had introduced policies to pay healthcare providers for treatments only once patients have waited 12 weeks or more. I cannot think of any clinical reason why someone should wait for 12 weeks before having any treatment. At the time, the Minister said that while there was

“no formal national policy supporting minimum waits”,

local areas may

“choose to include minimum waiting times in Activity Planning Assumptions to ensure delivery of targets within agreed financial allocations…to support commissioners in managing activity to ensure they can sustainably manage within their budgets”.

I do not understand why we would want to make people wait longer than necessary.

The Royal College of Surgeons has expressed concerns and made clear that minimum waits prolong “pain and anxiety” for those made to wait longer, saying that it is

“counterintuitive…to give commissioners the green light to impose 18-week waits, while simultaneously working to ensure patients begin treatment within 18 weeks.”

Age UK deemed it a “rationing approach” that is

“potentially harmful to the health and wellbeing of older people.”

NHS England has made it clear that ICBs cannot introduce minimum waits of more than 18 weeks—that is longer than the target, so that makes sense—but waits between 12 and 18 weeks are permissible. Will the Minister explain why that is a good idea?

Amendment 51 seeks to ban ICBs from introducing any operational policies requiring patients to wait a minimum number of weeks before they may access treatment. There are safety risks involved in introducing minimum waiting times. They distort clinical priorities and may make patients wait in unnecessary pain and anxiety. Treatment should be delivered when possible, based on clinical needs. If a patient has a high level of clinical need, they might need to be treated earlier than the minimum waiting time because of the suffering they are experiencing.

Minimum waits are not only detrimental to patient experience by forcing people to live in greater pain and discomfort; in some cases, the delay may make the patient’s condition worse, and the treatment they need may be more extensive and even more expensive. Their condition may even become life-limiting or life-threatening as a result of the delay. The introduction of arbitrary minimum waiting times that do not have any relevance to patient clinical need raises worrying issues, clinically, professionally and ethically.

Minimum waits will also hinder the NHS’ ability to cut waiting lists and get waits to within 18 weeks. Some providers will have a list of people who can be available at short notice for a procedure, who they can call on if there is a cancellation on the day. If that person has not waited the minimum, that may be left as a gap, and that operation or appointment may not happen. That is wasted NHS resource.

Each month that goes by, many people are added to the waiting list, and some are removed from it. We are aware that there seem to be a lot of unexplained removals from the waiting list, and that has spiked recently. Among the people treated by NHS providers in April, around 600,000 were treated within eight weeks of referral, versus 74,000 who were treated between 14 and 18 weeks. The introduction of a minimum waiting time will therefore push back many people’s treatment by as much as 10 weeks.

Minimum waits also worsen and entrench postcode lotteries, because patients who have differential waits, based on whether their ICB has decided to implement minimum waiting times, may experience differential levels of care because of where they live. They are also another way of undermining patient choice, because patients may want to be treated in one area or one hospital because of the waiting time. If they all have different minimum waiting times, that distorts patients’ ability to choose.

Minimum waits are also completely contrary to the 10-year plan for health, in which choice and productivity were considered central features, along with the Government’s wider commitment to keep people healthy. I hope the Minister will agree with amendment 51, which would ensure that minimum waiting times cannot be instituted.

Amendment 52 also concerns waiting times. You will no doubt have seen, Dr Huq, the many newspapers articles about the Government fiddling the figures on waiting times, and there has been a spike in removals from waiting lists. People have found themselves removed from lists or going back on lists, or have suddenly found out that their waiting time started more recently than they thought. Amendment 52 would require the Secretary of State to publish the number of patients who are taken off treatment waiting lists each month and why they were removed. It is important that we are able to explain to our constituents why the Government have decided to remove them.

[Helen Morgan]

I want to speak to amendment 63, tabled by my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron). As hon. Members know, he has campaigned passionately and for a long time on the provision of radiotherapy. His amendment seeks to ensure that there is sufficient and equitable access to radiotherapy. Radiotherapy is required by half of all cancer patients, and it is incredibly cost-effective, but England has fewer radiotherapy machines than comparable European countries, and thousands of people have to travel long distances and over 45 minutes for their treatment, particularly in my hon. Friend’s Cumbria constituency, as he has noted on many occasions.

The Darzi review noted that radiotherapy services are on their knees. They have some of the longest waiting times for treatment and vast parts of the country are classed as radiotherapy deserts, because of lack of accessibility. Radiotherapy currently has the worst 62-day performance of all main cancer treatments, and if we are serious about ensuring that all cancer targets are met by 2029, then we need the infrastructure, people and equipment to deliver them.

