Health Bill (Second sitting)

Helen Morgan Excerpts

Committee stage
Tuesday 16th June 2026 Public Bill Committees

[Karin Smyth]

Q Mr Blythe, what does the single patient record mean for you in running a big hospital?

James Blythe: I think the single patient record offers enormous opportunities to improve patient care. We know that we see patients every day whose quality of care and patient experience would be improved through having access to a continuous record that ran through primary and secondary care, mental health care and other services. To my mind, having had experience of working with systems that have introduced to some degree the single record or a single care plan, it will be extremely important that we take the time to train our clinical staff and adapt our operational systems so they use a patient record productively and consistently in the interests of better patient care. If we just put a single patient record into clinical settings without doing anything with the staff or services to make it useful, at best it will be inconsistently used and sometimes it will just be missed altogether. If we are going to invest, which I think is right, in a single patient record, we also have to invest in those systems and human factors around it, and make sure that we train people to use it well.

[Helen Morgan (North Shropshire) (LD)]

Q I am a member of the all-party parliamentary group on patient safety and I am also a vice-president of the Local Government Association.

Can I ask about Healthwatch? We heard this morning that ICBs will be taking on a chunk of the current operations of local healthwatches, but that they will not have any additional budget to enable them to do that. In fact, we know that their budgets have been significantly reduced. Could you elaborate on how you think that will work, and will it be as effective as the current system?

Sir Ciarán Devane: The ICBs have a capitation fee of £19.40, which they have to do everything out of. This is an additional duty placed on them. They will have to work out how to do it if there is no extra money coming, but it will be pressured.

I hear the argument that local healthwatches were variable. This function has been slightly outside and independent, playing back into decisions; we have to ensure that the level of independence remains somehow in how this is constructed, but that the variability is not just transferred from local healthwatches to how it is done within or across ICBs. Again, the implementation will need to be done well. That leads into the question about local authorities and the connection with them, making sure the democratic voice is brought in and equally the local voice. The legislation does not stop an ICB doing this well. Therefore, without the legislation, part of what we can be doing collectively is trying to make sure that what was good about healthwatches is preserved and is understood by ICBs. There are only 25 of them, so it should be a manageable task for the rest of us.

The effectiveness comes back to whether you believe this is a good thing. One of the things we have to do is secure that the benefits of having the patient voice in there, along with the clinical voice and the voice of the manager, at the same time, so that it is not a case of saying, “Oh, now we’ll go and consult the patients on the font size of the report,” but is authentic. That puts a lot of work on to the ICBs and on to those of us who believe passionately in engaging with the patient voice, but there is a risk because of that pressure. Done well, it will enable strategic commissioning and ensure the quality remains, but they are starting, if maybe not from scratch, from a new place.

[Helen Morgan]

Q My second question is similar. In reality and in practice, how do you envisage ICBs will be locally accountable once these legislative changes have taken place?

Sir Ciarán Devane: According to the ICBs we are talking to, which is all of them, they are saying that they believe in local authority engagement. We will be saying, “You may not be told you have to, but we would encourage you to do it.” I am sure that should be coming from the Department as well.

The witness to my right is an example of that; we know that when the NHS has really good local connections, you can get things done in the interests of your patients much more easily. The belief is there, but we need to make sure that the legislation is not seen as a signal that this is unimportant. That is a risk. As a representative organisation, we have to say to people, “We hear you saying that you really believe in this. Therefore, you need to demonstrate, not least to the Secretary of State, that you are following it through.”

I have a small additional point about mayors in unitary authorities being able to appoint somebody who is both the chair of the ICB and the local health commissioner. That should help. Those individuals will have to work out how to serve two masters, but that is okay—other people learn how to do that, too.

James Blythe: I would focus on a slightly different part of the Bill in terms of how this needs to work. There are 25 ICBs; that is quite a large footprint. From my experience of delivering meaningful collaboration and joint working between health and local government, I think it tends to happen at a more local level than that. The neighbourhood health plan in the Bill becomes extremely important. As a system, we should be very ambitious for those neighbourhood health plans. They should go a lot further than just describing what should happen in terms of improving health outcomes at a local level.

We should set an aspiration as a system that there should be a responsibility on health bodies and local government bodies to describe how changes will be made. The role of ICBs is to enable groups of providers and other organisations in local areas—most ICBs will have several places—to come together and not just work out what a local population needs, but actually do it. That will mainly be about relationships on the ground between an acute hospital team, a community services team, a mental health team and a social work team.

The role of ICBs is very much to give the contractual tools and mechanisms to local NHS organisations to work effectively with their local authorities so that there are really good neighbourhood health plans. Most importantly, they should not just write them but actually see them through.

[Liz Twist (Blaydon and Consett) (Lab)]

Q Sir Ciarán, the 10-year health plan, which is behind a lot of this, demands that we are really ambitious in involving patients and communities in shaping the services that they need. How can we best support ICBs, local authorities and other organisations to drive that change?

Sir Ciarán Devane: I go back to our having to convince people. Many people are convinced—that is probably the first thing to say. But we have to convince people of the benefit of doing this. Delivering the ambitious neighbourhood health plans that James describes will happen only if everybody is in the room and doing it.

I do not necessarily think that the legislation can mandate that belief or the way to do that. However, it can set an expectation for the ICB that, in developing its plans, it should be able to demonstrate that it has engaged with the local authorities, patient organisations and the public local to it. The legislation can set an expectation that the ICB is using population evidence to make the right commissioning choices and that, if reconfigurations, which may well be locally contentious, are to happen, engagement happens beforehand. As elected Members, the Committee will know that those conversations should start early and that local populations should not just be bounced into something.

It will be incumbent on the new department to set those expectations with the ICBs about the new way of working. That is the only way we are going to create an NHS that will be able to cope with the number of frail, elderly people with multiple morbidities. Those people are a consequence of the success of the NHS over decades. People are living longer with cancer; the prevalence of cancer—the number of people alive with cancer—has doubled in 20 years. But that means that there are four million people who are not necessarily well. The only way to cope with that is to make a significant and radical change to the neighbourhood health plans and bring the public with us. That will happen only with proper patient and public engagement.

