Health Bill (Eighth sitting)

Karin Smyth Excerpts

Committee stage
Tuesday 30th June 2026 Public Bill Committees

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

[The Minister for Secondary Care (Karin Smyth)]

The clause updates the National Health Service Act 2006 to abolish the requirement for integrated care boards and their partner NHS trusts to prepare and publish a joint forward plan and a joint capital resource use plan. The 10-year health plan aims to simplify local healthcare planning, and the Bill delivers that objective by removing legal requirements for integrated care partnerships, integrated care strategies, joint forward plans and joint capital resource use plans. Planning will now begin with the joint strategic needs assessment, developed by health and wellbeing boards. The assessment will inform a new neighbourhood health plan, replacing the joint local health and wellbeing strategy. ICBs will produce population health improvement plans, aligning multiple joint strategic needs assessments, neighbourhood health plans and local priorities across their wider populations. As a result, the planning process will be streamlined and less bureaucratic, and will deliver healthcare for local people based on local planning and strategy. I commend the clause to the Committee.

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

As the Minister said, the clause removes the need for ICBs and their partner trusts to produce a joint forward plan. The existing legislation requires ICBs and their partner trusts to prepare a plan setting out how they propose to exercise their functions over five years, which is reviewed and/or revised each financial year.

Joint forward plans address objectives in the Government mandate regarding the ambitions in the NHS long-term plan and planning guidance. Section 14Z52 of the 2006 Act sets out that an ICB and its partner trusts have to prepare such a plan before the start of each financial year and specifies what the plan must give regard to, including the ICB’s discharge of its duties—general duties and financial duties—under other sections of the Act. The plan must also cover steps that will be taken to implement the local health and wellbeing strategy, the particular needs of young people, and the particular needs of victims of abuse. ICBs and their partner trusts must publish the plan and give it to a set of specified authorities, and NHS England may give directions for that. Section 14Z54 sets out that an ICB and its partner trusts must consult people when developing such plans and that health and wellbeing boards must be involved. Section 14Z55 sets out that the relevant health and wellbeing board may give an opinion, and that when it does so, it must provide it to the ICB and its partner trusts.

Section 14Z56 sets out that an ICB and its partner trusts must prepare a joint capital resource use plan before the start of each financial year, and that the period may be determined by direction from the Secretary of State. Section 14Z57 sets out that an ICB and its partner trusts may revise the joint capital resource use plan, but if it is revised significantly, it must be published and given to the list of specified authorities.

Section 14Z58 sets out that an ICB must produce an annual report on how it has discharged its functions. It must explain how it has discharged its duties under other specified sections of the Act, review the extent to which it has exercised its functions in accordance with the forward plan and its capital resource use plan, review the extent to which it has exercised its functions consistently with NHS England’s views, and review steps it has taken to implement any joint local health and wellbeing strategy. The report must include details of expenditure and be given to NHS England by a specified date and then published.

In essence, the clause deletes sections 14Z52 to 14Z57. In some respects, it is legislative plumbing, to remove plans that are no longer necessary. The Government’s impact assessment notes that

“there is some duplication across planning documents. For example, the Joint Forward Plan covered the integration of services, which the Better Care Fund plan also considers, as does the Joint Local Health and Wellbeing Strategy.”

It goes on to note that duplication delivers an administrative burden, as staff

“complete parallel planning returns and fulfil competing data requests,”

so that is a positive aspect of the clause.

Will the Minister please address the following points? Section 14Z52 contains specific requirements to address the particular needs of young people and of victims of abuse. Where do they fall now? The NHS has a large maintenance backlog. What is the new mechanism for transparency of capital prioritisation decisions between the ICBs and the trusts? Can the Minister remind me and the Committee of other areas in which local democracy will be able to input into ICB planning once these planning documents are no longer required?

Under the Government’s strategic commissioning framework, ICBs have to develop population health improvement plans. Essex ICB published a document that is 148 pages long, with a particular focus on inequality. Is the Minister concerned about the length of some of the plans, the time it takes to produce them and the amount of bureaucracy involved, or does she think this is an improvement? What is the key objective in delivering these plans? Do the Government plan to introduce population health improvement plans through legislation? If they do not, Parliament will have scrutiny of the bureaucracy being removed but not of the bureaucracy that the Government replace it with. As the Minister once said:

“Local taxpayers deserve to know how their money is being spent.”—[Official Report, 13 June 2023; Vol. 734, c. 122WH.]

[Karin Smyth]

I thank the shadow Minister for her comments. I largely agree about legislative plumbing—that is a nice phrase. As she rightly highlights, and as is clear in the explanatory notes and so on, the duplication and administrative burden on all these bodies is considerable. On her question about objectives, we certainly want to streamline that so that ultimately, as well as organisations knowing the objectives they are pursuing, the local population—importantly to her concluding point—can readily see and address that, follow it through and hold people to account. I do think that 150-page documents are not always the easiest to see.

Young people will obviously be part of the joint strategic needs assessment, and ICBs will be mindful of the Government’s wider policy objectives, as we have discussed previously. With regard to maintenance and prioritisation of capital schemes, since coming into office we have already done a huge amount of work to streamline the relationship between NHS England and the Department of Health and Social Care—and, indeed, our friends over at His Majesty’s Treasury—in respect of the approvals process, making better use of capital and making that more transparent at local level so that individual organisations are involved in the prioritisation that comes forward to the ICBs.

Question put and agreed to.

Clause 22 accordingly ordered to stand part of the Bill.

Clause 23

Abolition of integrated care partnerships and strategies

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

[Karin Smyth]

The clause abolishes the requirement for ICBs and their partner local authorities to form an integrated care partnership. It also abolishes the related requirement for that partnership to prepare and publish an integrated care strategy.

These abolitions address the policy objectives of the 10-year health plan by streamlining the number of plans that must be created by local health systems and supporting key local stakeholders to work together more flexibly and effectively. The changes recognise that in many areas, integrated care partnerships have not had a positive impact on local health outcomes and have come with significant opportunity costs. Alternative planning approaches proposed elsewhere in the Bill and more broadly will enable local health bodies to plan for their patients in a way that is tailored to their strengths. However, I can reassure the Committee that where existing arrangements are working well, nothing in the Bill will prevent local areas from coming together to consider how best to integrate services and plan their approach to tackling the challenges they face. I commend the clause to the Committee.

[Dr Johnson]

In essence, the clause abolishes integrated care partnerships and strategies, which are where ICBs come together with local authorities to discuss how they can make their services more integrated. We know that many of the challenges facing the NHS are caused by difficulties in social care provision and some of the difficulties in social care provision are caused by issues with health provision, and that if those commissioning services in those two areas work together, we can see an improvement in both.

The Local Government and Public Involvement in Health Act 2007 made changes to local government structures and enhanced public involvement in health services. Section 116 requires local authorities to produce joint strategic needs assessments for the local authority and its partner ICB. When preparing the assessment, the local authority and its partner ICB must

“co-operate with one another…have regard to any guidance issued by the Secretary of State…involve the Local Healthwatch organisation”,

and involve local people and the relevant district councils. I note that later in the Bill we will also come to the abolition of Healthwatch.

Section 116 of the 2007 Act has been modified by the Health and Social Care Act 2012 and the Health and Care Act 2022 to ensure that references match the current NHS structure. For instance, in 2008 there were primary care trusts, rather than ICBs. Section 116ZA of the 2007 Act requires ICBs and local authorities whose areas coincide or overlap to create integrated care partnerships, which consist of a member appointed by the ICB, one from each responsible local authority and any other members that they choose to add; to some extent, they can determine their own procedures.

Section 116ZB of the 2007 Act requires ICBs to prepare an integrated care strategy

“setting out how the assessed needs in relation to its area are to be met by the exercise of functions of…the integrated care board…NHS England, or…the responsible local authorities”.

When developing that integrated care strategy, the integrated care partnerships must have regard to NHS England’s mandate and any guidance issued by the Secretary of State. Clearly, that would now apply only to guidance issued by the Secretary of the State, because NHS England is also being abolished. An integrated care partnership must publish its integrated care strategy and give it to each local authority and partner ICB. Integrated care partnerships must reconsider and, where necessary, revise the strategy each time they receive a new needs assessment.

Clause 23 deletes section 116(5A) of the Local Government and Public Involvement in Health Act 2007. That subsection required the local authorities to give a copy of the needs assessments to the ICBs, which is of course no longer necessary because they are being abolished. Clause 23 also deletes sections 116ZA and 116ZB of the same Act, which established ICBs and defined integrated care strategies respectively.

As Conservatives, we believe that streamlining bureaucracy is sensible, and I am sure that this is a well-intentioned reform. However, a survey conducted by the NHS Alliance in November indicated that a quarter of integrated care system leaders are likely to keep the integrated care partnerships anyway on a non-statutory basis, and 40% plan to fold them into health and wellbeing boards and working partnerships with the authorities. It is not really a ringing endorsement of the policy if a sizeable number of people intend to keep it anyway.

Like many other elements of the Bill, these changes are uncosted—if we read the impact assessment, it says “N/A” for the cost. Clearly, there will be a cost incurred by the abolition of the process, but there will also be an opportunity cost to services if ICBs and commissioners are not working together in the provision of social care as effectively as they were before. That will cost people in social care, and it will cost people in healthcare.

As recognised by the impact assessment that the Government have produced themselves, there is a risk of reduced focus on the wider determinants of health at system level. Committee members on both sides of the House have already stressed the impact that other health determinants can have on the health service and social care, and we have previously considered amendments to that effect.

Overall, it is regrettable that local government does not have the direct feed into ICBs that the design of those integrated care partnerships provided. Whether or not I agree, I can follow the theory or principle behind making the area covered more local, in line with the strategic authority. However, if the Government wanted to do that, I do not understand why they did not decide the mayoral areas first. At the moment, we do not know where the mayors will be, and where they are now is not where the ICBs are. The Government have decided to cut ICB budgets and force mergers before they have decided where the mayoral authorities will be in some cases. Even where there are mayoral authorities already, the Government have not mandated that the ICBs be coherent with them, and, therefore, in many cases, they are not. We have a very confusing pattern emerging, which may require further reorganisation of ICBs to line them up, with a further cost down the line.

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[Joe Robertson]

It is a pleasure to serve under your chairmanship, Sir Jeremy. There is a consensus—not just in this room, but within Parliament and going back several decades—that we want more integration and partnership working, particularly to bring together health and social care services, but this clause drives a coach and horses through that, and does so in a way that weakens rather than strengthens the Government’s plans to replace the system.

Local authorities bear responsibility for social care and public health in their areas, but they will no longer have a direct voice when it comes to integrated care boards. What we have seen to date is not an ideal system, or even a system that works particularly well, so I understand that the Government want to strengthen it, but we should not do that by removing the local government voice or making it indirect via a mayor who does not have the direct responsibility for delivering social care locally. Mayors may have some strategic oversight, but that is different.

Just last week, the Minister of State for Care appeared before the Health and Social Care Committee and was questioned on this very issue by me and others. His view was that the mayoral strategic partnership would be more than sufficient to make up for the local authorities losing their seat, but he faced particular scrutiny from the hon. Member for Chelsea and Fulham (Ben Coleman), who made some excellent points, which I will not repeat or paraphrase as they are on public record.

The gist of his argument was that local authorities have been ignored for too long when it comes to joining up health and social care services. This measure puts local authorities in an even weaker position and threatens what the Government are trying to achieve with social care, particularly for areas such as mine that have an older population and a relatively small unitary authority with so much responsibility to deliver on.

As my hon. Friend the Member for Farnham and Bordon has already said, the combined area of Hampshire and the Isle of Wight—or the Solent, as the Government like to call the Isle of Wight, despite the fact that fish cannot vote—is not set to get a mayor for a couple of years, but it will be at the vanguard of the Government’s plans. What about those areas for which there is no date, or even no plan for a mayor at all? It seems extraordinary that the Government would do away with the current set-up, imperfect as it is, and replace it with something that does not yet exist.

The Government have time deal with this problem. I am sure they quietly understand that there could be a problem. It is now on their shoulders to deal with it. I welcome the Minister’s reflections.

[Karin Smyth]

There has been a wide-ranging discussion on this clause. I remind Members that the abolition of ICPs is about reducing that complex legal framework, allowing for local decisions and putting partnership work in place in the most effective way. That is what the measure seeks to do. I do not think anyone has disagreed with the notion that the landscape is complex, and that people are producing a lot of reports. In future, health and wellbeing boards will be the focal point for the collaboration between ICBs and local authorities. They are statutory committees that bring together the NHS, local government and relevant community partners; set the strategic direction for health and care services; and oversee joint working in their area, which we are of course committed to making work in local areas. I do not think many people will disagree with that; I hope that is clear.

There is also an enhanced role, not only for the health and wellbeing boards—as I said last week, I think they have been underutilised in most areas; again, I do not think people generally disagree with that point—but for health scrutiny. Again, across the country, that has not been pursued to the greatest extent to create links with elected councillors in local areas.

We are clear that the role of local authorities is crucial at a local level—as the name describes—and particularly in working on our commitment for neighbourhood partnerships and developing the neighbourhood plan; most of that was covered in our sittings last week. I accept that there are a number of concerns about how that will work in different geographies. I think the Opposition said last week that a survey suggested a quarter of areas will keep those partnerships, which is absolutely fine. That is up to them.

On the one hand, the Opposition say that there is centralisation and a power grab in this Bill; on the other, they complain—I should not say complain, because it is their right and their job to do so—about the move to devolution and the freedom to allow, or indeed encourage, local leaders to work together across authorities on behalf of the populations they serve, even where some of them are politically divided, because the populations they serve voted for different people. It is incumbent on all of us as individual elected politicians to work with people—whoever the population around us voted for. These provisions provide for that.

[Edward Argar]

Can the Minister set out how she envisages health scrutiny committees having genuine teeth? Our cross-party health scrutiny committee in Leicestershire universally condemned a decision by the ICB—totally disagreed with it—and the ICB basically said, “Thank you; noted,” and carried on anyway.

[Karin Smyth]

We all have examples of decisions that are made in our constituencies that we do not like. Again, that is part of the democratic process, but I go back to my earlier point: either there is a centralised unaccountable body like NHS England making decisions, or the Secretary of State devolves those responsibilities.

It is incumbent on people and elected leaders locally, and the ICB, which is not elected, to work with local leaders on these decisions. ICBs will be held accountable through mechanisms in the Department of Health and Social Care. There will be decisions that people do not like—that is a consequence of some of these things—but the clause simplifies the landscape.