Cancer cases are expected to rise 30% by 2040, meaning that radiotherapy centres must be able to keep pace. Importantly, radiotherapy can also be used at an earlier stage in treatment, potentially saving lives, saving money and meeting important waiting time targets. We really ought to be leading the way on this and keeping pace with our European counterparts so that no one is left without the treatment they so desperately need. I add my support to amendment 52, because we do need to build confidence in the reduction of waiting lists, and more transparency around reductions would be helpful.

[Gregory Stafford]

Amendment 35 has not been moved, but it is very similar to new clause 35, which may be moved and concerns equipment. I will address both together. I think all in this Committee would agree that ensuring timely access to community equipment and wheelchair services is vital for patient independence, dignity and recovery. I have a number of constituents who believe that they are not getting access to that equipment in the time they would expect.

We also need to ensure that we give proper consideration to the efficiency and management of resources. In particular, we should look more closely at what happens after that equipment has been distributed. Too often, items such as crutches, wheelchairs or Zimmer frames are not reviewed after issue or returned when they are no longer needed. We are already seeing a massive financial consequence of that. It was reported last year that the Royal Berkshire NHS foundation trust is losing around £70,000 a year due to patients retaining unused mobility equipment. That might seem like a drop in the ocean for the NHS, but £70,000 could fund another nurse, if we include the on-costs. These things do have consequences.

Despite distributing thousands of items, only 38% of crutches and just 15% of Zimmer frames were returned in 2024. That represents a significant loss of reusable equipment and considerable pressure on NHS resources. It also gets into the mindset of how patients use and value those pieces of equipment and how NHS users think about resources. While I think that we all agree in this Committee that the NHS should be free at the point of use, one of the downsides of that is that patients rarely think about what the cost of their care contributes. I personally think that if people understood how much crutches or medicines cost, they would use them much more usefully. Plenty of times I have spoken to pharmacists in my constituency who tell me that once a patient has unfortunately died, their family then comes to the pharmacy with a sackload of drugs that have never been used. I think that if people understood the cost of those things, they would use them more effectively and with more caution.

This is not an isolated issue but indicative of a wider problem across the system. If we were to introduce firm timelines for provision, we would need to ensure that there is a robust process for recovery, reuse and proper management of that equipment. Therefore, while I am not supportive of amendment 35 or new clause 35, I ask the Government to consider how those proposals could be strengthened by embedding clear expectations about the return and reuse of that equipment so that public funds are used as effectively as possible.

I will now turn to the two amendments in the name of my hon. Friend the Member for Sleaford and North Hykeham. Amendment 51 is important because, while I understand the Government’s intention in clause 16, as my hon. Friend has mentioned, her amendment will prevent any artificial delays in treatment by ensuring patients are seen as soon as clinically appropriate, rather than being required to wait a minimum period. It simply protects the principle that care should be based on medical need—which I think we would all agree on—rather than some administrative target. It helps avoid situations where waiting times are managed on paper rather than reduced in reality. That ultimately safeguards patient outcomes and timely access to care.

Moving on to amendment 52, I add my strong support to this amendment, because it goes to the heart of trust, transparency and patient safety in the health system. I have been speaking to constituents and individuals from across the country who have contacted me after a video I posted on my social media that contributed to the exposure of the removal of 351,000 patients from waiting lists in March of this year. The stories I have heard are deeply troubling. Those include patients who have waited years for potentially life-changing treatment only to receive notification late—or in some cases not at all—that they have been removed from the list. For many it came as a shock, while for some it came after months or years of uncertainty. This is not some trivial administrative matter. I would sum up the Minister, when responding to questions on this point, as: “Nothing to see here, this is what always happens.”

There has been such a significant jump over a period of two months that there has to be something going on here. The experiences of patients who have spoken to me about this suggest that that is happening. For those patients it is the difference between treatment and deterioration, between hope and abandonment. It is also undoubtedly affecting more vulnerable and less technologically savvy pockets of society, such as the elderly.