--- Later in debate ---

[Karin Smyth]

Yes.

Professor Croisdale-Appleby: Fine. The Government’s move to the integrated patient record is absolutely excellent. Most of us have wanted that for a very long time, but we also recognised the IT difficulties in doing it, as well as the question of security. However, as digital has advanced, we have nutcrackers that we did not have before to crack that particular nut. I can but support that move.

From the point of view of the things that really matter, the ability of a person to feel that they can tell their story once—not time and again—comes up all the time in our research. With great respect to everyone here, we are very capable of standing up for ourselves and insisting that we get answers, but the people I deal with and have the privilege of representing are often not in that position at all. They are overwhelmed when they are repeatedly asked the same question, often in a language—medicalese, if you like—that they do not really understand and feel threatened by. The single patient record is going to go a long way towards helping with that situation. It is not the complete answer but at least it does the hygiene part, as opposed to the motivator part, very well.

Sarah Tilsed: It is an excellent initiative—1as the professor said, we have been calling for it for such a long time—but we really need to consider the consent and data elements. A lot of pieces of work that we have done with patients shows that people are happy with their data being shared for these electronic records, as long as they are transparent and patients know what is being done with their data—that is a really important point.

The care.data initiative and general practice data for planning and research—GPDPR—were great, but unfortunately, because they did not have genuine patient involvement right from the beginning, they failed. We need to ensure that the SPR does not fail. In terms of reaching underrepresented or less-heard communities, we need to ensure that we hear from those people straightaway. How do they want this to work? Do they want to know how their data is being used? How can we ensure that people who do not use the NHS app are involved and that their data is being shared? How do we approach people who are understandably very hesitant about digital technology and electronic records?

[Helen Morgan]

Q Sarah, the Patients Association has said that it is concerned about this reorganisation distracting from patient priorities. Could you elaborate on where those concerns come from and what should be done to mitigate that?

Sarah Tilsed: I said a lot about that earlier, in response to a previous question, so I am not sure how much more I have to add. I think my main point is that we must not divert attention away from the urgent priorities that patients are facing at the moment, ensuring there is a truly independent patient voice and trust—there is a lack of trust among patients, as I keep saying. How are we going to ensure that the reporting system is there for this?

Ultimately, patients need reform to lead to better care, not simply to different structures, which I fear is what often happens. Sir Robert Francis said, following the Mid Staffs situation, that patients must come first. Throughout the passage of the Bill, the Patients Association question will remain simple, and we will ask it time and again: will these changes actually help patients to receive better care, and how will we know if they do? That is the first principle to come back to. When everything is happening—all this restructure—how are patients going to be affected and involved in it?

[Helen Morgan]

Q My second question is about Healthwatch. The Committee heard this morning about the variability of Healthwatch’s effectiveness at a local level. What could be done to ensure that the best and most effective Healthwatch practice is rolled out across the whole of England?

Professor Croisdale-Appleby: Thank you for that question. One of the reasons there is a difference or variation among the 153 is that the amount of funding is very different. Some of them get 10 times the funding of others, which makes a difference to the scope of what they can do. What it does not allow—and I think Healthwatch England has an important contributory role in this—is a change in the quality of the way in which the research is done.

One of the things that I have encouraged very strongly—although it happened before I joined Healthwatch—is the use of qualitative as well as quantitative data. The system is awash with quantitative data, but that does not necessarily cut through to the way that people are, the way they think, the lexicon they use, the concepts they use in communication etc. One of the great strides that Healthwatch England and our 153-member network have made is the intelligent use of qualitative data. That is an art in itself—I would like to think that is a science, but it is certainly an art.

It would be easy to remedy that, in the sense that if the funding were more equitable, some of that variation would disappear, but the variation is not in the quality, the effectiveness of the listening or the ability to look thoroughly at the impact, and it does not affect the fact that the organisations concerned are held responsible for what happens to the recommendations in terms of implementation. That is uniform across the system—it is just the amount of it that will vary naturally, because of the differential funding.

[Laura Kyrke-Smith (Aylesbury) (Lab)]

Q To go back to the single patient record, I see huge potential—at least in my constituency, where we have real challenges with GPs and hospitals not talking to each other or sharing information. Nor do trusts and local authorities across Buckinghamshire, Bedfordshire and Hertfordshire share that information. Sarah has touched on this a bit already, but I am interested to hear from our other witnesses on how they think the single patient record would improve patient experience, and on how we would go about building public understanding and trust in a new system.

James Cooper: There are some big opportunities in the single patient record, with the caveats that Sarah mentioned on data governance and consent. For families of children who are seriously ill, it presents huge opportunities, as I said earlier, because of the complexity of their needs. Often, huge amounts of information need to be conveyed to any professional who the children come into contact with, wherever that is across health, education or social care.

Many professionals have a long-standing relationship with such families, whether they are NHS community children’s nurses, consultants with a speciality in the child’s condition or children’s hospice teams, but families often need to access emergency unplanned care, perhaps in the middle of the night or at weekends. In those instances, when they speak to paramedics and emergency doctors, it is imperative that they can convey the information as quickly as possible. In those instances, I can see huge benefits.

With issues such as advanced care planning, to reflect the needs and wishes of those families, in particular as the child is coming towards the end of their life, I think it is critical that the whole range of professionals involved in the care of children has access to that information. I will welcome much more clarity from the Government about when the families will benefit from that particular initiative.

Professor Croisdale-Appleby: May I add a short comment?

--- Later in debate ---

[The Chair]

Q Ms Higson, you clearly had an interest in the Minister’s last question. Is there anything you would like to say about that?

Maria Higson: A couple of things. One is that it is not possible to overstate the importance of the partnership working between the NHS and local authorities. If we want neighbourhood health and the shift to prevention more broadly to be successful, working closely with local authorities, including the public health teams—which were not in the question but deserve a mention—is imperative. I am sure we will come to the question about the relationship with the mayoralties. There is something about that geography question. The insight and experience that local authorities bring is really important. That is the one thing that I think ought to be mentioned.