[Gregory Stafford]

Will the Minister give way?

[Karin Smyth]

I will not; we need to move on from this point. Of course, if people want to keep the partnerships, they are totally able to do so. That will be up to local leaders to decide.

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

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[The Chair]

With this it will be convenient to discuss new clause 70—Duty to engage primary care providers in integrated care boards—

“(1) An integrated care board must take all reasonable steps to secure the meaningful involvement of primary care providers in the exercise of its functions relating to—

(a) service redesign,

(b) integration of health services,

(c) development of neighbourhood health services, and

(d) population health planning.

(2) In this section, ‘primary care providers’ includes—

(a) providers of primary medical services,

(b) community pharmacy contractors,

(c) providers of primary dental services, and

(d) providers of ophthalmic services.

(3) Under subsection (1), ‘meaningful involvement’ includes—

(a) involvement at an early stage in the development of ICB proposals,

(b) provision of sufficient information to enable informed participation of primary care providers in ICB functions,

(c) opportunities for primary care providers to influence ICB decision-making, and

(d) opportunities for primary care providers to deliver feedback on how their views have been taken into account in the delivery of ICB functions.

(4) An integrated care board must publish an annual statement describing—

(a) how it has complied with this section, and

(b) the impact of primary care providers’ involvement on decisions taken by the ICB.

(5) The Secretary of State may issue guidance about the application of this section to which integrated care boards must have regard.”

This new clause ensures a certain range of primary care providers are consulted by integrated care boards in the development of their healthcare plans.

[Karin Smyth]

Clause 24 abolishes the requirement for health and wellbeing boards to prepare and publish a joint local health and wellbeing strategy. Instead ICBs, local authorities and their partners must work together through the health and wellbeing board to develop a neighbourhood health plan, in line with this Government’s commitment in the 10-year health plan. The neighbourhood health plan should be updated regularly to reflect the needs of the local population, unless all partners consider the existing plan is sufficient.

In developing their neighbourhood health plans, responsible local authorities and partner ICBs must involve the people who live or work in the area of the responsible local authority. The neighbourhood health plan will cover most of the topics previously considered by joint local health and wellbeing strategies, but will also encourage a deep focus on tackling the challenges facing individual neighbourhoods. That may mean applying different geographical focuses to different elements of the plan, to ensure that planners are addressing the real and different needs of the diverse communities they serve.

These plans will outline how the NHS, local government and local partners intend to improve the health of people in their locality and reduce health inequalities through a joined-up neighbourhood health approach. The plans will consider how local services can help realise national NHS priorities, further public service reforms, and improve performance against the adult social care outcomes framework and the local outcomes framework metrics. To support this work, the Government also intend to provide local areas with guidance and we will work with systems to ensure this addresses the needs of local planners and local communities.

[Dr Johnson]

Clause 24 puts neighbourhood health plans on a statutory basis. Currently, section 116A of the Local Government and Public Involvement in Health Act 2007 requires local authorities and partner ICBs to prepare a joint local health and wellbeing strategy once they have received their integrated care strategy. Essentially, that means that the ICBs and local authorities produce their overall strategy, then it devolves down, and then the joint health and wellbeing strategy looks at how it will be delivered. The local authority and its partners must give regard to the integrated care strategy, the NHS England mandate and any guidance issued by the Secretary of State. The strategy must be published and local people and the local Healthwatch must be involved in its development.

Section 116B of the 2007 Act places a duty on local authorities and partner ICBs to have regard to various strategies when exercising their function, specifically, a joint strategic needs assessment, an integrated care strategy and a joint local health and wellbeing strategy. NHS England also has regard to these when providing healthcare for a specific area.

Clause 24 changes the JLHWS to a neighbourhood health plan. In many ways, that aligns with the shift in the Government’s 10-year health plan from hospital to community. As they have described it, more care in the neighbourhood will allow hospitals to focus on the more specialist care that may be needed, so more people can be cared for closer to home, which seems a reasonable aim.

However, if local authorities and partner ICBs have to give regard to what the centre is doing when developing neighbourhood health plans, to what extent does the Minister envisage that being directed? Local authorities and partner ICBs giving regard to the centre could mean there being a very loose requirement from the centre to provide for the local population, and then they get on with it; it could also be very prescriptive—my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) has talked about the pros and cons of having targets—with a whole litany of targets in the plans. Whether that squares with the Government’s claim to be devolving power, or whether it strikes as a centralising power, depends on how that is done and to what extent the Secretary of State plans to direct it. I would appreciate it if the Minister could talk about that.

As has been said, Sir Andrew Dilnot told the Committee that

“we cannot really address many of the fundamental problems facing the NHS if we do not sort out social care.”––[Official Report, Health Public Bill Committee, 16 June 2026; c. 84, Q131.]

The Government have asked Baroness Casey to review social care, but they have developed this measure in the meantime. Is that because they have been talking to her and know that it is the sort of thing that she will recommend—or are they putting the cart before the horse, as my hon. Friend the Member for Farnham and Bordon suggested?

Later in the Committee’s considerations, we will come to Healthwatch, its benefits and the concerns that I and, I am sure, many other Committee members have about its abolition. What mechanisms does the Minister envisage there being for local people—local patients—to contribute to the neighbourhood health plans? A local Healthwatch currently contributes to the equivalent, the joint local health and wellbeing strategy, as a way of ensuring that it captures patient and community voices. How will that be done otherwise?

Some 80% of the Government’s new neighbourhood health centres that will deliver these plans are expected to be funded through public-private partnerships. Does the Minister have any comments on that, particularly in the light of the expensive private finance initiative that the last Labour Government entered into and left us stuck with?

In March 2026, the Government produced a neighbourhood health framework policy paper, which identified the goal of reducing non-elective admissions for those with severe frailty. Given that goal, why are the Government not on track to deliver the fracture liaison service improvements that they promised?

The policy paper also commits to what it calls

“a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties”.

What is a “diversion rate”? It essentially requires more GP referrals to be rejected, so let us be clear about what that means. When someone, either hon. Members or constituents, goes to see their GP, they are referred to a consultant for care; I should declare an interest as a consultant in the NHS. The consultant will then review that referral and decide whether they think it is clinically appropriate to see the patient, whether a different specialty may be more appropriate, or whether they can give advice or make suggestions about treatment that could be given in primary care instead.

When a patient is given an appointment in secondary care, it essentially means that the GP has decided that they clinically need it, and the consultant has decided that they clinically need it too. If the Government want a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties, are they suggesting that patients who the GP and consultant agree clinically need an appointment should not get one? If so, why?

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[Gregory Stafford]

We can go back to the record in Hansard, but I do not remember mentioning anything to do with hospitals in what I just said; I may have had some sort of amnesia at that point. If the hon. Member is referring to the plan of the last Government, which was fully costed, for 40 new hospitals, then I am afraid I did not mention that. On his wider point, Conservative Members want to understand how local authorities and deliverers of primary care—dental services and so on—will be included and can have influence over the plans and strategies that ICBs draw up. I fully support that ambition; I just feel that, if we are to have that ambition, we need to table amendments and new clauses that the Minister might actually accept, so that we can go forward.

[Karin Smyth]

I thank hon. Members for their comments. I accept those made by the hon. Members for Winchester and for North Shropshire. I offer the Liberal Democrats the assurance that the Government fully appreciate the important role that primary care plays in informing ICB decisions, which is why we have retained the requirement that ICBs engage with their system partners, including primary care services, in the exercise of their planning and commissioning activities.

It is universally recognised that full engagement with providers, including primary care, is fundamental to good commissioning, and this is reflected in the strategic commissioning framework. The neighbourhood health framework sets out how neighbourhood health plans should be developed through health and wellbeing boards and with the involvement of system partners. We expect primary care to be fully involved in the process.

In addition, ICBs will continue to engage local representative primary care committees, such as the local medical committees. ICBs must comply with their duty to obtain appropriate advice from persons who have broad professional expertise in prevention, diagnosis or treatment of illness and the protection or improvement of public health. Primary care practitioners will remain key sources of such advice. Although I agree that experience of general practice is fundamental—as a commissioner, I worked very closely with general practitioners, who deal with 90% of patient contacts—I do not believe that placing an additional requirement on ICBs to engage specifically with primary care providers is necessary.

I will take this opportunity to clarify matters. We are moving between the roles of ICBs and local authority health and wellbeing boards. I know this is a subject of great interest and will continue to be debated in relation to those bodies’ commissioning and providing functions. The planning structure will be improved under clause 24, reflecting our commitment to neighbourhood health and making it a reality.

Planning begins with a joint strategic needs assessment developed by health and wellbeing boards; that assessment informs the new neighbourhood health plan, replacing the joint local health and wellbeing strategy. Meanwhile, ICBs will produce population health improvement plans, aligning multiple joint strategic needs assessments, neighbourhood health plans and local priorities. Patient and local voices must, of course, be embedded in ICB decision making and in the planning process. ICBs are being supported to do that. The strategic commissioning framework published on 4 November 2025 clearly set out that user involvement is key to strategic commissioning.

Having proper plans that address the needs of neighbourhoods will help the NHS to deliver for every community in our country. That is where the patient focus is and where people experience healthcare the most, and it is why we have made these commitments in neighbourhood health plans. I commend clause 24 to the Committee as the means to make that a reality.

Question put and agreed to.

Clause 24 accordingly ordered to stand part of the Bill.

Clause 25

NHS trust accounts

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

[The Chair]

With this it will be convenient to consider clause 26 stand part.

[Karin Smyth]

Clause 25 makes focused but important changes to the accounting and audit arrangements for NHS trusts by amending schedule 4 to the National Health Service Act 2006. It does not put additional burdens on NHS trusts; instead, the aim of the clause is to align the requirements for trusts with the updated accounting arrangements for foundation trusts made elsewhere in the Bill. The changes are needed as a consequence of the abolition of NHS England and the removal of the requirement for foundation trusts to have councils of governors and members.

The amendments the clause makes replicate trusts’ existing duties to keep proper accounts and records about those accounts, and to prepare annual accounts for each financial year. The clause also replicates the Secretary of State’s current power to direct an NHS trust regarding the form of its annual accounts, but extends that power of direction so the Secretary of State may also direct a trust to prepare accounts for a specified period—for example, when part-period accounts are needed. That will help to ensure a consistent approach to financial reporting while retaining the flexibility to keep requirements up to date.

The clause also sets out and strengthens how the audit arrangements for NHS trusts should operate, mirroring the approach for foundation trusts and integrated care boards. It provides that NHS trust annual accounts are audited under the Local Audit and Accountability Act 2014, as is the case currently, but it also provides that part-period accounts may be audited in accordance with that Act where the Secretary of State so directs.

The clause also enables the Comptroller and Auditor General to examine the accounts and related auditor reports, as is currently the case. To reflect the fact that the Secretary of State will have oversight of providers once NHS England is abolished, it requires the accounts and audit reports to be sent to the Secretary of State.

Taken together, these measures support transparency, consistency and robust financial assurance. They will help to reduce unnecessary divergence in accounting requirements across different types of NHS provider, while maintaining clear oversight of public funds. That is consistent with the Bill’s broader intent to support effective governance and clear accountability for providers.

Clause 26 makes minor technical amendments to ensure that the statute book remains clear and coherent as the Bill aligns the approach to audit and accounts across NHS trusts and foundation trusts. It sits alongside the provisions in the Bill that update the arrangements for the audit of foundation trusts following the abolition of NHS England and the removal of the requirement for NHS foundation trusts to have councils of governors and members.

The clause does that by amending or removing outdated transitory provisions relating to the audit of NHS trust accounts in two places: the NHS Act 2006 and the Local Audit and Accountability Act 2014. Clause 26 therefore supports the effective implementation of the wider measures in this part of the Bill by ensuring that the legislation is up to date, accurate and internally consistent. I commend clauses 25 and 26 to the Committee.

[Dr Johnson]

As has been said, clause 25 specifies how NHS trusts should handle their accounting. Paragraph 11A of schedule 4 to the NHS Act 2006 sets out the current obligations, which are that the trust must keep proper accounts, that the Secretary of State may give directions about how the accounts are held, and that the accounts must be prepared annually, may be examined by the Comptroller and Auditor General, and must be submitted to NHS England.

Clause 25 replaces paragraph 11A entirely. Under the new provisions, the reporting goes to the Secretary of State, instead of NHS England—which seems sensible, because the Government are abolishing NHS England—and the Secretary of State may give directions about “methods and principles”, as well as the “form and content”. The Secretary of State may also give directions about specified periods in which accounts are to be prepared.

Will the Minister explain why those provisions are felt to be necessary? There will be suspicion among some more cynical people that the power to specify periods could be used to be more flattering for the Government, or that methods and principles could be used to change the perception of the position. Can the Minister give an example of where she thinks such periods would be useful, and also say why she thinks it is necessary to enable the Secretary of State to give directions about methods and principles, and form and content, in a way that is not done at the moment?

The exception for charitable trusts of which the NHS is a trustee is being removed. Will the Minister explain why she thinks that is important, and in what situation she thinks that power would be used? Finally, will she say whether the financial directors of NHS trusts have been consulted about these changes? If so, what was their feedback?

Clause 26 tidies up relevant provisions in two pieces of legislation, as the Minister has described.

[Karin Smyth]

If there are specific examples that are helpful, I will write to the hon. Lady—I am not entirely sure I got the point about charities, but we will pick that up in Hansard.

As I outlined in my opening remarks, these clauses are about standardising the key requirements across the NHS provider landscape in relation to annual and other accounts and records in relation to those, and audit and reporting requirements, including keeping those up to date and having a consistent approach across all NHS provider types. Of course, we worked closely with NHS England colleagues and directors of finance in seeking to bring forward those provisions.

Question put and agreed to.

Clause 25 accordingly ordered to stand part of the Bill.

Clause 26 ordered to stand part of the Bill.

Clause 27

Special Health Authorities: establishment and exercise of functions

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[The Chair]

With this it will be convenient to consider clause 28 stand part.

[Karin Smyth]

Clauses 27 and 28 make amendments to the legal framework around special health authorities to give the Secretary of State the flexibility to best manage the reliable delivery of healthcare for patients and the public. As the Committee knows, special health authorities are independent bodies established by the Secretary of State, by order, to perform specific functions. They play a key national role in the health system, carrying out specific functions on behalf of the Secretary of State.