[Dr Johnson]

I should say that I am on a waiting list for treatment myself. The validation process seems to involve phoning people to check if they still need treatment, which after a long period is perhaps not an unreasonable thing to do. However, if they then say yes, they are phoned again a few weeks later; and if they say yes again, they are again phoned a few weeks after that. That puts pressure on people to say, “Okay”. If they are then asked, for example: “Would you be happy to see the consultant so that he can check that you are still listed for the right procedure, given that your condition may have changed and you may want to do something else?” it feels entirely unreasonable to say anything other than “Yes” to that. Would my hon. Friend be surprised to hear that when some people do that they find that they do indeed need the same procedure, but that their waiting time has now gone back down to zero?

[Gregory Stafford]

My hon. Friend makes two important points. First, of course there has to be a validation process. There has been for a long time, and I do not think that anyone is objecting to that. However, it is a question of how it is being articulated and the people it is focused on. It is being focused on vulnerable people. I have anecdotal evidence from conversations with a significant number of people since I posted that social media video that they feel pressured into coming off the lists. It does not help that trusts have financial incentives to take people off lists. Earlier this month, the Health Service Journal said that three trusts are earning more than £1 million in having people taken off lists. There is no problem with giving trusts a financial reward to do due diligence and validate the lists, but there is potentially a perverse incentive for trusts to try to knock people off them.

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[Gregory Stafford]

The hon. Gentleman is entirely correct, and I think I said some moments ago that I am not against a validation of the list—I think I even said that I am not against some sort of financial incentive to clear the list. My concern is the extraordinary jump in the baseline in the last month or so: 351,000 people have been removed from the list for no apparent reason.

While I have been having anecdotal discussions with patients, my hon. Friend the Member for Sleaford and North Hykeham has been doing something a little more robust. It would be interesting to see the outcome of her endeavours and researches and to find out exactly what is happening in those areas. Anyone with a modicum of inquiry and common sense would say that the significant jump that we have seen in a single month deserves at least a level of interrogation, which the hon. Member for Bury St Edmunds and Stowmarket is not allowing in his comments.

[Dr Johnson]

Does my hon. Friend agree that when somebody—particularly a vulnerable person—receives a call asking them whether they would be prepared to see a consultant to see whether they still need treatment, they are aware of all the noise in the media? They are aware that other people are waiting. People do not want to waste NHS resources. The first time, they may think it is a routine process but, when they receive the second or third call, they may start to think to themselves, “They are trying to tell me that they want to do something else. Maybe I don’t need it as much as other people.” They feel obliged and pressurised into saying they do not need the procedure when they do.

[Gregory Stafford]

My hon. Friend is absolutely right. The danger in this process—especially the multiple instances of chasing within a period of weeks, which sometimes happens—is that pressure is put on patients. Again, I know anecdotally from patients who have been speaking to me that those who are most compliant—if I can put it like that—and do not want to make a fuss are generally older and vulnerable people, who feel that they are perhaps causing an inconvenience to the system. They see people with, in their view, more serious conditions or a greater need. We need to be very careful about creating perverse incentives, financial or otherwise, to try to take some of those people off the list. As I say, the significant jump that we have seen deserves more scrutiny and inquiry, and that is why I am very supportive of my hon. Friend’s amendment.

We need to understand whether patients are being removed because they no longer require treatment, as the hon. Member for Bury St Edmunds and Stowmarket said—which is, of course, entirely appropriate—or just to improve targets, present an improved picture of waiting lists, and unlock the financial benefits tied to performance metrics. There is a troubling echo here. We saw similar practices in the 2000s when patients were removed or reclassified in ways that reduced waiting list numbers without genuinely improving access to care; it damaged confidence in the system then and it risks doing so now. What concerns me most is that we may be repeating that pattern. If the Government find they cannot meet their waiting list targets, there is a real danger that the pressure to do so will translate into decisions that, intentionally or not, compromise patient safety and fairness.

[Gregory Stafford]

There have been a number of reports of situations where people have not received care and have died because of that, so I do not see the hon. Member’s point. I think that, with amendment 52, my hon. Friend the Member for Sleaford and North Hykeham is trying to ensure that when the statistics are published, we can scrutinise the reasons behind them. The hon. Member for Ashford may be entirely right; let us imagine that is the case, and there is no gamifying or pressure going on. Why not allow the public to see that? Why not put to bed the HSJ stories that say there is something fishy going on? He should welcome that level of transparency and scrutiny to back up his argument if he is correct.

[Dr Johnson]

The hon. Member for Ashford talks about social media and social media comments. I wonder if, where the DHSC or the Government have put that waiting lists are falling, my hon. Friend has read any of the comments that come in from the general public below such proclamations.