[Helen Morgan]

Q I am a vice-president of the LGA, and I am also on the all-party parliamentary patient safety group, just to declare that interest up front. I will use the example of my own local authority, Shropshire, which is a unitary authority. It is extremely financially challenged and operates with an ICB in a similar situation. The hand-off that Sally described between continuing healthcare and provision of social care is really problematic because neither organisation really wants to pay for the care for the people who need it because they do not have the funds. It is a really tense relationship between the two.

I am really concerned that that will become even more problematic because they cannot work together, given that we are not a combined mayoral authority, that we will not have a mayor sitting on our ICB and that our ICB merged footprint does not fit with our local authority geography. How can the health and wellbeing boards work between the two organisations to deliver good social care?

[The Chair]

Is that directed at any particular witness?

[Helen Morgan]

I am directing it at all three, if that is okay.

[The Chair]

Let us start with our councillor in the middle.

Councillor Wright: It is a challenge. I completely hear that; continuing healthcare is a really difficult one. It is right to say that residents are seen as a financial burden, which should not happen. That is why we need strong health and wellbeing boards. We need strong, honest conversations between local authorities and the NHS for ensuring that good continuity of care.

Obviously, I think the overall aim of the 10-year health plan is to move much more to a model of prevention and treatment in the community, where we hope that we could intervene earlier and set up good standards of care before it gets to a stage where it becomes so adversarial. That is what we are aiming for. We have challenges in our local authority and have had to push back on a few cases where we felt the NHS should be helping those people.

Sally Burlington: The problem is getting bigger over time. We did some joint work last year with the NHS Confederation to look at those difficult issues on the boundaries between health and social care, including continuing healthcare and mental health aftercare. That identified some good models. We see arrangements for joint commissioning of continuing health care, which can work well. We have seen a little bit of withdrawal from that by some ICBs.

Part of the issue has to be that we are seeing a real intention to cut costs, and that leads to lots of reviews taking place that do withdraw continuing healthcare. We have seen that trend while the demographics are pointing to potentially more demand, not less. I do not think there is a substitute for better relationships. The legal framework is pretty clear. A helpful way into the problem would be to find a way to have a set of conversations at a national level about what the right solution for people is—start there and then think about whether the reviews are right in the ways that they are taking place.

Maria Higson: The only thing I would add is that it is tricky when we apply a broadbrush approach of, “Well, it’s going to be about the mayoralty and so on.” In reality, certainly within London, we can describe ourselves as a system of systems. We work with six local authorities across one ICB, now partnering with south-west London as well. It is not as easy as “one approach fits all”. As this Bill goes through implementation, it will be important to be conscious of that to get the best out of those relationships.

[Helen Morgan]

Q Do you think that the health and wellbeing boards, as envisaged by the Bill, will be the right structure to deliver those relationships, and how do you ensure that they have the right skills?

Councillor Wright: I chair a health and wellbeing board, and everyone comes to those; there are really good conversations and really good reviews of what is happening. I think they are in a really good position. What I worry about is how much influence they will have over NHS wider strategy.

I was at a King’s Fund day, and someone said something that I thought was so true: the Health Bill and the NHS 10-year plan is the NHS 10-year plan. The NHS will be judged on how it achieves what it is meant to achieve. Although, as local authorities, we want to help with prevention and those wider determinants of health, ultimately the responsibility sits with the NHS.

It is about trying to work out how we have better conversations with the NHS, to say, “We have done neighbourhood health for years; this is what we do as local authorities. We look at all these things and we use public health and our adult social care system to create healthy environments. We need you to be on board with us.” I therefore think there is something about the power dynamics regarding health and wellbeing boards and how we address them. But overall, I feel that they are the best way of ensuring community health.

The other thing is about geographies. Health and wellbeing boards might not match neighbourhood health geographies, so there are also some challenges in working out how that will work.

[Edward Argar]

Q Having been both a local councillor and a Health Minister, I am very conscious that the real test of any joint working arrangements between different bodies comes when budgets start getting a little tighter. We see that tension growing a little bit with the cuts made to ICBs’ budgets.

I was the Minister who created ICBs, and I sat on that Bill Committee with the current Minister for Secondary Care. I am getting a sense of déjà vu—we are on different sides of the Chamber now, but we sat through the Committee stage of the Health and Care Act 2022 together. I deliberately created ICBs to match the geography of upper-tier authorities because health and social care is essentially one system. If one bit does not work, the other bit does not work.

Since then, we have seen significant mergers and larger areas, further removing them from that direct relationship and read-across. Although the good ones do, I fear that a lot of NHS ICBs do not fully reflect the intention behind their creation, which was to see them as a genuinely collaborative exercise with equal voices in the room.

My question is: if we see ever-larger areas or fragmented areas, whether through neighbourhood health plans or mergers and acquisitions among ICBs, how do we maintain genuine local accountability and the relationships that underpin any structure written in law, on a piece of paper or in guidelines?

Notwithstanding what is being done about the health and wellbeing boards’ increasing involvement, do they actually have the teeth they need? In my experience, however good the collaboration, it is within the ICB boardroom that the decisions are actually made. However well things have been discussed beforehand, the ICBs will make their own decisions based on their own priorities. Does the removal of that voice from the ICB strengthen or weaken the ability to see this as one local system and to deliver a genuinely holistic local solution?

Councillor Wright: It will probably weaken it, unless we are given more say in our local health and wellbeing board. Our Thames Valley ICB has one director of public health. Thames Valley ICB I think has nine local authorities, and one chief executive and one director of public health sit on the board, so already the voice on it is quite small. If we lose that voice, where would we have those conversations? That brings me back to the whole thing about health and wellbeing boards needing to be stronger, definitely.

Sally Burlington: We would agree with that. If you take away the voice that is able to speak on behalf of social care, public health and wider public services, it will be harder and an additional job to bring in that consideration. It will be even harder to expect there to be notional teeth in that relationship, so we have concerns about that.

Maria Higson: It is also worth recognising that the delivery of any strategy or plan will require partnership working with local authorities, so whether or not they are in the room, they will be needed for delivery, and the proof is always in the pudding. For me, the partnership is somewhat non-negotiable in order to achieve delivery.