Clause 27 does two key things to the special health authority legal framework. First, it amends section 28 of the NHS Act 2006 to increase the scope of functions that a special health authority could be established to deliver. Currently, the Secretary of State can create a special health authority only for the purpose of exercising functions under the 2006 Act. The clause allows a special health authority to be established to exercise functions under any other Act as well.

Secondly, the clause amends section 29 of the 2006 Act, which currently enables regulations to provide for the functions of a special health authority to be carried out flexibly, by another special health authority or jointly with one or more other special health authorities. That applies only to functions that the Secretary of State has directed the special health authority to exercise under section 7 of the 2006 Act. The clause removes that limitation, so that those arrangements can be made for any functions of the special health authority, not just those that it is directed to carry out under section 7.

These changes are needed because the health and care system is underpinned by a range of statutory functions that do not sit exclusively within the 2006 Act. The Secretary of State needs to be able to establish special health authorities to carry out those wider functions, and to give those functions to existing special health authorities. The clause ensures that the Secretary of State has the modern, adaptable tools required to place specialist functions in the right national body, with the appropriate governance and accountability. Equally, special health authorities need to be able to work with other special health authorities across all their functions in a way that best serves the needs of the wider health and care system.

On occasion, it is necessary for Ministers to merge, alter or abolish special health authorities, either because of changing circumstances or to ensure the smooth and effective running of the system. Clause 28 provides the flexibility to transfer and redeploy staff. It allows regulations to be made to enable staff to be transferred to an integrated care board or another special health authority. These changes ensure that staff can be transferred where they may be needed most, allowing for flexibility to direct resources in the health system.

The clause also allows for arrangements to be made for a special health authority’s staff to be made available to another special health authority, a local authority, the Secretary of State or an integrated care board. That may be necessary during an emergency or to provide specialist support to help an organisation achieve a particular outcome. The clause also allows the Secretary of State to give directions to a special health authority to make staff available to another special health authority or integrated care board or the Secretary of State.

Clause 28 also amends the existing power to make regulations about the sharing of information with other bodies, to allow information to be shared with integrated care boards in addition to the Secretary of State and other special health authorities. That allows for information to be shared across the system so that national and local functions can be successfully fulfilled and supports a more joined-up health system.

Clauses 27 and 28 provide for future-facing updates that will support effective administration and ensure the more reliable delivery of healthcare for patients and the public. I commend them to the Committee.

[Dr Johnson]

Special health authorities are, in essence, specialist health authorities set up by the Secretary of State, usually to provide an England-wide service of some form. Examples include NHS Blood and Transplant, and the NHS Business Services Authority, which provides NHS pensions—I should declare that I have an NHS pension—admin for prescription exemptions and other such business-type functions. We also have NHS Resolution, which deals with clinical negligence claims, and the NHS Counter Fraud Authority.

In principle, special health authorities are useful in some cases, but they are effectively a form of quango. Can the Minister explain when she thinks the Government might want to set up a special health authority, rather than using a department within the DHSC to deliver the same thing? There are plenty of other nationally delivered services, and although the Government have suggested that some services, such as screening, will become localised as part of the Bill, some things will remain national. Can the Minister give some examples of what the new provision will be used for?

I can see there is provision for flexibility, but the special health authorities would require setting up, and there are set-up costs and costs associated with branding and those sorts of things. How does the Minister envisage those costs being provided for, and when will it be necessary for the Government to use them rather than just using the Department?

Special health authorities have been created, reconfigured and shelved many times. For example, the National Treatment Agency for Substance Misuse became part of Public Health England in 2013, and the NHS Institute for Innovation and Improvement was closed in the same year. The functions of the National Patient Safety Agency went to the NHS Commissioning Board Special Health Authority, later known as NHS England, in 2012 and then to NHS Improvement in 2016. Widening the scope could leave us with more quangos than are necessary.

Which specific functions do the Government plan to move into special health authorities under this widened power? Have the Government just decided that they need this power and are increasing the scope because they are abolishing NHS England without a proper plan? Is this power just to cover themselves in the event that, as they start to make a plan, they find out they need it?

Clause 28 enables the Secretary of State to make regulations for the transfer of staff from one special health authority to another, or to an ICB. Paragraph 3(8) of schedule 6 to the National Health Service Act 2006 states:

“Regulations may provide for the transfer of officers from one Special Health Authority to another”,

or to NHS England,

“and for arrangements under which the services of an officer…are placed at the disposal of another Special Health Authority”,

or NHS England, or a local authority. Paragraph 3(12)(a) states that the Secretary of State may give directions

“to place the services of any of its officers at the disposal of another Special Health Authority”,

or NHS England. Paragraph 13 states:

“Provision may be made by regulations with respect to the recording of information by a Special Health Authority, and the furnishing of information by a Special Health Authority to the Secretary of State, another Special Health Authority”,

or NHS England.

Clause 28 modifies that paragraph such that regulations can now provide for the transfer of an officer to an ICB—that is a new power—as well as a special health authority and a local health authority, but no longer to NHS England because NHS England is being abolished. Regulations can now provide for an officer’s services to be placed at the disposal of the ICB and the Secretary of State, which is a new power, as well as the special health authority or local authority, but no longer NHS England. The clause modifies paragraph 3(12)(a) of schedule 6, so that directions may be given about placing the services of officers at the disposal of the special health authority and, newly, the Secretary of State or an ICB, but not NHS England. As the Minister said, the clause also modifies paragraph 13 of schedule 6, so that a special health authority can be required by regulations to pass information to integrated care boards, which is a new power, but no longer to NHS England.

NHS England is to be abolished, so it is sensible to say that staff can no longer be placed there—that seems an entirely reasonable exercise—but the legislation providing for special health authorities essentially contains open-ended spending power. Remuneration of the special health authority chairman and staff can be determined by the Secretary of State, with the approval of the Treasury. Does the Minister foresee an upper limit to those sorts of salaries?

People will essentially be able to transfer from one special health authority to another, or to an ICB—or be placed at the disposal of another special health authority, an ICB, a local authority or the Secretary of State. Will the Minister talk about the location, pension and salary of those individuals? We heard yesterday that the future Prime Minister, the right hon. Member for Makerfield (Andy Burnham), may want to move a whole load of civil servants from London up to Manchester. That will clearly be within his gift if he becomes Prime Minister, but for individuals who work in one location to be asked to move to another is disruptive to their family and social lives, and involves significant relocation costs. If people are moved in the way that clause 28 describes, particularly by transfer, what choice will they have? What will happen to their pension, salary and other terms and conditions, and will they have a choice of location or not?

[Gregory Stafford]

Very briefly, on clauses 27 and 28, I am sure the Committee is aware that special health authorities were initially established under the National Health Service Act 1977. Since then the number of special health authorities has expanded and contracted a number of times over the years to leave us with, currently, NHS Blood and Transplant, and the Business Services Authority, which covers pensions, as my hon. Friend the Member for Sleaford and North Hykeham mentioned—I should declare that I have an NHS pension, albeit a very small one—as well as the NHS Litigation Authority, also known as NHS Resolution, and the NHS Counter Fraud Authority.

The mood music and the direction of travel, certainly since 2006, has been to reduce the number of special health authorities. On my reading, clauses 27 and 28 suggest that the Government are potentially looking to expand the number of special health authorities, given the Secretary of State’s direction under clause 27 and the practical steps for staff transfers in clause 28. Is the Minister looking at, for example, a special health authority to deal with artificial intelligence? Clearly that is something the NHS will have to embrace—or deal with, depending on which end of the AI argument one is on—rapidly over the coming years. Is that a potential area for a special health authority? Perhaps the Minister could outline where she sees the special health authorities acting and what their remits might be.

[Karin Smyth]

To be clear, in response to the comments of the Opposition spokesperson, the hon. Member for Sleaford and North Hykeham, it is not currently our intention to set up any new special authorities to deliver any specific functions. We are taking this opportunity to update the legislative framework and ensure that in future the functions that a special health authority could carry out are less limited. The current legislative framework limits the remit of such authorities to their functions under the NHS Act 2006, which is outdated and does not reflect changes since that time. There are functions of the Secretary of State under the Health and Social Care Act 2012 that we may want special authorities to carry out in future. I agree with the Opposition spokesperson that the situation is complex. We have had a lot of changes over many years, as both she and the hon. Member for Farnham and Bordon said. I agree that we need flexibility for future provision, and that is what the clauses provide.

We have no immediate intention to delegate specific functions of the Secretary of State. However, following the abolition of NHS England, a range of functions may need to be established, as the hon. Member for Farnham and Bordon outlined. Those functions could, as an example, include the data and information functions in part 9 of the Health and Social Care Act 2012, which currently sit with the Secretary of State.

I assure the Committee that the clauses do not change the existing processes or scrutiny that exist around setting up a special health authority. They are, as I think the Opposition spokesperson said, about future-proofing. I commend the clauses to the Committee.

Question put and agreed to.

Clause 27 accordingly ordered to stand part of the Bill.

Clause 28 ordered to stand part of the Bill.

Clause 29

Constitution of NHS foundation trusts

[The Chair]

We now come to group 24, and amendment 73 to clause 29 tabled by Charlie Maynard. Does any Member wish to move amendment 73? With that not being so, the question becomes that clause 29 stand part of the Bill.

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[The Chair]

With this it will be convenient to discuss the following:

Amendment 74, in schedule 3, page 80, leave out paragraphs 5 to 8.

This amendment would retain the requirement for NHS Trusts to have a Council of Governors.

Amendment 75, in schedule 3, page 80, leave out paragraph 14.

This amendment would retain the requirement for NHS Trusts to have a Council of Governors.

Government amendment 19.

Amendment 36, in schedule 3, page 82, line 3, at end insert—

“(1A) The function under sub-paragraph (1) must be exercised by a person employed in the civil service of the State, and a Minister of the Crown or a special adviser must not be involved in any decision relating to such an appointment, suspension or removal.”

This amendment would ensure that civil servants are responsible for the decision making and appointment processes for trust and ICB leaders, rather than Ministers or Special Advisers.

Schedule 3.

Clause 30 stand part.

New clause 59—Independence of appointments—

“The Secretary of State must make provision to ensure that operational decisions regarding the appointment, suspension or removal of—

(a) chairs and directors of NHS trusts and NHS foundation trusts, and

(b) chief executives of integrated care boards,

are made exclusively by persons employed in the civil service.”

[Karin Smyth]

Amendment 19 reinstates in primary legislation the requirement in schedule 7 to the National Health Service Act 2006 for an NHS foundation trust board to include one executive director who is a medical or dental practitioner, and another who is a registered nurse or midwife.

I want to be clear to the Committee from the outset that there was never any intention to change the policy on the clinical membership of NHS foundation trust boards. Foundation trusts would still have been expected to have appropriate clinical leadership on their boards, but we had heard from ambulance foundation trusts that the current framing of the requirement for clinicians is not always helpful, and greater flexibility was therefore required. However, we also heard from important stakeholders, including the Royal College of Nursing, that removing the requirement from primary legislation has been perceived as deprioritising clinicians, which is absolutely not the case. We have therefore tabled amendment 19 to remove any doubt.

These roles provide valuable clinical oversight of board governance in decision making in foundation trusts, and are essential to ensuring the safety and quality of patient-facing services in the NHS. At the same time, some providers may need different clinical expertise at board level. For example, in ambulance trusts, an experienced paramedic may be better placed to provide the relevant clinical guidance and oversight. The amendment therefore gives the Secretary of State a regulation-making power to create exceptions to the requirement following engagement with relevant stakeholders. That preserves the current position in primary legislation while allowing for targeted flexibility for ambulance or patient transport-focused foundation trusts where appropriate. I commend amendment 19 to the Committee.

Clause 29 introduces schedule 3, which makes changes to the governance and constitution of NHS foundation trusts. It removes the various statutory roles of foundation trust members and councils of governors, and repeals the requirement for FTs to have them. Amendment 73 to 75 look to oppose that, but I do not think that we are discussing those.

[The Chair]

Order. Forgive me; let me interrupt to explain. I asked if anyone wished to move amendment 73, and no one did. We will come to amendments 74 and 75, so the Minister is welcome to speak to those amendments now or at the end of the debate if she wants to. Other members of the Committee may wish to move those amendments subsequently.

[Karin Smyth]

Thank you for the clarification, Sir Jeremy. I will come to amendment 75 at the end of the debate.

The Bill’s removal of councils of governors from NHS foundation trusts is part of delivering the 10-year health plan goal of hospitals putting patient experiences and outcomes at the heart of their decision making. That is not because we want to rid the system of local voices in democratic accountability—far from it. Although governors have provided helpful advice and oversight for some foundation trusts, we expect the next generation of NHS foundation trusts to put in place more responsive and flexible arrangements for drawing on patient, staff and stakeholder insight.

Rather than a one-size-fits-all model, providers should develop engagement arrangements that reflect their local populations, geographies and healthcare needs. Foundation trusts will have the option to retain aspects of their engagement model where it is working well, but can take a different approach if needed. Following Royal Assent, foundation trusts will be expected to have those arrangements in place and will be assessed as part of the non-statutory advanced foundation trust process.

Schedule 3 makes related changes to governance and decision making, in line with the Government’s policy to streamline oversight of providers and reduce duplication in the system. For example, the legal powers to appoint chairs and non-executive directors of foundation trusts and NHS trusts will, in future, both sit with the Secretary of State while supporting the effective use of talent across the NHS. Other functions of the council of governors, such as reviewing plans and major transactions, currently duplicate existing NHS England responsibilities, which will transfer to the Secretary of State through this Bill. Removing those requirements will therefore reduce duplication in the system.

Schedule 3 will also give the Secretary of State responsibility for approving changes to foundation trust constitutions and material changes to private patient income, and deciding chair and non-executive remuneration. The Secretary of State will take on the oversight role currently exercised by NHS England, and previously Monitor, including monitoring foundation trust performance, use of resources and governance. That will support system alignment and ensure that appropriate accountability arrangements are in place. Can I seek clarification, Sir Jeremy, that I can speak to clause 30 at this point?

[The Chair]

Yes, we are debating all the provisions in this group together, so the Minister is welcome to speak to clause 30 now or later, when she winds up.

[Karin Smyth]

Thank you, Sir Jeremy. Clause 30 clarifies how NHS foundation trust status will be applied for and granted following the abolition of NHS England and the removal of the council of governors model. The Government are committed to reinvigorating the foundation trust sector by granting high-performing providers greater freedoms and autonomy. The power to authorise foundation trusts originally sat with Monitor and passed to NHS England in 2022. The clause, alongside schedules 3 and 11, sets out how that power will operate when it transfers to the Secretary of State. It also makes consequential amendments to the authorisation process, including removing requirements linked to recruiting members and electing governors. The Secretary of State will also set the criteria for becoming a foundation trust. I commend the clauses and the schedule to the Committee.