[Gregory Stafford]

My hon. Friend tempts me to be political; I will rise to that briefly. Yes, I have seen them and she is right. There is a clear concern that when the Government make all these proclamations about how brilliant the NHS has suddenly become, the reality on the ground does not meet that for many patients. However—I am being gentle now—that is probably not exclusively a problem with this Government. My right hon. Friend the Member for Melton and Syston might kill me, but I am sure other Governments have done something similar.

I will go back to amendment 52 because I think it is really important. Let me be clear: it would not prevent people being removed where appropriate; it would simply require the Government to be honest about why. It requires the Secretary of State to publish the number of patients removed from waiting lists each month and, crucially, the reasons why. If everything is being done properly there should be nothing to fear from such transparency, but if there are problems, sunlight is the best disinfectant and the amendment is exactly what we need. We owe it to our constituents and to every patient in the country to ensure that waiting lists are not improved just on paper, or in a press release, or in a social media tweet, or at the expense of the care of real people but actually improved.

If we are to strengthen patient choice, particularly in relation to community services that substitute for or prevent hospital admission and treatment, there are some good measures in clause 16. However, as my hon. Friend the Member for Sleaford and North Hykeham said, there are concerns, so I hope the Minister will be able to pick those up in her comments when she winds up.

[Karin Smyth]

There are a number of amendments in the group. Amendment 35 was not moved but as the hon. Member for Farnham and Bordon spoke to it, I will comment on that amendment, which is in the name of my hon. Friend the Member for Bexleyheath and Crayford (Daniel Francis). Community equipment and wheelchair services are really important to us and—to allay the concerns of the hon. Member for Farnham and Bordon—that is why the medium-term planning framework requires that, from this year, all ICBs and community health services must actively manage and reduce waits over 18 weeks and develop a plan to eliminate all 52-week waits. I assure the Committee that we will hold the ICBs for their performance. The community health services situation report has a specific monitoring line, covering children and young people and covering adults, for the wheelchair, orthotics, prosthetics and equipment category. We intend to continue that work following NHS England’s abolition. Consistent national standards will help us to identify the best and the weakest-performing areas, to identify what improvements need to be made and to tackle the longest waits.

Amendment 52 was tabled by the hon. Member for Sleaford and North Hykeham. We are committed to ensuring that all patients receive the NHS care they need in a timely manner, and I recognise the importance that Committee members have placed on that matter. The NHS constitution sets out that patients should start consultant-led treatment within 18 weeks of referral, and it is imperative that the system continues to work towards returning to and then upholding that standard.

I listened with great care to the comments from Members on the Opposition Benches, but I was here—as were you, Dr Huq—during the last couple of Parliaments; I was here as waiting lists rose and rose after 2012, under the previous Government’s stewardship, until they reached 4 million people, all waiting an inordinate amount of time. That Government had no kind of approach to reducing the numbers; they were quite content to have 4 million people on waiting lists, and to never bring forward measures to change that. They were quite content not to challenge NHS England or trust boards about why people across the country in all our constituencies were languishing on those lists. We are determined to resolve that situation.

[Dr Johnson]

Will the Minister give way?

[Karin Smyth]

I will move on. It is absolutely right that integrated care boards, as local commissioners, retain the ability to manage their services and waiting lists effectively, given the shocking numbers that they have inherited. This is complicated, difficult work: commissioners have to balance demand, capacity and clinical need, and a prohibition such as the one set out in the amendment would threaten to remove legitimate flexibilities that are required at the local level to ensure that services are delivered safely and efficiently.

We are clear that systems should not be setting minimum wait times that exceed the 18-week constitutional standard, but hon. Members will appreciate that not all elements of waiting are inappropriate. In many cases, they reflect clinical pathways, sequencing of care or the need to prioritise the most urgent patients. It is imperative that clinical judgment and urgency remain the key drivers of prioritisation, which is something the amendment threatens to remove.

Turning to amendment 52, I recognise that Members across the House are committed to ensuring that all patients receive the NHS care they need in a timely manner. Validation is a routine and long-standing part of waiting list management by providers. It ensures that patient records are accurate, that patients are on the best pathway to meet their needs and that they still need their appointments. Routinely validated waiting lists will support a return to the 18-week NHS constitutional standard.

Reasons for removal as a result of validation include a patient no longer needing their appointment or there being a duplicate appointment. The previous Government left behind some systems and trusts in such a poor condition that they give out duplicate appointments, and we need to resolve that as part of our work. Other reasons for removal include a patient’s record not being properly updated following treatment or a clinical decision—another sign of the inefficiency that the previous Government left behind.