--- Later in debate ---

On resuming—

[Helen Morgan]

Q We have talked a lot about the single patient record, but I want to touch on whether the Bill does enough for people who have historically not been listened to, as we have heard has been the case for carers and women who have suffered in the maternity system. Does the Bill deal with the problem of people not being listened to? What opportunities are there to improve the Bill in a way that improves the situation?

Paul Farmer: Listening to patients is an incredibly important part of any health system. It is necessary to make sure that the right mechanisms are in place at both the individual and the systems level. The aspects of the Bill that cover patient experience need careful consideration.

Many people were fans of what Healthwatch delivered, and others were not, but it had a clearly established system and mechanism in place to ensure that patient voices were heard. It is important that clear systems are established to ensure that that patient experience is heard. I have operated around the health system for a number of years, seeing a number of incarnations of patient voice organisations and representation; you really have to think about it from the individual and the whole-system level—from top to bottom.

It is important that the Committee looks at the provisions in the Bill in that context to make sure that where there are good supports, they not only are preserved but can be built on. For example, how do you make sure that patient voice is heard at ICB level, in providers and, in particular, in the new world of neighbourhood health?

Kath Abrahams: Helen, it is a great question. Clearly, the Bill itself, and certainly the single patient record, are never going to replace wonderful, kind and compassionate care where people feel they are listened to. As I have already said, but I will say again, a combination of people not being listened to at all, despite knowing their own health better than anyone else, or having to retell their stories has very challenging consequences. Both leave somebody feeling that nobody really cares or understands them.

I spoke to a supporter of Tommy’s this morning who has had five miscarriages. She was saying it appears to be quite a small thing, but every time she went to see a clinician, they said, “Oh, you’ve had four losses” or “You’ve had three losses.” It was about them not understanding, and her having to correct her records and getting letters through. It is about that sense of not being listened to.

As we develop the Bill, women and birthing people, from a maternity perspective, should have the opportunity to contribute to the way something like the single patient record is shaped. You could have a digitally accurate system that did nothing to reassure women or help them feel looked after or listened to, or you could have a beautiful system where the information was recorded in such a way that it really helped.

Alongside that, clinicians need to continue to receive the right sort of training. They need to have enough time. As Paul said, you need those patient voices involved in overseeing how things are going, and able to contribute and help. The Bill itself, as a mechanism, will not do enough. This is about designing it carefully with patients in mind and, in the case of maternity services, involving women right from the start.

Emily Holzhausen: There are provisions in the Bill that transfer responsibilities from NHS England to the Secretary of State in relation to involving patients, and it is very explicit that this also involves carers. It is very important that explicit Healthwatch duties to involve carers have been transferred into the Bill in relation to integrated care boards. That matters because their portfolio of commissioning different services is increasing, as is that of local authorities.

Those are strategic duties. The reason why that is important, to be very specific about carers, is that they provide £152 billion-worth of care. They outnumber staff three to one. They are experts in care over time and they want to be involved. Of course, what colleagues have said about good practice is critical to look at.

The changes to Healthwatch—others have raised this—do not consider the person’s journey across different services, health and care. There is an independent voice that we do not have, and will not have, in quite the same way. A very small proportion of carers felt that, if they raised a complaint, it would be acted on. That kind of independent voice is actually very important.

As Kath said, those duties are really important, but we need top-to-toe listening to patients. We also need to be explicit about listening to carers, not just on behalf of the patient, but by asking, “What is your experience as a carer of managing this care?” because that is very different. To be honest, I do not think we have the right data flows behind that to collect and understand people’s journeys and improve things. I hope that that is also something that will be looked at.

[The Chair]

I do not think there are any further questions. I am sorry to have kept you waiting so long for what has been a relatively short period of time, but it was important that all Front Benchers, and any other Members who wished to do so, had the opportunity to question you. Thank you all very much for being so patient and for giving us the benefit of your thoughts and wisdom.

Examination of Witnesses

Dr Michael Cocker, Dr Towhid Imam and Dr Nicola Byrne gave evidence.

--- Later in debate ---

[Karin Smyth]

Q Dr Byrne, you talked about the issues around trust, which we absolutely recognise. We hear quite a lot about the work going on to try to get the legislation right technically, but, further to what you have suggested, how would you advise the Government to communicate clearly about the benefits, while understanding people’s concerns about getting a single patient record, should the legislation become law?

Dr Byrne: You have to show that you take the risks and people’s concerns seriously, and give a credible analysis of the risks. The key thing is to engage with the risks meaningfully. You should then think about what safeguards you could put into the Bill and future regulations that would actually be effective and be seen as credible, depending on what risks you are trying to address.

I know it is difficult to get into the detail on the primary legislation at this stage, not least because you are trying to sequence things when we do not yet know what the SPR will be, which I appreciate is a further constraint. I would suggest that you consider putting in the Bill one particular safeguard relating to secondary purposes. People have concerns around two main things: confidentiality and their privacy, and secondary uses—who might access their data in future, and why and for what purpose, other than for their direct care. Focusing on that second factor, there are lots of things that might come up that you could do in regulations, but right now, I would suggest that you could build in the safeguard of an independent oversight mechanism for how decisions are made on who gets to access the data and why. In that, you can involve public and layperson representation to bring in that consideration of the risks that matter to the public, alongside the potential benefits.

That could be helpful for two reasons. First, it would be a safeguard against having any unchecked decision-making power on access, whether now or in future. Secondly, it recognises the reality of human systems and organisations. No one expert or small group of experts, however wise or whatever their integrity, can see the whole picture and have a 360° view of what matters to the public. It would be a meaningful way to give the public agency and representation in that decision making—a meaningful exercise of citizen control, if you like. As humans, we are at our best and our decision making is at its safest and strongest when we get a diversity of perspectives involved—as, indeed, the Committee is doing right now. In this context, that should involve patients and the public.

My second point, which is perhaps germane to your wider discussions around the Bill, is that no one organisation can effectively and consistently scrutinise and challenge itself. That goes for questions around data use and access—and wider, as well—in your considerations.

[Helen Morgan]

Q I think everyone is agreed about the transformative potential of the single patient record, and we have heard various concerns around privacy and the types of use. I am interested in how all these different systems can speak to each other, because, in my experience as an accountant, you can have interoperability, but if the data that you are interoperating with is not consistently curated, you have a problem, because you have something that looks the same for everybody, but that actually means something very different to each person who inputs that data.