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[Gregory Stafford]

My hon. Friend is right that there will be a gap in local decision making on these issues. It goes back to that tension I described some moments ago: the Government’s stated intention is to devolve powers locally, but they seem to be pulling so much power up to the Secretary of State that we will lose the ability to make local decisions for the benefit of local populations where appropriate. We have a stated ambition for neighbourhood health, but those neighbourhoods are rapidly expanding in this legislation to become areas of millions of people. Local people who are interested in their local health delivery or local hospital trust would not see that as local decision making, and there is the gap that my hon. Friend describes.

I do not think that amendments 74 and 75 have been moved, so I will not talk about them. Government amendment 19 will require

“NHS foundation trusts to have at least one executive director who is a registered medical practitioner or a registered dentist and another who is a registered nurse or a registered midwife.”

As also stated in the explanatory note, and as the Minister mentioned, regulations may create exception—for example, for ambulance trusts. That is the right decision, and it is important that we have medical experience on foundation trust boards. I am interested in understanding from the Minister, first, why she has chosen a medical practitioner or registered dentist. Does she see some equivalence in their expertise that could be substituted? I have great respect for doctors and for dentists, but they have potentially different clinical expertise. If a foundation trust does no oral healthcare or maxillofacial reconstruction, and does no dentistry or allied specialties, would it really satisfy requirements to have a dentist on the board? Likewise, given that the amendment also refers to a registered nurse or midwife, if a trust has no maternity services, would having a midwife on the board really satisfy the requirement of that trust to have nursing care input? I ask those questions, and I would be interested in the answers.

Likewise, there is the exemption for ambulance trusts. Like my hon. Friend the Member for Sleaford and North Hykeham, I would be interested to understand from the Minister why she thinks ambulance trusts do not need a medical practitioner on their boards, given that they are doing medicine. Plenty of consultants work alongside paramedics and in ambulances, so again I am not quite sure why she is making that exemption. I would be interested to hear from her on that.

I understand the intention behind Liberal Democrat amendment 36. Once again, it is trying to soften the Secretary of State’s power grab over decision making—like the hon. Member for North Shropshire, I am not saying anything against the current Secretary of State, but a future Secretary of State could be different. The aim is to try to temper that in some way. Unfortunately for the hon. Member—I have sympathy for the amendment—the stated intention of the Bill is to pull more power to the Secretary of State. The Minister may surprise me, but I fear that the amendment will not find favour with the Government, because the whole Bill is about pulling more power to the centre, certainly when it comes to appointments, and to the Secretary of State.

However, the Minister should think about how future Secretaries of State may have to go through some process whereby their decisions are checked and justified, especially at local level. If we want local people to have influence and say over their local health systems and trusts, there needs to be some sort of bridging legislation or bridging process to ensure that whatever a Secretary of State decides, it has the confidence and support of local people and local service providers.

[Karin Smyth]

I think I am almost going to agree with the hon. Gentleman on his final point. It is important that local people have confidence in how their local systems are run and managed and, clearly, in the outcomes.

I will come first to the issue of governors and boards and then move to the amendments. I think we have all had emails, as is quite right, from local board members. Let me say, as I did earlier, that that is with good intent; they are very good people, who have given public service to be part of their local health system. As I said, this provision is no judgment on them; it is, as we heard, about effectively making the really important patient voice and patient experience central to the functions of the organisations delivering our healthcare. As I said in previous sittings, a debate will continue to be had about where we most effectively have that, but our intention throughout the 10-year health plan and this Bill is about devolution to providers and to ICBs and about making boards, as I also said in a previous sitting, responsible and accountable for the outcomes.

Let me outline broadly, because I think this is of interest to people, the impact on governance and the role that governors had. Just to be clear, since the creation of foundation trusts in 2004, NHS England—and, before it, NHS Improvement and Monitor—has had a statutory role to oversee the governance of NHS foundation trusts, including holding the whole board to account and taking steps where it identifies weaknesses in how foundation trusts are being run. The regulatory function is underpinned by the NHS provider licence, which will continue when NHS England’s functions pass to the Secretary of State. That is why we do not consider that the removal of the council of governors will have a negative impact on the governance of FTs, as some hon. Members have suggested.

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[Dr Johnson]

Will the Minister give way?

[Karin Smyth]

I will move on, if I may. I think my response will the cover the issues raised in the debate.

On amendment 36 and new clause 59, I note the concern that the Secretary of State could act inappropriately when making appointments to the boards of ICBs and NHS trusts and foundation trusts. We discussed democratic accountability in a previous sitting, and at the end of the day it is up to the British public whom they elect to Parliament and as the governing party.

Transparency and democratic accountability are at the heart of our reforms. It would not be right for the civil service to be given sole legislative responsibility for appointments to NHS trusts, foundation trusts or integrated care boards. Ministers are democratically accountable to Parliament, and civil servants act on their behalf under the Carltona principle. Civil servants serve and advise the Government, and act on behalf of Ministers, but it is for Ministers to take decisions and to be held accountable to Parliament for the performance of the NHS. The civil service will run fair, open and equitable campaigns to fulfil these roles and will recommend appropriate candidates to Ministers.

Ministers are under a duty to comply with public law principles and to act reasonably, and will adhere to the Nolan principles, including objectivity, transparency and integrity, in discharging this function. The practical arrangements for appointments are being developed as part of the transition planning for the integration of NHS England’s functions into the Department, and will be based on these principles. It would therefore be inappropriate to exclude Ministers entirely from the appointments process. I urge hon. Members not to push the amendments to a vote.

[Dr Johnson]

Will the Minister give way?

[The Chair]

With this it will be convenient to discuss the following:

Schedule 4.

Clauses 32 to 34 stand part.

[Karin Smyth]

I will address clauses 31 to 34 and schedule 4 together. Clause 31 ensures that NHS foundation trusts are subject to the same robust, transparent audit regimes as other NHS bodies. Together with schedule 4, clause 31 makes provision about the audit of NHS foundation trust accounts, which is needed as a consequence of the abolition of NHS England and the removal of the requirement for NHS foundation trusts to have councils of governors and members. Schedule 4 does that by removing the current bespoke provisions related to the auditing arrangements for the accounts of foundation trusts and amends the Local Audit and Accountability Act 2014 so that foundation trusts are subject to the auditing regime under that Act. This means that foundation trusts will in future be subject to the same auditing requirements as trusts and integrated care boards, ensuring a clear, consistent and transparent framework for local audit across NHS provider organisations. Taken together, these measures strengthen consistency in financial reporting and audit assurance across the NHS provider sector, while preserving the independence of the local audit process.

Clause 32 repeals provisions of the NHS Act 2006, requiring NHS England to maintain a register of NHS foundation trusts and a power to charge fees related to maintaining the register. The register formed a repository of documents that related to how foundation trusts were governed and regulated. However, removing the requirements does not mean there will be no transparency. NHS foundation trusts are already required to publish the information provided on this register, and where a foundation trust is placed into special administration the administrator is required to publish its report. As a result, the additional requirement to maintain a register is unnecessary, burdensome and duplicative, providing the public with no new information. For those reasons we are removing that bureaucratic duty in the Bill.

On clause 33 stand part, the Department of Health and Social Care, like all Departments of State, has a responsibility to diligently and responsibly steward taxpayer’s money in delivering services to the public. Clause 33 updates and strengthens existing legislation to make sure we have the statutory tools we need in order to effectively manage and oversee the finances of the NHS. It does that by updating sections 42B and 42C of the NHS Act 2006 so that the existing last-resort statutory capital spending limit for foundation trusts can also apply to revenue expenditure for a given year.

Foundation trusts account for a substantial proportion of NHS revenue spending, at around 40%, and continue to benefit from significant operational autonomy, including the freedom to retain and reinvest surpluses. We remain committed to seeing those freedoms expanded further through our advanced foundation trust programme. However, this strengthened power ensures we have a financial framework that makes it easier to consider additional freedoms. The Department must therefore ensure it has in place robust tools to oversee the finances of the health service, to reassure taxpayers and Parliament that public money is being managed effectively and to ensure that the Department can meet its financial obligations.

The power will remain subject to strong safeguards, including a mandatory consultation period with the foundation trust before any order is made, the requirement for any order made to be published, and detailed statutory guidance setting out the circumstances in which the power would be used and how limits would be determined. Crucially, this is a last-resort measure. This power would be used only in exceptional circumstances—for example, when the Secretary State thinks there is a risk of breaching a departmental delegated expenditure limit. I should note that the existing capital backstop on which it builds has never been used. The purpose here is not routine financial management, but assurance. By ensuring that foundation trust freedoms operate within a viable and sustainable framework, the clause helps protect those freedoms rather than undermine them.

Finally, clause 34 makes straightforward but important provision about financial accountability when NHS organisations change legal form. It requires an NHS foundation trust that has been newly authorised, or that has recently acquired an NHS trust or another NHS foundation trust, to prepare the final accounts for its predecessor organisation. As the Committee will appreciate, organisational change, whether through authorisation to foundation trust status or through acquisition, can bring real benefits for local services, but it can also create a practical issue at financial year end. The predecessor body will have ceased to exist in its previous form and so will not be in a position to complete and sign off its final set of accounts. Clause 34 addresses that gap by making clear where responsibility sits—

Health Bill (Ninth sitting)

Karin Smyth Excerpts

Committee stage
Tuesday 30th June 2026 Public Bill Committees

[The Chair]

I remind the Committee that with this we are considering the following:

Schedule 4.

Clauses 32 to 34 stand part.

[The Minister for Secondary Care (Karin Smyth)]

I will start where I left off. Clause 34 addresses the gap by making it clear where responsibility sits, so that there is no doubt about who must produce the final accounts and ensure that they are completed properly, and about how those accounts should be audited. We think this is a proportionate provision to ensure continuity and clarity on how NHS money has been managed during organisational transition. I commend the clauses to the Committee.

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

Clause 31 introduces schedule 4, which essentially makes series of amendments to other Acts. It amends the Public Finance and Accountability (Scotland) Act 2000 to remove a cross-reference to other categories, and it amends the Audit and Accountability (Northern Ireland) Order 2003 and the Public Audit (Wales) Act 2004 for similar purposes. It also amends the National Health Service Act 2006 by deleting section 62 and schedule 10, relating to the audit of accounts of NHS foundation trusts, to end the old audit scheme.

Schedule 4 amends section 3 of the Local Audit and Accountability Act 2014 so that foundation trusts are now included in the list of bodies that must keep accounts in the standard way, it amends section 4 to specify which documents count as accounts of foundation trusts for the purpose of auditing, and it amends sections 8 and 10 so that the auditor appointment procedure and the auditor panel’s role now cover foundation trusts.

In addition, schedule 4 rewrites section 13 of the 2014 Act so that if a trust fails to appoint a local auditor, it is the Secretary of State’s job to step in. Previously, that was NHS England’s job; clearly, that needs to change, because NHS England is being abolished. The schedule also amends section 21 so that the auditors’ general duties now apply to foundation trusts too, and it amends section 30, relating to unlawful expenditure and activity, and section 32B, relating to the independence requirement, to remove a now-redundant item from the list.

Schedule 4 also amends schedule 2 to the 2014 Act to formally add foundation trusts to the official list of audited bodies; schedule 5 so that the rules on who can be a local auditor now cover foundation trusts too; schedule 6 to remove an outdated segment from the audit practice code rules; schedule 7 to tidy the reporting rules and extend them to foundation trusts; schedule 9 to realign data matching rules that apply to foundation trusts in the new system; and schedule 11, relating to the disclosure of information, to remove a reference to NHS England, which is no longer necessary because NHS England is being abolished. In general, clause 31 aligns the audit process for accounts of foundation trusts with those of standard trusts and integrated care boards.

Clause 32 removes the need for NHS England to maintain a register of foundation trusts and the fees associated with maintaining it. Section 39 of the NHS Act 2006 requires NHS England to maintain a current register of NHS foundation trusts and specifies what must be in that register. Section 50 states that an NHS foundation trust must pay NHS England a fee that NHS England may determine in respect of exercising its functions under section 39, which relates to keeping the register, and section 39A, relating to a panel for advising governors. Clause 32 deletes sections 39 and 50. The explanatory notes say that the requirement to maintain a register does not need to be transferred to the Secretary of State when NHS England is abolished because, the Government argue, the information will already be available centrally, and there is no need for a fee to keep that in place. That seems sensible to me.

Clause 33 enables the Secretary of State to impose limits on a foundation trust’s annual capital or revenue expenditure. Section 42B of the 2006 Act allows NHS England to make an order imposing a limit on the capital expenditure of a foundation trust in a single year. Section 42C sets out that NHS England must publish guidance about the exercise of its power under section 42B, including about the circumstances in which it is likely to make an order and the method it will use to determine the capital expenditure limit. Clause 33 entirely replaces sections 42B and 42C with rewritten sections, with some notable changes. The wording is changed from “capital expenditure” to “expenditure”. The power is therefore widened from capital expenditure limits to limits on any expenditure—capital and revenue. The Secretary of State replaces NHS England as the entity with the power to impose limits, which makes sense, and the subsection requiring an order to specify the trust, the financial year and so on has been removed in full.

The change gives the Government financial control to stop overspending by NHS foundation trusts. I note that in financial year 2023-24, NHS trusts overspent by £1.2 billion, so presumably this is the Secretary of State getting a tighter grip on spending. In some respects that is sensible, but overspending is often due to staffing costs and day-to-day pressures, not capital expenditure, so there is an argument that the capital limits themselves are not sufficient to deal with the problem. Under the new governance model, the Secretary of State has oversight and responsibility for the health service, and financial control aligns with those changes. The new power could prevent one organisation’s failures from undermining the health service’s wider financial position or impacting other providers.

However, the purpose of foundation trusts is supposed to be that they have greater independence over spending, and the Government have stated that their aim is to create a more devolved and autonomous health system. How does broadening the Secretary of State’s ability to interfere in expenditure devolve power or make foundation trusts more independent? Imposing expenditure limits may control overspending on paper, but it does not address the reasons why it is happening, so limits could lead to a deterioration in the health services delivered by some trusts. What plans does the Minister have to deal with that?