[Karin Smyth]

Once again, my hon. Friend is absolutely right. He is expert on this issue and has outlined to us some excellent clinical examples. I look forward to debating the single patient record further in Committee.

Importantly, any patient removed from a waiting list should be notified alongside their GP. Data on the total number of removals from waiting lists is published by NHS England. That data includes, but cannot separately identify, patient pathways removed as a result of validation. The Department remains committed to the transparent publication of official waiting list statistics following the abolition of NHS England, although there are no plans to publish more detailed breakdowns. NHS staff are delivering record levels of elective activity, which has enabled us to meet our interim target of 65% of patients being seen within 18 weeks.

[Dr Johnson]

If a person has been waiting more than 18 weeks, the trust calls them and asks them to see a consultant to check whether they still need the appointment or whether they need a different treatment. If, after having that appointment, they are told that they still need the treatment, that same day they go back on the waiting list as if it were day one. Therefore, they have not waited less than 18 weeks, even though the Minister’s statistics might suggest they have. Does she accept that?

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[Edward Argar]

The hon. Member for North Shropshire makes the point very well. Back when I was a Minister, and subsequently shadow Secretary of State, she raised that point with me. The clause is sensible. The Minister articulated concisely and reasonably why it is necessary. It is the nature of any devolution arrangements that a little bit of cross-border co-operation is required along the border to make sure that services work effectively for people. This may have changed, but in my experience the majority of those crossing the border were people from Wales coming for secondary care services in a hospital on the English side of the border, so I think the clause is entirely reasonable.

I echo the hon. Lady’s request: I would be grateful if the Minister updated the Committee on what conversations she has had, particularly with the Welsh Government, but also with the Scottish Government, to ensure that there is reciprocity and that they will put an equivalent provision into their laws to ensure that patients in England are taken into consideration in their healthcare planning.

[Dr Johnson]

The clause imposes a duty on ICBs to have regard to the likely impact of their commissioning decisions on areas of Wales and Scotland close to the border. In some respects, this is like other parts of the Bill—a statement of the obvious regarding a person’s job. Are we suggesting that the Secretary of State, and in particular ICBs, would not consider the effect of their decisions? I hope that they would, but, given that the clause is there, what teeth does it have? What if they do not? Is there any consequence in the Bill if they do not? As others have said, will the Minister confirm whether there is a reciprocal agreement with Wales and Scotland? If there is not, what negotiations has she entered into and what progress are they making?

[Karin Smyth]

As an MP in Bristol, which is not quite on the border, but is pretty close, I absolutely understand. We have relationships with our Welsh colleagues and I have been involved in debates on this matter. The clause ensures that, with the abolition of NHS England, regard is had to to arrangements with our colleagues across the border. We all understand that devolution means that different arrangements will be made in the constituent parts of the United Kingdom. It is not for the UK Government to determine what those are, because they are devolved. However, I assure members of the Committee that across the piece in the Department, and indeed across the Government, regular meetings and conversations on these and other matters with regard to the devolved functions are a regular part of the work that we do.

Question put and agreed to.

Clause 17 accordingly ordered to stand part of the Bill.

Clause 18

Transfer schemes in connection with integrated care boards

Question proposed, That the clause stand part of the Bill.

[Karin Smyth]

The clause gives the Secretary of State the powers to make transfer schemes where an ICB is being abolished or established, or where the area covered by an ICB is being amended. A transfer scheme ensures that all the staff, property rights, responsibilities and liabilities, other than criminal liabilities, of the ICB being abolished are transferred to another ICB. That ensures that the ICB taking over has the appropriate information and resources to continue to arrange healthcare services for their population. In the past, that has been used to support the restructuring of ICBs to achieve geographical boundary alignment with strategic authorities, as set out in the 10-year health plan. The power also allows transfers to the Secretary of State and, when a new ICB is established, allows the transfer of staff from an NHS trust or foundation trust or from a special health authority.

Following the abolition of NHS England, we expect that Ministers will continue to need to be able to make transfers between ICBs. The clause allows that as needed. I therefore commend the clause to the Committee.

[Dr Johnson]

I have one question for the Minister. Which ICBs does she envisage being abolished, or is this just a precaution for the future?

[Karin Smyth]

It is precautionary to give the power in the event—future-proofing the Bill.

Question put and agreed to.

Clause 18 accordingly ordered to stand part of the Bill.