Do you have any advice for us on the development of that single patient record and how we make sure that the data is clean and consistent between trusts and different systems, so that the single patient record is actually meaningful? I will ask Dr Cocker first, if he is the technical expert.

Dr Cocker: I would not go that far—my involvement in this whole project is clinical, rather than having any sort of particular technical expertise. I think that is a pertinent issue, however, because, as has been discussed previously, if an error enters the SPR—say, a code is incorrectly followed through into the system—that error can then perpetuate. That is the risk of a single record: a documentation error can ripple out, rather than being contained within the system it originated in.

Does safeguarding that involve putting requirements on the providers of systems to mean that data can be exported in, maybe not a standardised format, but a set of formats that the SPR recognises? It is a technical question that I do not know the answer to, or the possible solutions to, but that would be one of my suggestions. Rather than having hundreds of different systems that all require slightly different solutions in order to be fed into the SPR accurately, there could be some sort of framework setting out requirements on the providers of the software products used by all the different organisations that will feed into the SPR.

Dr Imam: Like Dr Cocker, I am not technical but, from previous pieces of work that I have been involved with, some of it is to do with the data architecture and making sure that you can agree on the fields being used across the various systems. On frailty specifically, we have had the question of, “If we have multiple source systems that have the same field, which one should we be showing within the single patient record?” Our thinking at the moment is that we would show various entries, with who they have been done by and at what time, so that the clinician could decide how to interpret that data.

[Helen Morgan]

Q My other question is about digital exclusion. This is particularly for Dr Imam, because we associate older people with being digitally excluded, although I know it is not exclusively older people who are digitally excluded: how would you envisage the digital record interacting with something more analogue for people who cannot use the NHS app for whatever reason?

Dr Imam: That is a really important question; it is something that needs to be thought about very carefully when it comes to the implementation. From my previous NHS England experience, where we have had digital innovations implemented in the older age group, or among those who are perhaps traditionally digitally excluded, that has included partnerships to enable people to have the option of someone coming around, and there has been a thought process regarding people who perhaps cannot engage with technology as easily. That could involve people from the voluntary, community and social enterprise sector—for example, we had Age UK in the previous panel. There are lots of good examples of that type of work to ensure that people are not disadvantaged.

Dr Byrne: There is an opportunity here in the context of digital exclusion. In a digital-first NHS, it is really helpful to think continually about what the analogue version of the system is in the event of further cyber incidents and outages of the system. We need to continually build and maintain a resilient system for the times when digital-first is not available. It is an important opportunity to do so if we think about that question of exclusion.

[Sojan Joseph]

Q I was listening to Dr Byrne’s concerns about confidentiality and trust. I want to declare that I have worked in the NHS in the mental health sector for many years. I worked in one of the biggest mental health trusts, Kent and Medway mental health NHS trust. We use an electronic patient record called Rio. As Dr Cocker said, before anyone is given access to the record, they have to have training on information governance and data protection, and access is given based on their role. That system creates an audit trail, so patients can request to see how many people have accessed their information in the last month or two—there are facilities on the system to check that. Is staff training and raising awareness among patients important for creating trust and confidentiality?

Dr Byrne: Those things are very important, yes. There are some technical solutions. Again, the SPR is an opportunity to look at that across the system, because systems vary greatly in the sophistication of their audit function, for example. Even when there is an audit function, if someone has legitimate access through their role as a doctor or a nurse, it can be difficult to know whether their access in any particular case is legitimate. These are not common occurrences, but it is extremely distressing for patients if their confidentiality is breached for any reason.

It is not simply a matter of technical controls. We need to look at how we build stronger, more effective deterrents across the system by having effective sanctions when incidents do occur. I am keen to look at that and delighted that the Department of Health and Social Care and NHS England are, I think, very interested in having that conversation with me. At the moment, it certainly seems that there is a variable response across the system to inappropriate access.

Looking ahead to the SPR, we need to look at that make improvements, so that the public can have faith that, given the harm that it can cause them, it will be taken very seriously if anyone does access their records inappropriately. There are technical, cultural and system aspects to think about here. The SPR is definitely an opportunity to do that, and I am very keen to work with other stakeholders on that.

--- Later in debate ---

[Karin Smyth]

Q It is always good to have a doctor from the NHS supporting managers in the NHS, having been one. I declared my interest earlier that I am a member of Managers in Partnership.

We had a lot of change with the Health and Social Care Act 2012, and the Bill seeks to reverse that in terms of the architecture of the NHS. We absolutely appreciate as a Government that that is very difficult for staff working in it. I appreciate that the operating model and so on is coming forward, but could you say a bit about people’s feelings about the Bill? There will be more clarity to the centre and the role of providers is not changing, while the real change is around commissioning functions and, as you said, commissioning support organisations. We heard earlier that everything is being reorganised. That is not true, but there is a big change in the geography and the functions of ICBs and commissioners, and the Secretary of State’s role will clearly be different. What might people’s approach to that be?

Jon Restell: Clarity, definitely. No one wants to start with the system that came in in 2011 and 2012. Successive Governments started to correct it almost as soon as it was put in place. I think most people would welcome sorting out the clarity around commissioning there, but I do not think that is the same thing as cutting 50% of those organisations’ staff and running costs. You are clarifying the relationship between the centre and ICBs, commissioning and providers. You still need enough managers with enough skills working in the right system to deliver. That is the nub of what we are doing.

For us it is not really about how the Bill will eventually pan out; it is about the cut and how that is being administered by NHS England, the Department and ICBs. The whole system of management is under strain across the health service. You say that providers are not changing but they are also being asked to take out quite significant amounts of management resource. They are merging to form bigger, potentially more centralised units that may be less responsive and less innovative. I think that organisational form is really important, even if the headline of the Bill might tidy up and clarify those relationships, which would be welcome.