Because the power moves from an arm’s length body to the Secretary of State, interventions could be politically motivated, rather than in the best interests of the NHS. How does the Minister consider that that will be managed?

The power for the Secretary of State to impose expenditure limits at any time during or before the financial year could create uncertainty among trust leadership and undermine long-term planning. If a trust is given a budget for the year, it knows what it has to work with, but if somebody says halfway through the year, “Actually, you are going to have to work with less money than that,” it is very difficult for the board to plan its expenditure, because it is always looking the other way. Why does the Secretary of State need that power? Can the Minister clarify that, if there is a change in the expenditure limit during the year, it will always be revised upwards, and never downwards?

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[Karin Smyth]

I thank the shadow Minister for in general, I think, agreeing that the alignment of many of these processes is quite sensible.

The shadow Minister talked in general terms about financial controls. The Government take financial controls and our responsibility for taxpayers’ money very seriously. As I said last week, from very early on, we were very keen to ensure that there is a grip on NHS finances in order to properly deliver the sort of healthcare that all our constituents deserve. We take that very seriously. There has not been that sort of grip at board level and through the system in recent years. As a result of the measures that we have taken, I think this is the first year in six or more years that the NHS has not gone back to the Department for additional funds to get through the year. The Committee can be assured that financial control is important.

The shadow Minister referred to limits. Of course they are overall limits; the Secretary of State does not go line by line through what a trust spends. I understand the point that people are trying to make to conflate some situations, but of course it is an overall limit.

The safeguards in these provisions are designed to protect foundation trusts’ freedoms and not constrain them, but a foundation trust can enjoy such freedoms only if it is in a well-overseen and stable NHS financial system. By including a backstop for use in exceptional circumstances, clause 33 helps to safeguard public funds and will help the Department to meet its financial obligations, which I think hon. Members understand. It is a usual process for the Department to go through, as anyone who has sat on the Public Accounts Committee will know. Adherence to the departmental expenditure limit creates and maintains the necessary environment for the foundation trust to exist.

Question put and agreed to.

Clause 31 accordingly ordered to stand part of the Bill.

Schedule 4 agreed to.

Clauses 32 to 34 ordered to stand part of the Bill.

Clause 35

Conversion of failing NHS foundation trust into NHS trust

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

[The Chair]

With this it will be convenient to discuss the following:

Schedule 5.

Clauses 36 to 38 stand part.

Schedule 6.

[Karin Smyth]

During the process of producing our 10-year plan, we were clear that, as much as we will reward the best performing providers with new freedoms to innovate, we will not hesitate to act on poor performance, and this group of measures deal with just that: action in the event of a failing provider.

Clause 35 and schedule 5 insert new provisions into the NHS Act 2006 to enable the Secretary of State to, by order, convert a failing foundation trust to an NHS trust. This is intended to take place only in the most critical circumstances, and where it is in the public’s best interest for the Secretary of State to be able to direct the trust about how it should exercise its functions, to address safety or other issues at the trust. Foundation trust status should be a mark of good performance, and there must be a mechanism to remove it when performance is seriously deficient. This deauthorisation power will help to maintain the integrity of the reinvigorated foundation trust status and provide an additional incentive for challenged foundation trusts to improve.

The power to make a conversion order can be used where the foundation trust has failed to comply with a condition of its provider licence or with another legislative requirement. In deciding whether to make a conversion order, the Secretary of State must consider various factors, including the seriousness of the failure, the health and safety of patients, the quality of the provision by the trust of goods and services, the financial position of the trust, and the way the trust is being run.

The conversion power is also subject to two additional requirements. First, the Secretary of State must publish guidance about the matters they will consider in deciding whether to exercise the conversion power, including the factors I just outlined. They must consult on any such guidance before its publication. Secondly, where the Secretary of State proposes to use the power, they must first consult the foundation trust in question, any integrated care boards in the areas in which the trust operates, and any other person to whom the trust provides goods and services, and whom the Secretary of State considers it appropriate to consult.

Clause 35, together with schedule 5, also inserts new schedule 9A into the NHS Act 2006, which sets out the immediate consequences of a conversion order. Deauthorising a foundation trust has no impact on the property it holds, the contracts it has with commissioners and other groups, or the terms of employment of employees. These powers set clear organisational consequences for significant underperformance and allow the Secretary of State the freedom to take action to protect patients in extreme circumstances.

Clause 36 contains another critical power to allow action in the case of a failing foundation trust. It allows the Secretary of State to add conditions to an NHS foundation trust’s provider licence where they consider that the trust will breach its licence conditions due to issues with its governance. The clause is a consequence of abolishing NHS England and makes changes to the powers currently held by NHS England under section 111 of the Health and Social Care Act 2012, to confer them on the Secretary of State, with additional consequential changes reflecting the abolition of councils of governors.

The clause sets clear expectations for a foundation trust through the licence conditions and provides the Secretary of State with a transparent mechanism to take more urgent, targeted enforcement action to address failures of governance. Should the foundation trust breach any conditions imposed via section 111, the Secretary of State may require it to make changes to the executive directors of its board as necessary, including removing or suspending executive directors, replacing executive directors with interims, and preventing the trust from appointing specific individuals. If the foundation trust fails to take those actions, the Secretary of State may implement the changes.

To reassure the Committee, there are clear safeguards underpinning the clause, which can be used only where there is evidence that failures of governance in the foundation trust will cause it to breach the conditions of its licence. Further, acting under section 111 does not preclude the Secretary of State from using their other regulatory powers, including to require the foundation trust to take steps to address a breach of any condition of the licence, or to accept undertakings from the trust to address the breach.

Finally, the section 111 power was originally granted to Monitor in 2012 under transitional arrangements, as it was anticipated that the power could be withdrawn once governors had transitioned into their roles and could hold boards to account without outside intervention. Over 13 years on, that has proven not to be the case. With the abolition of the foundation trust councils of governors, it makes sense to repeal the provisions under sections 112 to 114 of the same Act that made it transitional.

Clause 37 makes changes to the special administration framework to ensure that it continues to function coherently after the abolition of NHS England. The clause makes focused, technical amendments to the Health and Social Care Act 2012 to amend the framework for establishing a mechanism for financial assistance in cases where a provider is subject to a health special administration order under chapter 5 of that Act. It also amends the Act to remove the duty to establish a mechanism for financial assistance to foundation trusts to which a trust special administrator has been appointed. The duty no longer needs to apply to foundation trusts, because the Secretary of State already has the power under provisions in the NHS Act 2006 to provide financial assistance to NHS foundation trusts if needed.

With the abolition of NHS England, the duty to establish a mechanism for financial assistance for independent providers will be retained and conferred on the Secretary of State. It is worth noting that the provisions related to financial assistance in special administration cases, and chapter 5 of the Health and Social Care Act 2012, which sets out the powers and processes for the making of health special administration orders, have not yet been commenced. However, the amendments made by the clause ensure that the special administration regime can operate smoothly if it is ever needed.

The clause does not create new financial support mechanisms, but ensures that existing ones can be used appropriately in the reformed system. In short, clause 37 ensures that the legal framework reflects the new institutional landscape while retaining the ability to act swiftly to safeguard continuity of services during special administration.

Clause 38 makes changes to the trust special administration framework to ensure that it continues to function coherently after the abolition of NHS England. This clause, together with schedule 6, make targeted changes to the trust special administration process set out in the NHS Act 2006 for NHS trusts and NHS foundation trusts as a consequence of the abolition of NHS England. It also aligns more closely the processes between NHS trusts and foundation trusts.

Trust special administration is, and will remain, a last resort mechanism used only in cases of serious failure. It is used to protect patients, stabilise services and put the organisation back on a sustainable footing. Where deemed necessary, a trust special administrator would be appointed to manage the trust and work with relevant key stakeholders to develop recommendations regarding the organisation and its services.

The amendments made by schedule 6 remove functions that currently sit with NHS England and confer the key decision-making functions on the Secretary of State, who will provide clearer lines of accountability and faster decision making when rapid intervention is required. The amendments also simplify the steps involved in the TSA process, with the aim of improving the speed of intervention and providing transparency. They align more closely the processes for trusts and foundation trusts, and set out a simpler process in relation to the administrator’s draft report, consultation and final report. They also require, as is the case now, that key documents and decisions are published and laid before Parliament. That will help ensure proper and meaningful scrutiny of the TSA process and outcomes. It also helps ensure that affected patients, staff and local partners have the opportunity to engage during the process, while maintaining the balance with the need to deliver timely intervention and secure continuity of safe services.

In addition, the amendments in schedule 6 make changes to the role of the Care Quality Commission in trust special administration. The CQC will be able to recommend that a trust special administrator should be appointed. The Secretary of State is also required to consult the CQC before making an order, ensuring that independent expertise on quality and safety informs decisions and that intelligence on service performance is co-ordinated.

The provisions in the Bill ensure that the process remains fit for purpose, proportionate, and aligned across NHS trusts and foundation trusts. They support faster, more coherent decision making in the most serious cases, with the aim of protecting patients and securing sustainable, high-quality services for the future. Taken together, the clauses provide the necessary tools for the Secretary of State to take proportionate, swift and decisive action in the event of provider failure. I therefore commend these clauses to the Committee.

[Dr Johnson]

Clause 35 essentially establishes the right of the Secretary of State to convert a foundation trust into an NHS trust in certain circumstances. Currently, section 25 of the NHS Act 2006 establishes trusts and introduces schedule 4 of the same Act, which makes provision about NHS trusts. Section 56AA sets out how additional requirements concerning acquisitions of a trust or foundation trust are to work. Clause 35 deletes section 25(2), which specifies that an order in this context is referred to as “an NHS trust order”, and amends subsection (3), so that no order under section 25—previously no “NHS trust order”—can be made until any consultation that has been prescribed is complete.

Clause 35 introduces proposed new section 57B into the 2006 Act, “Conversion of failing NHS foundation trust into NHS trust”, which provides the Secretary of State with the power to convert if the foundation trust breaches its licence or other legal duties. The trigger is broad and includes non-compliance with any statutory requirement. The proposed new section requires an order to specify when it takes effect and also requires the Secretary of State, when deciding to issue an order, to consider among other things

“the seriousness of the failure…the health and safety of patients…the quality of the provision by the trust of goods and services…the financial position of the trust, and…the way that the trust is being run.”

Before making an order, the Secretary of State will be required to consult the trust, any ICB where the trust has facilities and

“any other person to whom the trust provides goods or services…whom the Secretary of State considers it appropriate to consult.”

The proposed new section also provides the Secretary of State with the power, when the conversion order is made, to

“terminate the appointment of the chair or any executive or non-executive director”,

and to

“appoint a person to be the chair or an executive or non-executive director”.

It also time-limits the powers to intervene with management to one year after the order is made.

Clause 35 also introduces proposed new section 57C into the 2006 Act, “Guidance about conversion”, which requires the Secretary of State to publish guidance about matters to be considered when deciding to make an order and requires them to consult persons considered appropriate before publishing or revising guidance. The clause removes “NHS trust order” from section 276 of the 2006 Act, “Index of defined expressions”, and updates schedule 4, so that an NHS trust may be established by an ordinary order under section 25 or a conversion order under proposed new section 57B.

Schedule 5 to the Bill inserts proposed new schedule 9A to the 2006 Act, “Conversion of failing NHS foundation trusts”, which provides that, on conversion, the foundation trust’s chair and directors become the initial chair and directors of the new NHS trust, unless they are removed by the Secretary of State under the procedures we have just talked about. The proposed new schedule initially keeps the board the same size, until new arrangements are made. It provides that the foundation trust’s public dividend capital carries over to the NHS trust and that the conversion does not affect continuity of the body —it will remain the same organisation, just with NHS trust status.

The proposed new schedule provides that the trust’s property and liabilities, including criminal liabilities, continue unaffected. It also provides that existing contracts continue and that the trust remains party to them. It clarifies that those contracts do not automatically become NHS contracts under section 9(1) of the 2006 Act, provides that the trust keeps any corporate memberships that it held before the conversion, and clarifies that the continuity provisions do not affect the Secretary of State’s wider powers to make directions.

The Secretary of State will have a direct power to act where the foundation trust has failed—for instance, where there have been patient safety lapses—and there are clear benefits to that. There are also transparency requirements built in: the Secretary of State must publish guidance and consult before issuing guidance or undertaking conversion, and the power to change the management is limited to a year.

However, the last Labour Government said that independence was central to the success of foundation trusts. In 2005, the then Secretary of State, Patricia Hewitt, said:

“We know that independence from central Government control and greater freedoms are giving NHS foundation trusts the opportunity to innovate new approaches to healthcare and healthcare services, for the benefit of NHS patients.”—[Official Report, 7 November 2005; Vol. 439, c. 5WS.]

The challenge with innovations is that, even with the very best intentions and the very best advice, some will work and some will not. If any failure at all is a reason for trusts to be taken over, will that cause them to be shy about innovating, for fear of their independence being undermined as a result? There is a balance to strike, so I wonder whether the Minister will comment on that.

The change also makes it easy for the Secretary of State to convert a foundation trust for political reasons—for instance, because of pressure from local Members of Parliament. That is a positive in some ways and a negative in others. Again, it could have a chilling effect on the very autonomy and innovation that Ministers want to see, so the question is how they think they will balance that.

--- Later in debate ---

[Edward Argar (Melton and Syston) (Con)]

I will endeavour to be relatively brief in my reflections, and I will address, particularly, clauses 35 and 38. I can see a logic to what the Minister proposes in them. On clause 35, we know that foundation trusts face challenges. We saw that writ large with the scandal at Mid Staffs, and in my time as a Minister, several foundation trusts required intervention—maybe not on that scale—or required improvement. I pick on them just because they are in my head—I do not know the situation today. I am looking across at the hon. Member for Ashford, because going back some years to when I was a Minister, East Kent hospitals NHS foundation trust faced some considerable challenges. I am not necessarily saying that that meets the bar for intervention, but foundation trusts have challenges from time to time.

I should also declare an interest: I was born in the forerunner of the William Harvey hospital—the old Willesborough hospital—in the hon. Member’s constituency. I recognise that on occasions foundation trusts get into serious, or less serious but still challenging, circumstances. So I can see where the Minister is coming from, but I have a few questions for her.

First, we recognise that although foundation trusts can get into bother, so too can NHS trusts. NHS trusts can underperform, have safety issues or have financial or other performance issues. I am interested to hear the Minister’s reflections on why she believes that removing foundation status and the organisation becoming an NHS trust will necessarily solve those problems, when many NHS trusts can have equally significant challenges. I would welcome the Minister’s reflections on that.