Clause 19

Integrated care boards: power to provide assistance

Question proposed, That the clause stand part of the Bill.

[Karin Smyth]

The clause relates to the power for integrated care boards to provide assistance and support in relation to the health service. It replaces section 14Z48 and, in part, section 12ZA of the National Health Service Act 2006 with a clearer and more flexible power. At present, the various ICB assistance powers are narrower and more confusing. Section 12ZA provides for certain forms of practical assistance in connection with ICBs’ commissioning functions, while section 14Z48 provides a more limited power to make grants or loans. Other specific assistance powers sit elsewhere in the legislation, including in sections 96, 112, 124 and 147, which allow assistance and support for primary medical services, dental, ophthalmic and pharmaceutical services.

Clause 19 replaces all those separate powers with a general power for ICBs to provide assistance or support. The clause will make it clearer when an ICB may support providers, prospective providers or other activity connected with the health service. It will allow an ICB to provide assistance or support to a person who is providing or proposing to provide services as part of the health service. It will also enable an ICB to support a person who is carrying out or proposing to carry out activities that the ICB considers to be conducive to the health service. The assistance may include financial assistance, making available the services of ICB staff, or making available any other ICB resources. The clause also allows assistance to be provided on agreed terms, including terms about payments by or to the integrated care board.

The clause supports ICBs in their role as strategic commissioners. ICBs need to be able to support the development, improvement and resilience of services for their populations. They need to be able to cultivate their provider sector to meet the needs of the people they are responsible for, and they need to be able to do so in innovative and flexible ways. The clause gives them a clearer statutory basis for doing so. This is only an enabling power; it does not require an integrated care board to provide assistance and it does not create any entitlement for a person to receive assistance, nor does it disapply the ordinary legal and financial controls that apply to integrated care boards, or any other element of the usual way in which NHS bodies are overseen and regulated.

The clause should be read alongside clause 9, which creates a broadly analogous assistance power for the Secretary of State. In combination, the clauses support the move to a simpler, more flexible statutory framework that enables everybody, from the centre to ICBs, to discharge their responsibilities in ways that can be adapted to the complexity and multiplicity of circumstances they will inevitably encounter. I commend clause 19 to the Committee.

[Dr Johnson]

The Government’s explanatory notes state that the clause is intended to give ICBs the ability to provide a broad range of support to those involved in providing or administering the health service. The flexibility there aligns with the Government’s stated vision for more autonomy across the system. I have a couple of questions. If the ICB were to provide support in a way that was out of line with good practice or what is expected by the Department, what would be the recourse? Where will it be possible for right hon. and hon. Members to see the financial expenditure that ICBs make in any such circumstance?

[Karin Smyth]

I thank the shadow Minister for her questions. ICBs are part of the accountability outcomes framework, so they will be monitored in the usual way, and any expenditure by the ICB—and, indeed, by the Department—is recorded in the departmental accounts.

Question put and agreed to.

Clause 19 accordingly ordered to stand part of the Bill.

Clause 20

Performance assessments of integrated care boards

Question proposed, That the clause stand part of the Bill.

--- Later in debate ---

[Karin Smyth]

I recognise the right hon. Gentleman’s expertise as a former Minister in this role. I do not want to mislead him, so I will come back to him in writing on both those points, if that is acceptable. He tempts me to be more prescriptive than I think we intend to be at this point, but I will ensure that he gets a proper answer to both questions. I commend the clause to the Committee.

[Dr Johnson]

As has been said, the clause replaces the part of the NHS Act that requires NHS England to carry out performance assessments of the ICBs and rewrites it so that the Secretary of State has to carry out those assessments. That makes some sense, but, as the Minister said, it takes out the criteria against which the ICBs will be assessed.

I accept what the Minister says—she wants those criteria to be set out more flexibly than can be done in primary legislation—but it is not reasonable or fair to assess people against criteria that they do not know in advance. It will be important, will it not, that ICBs know in advance what those criteria will be? Given what she said to my right hon. Friend the Member for Melton and Syston about writing to him, will she commit to writing to us to say not only what the criteria will be at the moment, but how far in advance ICBs can expect to receive them before they are expected to work to them and then be assessed against them?

Will variation be a factor in whether an ICB is deemed to have been performing well or not? We know that there is a tension in the Bill between the Secretary of State’s need to equalise provision and the ICBs’ desire and intention to vary it and innovate. Given that the Secretary of State is a political individual, how will the assessment process be conducted in a way that gives ICBs and their leaders confidence that there will not be political interference in it?