A point made by a lot of members, particularly those in ICBs, is that they do not think that the model design—where we started with ICBs, then went to regions and we are eventually going to get to the target operating model for the Department—is being done at a time where you can see the proper connections that need to be made between those organisations. When the system is up and running, how well will it work together to share information, share risk and so on? It feels like the Bill is very high level and the detailed design of the organisations is being undertaken in a completely fragmented way. People see that as potentially requiring the next round of reorganisation. You are a former NHS manager, Minister; you know how often reorganisation is reached for as the solution. I genuinely feel that people have got to the point where enough is enough. That kind of continual change will create more and more problems for doing the things that the public actually want to see: innovation, improvement in the quality of service and happier staff—all the things that managers should be focused on, not the merry-go-round of organisational change.

[Helen Morgan]

Q I will ask about the additional responsibilities that the Bill confers on ICBs. There are additional commissioning responsibilities and an additional requirement to look after what was Healthwatch—the patient voice element. As you have described, you have lost a large number of staff, you have a bigger geographic footprint and you have also lost quite a lot of budget. What do you stop doing, and what is being transferred out to other provider organisations? If the role of such organisations is changing to include some things that the ICB was doing, does that need to be clarified in the legislation?

Jon Restell: It certainly needs to be clarified. Whether it needs to be clarified in legislation, I do not know. Leaving aside the fact it took a very long time to get permission to move forward with their consultations, ICBs were thinking about what they needed to do around May or June last year. They will have made a lot of decisions and a lot of staff will have gone already based on the then understanding of what an ICB was supposed to be doing, based on the ICB blueprint that was published by NHS England, so I think that resource has gone. The people who may be connected with the functions that you are talking to have also gone in many cases. The question for me is: if the ICBs are to get more things to do, what is the implication for their running costs? As you know, they are currently capped at about £19 per head. If they get more functions, will they get more resources to do that? Will there need to be other ways of delivering those functions? I do not think that a lot of them can stop doing statutory functions, but that means all the good stuff that we want to see done in health systems—the innovation and the discretionary stuff, much of which is already on hold—will probably be the stuff that goes while they deliver their statutory obligations.

On the providers side, we need urgent clarity about what is going to go to the providers’ responsibility because they are taking out a lot of costs. I do not think that all, or many, providers know that these plans are afoot for them. That will create quite a shock. Again, they are choosing people to go now based on their current understanding of what is needed.

[Helen Morgan]

Q If I may ask a related question, one element of the Bill is the reorganisation of who sits on the ICB. We have seen the removal of local authority representatives and their replacement by a mayor or his or her appointee. What concern does that cause to your members—or do they think that is the right way to go?

Jon Restell: A lot of the concern is to do with the political make-up of mayoralties in the future and what that might mean; if mayors have an ever-growing responsibility and say in the who, what and where of health services, that is probably different from the more representative, advisory function that they have had. That really needs to be thrashed out: is that the new democratic accountability for health services, or does it remain, as now, with the Secretary of State, accountable to Parliament, making provision for healthcare? It feels a little unclear how much decision-making power those new local government voices will have on ICBs. Have people raised that as a concern? Of course they have; it is uncharted.

[Helen Morgan]

Q I am a vice-president of the Local Government Association. With changes to the better care fund pooling and the link-up with local authorities, are there concerns at ICB level that the partnership with social care will start to become more difficult?

Jon Restell: I cannot comment specifically on the BCF, but a general theme coming out of what our members are telling us in surveys, and in the regular surgeries and meetings that we have with them, is the sense that policy at the moment is trying to get you thinking in terms of your own organisation again, and thinking less about system-wide transformation, innovation or co-ordination. ICBs are getting bigger and providers are getting bigger. It is some of the system stuff, where I think a lot of our members would say the innovation will come in the way different organisations try to solve problems around patients and populations, that they feel is at risk, by the way—not just from the Bill putting things together, but from the stripping out of resource to do anything different.

[The Chair]

Thank you very much indeed, Mr Restell. Thank you for your patience, thank you for coming and thank you for the evidence you have given. It is greatly appreciated.

Examination of Witness

Sir Andrew Dilnot gave evidence.

--- Later in debate ---

[Karin Smyth]

Q As you say, the Bill does not deal with social care, but it is great to have your expertise here. Do you think the Bill should or could have included social care at this stage?

Sir Andrew Dilnot: The question of the fine details of how legislation should be passed is certainly outside my skillset, so I have to be agnostic about whether the Bill should have addressed the wider questions of social care. On the question of whether we could address social care or not, the answer is definitely yes. After all, several Governments over the last few years have promised to do so. The former Secretary of State for Health and Social Care, when he was the shadow Secretary of State during the election two years ago, promised that he would do it. Such measures have received Royal Assent twice, but they have still not taken place, even though they were promised by the then shadow Secretary of State for Health and Social Care, before he became the Secretary of State.

Yes, we definitely could do it. The amounts of money involved, while of course significant, are small relative to the aggregate costs of the NHS or the uplift in spending on the NHS that, with my full support, we have seen in the last couple of years. I think it is a genuine puzzle and a black mark for all of us, including me, that all these years have gone by and we have done nothing. We have a social care system that is supported by millions of wonderful informal carers and about 1.5 million formal carers, benefiting hundreds of thousands of people, but it is creaking under intolerable strain. It really makes no sense to me, and I really do not know why or how we have managed to go for so long without addressing it. We should do so, not only because it is the right thing to do, but because it is now so bad that it is doing direct, instrumental damage to the NHS.

[Helen Morgan]

Q You just used the phrase, “instrumental damage to the NHS”. Can you elaborate a bit on that, and perhaps explain how the NHS might be able to function better if there were a mechanism within the Bill to sort out social care?

Sir Andrew Dilnot: I think there are two main ways. The first, and perhaps the one that has received most attention, is that there are people who have been hospitalised, perhaps following a fall or infection, who have some mobility challenges and need some care, but who cannot leave hospital because a social care package is not available for them in the community. That is extremely damaging for the NHS, because if we have somebody in a bed that they do not need to be in because they have nowhere else to go, not only are we spending money having them there but we are then not able to use the bed for other activities.

If you have somebody with a delayed transfer of care that means they are stuck in hospital, when they do not need to be, for 20 days, which is not uncommon, very large numbers of elective procedures cannot take place because that bed is being used. That is a dead-weight loss from the system.