In terms of whether a conversion was to take place—if the Secretary of State determined that that was expedient and it met the criteria—what would the timescales and process be if, further down the line, a foundation trust wished to reapply for its old status, having previously converted to an NHS trust? Would that be possible, and how would it work? I suspect that there would be a significant number of hurdles to get over to prove that it had achieved that status. I would welcome the Minister’s reflections on that point.

Finally, on clause 38, what the shadow Minister, my hon. Friend the Member for Sleaford and North Hykeham, touched on gives me a little cause for concern. Essentially, this appears to be a further centralisation of powers in the Secretary of State’s hands, particularly with the changes to the role of the CQC. It effectively downgrades the CQC’s power as the independent regulator in these matters. Instead of the CQC being able to initiate the appointment of a TSA where, on safety grounds, they consider it to be necessary and the criteria met, that power will sit with the Secretary of State, who will be required to consult the CQC, but it will seemingly lose its ability to take that initiating step irrespective of what they have seen in any inspections. I would be grateful if the Minister addressed and potentially reassured me on those points.

[Karin Smyth]

As people who have been listening will know, this is a chunky set of clauses on some technical details. Let me broadly pick up some of the key points.

I want to be very clear about deauthorisation and our seeking to establish, essentially, a more dynamic model. As I said, the coalition Government repealed the legislation on deauthorisation in the 2012 Act. Although other regulatory levers exist to manage poor performance, we are using two core arguments. First, converting foundation trusts into NHS trusts will enable the Secretary of State, if needed, to intervene further through their power of direction over NHS trusts. The Secretary of State will therefore be able to focus on the patient and public interest over preservation of providers’ statutory freedoms in cases of serious failure. I hope that that addresses some of the points that have been raised. Secondly, having a more dynamic environment with the potential for deauthorisation in such cases, and the consequent loss of statutory autonomy, may act as an incentive for challenged foundation trusts to improve, and it would show that there are consequences.

As I think the hon. Member for Sleaford and North Hykeham knows, the usual processes exist for managing performance across various aspects of the provider. They will continue. This is for exceptional circumstances. As I said, this is about maintaining a more dynamic model than the one we have. The purpose behind her questions about continuous service—the purpose of having a range of failure powers—is to ensure continuity of care for patients and the public. The analogy with general practice does not hold; this is a very different set of circumstances. But, obviously, she raises an important point about public concern relating to the service’s provision, and I assure her on that. We need to make sure that we diagnose the situation, provide the trust with support and assess which toolbox is most applicable.

The CQC can recommend that a trust special administrator should be appointed where it is satisfied that there is a serious failure to provide services of a sufficient quality, and it must provide a report on the safety and quality of services following the appointment of an administrator. The Secretary of State must also consult the CQC before making an order to appoint a trust special administrator.

Question put and agreed to.

Clause 35 accordingly ordered to stand part of the Bill.

Schedule 5 agreed to.

Clauses 36 to 38 ordered to stand part of the Bill.

Schedule 6 agreed to.

Clause 39

Joint working and delegation arrangements

--- Later in debate ---

[The Chair]

With this it will be convenient to discuss the following:

Government new clause 20.

New clause 26—Arrangements between NHS bodies and local authorities: duty to review—

“(1) The Secretary of State must conduct a review of the effectiveness of arrangements entered into by NHS bodies and local authorities under section 75 of the National Health Service Act 2006 (arrangements between NHS bodies and local authorities).

(2) In conducting the review, the Secretary of State must consult—

(a) NHS bodies,

(b) local authorities, and

(c) any another person that the Secretary of State considers it appropriate to consult.

(3) Having conducted the review, the Secretary of State must consider whether the power to make regulations in section 75(1) or the power to issue guidance in section 75(6) of the National Health Service Act 2006 should be exercised in order to improve the effectiveness of arrangements under that section.

(4) The Secretary of State must lay before Parliament, and publish, a report of the review.

(5) The report of the review must explain whether the Secretary of State decided to exercise the powers in section 75(1) and (6) of the National Health Service Act 2006 and the reasons for that decision.

(6) The Secretary of State must comply with the requirements of this section before the end of the 12-month period beginning with the day on which this Act is passed.”

This new clause requires the Secretary of State to conduct a review into arrangements under section 75 of the National Health Service Act 2006, and to consider whether to require NHS bodies and local authorities to enter into arrangements with each other if this is likely to lead to an improvement in how their functions are exercised.

[Karin Smyth]

Government new clause 20 and clause 39 both look to strengthen joint working arrangements across the health system. Clause 39 is part of the architecture of the Bill that allows the delegation of functions from the Secretary of State to NHS bodies, local authorities or other relevant organisations. The clause builds on the existing delegation powers in section 65Z5 of the National Health Service Act 2006, which already allow NHS bodies to delegate functions and pool resources with one another and with local authorities or other relevant bodies on a voluntary basis. It is a well-used voluntary power that enables systems to develop joint working and ensure that health functions are carried out by the most appropriate body or groups of bodies. The result is stronger integration, with better joint working between NHS and local government, and services better tailored to meet local needs.

With the abolition of NHS England and the new functions of the Secretary of State, it is right that the Secretary of State should have the flexibility to delegate their health functions appropriately and efficiently under a voluntary arrangement, as and when necessary. We would not want to exclude the Secretary of State from joint working arrangements, if joint working would bring benefits to patients and the public. The power is therefore purposefully broad to allow that, including allowing the Secretary of State to delegate to a range of public bodies, establish joint committees and pool funds. It also allows the Secretary of State to issue guidance to relevant bodies about the use of their powers under sections 65Z5 and 65Z6.

This proposal is not, however, a means to avoid accountability. Accountability for any function delegated through this power remains with the person delegating it whereas liability rests with the person to whom the function is delegated. Accountability, as opposed to liability, means that the body delegating a function must provide oversight for how their functions are carried out and ensure that any issues are dealt with. Ultimately, the Secretary of State will continue to be accountable to Parliament for the health service in England, including any delegated powers. I am sure that Parliament will relish holding all Ministers to account.

Building on our ambition to support greater local partnership working, as set out in our 10-year plan, we have tabled Government new clause 20 to strengthen section 75 of the NHS Act 2006 by providing much greater scope for combined authorities, combined county authorities and the Greater London Authority to use these arrangements. Section 75 currently supports flexible voluntary partnership arrangements, including the pooling of budgets between NHS bodies and local authorities. These arrangements are a critical tool in supporting local collaboration and ensuring more joined-up working within systems.

The new clause looks to strengthen the section 75 guidance-making power. At present, that power only covers consultation and applications for consent on section 75 arrangements. The Government’s new clause will extend the guidance power so that it can cover all aspects of section 75, helping us to support the wider and more effective use of partnership arrangements. For those reasons, I commend new clause 20 and clause 39 to the Committee.

[The Chair]

I do not think that the Minister addressed new clause 26, so does she wish to do so now? [Interruption.] She need not worry about it, I am told.

--- Later in debate ---

[Gregory Stafford]

I want to touch briefly on clause 39, Government new clause 20, and new clause 26, tabled by the hon. Member for Oxford West and Abingdon in her role as Chair of the Health and Social Care Committee.

I recognise the intention behind clause 39. Greater collaboration between the NHS, local authorities and other public bodies has the potential to improve the co-ordination of services and deliver a more integrated approach to population health, which I think we all welcome. However, it sits slightly uncomfortably with other clauses we have debated that appear to draw local authorities and the NHS further apart. In this case, it looks like they may be brought together.

As the clause expands delegation and joint working powers, I would be interested to understand from the Minister where the oversight and safeguards for accountability for spending the joint budgets would sit. Would it be with the NHS, local authorities or somewhere else? We hope that everything goes well, but if services fail or financial problems emerge, the public deserve to know who precisely is accountable for those budgets. As I have said in debates on numerous other clauses, I continue to be concerned by the broad powers that the Bill gives to the Secretary of State. I have the same concerns about this clause.

On Government new clause 20, bringing health services and wider local government functions together is really important, particularly where combined authorities have responsibilities that affect the wider determinants of health. However, once again, I am concerned about the fact that the new clause further complicates an already crowded accountability landscape. As more functions are delivered through pooled budgets and joint arrangements, it becomes harder to identify who is responsible for outcomes, spending decisions and—hopefully not, but potentially—service failures. I welcome the flexibility, which I think has value, but it must be balanced with transparency and democratic accountability. I am not convinced that the new clause gets that right.

On new clause 26, as I have said before concerning amendments and new clauses that have come from the Health and Social Care Committee, it is often difficult to get entire agreement on these things because of the cross-party nature of the Committee. Therefore, new clauses and amendments that come out of the Committee are in some ways aspirational, rather than ones that hit the nail on the head.

The new clause suggests that the Secretary of State carry out a review of how effective section 75 arrangements are—the hon. Member for Winchester outlined evidence that in some cases, the use of section 75 arrangements has not always been effective—consult NHS bodies, local authorities and anyone else considered appropriate; consider whether existing powers should be used to improve those arrangements; publish a report and lay it before Parliament; explain whether the Government intend to use their powers to change regulations or guidance and why; and complete all that within 12 months of the Bill passing, which I think is a reasonable timeframe.

Section 75 arrangements already play an important role in bringing together health and social care. It is reasonable to ask, as the hon. Member for Winchester did, whether they are delivering the benefits in the most effective way possible. I would potentially say that this proposal does not go far enough. The new clause would require a review, a consultation and a report, but would not require any action to follow that. The Secretary of State need only “consider” whether existing powers should be exercised and explain the reasons for any decision. If the review identified significant weaknesses, there is no obligation in the new clause, as far as I understand it, to implement those changes.

I agree that the new clause is well-meaning. It has some good recommendations, and I hope the Minister takes on board its sentiment, but it probably does not have the teeth and the power to make it an effective part of the Bill.

[Karin Smyth]

I got a little confused at the end, but I think the Opposition generally accept the power in this clause. The hon. Member for Farnham and Bordon contended that this Bill and previous amendments to it will drive local authorities and the NHS further apart; just to have it on the record, I do not accept that that is true at all. Section 75 of the National Health Service Act 2006 and the work that we are doing on this further highlights the effect of some of the things that we are trying to do.

The hon. Member for Winchester raised new clause 26. I have sympathy for the intention behind the new clause. We all want health and care services to work closer together, as I have said repeatedly, and we agree that the partnership framework under section 75 of the National Health Service Act 2006 is a useful tool for doing so. While I understand the new clause, it is not necessary. The Department can review the section 75 framework without needing legislation, and indeed it has already done so. The Department carried out a review of section 75 in 2023, as has been said. Since then, we have continued to consider how these partnership arrangements can best support health and care integration.

The new clause would risk duplicating ongoing work. Furthermore, that work is not a one-off exercise but an ongoing process of learning and improvement across the country, and we want something that is responsive and flexible enough to respond to changes in health and care services and to the changing needs of people who use them. For that reason, I do not consider requiring a single statutory review to be the most effective approach.

Hon. Members raised important issues about clarity of accountability and responsibility. To reiterate, the legislation is clear: the legal responsibility or liability for a function being carried out properly rests with the receiving party; however, the delegating party is accountable for that function being carried out, and they must know how it is being carried out and make sure that any issues are addressed. The hon. Member for Sleaford and North Hykeham rightly alluded to one of the examples that we are exploring around section 75, which is how it might support key priorities in delivering neighbourhood health, to make absolutely clear and sure that we bring services closer together.

Both spokespeople outlined a quote from Melanie Williams of ADASS. Although I do not know the whole context of the quote, I understand the frustration of colleagues in social services and this whole area as it is one that I worked in myself. I understand the issue, but it is slightly different because it concerns the what, rather than the how, of what is being discussed. Section 75 is part of the how. We want to make this easier for people who are trying to do the right thing, and these provisions, which I commend to the Committee, do just that.

Question put and agreed to.

Clause 39 accordingly ordered to stand part of the Bill.

Clause 40

Consolidated accounts

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

[The Chair]

With this it will be convenient to discuss clauses 41 and 42 stand part.

--- Later in debate ---

[Karin Smyth]

We know that robust finances are an essential part of the health service. The financial accounts related to the NHS are of keen interest to His Majesty’s Treasury and indeed to Parliament. The Government are especially mindful of the keen interest of the Public Accounts Committee in this area. Under current arrangements, NHS England prepares a set of financial accounts for all NHS trusts and foundation trusts, and that is audited by the National Audit Office. That is the point at which the National Audit Office conducts its oversight of NHS providers, with that feeding into the National Audit Office’s assurance over the Department of Health and Social Care group.

The financial accounts for integrated care boards are currently included in the NHS England group accounts, which are presented separately and audited by the National Audit Office. With the abolition of NHS England, the Government intend to reduce central administration costs, so financial reporting needs to be proportionate while balancing stakeholders’ keen interest in financial information related specifically to the NHS. Clause 40 therefore replaces the current consolidated accounts of NHS providers with a single set of consolidated accounts for the NHS covering its trusts, foundation trusts and integrated care boards. That consolidated account will continue to be audited by the National Audit Office.

We believe that bringing the accounts together in this way will assist the public, Parliament and the National Audit Office in scrutinising NHS expenditure. Although it is not covered by the clause, it is important for the Committee to be aware that there will be no change to the current requirement for the Department to publish a Department of Health and Social Care group annual report and accounts that will consolidate the NHS accounts with the core Department and other group bodies—for example, its arm’s length bodies.

However, the Government recognise that only reporting figures for the NHS in the overall Department group would reduce transparency compared with the current structure of NHS financial accounts. The clause therefore seeks to prioritise high quality audited financial accounts information being made available while balancing against administrative costs, both of which are important to the Government.

Clause 41 amends the Secretary of State’s existing power to create a scheme allowing NHS bodies to pool funds to cover property losses and legal claims arising from their healthcare activities. They ensure that when liabilities arise, whether from damage to property, negligence or other claims, there is a clear and consistent mechanism through which those liabilities can be managed and resolved. In doing so, they protect the financial stability of the NHS. The clause updates the legislation for the new landscape by removing NHS England from the arrangements and ensuring that responsibility for administrating the schemes rests appropriately with the Secretary of State.