[Karin Smyth]

Of course ICBs will know how they are going to be assessed; that will be in guidance in the usual way. In the last two years, in planning terms, we have brought forward all that work for the system—including on the finances—in order that the system works more efficiently, and we will continue to seek to do that.

The hon. Member, as she has several times in the Committee, returned to the question of variation. When there is devolution and local systems are different, there will be a degree of variation, as I have said. In performance management terms, where there is unwarranted variation, we will seek justification and understanding of that. Sometimes, there is variation for geographical reasons. There may also be historical structural reasons in a local system, or temporary reasons why performance is variable. We would look at that as part of that general work.

Question put and agreed to.

Clause 20 accordingly ordered to stand part of the Bill.

Clause 21

Membership of integrated care boards

[Dr Johnson]

I beg to move amendment 46, in clause 21, page 15, leave out from line 33 to line 6 on page 16 and insert—

“(2) The constitution must provide for the ordinary members appointed as mentioned in sub-paragraph (1)(b) to include—

(a) at least one person nominated by one or more NHS trusts or NHS foundation trusts which provide services under arrangements made by the integrated care board, in accordance with regulations made under sub-paragraph (2A);

(b) at least one person nominated by a body representative of providers of primary medical services whose area falls wholly or mainly within the area of the integrated care board, in accordance with regulations made under sub-paragraph (2A);

(c) at least one person appointed by a local authority whose area falls wholly or partly within the area of the integrated care board; and

(d) at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with, or includes the whole or any part of, the integrated care board's area (if any).

(2A) The Secretary of State may by regulations make provision about the nomination of ordinary members under sub-paragraph (2)(a) and (b), including provision about which NHS trusts, NHS foundation trusts or representative bodies are entitled to make nominations.

(3) The constitution must set out the process for making nominations under sub-paragraph (2).

(4) A person making a nomination under sub-paragraph (2) must have regard to any guidance published by the Secretary of State as to the selection of candidates.”

This amendment modifies Clause 21 so that, rather than replacing the existing mandatory membership requirements in Schedule 1B to the National Health Service Act 2006 with a requirement for mayoral representation alone, the new sub-paragraph (2) reinstates and consolidates the full range of required ordinary members.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 25 in clause 21, page 15, line 38, at end insert—

“(2A) The constitution must also provide for the ordinary members appointed as mentioned in sub-paragraph (1)(b) to include at least one member nominated jointly by the local authorities whose areas coincide with, or include the whole or any part of, the integrated care board's area.”

This amendment would require integrated care boards to have a member jointly nominated by local authorities from within the board's area, as is currently the case but would otherwise be removed by clause 21.

Amendment 45, in clause 21, page 15, line 38, at end insert—

“(2A) The constitution must provide for the ordinary members as mentioned in sub-paragraph (1)(b) to include at least one member nominated by local primary care providers.”

This amendment would ensure that ICBs have to have representation from primary care providers.

Amendment 26, in clause 21, page 16, line 3, leave out from “mayor” to “sub-paragraph (2)” on line 4 and insert

“or local authority nominating an ordinary member as mentioned in sub-paragraphs (2) and (2A).”.

This amendment is consequential on amendment 25 and would require a local authority involved in nominating a member of an integrated care board to have regard to guidance published by the Secretary of State.

Amendment 27, in clause 21, page 16, line 9, at end insert—

“‘local authority’ has the meaning given by section 2B(5);”.

This amendment is consequential on amendments 25 and 26 and defines the term “local authority”.

Clause stand part.

[Dr Johnson]

At present, integrated care boards will have a chair, a chief executive and at least three further ordinary members. Those three ordinary members will include a representative of the NHS trusts and NHS foundation trusts in the area, someone from the primary medical services in the area and someone nominated by the local authority areas within the ICB area. Under the clause, the requirement for those individuals is replaced with a requirement to have someone from each of the mayoral authorities.

Because of the order in which the Government have done this—removing half the budget from the ICBs, which has caused them to merge in a way that is not coherent with the Government’s not-yet-complete local government reorganisation—we have a situation where representation is not even. For example, in my ICB area the Mayor of Greater Lincolnshire and the Mayor of the East Midlands will each be able to choose someone to represent them on the board, but the proportions of the population are not even. Lincolnshire will be over-represented, which is not an issue for my constituents, but it may be for those from Nottinghamshire and Derbyshire. Likewise, the northern part of Greater Lincolnshire, which is in a different region, has a small population relative to its ICB. Some mayors will therefore have representation that is not proportionate to their population size.