There is another thing that I think is at least as important, which is that, because of the lack of good social care, we have people falling, injuring themselves and needing to be hospitalised. We have people sustaining more urinary tract infections than they perhaps would if they had good social care. That is adding an additional burden, which the NHS deals with as well as it can, but all of this just seems unnecessary.

Social care appears to be so invisible to us all. It is easy to blame politicians, and of course it is politicians like you who ultimately have to vote for these things, but the electorate—the whole of our society—have to look at ourselves and ask, “Why can’t we make this challenge, which is so significant, better?” Any of you who have experienced it in your own family know how brutal and difficult it can be.

If I can be allowed one more general point, we should reflect that this is the result of the great triumph of the last 150 years. At the beginning of the last century, across the world, average life expectancy at birth was 32, and now it is 73. In this country, average life expectancy at birth in 1900 was 46, and now it is 81. We have added 35 years to the expectation of life from birth, which is an astonishing transformation. Some consequences come with that, one of which is that there is much more social care to be done, but we should be celebrating this, delighting in it and doing it well, instead of hiding it away and ignoring it for so long that it is doing real damage to the NHS, let alone to the lives of people who need social care.

[Helen Morgan]

Q I will put words in your mouth, and you can disagree with me. Do you think the Bill should tackle the point about having a properly funded care service so that the transition from hospital to the community can actually take place? As you have just said, if people are not cared for properly, they end up back in hospital, and everyone here agrees that is what we are trying to avoid.

Sir Andrew Dilnot: Yes, it is very odd. It is worth doing the odd thought experiment: imagine that the bit of healthcare that was underfunded and available only subject to a means test, and not free, was for heart disease. We cannot imagine it. The fact that it is dementia and severe arthritis means we have drawn an arbitrary line, and while that line still exists and there is still inadequate funding, even in a means-tested system, we are hamstringing the NHS. Now, that is not the most important problem, which is that we are failing to give people flourishing lives and allow them to live to the full, but it is now so bad that it is actually making it hard for the NHS to work.

[Joe Robertson]

Q Hospital pressures on the Isle of Wight are particularly severe, and part of the way of dealing with so-called corridor care is for the hospital and local authority to look at discharging some frail patients to the mainland, including those living with dementia, which is plainly not a solution by anyone’s normal interpretation. Is there anything in this Bill, notwithstanding that it does not deal with the fundamental problems of social care, not only that can help to resolve those sorts of situations, but that could help to resolve them if it went a little further? I am looking for opportunities to use the Bill to try to do a little more in and around discharge and social care.

Sir Andrew Dilnot: That is a very good question, to which I do not have a very immediate answer. Well, I do have an immediate answer, which is that, as far as I can see, it is nothing very substantial.

The single patient record offers some prospects here, and it is terribly important for people receiving social care, which again reflects how much longer we are living. There is much more multiple morbidity now. Many of the people who can and are benefiting from social care will have quite complicated medical experiences and histories. That is the kind of group that could particularly benefit from a single patient record, so that we are not having inappropriate prescription and so on. That is going to help, but it will be a second-order issue.

Let me be very blunt. There are two fundamental challenges facing the social care system. The first is that the means-tested bit of it, where we say, “If you don’t have any resources of your own, the state will look after you,” must be a minimum for any humane society. Essentially every year for at least the last decade, the Treasury has announced emergency funding for that in year. That money then does not get spent well. Honestly, if you are announcing an emergency package every year for 10 years, it is not an emergency package. You should wake up, pay attention, have a mature response and fund that system properly. That is the minimum.

The second is that the only big risk we all face that is not pooled is social care. Our risk of healthcare is pooled by the state, our risk of having a car accident or our house burning down is pooled by private insurance. This is the one risk that is not pooled, and the reason is that the state does not, and the private sector cannot. The reason the private sector cannot is that it is too far ahead for a private insurance market to deal with it, so only the state can pool the risk. If there is any area where the case for social insurance is absolutely clear, it is social care; the case is even more powerful in social care than it is in health.

At the moment we have a situation where often people will feel that the best thing that can happen to them, if they think they might have a social care need, is that they die before too long. It is a bit like standing in the middle of the road with a lorry driving towards you and hoping that the best thing that might happen is that you die before it hits you. That is not a good way to be running any kind of society or country. Those challenges—the lack of adequate funding of the means-tested system and the lack of any risk pooling for the population as a whole—lead directly to the kind of experience that you are describing in the Isle of Wight, where there is simply excess demand and so we are trying to ship people across to the mainland. It is a reflection of the fundamental challenges that we have ignored for 35 years.

--- Later in debate ---

[Liz Twist]

Q Minister, we have talked a lot today about ICBs, the local government Healthwatch and the single patient record, and we have heard some interesting comments. Can you summarise why you believe it is important that we look at this legislation now?

Karin Smyth: I will come to the single patient record because I think it is a gamechanger. We have heard today from some fantastic experts about the work they are doing to identify how it might work and how we might bring patients and the public with us. Again— I do not think we should just bank this—we have not heard anybody object to it.

We did have some evidence highlighting how things have gone wrong in the past. I worked at a primary care trust and clinical commissioning group at the time when care.data was brought forward. We can all point to where it has gone wrong, but nobody has said that this is not the right thing to do. That is good, but there is still a lot of detail to go through.

We need to keep highlighting the benefits. We heard from Peter Prinsley about whether patients have more control—we do think this is about empowering patients. That was what we said in the 10-year plan. The 10-year plan is about empowering patients in this very large system, for which they are now paying £200 billion of their taxes.

We heard from the excellent clinical panel. I defer to clinicians about what they need, both if they are dealing with chronic long-term conditions—we heard that it can sometimes take two and a half hours for an assessment—or if they are working in a busy emergency department. The fact that this is needed will be controversial. There will be a lot of questions about it and a lot of concern about privacy, data, cyber and so on. We need to hold on to those benefits, which are huge in clinical terms and for patients.

Another point we heard, which is also true, is that people think this already happens. People do not understand why, when they turn up at an A&E in Whitby, as we heard, or somewhere else, and then go back to central London, the systems cannot talk to each other. For me, that is about people’s trust and belief in what is a public service. It is a really important part of that.