Although the clause is targeted and technical, its effect is essential in that it ensures continuity and legal clarity and continued effective operation of arrangements that underpin confidence and functionality across the health service. Clause 42 is a necessary technical and structural change that supports the new statutory framework following the abolition of NHS England. It removes provisions in the NHS Act 2006 and the Health and Care Act 2022 that relate specifically to NHS England’s funding and financial responsibilities, which will no longer be required once NHS England ceases to exist. The clause avoids duplication and confusion and ensures that financial accountability is clearly defined in the post NHS England system. Under the reformed framework, the Department is responsible for the overall funding of the NHS and for national financial assurance, while integrated care boards and providers continue to operate within defined statutory financial duties and controls.

Clause 42 plays an important housekeeping role, providing legal clarity and underpinning a more transparent and coherent financial framework that is fit for the NHS future operating model. I therefore commend the clause to the Committee.

[Dr Johnson]

Clause 40 prepares for the preparation of the annual accounts of NHS trusts and integrated care boards. Existing legislation in section 65Z4 of the NHS Act 2006, “Consolidated accounts for NHS trusts and NHS foundation trusts”, requires NHS England to prepare a set of accounts every financial year and consolidate the accounts of all the trusts and NHS foundation trusts. The Secretary of State can give directions about the content for methods and principles, and the accounts must be accompanied by reports or other information as directed by the Secretary of State. A copy may be sent by NHS England to the Secretary of State and the Comptroller and Auditor General. The latter must then examine and certify those accounts before sending a copy to the Secretary of State and NHS England, and NHS England must then lay a copy of the consolidated accounts and the Comptroller and Auditor General’s report before Parliament. That is how it works at the moment.

Clause 40 rewrites section 65Z4 and the duty to prepare the consolidated accounts every financial year moves to the Secretary of State, and the list of what gets consolidated now includes the ICB accounts. The power to give directions to NHS England about accounts is removed, which is fair enough because there would be no need for it, as the Secretary of State is now preparing them and NHS England will cease to exist. The requirement for the accounts to be accompanied by such reports or other information as the Secretary of State may direct has been removed. The accounts go straight to the Comptroller and Auditor General, who reports back only to the Secretary of State. At the end, the Secretary of State lays the accounts before Parliament. The changes are necessary owing to the abolition of NHS England.

I want to ask about the consolidation, including the ICB accounts, which was not there before, and what impact that will have. Will the accounts be sufficiently detailed so that it is possible to disaggregate that information if people are interested in doing so?

Clause 41 changes which NHS companies can be covered by the scheme that meets certain losses, legal claims and liabilities. Currently, section 71, “Schemes for meeting losses and liabilities etc of certain health service bodies”, of the NHS Act 2006 enables the Secretary of State to establish schemes to meet the losses of NHS England, ICBs, trusts, the National Institute for Health and Care Excellence, the CQC and several other bodies. The list of bodies includes

“(ha) a company formed under section 223 and wholly or partly owned by the Secretary of State or NHS England”.

In the new legislation, clause 41 rewrites paragraph (ha) so that it is

“a company formed under section 223 other than by an integrated care board by virtue of section 223A”.

That narrows the scope of the liability scheme by preventing ICB-created companies from automatically gaining protection, presumably to encourage ICBs to manage risk responsibly.

--- Later in debate ---

[Gregory Stafford]

I wish to carry on the point that my right hon. Friend the Member for Melton and Syston has just raised. He rightly says that there is a transparency element to this, so that the public and any other interested party can look at the individual accounts of an ICB or a trust. Going further than that on the technical elements, my understanding is that NHS England’s own guidance notes suggest that consolidation does not just bring accounting under one set of accounts, one umbrella or one document. Within that accounting, however, adjustments and eliminations of transactions between NHS bodies can happen. Therefore, the aggregated figures do not necessarily reflect the financial reality of individual organisations.

I understand why that might be entirely appropriate from an accounting point of view, but it can make it harder for external observers to understand exactly where the pressures are coming from, where they are concentrated and, in a world where we want accountability, who should be held responsible for addressing them. That is all I need to say on that point.

[Karin Smyth]

I am pleased that, in an outbreak of cross-party agreement at 3.20 pm on a Tuesday, I completely agree with the comments made by the hon. Member for Farnham and Bordon and the right hon. Member for Melton and Syston. It is a point that I made myself: the ability of Members of Parliament and the public to understand the granularity relating to their local providers and ICBs is very important for transparency and accountability. I hope Committee members recognise that I have tried to drive much more transparency in that system. They are absolutely right that that is separate from this clause, and we will continue to expect providers and ICBs to do that; I hope that addresses that point.

To add further clarity on the wider point the clause deals with, the consolidated accounts we prepare include some analysis by different types of body. That will mean separate information about NHS providers being included in the document, such as a summary of income and expenditure. Separately, providers and ICBs will continue to publish accounts so that people can look at those. The Government will listen to any feedback from users to adapt the nature of this content in future years after the initial publication, recognising that this is a new development following the abolition of NHS England. We are also mindful that too many separate publications add to administrative costs and risk losing focus. The intention is to have transparency at the local level, building that up to do something more sensible and cost-effective that is also transparent at national level. I commend the clauses to the Committee.

Question put and agreed to.

Clause 40 accordingly ordered to stand part of the Bill.

Clauses 41 and 42 accordingly ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Emma Foody.)

Health Bill (Sixth sitting)

Karin Smyth Excerpts

Committee stage
Thursday 25th June 2026 Public Bill Committees

[The Minister for Secondary Care (Karin Smyth)]

Clause 12 inserts new section 3B into the National Health Service Act 2006, re-establishing the responsibility of the Secretary of State to commission services. Although we intend ICBs to commission the vast majority of services, as we discussed this morning, we will use this regulation-making power to set out the small number of specialised services that the Secretary of State will be responsible for. That may include, for example, proton beam therapy, alongside a small number of other specialist services not currently suitable for ICB commissioning, such as gender dysphoria services and clinical genomics. By their nature, those are services to which national commissioning is appropriate because, for example, they have fewer patients or providers, greater or changeable costs, or they require specialist clinical expertise and input. Having a regulation-making power allows us to future-proof the system and update the regulations when new services or treatments emerge, or when services become cheaper or mainstream and therefore sit better with ICBs.

I now turn to amendment 57, which was tabled in the name of the hon. Member for Sleaford and North Hykeham. I recognise that any change to the way these services are commissioned matters enormously to the patients who depend on them. The hon. Lady used the word “worried”, and I understand that. Any change must be made with the greatest of care. However, the amendment would require the Secretary of State, before any regulations are made that alter the range of nationally commissioned services and regardless of the scale of the change, to publish a transition plan covering seven prescribed matters, to consult five prescribed categories of persons for a minimum of 12 weeks, to publish a response to that consultation and then to wait a minimum of 60 days before the regulations can be made.

As I have said, I understand and share the concern about continuity of care and the careful allocation of responsibility that lies behind it, but the proposals in amendment 57 are not the right way to address that concern. It proposes a fixed sequence of steps with minimum time periods that would apply to every change without exception. Taken together, the prescribed steps would add the better part of half a year to any change, including changes that are minor or technical, or that, for reasons of clinical safety, need to be expedited. That would create delays for patients and uncertainty for the wider system over where commissioning responsibility sits.

I would like to offer assurance on some of the concerns raised today. I commend my hon. Friend the Member for Blaydon and Consett, who has spoken to me regularly about her concerns, for the work that she does in this area. I also commend the Lib Dem spokesperson, the hon. Member for North Shropshire, for her work on spinal cord injuries. I have met the chair of the APPG on spinal cord injury to discuss this topic. I would like to thank Bristol Councillor Kelvin Blake, who has a spinal cord injury and who for many years has impressed on me the difficulties faced by people with spinal cord injuries who are wheelchair dependent. I commend the work of people with these conditions who, as the hon. Member for Sleaford and North Hykeham said, struggle through a system that they should not have to struggle through. We want to make sure that these changes are assured, and I commit to working with hon. Members to do that as the Bill goes through.

I can assure the Committee that any significant change to nationally commissioned services will be accompanied by proportionate and appropriate engagement with patients, clinicians and the bodies affected. Change will always proceed according to appropriate transition arrangements. Each service, as hon. Members know, has very different patient needs and commissioning requirements, and demands different skills to commission effectively. The framework the Government are proposing will enable the Department to manage these processes flexibly and proportionately.

The hon. Member for Sleaford and North Hykeham asked about arrangements for new organisations. In a changing organisation where people are coming forward for redundancy and in a new organisation that is taking shape, it is important that the executive looks at all redundancy requests and changing needs with regard for critical business infrastructure and the retention of skills. That is what we are currently doing.

The hon. Lady also asked about funding. The Bill allows the Secretary of State to set out which ICB pays for whom, and there are clear rules for people in prisons and those not registered with a GP currently under the guidance of court, which is called “Who Pays?” There are also long-standing processes for ICBs to pay each other as needed. The hon. Lady also asked about high security mental health services; I can assure her that we have no plans to ask the private sector to provide services. The power to direct has been updated to ensure that directions would bite on non-NHS providers if that changes in future.

Clause 13, which is part of this group, is a technical clause that permits the Secretary of State or an integrated care board to confer on a person discretion in relation to anything that is to be provided under the commissioning arrangement. In practice, this means that they could undertake some activities traditionally carried out by a commissioner, such as reviewing how services are provided for a population and designing the way that those services will be delivered within the parameters set by the commissioner. These activities would be clearly set out and measured under the contract, and the commissioner would retain overall responsibility for the delivery of their functions. Currently, integrated care boards are already permitted to do this, and with the transfer of NHS England’s commissioning powers to the Secretary of State, we propose a similar approach for services that are commissioned nationally.

I hope that I have been able to reassure the hon. Member for Sleaford and North Hykeham, and that she will withdraw her amendment. I commend clauses 12 and 13 to the Committee.

[Dr Johnson]

Unfortunately, the Minister’s reassurances have not convinced me. In relation to change, “significant” means various things to different people. As for “proportionate”, what is “proportionate” to one person is not necessarily “proportionate” to another.

Amendment 57 makes reasonable provision for a situation in which there is a change from national to local commissioning, or from local to—mostly, it is from national to local commissioning. Therefore, I would like to push it to a vote.

Question put, That the amendment be made.

--- Later in debate ---

[The Chair]

With this it will be convenient to discuss the following:

Clause stand part.

Government amendments 14 to 18.

Schedule 1.

New clause 2—Right to a GP appointment—

“(1) The Secretary of State must by regulations, within six months of the passing of this Act, establish a scheme to provide every patient with the right to a GP appointment within seven days of seeking one.

(2) The scheme should include a right contained in the NHS constitution for a patient to receive a GP appointment within seven days, or 24 hours if urgent.

(3) The Secretary of State may review the scheme every three years from the day on which this Act is passed and amend it through regulations made by statutory instrument.

(4) A statutory instrument under this section may not be made unless a draft has been laid before and approved by a resolution of each House of Parliament.”

This new clause requires the Secretary of State to introduce a scheme to ensure that patients have the right to see a GP within seven days.

Government new clause 21—Dispensing medical practitioners etc.

Government new clause 22—Inadequate provision of pharmaceutical services.

Government new clause 23—Pharmaceutical services: appeals etc.

New clause 30—General Ophthalmic Services: national framework, tariff and protected funding—

“(1) The Secretary of State must by regulations establish and maintain a national service specification for the primary ophthalmic services referred to in section 115 of the National Health Service Act 2006 (in this section referred to as general ophthalmic services, "GOS"), setting out the minimum standards of access and provision that integrated care boards are required to secure.

(2) Regulations under subsection (1) must establish and maintain a national tariff for GOS, setting out the prices at which GOS must be commissioned by integrated care boards.

(3) An integrated care board must commission GOS in accordance with the national service specification and national tariff established under subsections (1) and (2), and may not exercise any discretion to vary, restrict or reduce provision below the standards so specified.

(4) The Secretary of State must ensure that funding for GOS is allocated to integrated care boards as a ring-fenced, protected funding stream, which—

(a) may not be applied by an integrated care board to purposes other than GOS; and

(b) may not be reduced by an integrated care board in order to meet expenditure requirements in respect of other services.

(5) In determining any expenditure limits or resource allocations for integrated care boards under the National Health Service Act 2006, the Secretary of State must calculate and separately identify the GOS component of each board's allocation.

(6) The Secretary of State must lay before Parliament a report in each calendar year assessing the extent to which integrated care boards have complied with their obligations under this section.”

Government new schedule 1—Pharmaceutical services: appeals etc.

New clause 52—Access to dental provision: Dental deserts—

“(1) Within six months beginning on the day on which this Act is passed, the Secretary of State must establish a scheme to improve access to dental provision (“the Scheme”).

(2) The purpose of the scheme is to end dental deserts.

(3) A dental desert is defined as any local authority area with fewer than ten active dental practices per 100,000 people.

(4) The scheme must make provision to support integrated care boards to—

(a) guarantee emergency access to an NHS dentist,

(b) provide free dental checks up for—

(i) children,

(ii) mothers within one year of having given birth,

(iii) pregnant women, and

(iv) low-income households, and

(c) guarantee dental appointments for persons commencing—

(i) surgery,

(ii) chemotherapy, or

(iii) transplant procedures.

(5) The Secretary of State must, before publishing the scheme, issue a reformed dental contract.

(6) The Secretary of State must, within six months of the establishment of the scheme, publish a dental workforce plan to support delivery of the scheme.”

This new clause would establish a scheme to support integrated care boards to end dental deserts.

[Karin Smyth]

Primary care is the front door to the NHS and is critical to delivering our neighbourhood health agenda. The neighbourhood health service will bring care into local communities, ending fragmentation and preventing unnecessary hospital admissions. To support that, alongside clause 14, which I will discuss shortly, we have tabled new clauses 22 and 23 and new schedule 1, to strengthen action in the event of local pharmacy challenges and streamline the appeals process.

On new clause 22, many hon. Members will know how the closure of a local pharmacy can significantly affect a community. Pharmacies close for a range of reasons: voluntary closure, business failure or emergencies affecting the premises or surrounding area. Even where a pharmacy remains open, unforeseen or unexpected events can disrupt access for local people.

The NHS Act 2006 sets out how ICBs should commission pharmaceutical services in normal circumstances and what can be done if those arrangements fail. Section 133 of the Act is intended to deal with exceptional situations where standard commissioning processes are too slow and rapid action is needed to restore provision while long-term solutions are put in place, if required. However, the current wording of section 133 is widely interpreted as applying only to large-scale national emergencies, as it refers to inadequate provision affecting a significant number of people. It is unclear whether that would cover more localised situations, such as a village cut off by flooding following a bridge collapse, or where the only pharmacy serving an area closes unexpectedly, creating an urgent unmet need, as we have seen happen. It is also unclear how the Secretary of State would authorise alternative arrangements.