There is surely a risk that the next step will be for the Government to say they want to make things more even, with ICBs working in relation to mayoral authority areas. Yesterday, the Minister for Care suggested at his appearance before the Health and Social Care Committee that the ICBs should be aligned with strategic authorities, but the only way in which that can happen once the Government have decided where the strategic authorities will be is if things are changed once again.

That brings ongoing costs—financial costs, opportunity cost for service development, and cost to the people delivering these services. The people working hard to try to deliver the Government’s plan find themselves and their jobs threatened and chopped and changed all the time. We heard evidence that the concentration on reorganisation rather than service delivery, provision and development is causing distress to those people.

We also heard about the effect on social care, which, certainly in Lincolnshire and in other places, is delivered by the upper-tier local authority, but not all mayors have any responsibility for health—our mayor does not. We will therefore have someone who is not responsible for health on the ICB while someone responsible for delivering social care will have their seat on the ICB removed. I am afraid that I simply do not understand that. I watched through several times the Minister for Care’s Select Committee appearance, and I still do not understand the rationale. I will be grateful if the Minister for Secondary Care could explain that.

--- Later in debate ---

[Gregory Stafford]

The clause will replace the constitutional requirements contained in paragraph 8(2) to (4) of schedule 1B to the 2006 Act so that “ordinary members” must now include at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with or includes the whole or any part of the ICB’s area. The ICB’s constitution must set out a process for making such a nomination, and a mayor nominating an ordinary member must have regard to any guidance published by the Secretary of State, following the abolition of NHS England, as to the selection of candidates.

The definition of a local authority in paragraph 8(7) of schedule 1B to the 2006 Act will be replaced with the definition of a mayoral strategic authority. Sub-paragraph (1), outlining the process to determine the appointment of an ordinary member, and sub-paragraph (6), specifying that one ordinary member must have knowledge and experience in mental health services, are both retained. The clause therefore represents a clear shift in the structure of integrated care boards and, in my view, an unwelcome one, by removing the requirement for representation of GPs, local authorities and NHS trusts, while introducing a requirement for representation from mayoral authorities.

Those are not minor features of the system. The inclusion of local authorities in particular was designed to ensure that decision making reflected local needs and supported genuine integration between health and social care.

For as long as I can remember, Governments of all colours have talked about bringing health and social care together. Some have been more successful at that than others, but there should be agreement across the House that much more needs to be done. With this clause, the Government seem to be taking at least one step back—I would say numerous steps—from trying to bring health and social care together. Like my hon. Friend the Member for Sleaford and North Hykeham, I watched the Health and Social Care Committee’s discussions with the Minister for Care yesterday, and I too cannot fathom why the Government are doing it. I hope that it is an oversight and that, once the Minister goes away and reflects on it, she will look to table some amendments further down the line—I am sure that she will vote against ours today—so that we can bring these matters back.

I am especially concerned about the removal of local authority representation. We are effectively asking local authorities to continue to deliver vital services while removing their voice in the room where strategic decisions about health and social care are made. That raises a fundamental question about how the integration is intended to work in practice. There is also a broader concern about the direction of travel. We are moving away from place-based representation towards a model that places greater emphasis on these mayoral structures, yet the legislation is not prescriptive about who the mayors appoint, and colleagues within and without this Committee have already raised concerns that there is a gap in the understanding at the centre about how local authorities operate in practice.

That brings me to the point raised by my hon. Friend the Member for Sleaford and North Hykeham and the hon. Member for Winchester. I apologise; the Minister said that she did not want a geographic tour of our constituencies, but I am afraid that she will get one now. Part of my constituency sits in Hampshire in the Hampshire and Isle of Wight ICB, and as the hon. Member for Winchester said, we may or may not have mayoral elections in a year’s time. Hampshire county council has launched a judicial review against the proposed local government reorganisation; if that is successful, or even if it delays the process, this Bill will come into effect without our having a mayor, and there will be no representation for anybody on this board. We need clarity from the Minister on who will represent the people on the board if there is no mayoral authority. I would say that local authorities—Hampshire county council in this case—should remain on that board, at least until there is a mayoral authority.

[Dr Johnson]

Where a mayor is from one political party and local authorities are run by different political parties, the mayor, as part of the ICB, will be able to make decisions about spending done by authorities that are run by different parties. That will surely create a political conflict, or at least the potential for one.