On abolishing NHS England, I do not think anyone has come to one of my constituency surgeries and said, “Please do this,” or talked about it in great detail, but people do understand. My experience in opposition and so far in government is that MPs are perplexed when they try to intervene on behalf of patients, or to get an answer locally as to why on earth chief executives of ICBs or trusts sometimes do not respond even to a Member of Parliament’s requests for meetings. I find that shocking, but it does happen. How on earth is a patient or somebody struggling through the system expected to get a response? Getting it right is not black and white, and it is not easy to get the balance right between the Secretary of State’s democratic oversight and autonomy at a local level, but the Bill starts the process of doing that, and it is fundamentally important.

Regarding the other provisions, I accept that great work has been done by many people in Healthwatch and its predecessor organisations, and by people working in the patient safety landscape, but again it is not working. I think that those bodies have been allowed to abdicate responsibility for the core role of patient experience and patient voice. That is not their homework; it is their actual job. It is not something that should be outside, and that is why I think this Bill is really important.

[Helen Morgan]

Q I think I would agree with you, Minister, that no one thinks that abolishing NHS England is, in itself, a bad idea, given the duplication and cost. People do not think that a single patient record is a bad idea; I think that they assume that it already exists, and it could be transformative. There are therefore some really good points of agreement on the Bill.

It would, however, be helpful to reflect on where there is not agreement: on abolishing Healthwatch and HSSIB. You make the very good point that they have not been successful in their current incarnation, but it is important to consider whether that is because they do not have teeth, or because the organisations that they are trying to change are defensive.

We heard earlier about the culture of fear, and I think that we have probably all had people in our surgeries who can describe being frightened to speak up about their own personal care because they feel that they might be victimised for it. I know of clinicians who are frightened to speak up about their own experience in the organisation in which they work, because they feel that they will be punished for it.

In the light of that defensive culture that we know exists in the NHS, and has been highlighted time and again—Mid Staffs; the Shrewsbury and Telford maternity scandal—is the answer not to put the patient voice in the organisations that have a culture problem, but to give those other organisations the teeth they need, or confer a duty on the ICBs or providers to act on recommendations that are given to them, because I think that might be a more helpful way of dealing with this problem?

Karin Smyth: I think that gets to the crux of some of this. We will discuss it a lot in Committee, and I am obviously very open to keep discussing it.

Thank you for your support on the main provisions. I do not take that for granted because, again, they are still controversial. However, as I think I said earlier, you are right, although it is not true everywhere. I am not blaming individuals, because I think that people have been trying to do a difficult job, particularly in getting us through the pandemic and beyond. But they are defensive. That is why Members of Parliament and others do not get responses to their phone calls or their emails. That is a culture that we have to change, and we need to support people to change.

One of the things that we will do is to bring in regulations—that is a manifesto commitment from the Government—but another commitment that we have made outwith the Bill is to develop a leadership college to support in particular clinical and non-clinical managers, who have a very difficult job, in having the right skills for the new world, which patients and the public rightly expect to be more open and more transparent. We have to change this defensive culture.

However, even since Francis, the adding of bodies and the adding of recommendations, and with the bad experience that you have done so much around, something different has to happen. Again, what we heard from Jeremy Hunt was that we needed to put more prescription into the system and yet more requirements to do something without actually making that someone’s central function and job.

Now, it is a source of disagreement. As I have said, I think that there is a philosophical disagreement about the best way forward. It is not an antagonistic disagreement; there are fundamentally different views about what to do. We will continue to have discussions, because I think that ultimately we all want the same thing: a more open, transparent and supportive culture. By the way, nobody wants to work in a defensive culture, so I think people want that outcome.

It is up to us as politicians to support difficult conversations and trade-offs that happen locally. My view has always been that politicians will support difficult conversations and trade-offs—we heard a little bit about reconfigurations earlier—if the system provides good clinical rationale, good data and good evidence, but those bits of it do not always line up.

That is what I would like to get to. I absolutely understand and hear what you say—we will hear more about it and discuss it more, and I have read all the amendments about the best way forward. I think that we all want to get to the same place, but what is the best way to do that, given that we all know that this is really not working and cannot continue?

[Helen Morgan]

Q I have a technical question about foundation trusts. The 10-year plan says that foundation trusts could be given population health responsibility for commissioning and budgets. I do not understand how that fits in with the Bill. Could you clarify whether that is not envisaged for now or if it is lurking somewhere in the Bill that I have not spotted?

Karin Smyth: I will need to come back to you on the detail of that. In much of the Bill, we are trying not to over-prescribe. However, we need to get foundation trust licensing right. There are some things that are needed in the Bill, which is what we have put in as far possible, and some things that are not. Can I come back to you on that specific point if that does not answer your question?

[Helen Morgan]

indicated assent.

[Jo White]

Q You are speaking with tremendous passion and I can tell that you see this as an opportunity to make the NHS function far better. You mentioned at the very beginning that it took eight months to make the announcement that you were going to abolish NHS England. How quickly did you realise that NHS England was malfunctioning, far too bureaucratic and not delivering on the priorities for people in this country?

Karin Smyth: That is a good question. When I was in opposition, I spoke frequently about accountability and democracy, as the hon. Member for Sleaford and North Hykeham was trying to highlight—I am sure that we will hear some more quotes. I cannot speak for the former Secretary of State, as he is not here, but it did surprise us going into the financial year when, despite very clear direction and expectation about the financial situation that the Government inherited and what needed to happen, we were still faced with a very large projected deficit. The duplication meant that there were a lot of people in the room and clearly things were being handed off and that was not working. Ultimately, this is a question that always lurked. I know that the right hon. Member for Melton and Syston is here, and during the passage of the Bill that became the Health and Care Act 2022, we said to the Department that that might have been the opportunity to act. I think that previous Secretaries of State, as was alluded to earlier, thought that they might do that. Ultimately, the benefits of doing it now outweigh the risks and that is the only way to make the system change. We heard from the King’s Fund about opportunity costs and that the benefits do not outweigh the risks—we do not think that is true.