To address those issues, new clause 22 ensures that ICBs can respond swiftly to exceptional circumstances, regardless of scale. It removes the unnecessary provision for the Secretary of State to make arrangements himself and clarifies that authorisation to ICBs should be given through directions. The directions will be limited to six months, with the possibility to extend further if required. This change maintains appropriate national oversight while preventing misuse of the powers. It is a sensible and proportionate amendment that gives the system the flexibility it needs in exceptional circumstances while retaining proper safeguards.

New clause 23 and new schedule 1 simplify the appeal framework for NHS pharmaceutical services by allowing appeals that are currently split between different routes to be heard by a single appeal authority. At present, where concerns arise about a pharmacy contractor, different appeal routes may apply depending on whether a case is characterised as one of fitness or of performance. In practice, however, that distinction is not always clear and the current system can create unnecessary complexity and duplication.

New clause 23 and new schedule 1 address that problem, providing for such appeals to be heard through a single route, which we intend to designate in regulations as NHS Resolution. It is a practical and proportionate change; NHS Resolution already has substantial experience in handling disputes involving NHS pharmaceutical services and is well placed to provide a clear, consistent and independent route of appeal. Importantly, this measure does not change the position in relation to the fitness to practise of individual pharmacy professions. Cases concerning individual practitioners will continue to be dealt with separately by the General Pharmaceutical Council.

By simplifying the framework, this measure will help to ensure that related issues can be considered more coherently, reduce fragmentation in decision making and support the effective oversight of NHS pharmaceutical services. In short, it aligns the appeal system more closely with operational practice, reduces unnecessary complexity and preserves the appropriate safeguards for individual practitioners.

The remaining Government amendments are consequential on those changes, or are technical changes that have emerged as necessary following drafting of the wider Bill. I will speak to new clause 21 in particular, as it updates section 132 of the 2006 Act so that the legislation reflects current commissioning arrangements for pharmaceutical services. Section 132 currently allows, in addition to retail pharmacy business, arrangements to be made with individual doctors and dentists for the provision of pharmaceutical services.

That wording reflects an early model of care. In practice today, arrangements for primacy medical services are made with GP practices, not individual general practitioners, and patient lists are held at practice level. New clause 21 therefore brings the legislation into line with the way services are already commissioned and delivered. It will mean that, where such arrangements are made with dispensing doctors, they are made with GP practices rather than individual GPs. It also removes provision to make such arrangements with dentists, to reflect the fact that that provision is redundant.

In summary, new clause 21 is a technical amendment, which does not change current practice but simply updates the statute book to reflect modern NHS arrangements. Patients in rural areas eligible to receive medicines from the dispensing doctors will continue to receive that service as they do now.

[Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)]

I have received representations from rural dispensing practices in my constituency about the provision of vaccination services. I understand that dispensing general practitioners are having difficulty securing the funding to provide vaccinations, particularly the new meningitis vaccination for young people. Does the Minister envisage that the change being proposed will have any effect on that arrangement?

[Karin Smyth]

The changes here, as I have outlined, are bringing practices in line in terms of the regulation. I think the issue my hon. Friend really addresses is the arrangement between those local practices and the ICB as the commissioner on where the service is provided. Ordinarily a commissioner would seek to make sure that a rural area had provision from somewhere in particular; I am happy to talk to my hon. Friend outside the Committee if there is a problem in his local area.

--- Later in debate ---

[Edward Argar]

The hon. Gentleman makes his point in a typically reasonable way. Of course, he is right to talk about the need to shift, where we can, from acute settings to either community settings or, ideally, a preventive setting or focus. The Minister may well disagree with me, but I think that is a desire or thread that, however well implemented or otherwise, runs consistently through Governments. It ran through the Blair-Brown Government, the previous Liberal Democrat and Conservative coalition, the Conservative Government and into what the previous Secretary of State announced and what the Minister today is seeking to achieve. I do not think that anyone would disagree with that. We will always need those acute settings for particular treatments and cases, as well as for those very specialist pieces of work or for people with significant illnesses.

There has always been a desire to push the care into the local community. GPS are a central part of that, as are—to address the points raised by my hon. Friends earlier—our community pharmacists and other pharmacists. Pharmacies remain an improving but underused resource as part of that preventive picture. I do not disagree with the hon. Member for Winchester in that, but one can agree with the objective, but nonetheless gently push a little on the detail. As we know, the devil is in the detail, and people will want to see a deliverable plan.

That is one of the challenges that I have had in Melton Mowbray, where the ICB says it will do one thing and then says, “Actually, no, we can’t do that anymore.” Expectations go up and down and people are understandably frustrated. When we put such proposals forward we need to be robust in how we are going to achieve them and in their practicalities. The Minister may wish to make further observations.

[Karin Smyth]

I have enjoyed the “back to the good old days” of the Lib Dem-Tories. They tell us we live in fractured political parties, but I quite like the old days.

On new clause 2, I understand the intention that GP provision is important to us all and to our constituents. We have recruited over 2,000 more GPs since 2024—the highest number of qualified GPs since 2015—and there is provision to ringfence money for even more. We all know the importance of timely access to general practice, and patients need to be confident that they can get that care urgently and receive it promptly.

We are seeing improving signs. According to the ONS, the number of people who say it is now easy to contact their GP practice is up 14% since 2024, and that satisfaction is rising. Importantly, 69% of patients are seen within seven days and 44% are seen within the one day that they have requested an appointment, irrespective of urgency. That is the progress that we are encouraging, but we are not complacent; we recognise that there is more to do.

We also recognise that not everyone not seen within seven days is experiencing an unnecessary delay. Not every patient requires an appointment within seven days, and many people book appointments in advance for routine reviews, medication checks, to ensure that they see their preferred clinician or to fit around work and other life responsibilities. The new clause would cut across that flexibility by imposing a more rigid approach to appointment allocation, weakening both clinical judgment and patient preference. We do not believe that would be the best for patients or safe care. We must protect both clinical judgment and patient choice. We therefore cannot support the new clause.

We are clear that if someone is unwell and a doctor needs to see them urgently, they should be seen that same day. NHS England’s medium-term planning framework, which was published in October 2025, sets out an ambition for all clinically urgent appointments to be delivered on the same day, ensuring that patients assessed as needing urgent care are prioritised appropriately. We have made changes to regulations to require clinically urgent requests to be dealt with on the same day to support that ambition within the 2026-27 GP contract. We will publish data on that progress soon.

On new clause 52, we know that dentistry is broken and that we need to rebuild it. That includes ensuring an urgent care safety net across the country by reforming the dental contract and developing the 10-year workforce plan This new clause is unnecessary; we have delivered 1.8 million more dental treatments, and from April we began introducing a package of reforms to address some of the pressing issues that dentists and dental teams have been experiencing. Those reforms will prioritise those with the greatest need, shifting care away from clinically unnecessary check-ups. We are also including dental school places, and we will make more provision in our upcoming workforce plan.

The Government are committed to more fundamental contract reform by the end of this Parliament, which will include publicly consulting on future proposals. I make no apologies for taking the time to get that right. The issues are complex; this has not been done for a long time and there is no consensus on the perfect approach. On that basis, I commend clause 14 to the Committee.

Question put and agreed to.

Clause 14 accordingly ordered to stand part of the Bill.

Schedule 1

Conferral of primary care functions on integrated care boards etc

Amendments made: 14, in schedule 1, page 60, line 19, leave out sub-paragraph (2).

This is consequential on NC21.

Amendment 15, in schedule 1, page 60, line 26, leave out “(a), (b), (c) and”.

This is consequential on NC21.

Amendment 16, in schedule 1, page 60, line 36, leave out paragraph 46.

This is consequential on NC22.

Amendment 17, in schedule 1, page 65, line 5, leave out paragraph 65.

This is consequential on NS1.

Amendment 18, in schedule 1, page 75, line 1, at end insert—

“(4) In subsection (5), in the definition of ‘relevant area’, after paragraph (b) insert—

‘(ba) in relation to an integrated care board, in a case where a person has at any time provided or performed services by arrangement or contract with the board, means the prescribed area (at the prescribed time).’”—(Karin Smyth.)

This adds an amendment to section 259 of the NHS Act 2006 that is consequential on the transfer to integrated care boards of NHS England’s commissioning functions in respect of primary care.

Schedule 1, as amended, agreed to.

Ordered, That further consideration be now adjourned.—(Emma Foody.)

Health Bill (Seventh sitting)

Karin Smyth Excerpts

Committee stage
Thursday 25th June 2026 Public Bill Committees

[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.

[Helen Morgan]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 15 ordered to stand part of the Bill.

Clause 16

Regulations about commissioning by integrated care boards

--- Later in debate ---

[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.

[Dr Prinsley]

I am interested to hear what the Minister has to say, but does she agree that this is yet another reason why we must go full speed ahead to get the single patient record sorted out?

[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?

--- Later in debate ---

[Karin Smyth]

The hon. Lady outlines a particular case, and if she wants to raise that separately, I am happy to come back to her with a fuller answer. As she knows, and as the hon. Member for Farnham and Bordon also knows from his work with Getting It Right First Time, there are complications in some of this. I do not accept the hon. Lady’s point, but if there are particular or anecdotal examples of what she referred to, I am absolutely prepared to look at them.

Patients, with their GP, need to understand what is happening. That is a key part of our elective reform plan. If patients are on the list for a long time, they should be told why, and what alternative provision can be made for them. We are taking an active approach to supporting and empowering patients with information and knowledge, and being transparent about how we get down the shocking lists that the Conservatives left us, which stood at 4 million people before the pandemic.

--- Later in debate ---

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

[Karin Smyth]

We know that in some areas of Scotland and Wales that are near the border with England, the way that health services are planned and commissioned in England can have implications for the people who live in Scotland or Wales. That is why clause 17 inserts new section 14Z45E into the 2006 Act, to place a duty on integrated care boards, when exercising their commissioning functions, to

“have regard to the likely impact of those decisions on the provision of health services”

to persons in Scotland and Wales living near the English border.

I assure the Committee that the clause will operate solely in relation to the exercise of ICB commissioning functions in England. It will neither confer functions on ICBs in relation to the commissioning or provision of services outside England, nor affect the responsibilities of devolved Administrations for the organisation and delivery of health services in Wales and Scotland. I commend the clause to the Committee.

[Helen Morgan]

I want to draw the Minister’s attention to some of the difficulties relating to cross-border healthcare in a border area. I represent an area on a border. North Shropshire has a very wiggly, for want of a better word, border with Wales, which means that some English constituents are registered with a GP surgery in Wales but receive their secondary care in England. That causes significant difficulties for them because of the lack of joined-up communication between the two Administrations. I seek assurance from the Minister that as ICBs in England will have to pay regard to people who live near the border in Wales, conversations are going on with the commissioners in Wales to ensure that that process is as smooth as possible.

[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.

[Karin Smyth]

The clause transfers the requirement to conduct annual assessments of integrated care boards from NHS England to the Secretary of State and focuses the assessment on the statutory functions of the organisations. To do that, it removes a prescriptive list of duties to be assessed that was inserted by the Health and Care Act 2022.

ICBs are essential to delivering our health mission. They are responsible not only for arranging healthcare services, but for planning how those services will focus more on prevention, digital innovation and delivery in the community. It is therefore entirely appropriate that the Secretary of State should hold ICBs to account and undertake a meaningful assessment of their performance.

Currently, NHS England assesses the performance of ICBs annually, reviewing how well they have performed against a list of duties prescribed by the current legislation. The process for those assessments is set out in guidance each year and is driven by both publicly available performance data and local insight. The results are published online and form part of the ongoing performance conversation between NHS England and each ICB.

Although NHS England can choose to assess more than those statutory duties as part of that process, the duties form a static list of requirements that are already expected as part of the ICBs’ statutory functions. Having such a list may inadvertently skew attention away from other priorities in the 10-year health plan and our mission. As we reform the NHS, the ICB performance assessment will need to adapt to the evolving role of ICBs as strategic commissioners and reflect new models of commissioning. The list of duties will therefore become too prescriptive to provide the accountability intended. The clause allows a more nimble and flexible approach, ensuring meaningful assessment of ICB performance.

[Edward Argar]

The Minister has saved me from having to give a speech on this clause, so I will ask her a couple of questions instead. Does the Secretary of State intend to publish the list of criteria against which he will require assessment to take place, so that it is transparent what is being considered? Notwithstanding the Minister’s point about the 2022 legislation, the Secretary of State will define the list, so will he publish those criteria? Within what period following the end of the financial year will the Secretary of State commit that the results will be published?

[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.

--- Later in debate ---

[Edward Argar]

I take the hon. Gentleman’s point to a degree, but I would refute a chunk of it. We need within the organisation people who have those technical skills and know how to commission, draw up a specification, put it out to tender, or work out what is needed and ensure that what is delivered reflects what was commissioned and that the performance is what is sought to meet the needs of the local area. At board level, we need representation from local authorities and others, because it sets the strategic direction.

The board members are not the people who are going to sit there and write the commissioning document. They will probably approve it, but they are not the experts who will be drafting it. We are talking about two different functions, and I argue that when a board-level decision is being made, we want those voices in the room to ensure that those different perspectives are reflected and there is that critical challenge to what is proposed by the executive directors. We essentially have non-executive directors who are there to challenge, to question—perhaps to agree, but perhaps to push back on things. That is how many boards operate.

In what is proposed, we lose some powerful voices from round the table. They may not carry the day, but those voices should be heard. Having sat where the Minister is sitting now, I appreciate that she may not be willing or in a position to accept the amendments, but I hope that she will take away and reflect further on the challenges of representation.

[Karin Smyth]

I absolutely recognise that this is an area of huge interest to hon. Members across the piece. I assure colleagues that officials and I have been working with representatives of the Local Government Association and mayors throughout the development of the Bill and the future architecture, and we will continue to do so. We will continue to have discussions and to make sure we get this right, because it is complex and complicated. Given that we are all politicians, we understand. Many of us have been councillors and local representatives, and have spent a lot of our time—sadly, for officials—knocking on doors, going out and persuading individuals to vote for these people. We understand that it is quite personal and we want to get it right.

If I may, I will not take any interventions so that I can address the amendments and our approach to ICB membership. As my hon. Friend the Member for Bury St Edmunds and Stowmarket said, ICBs are commissioners. This is a fundamental shift, which I will come on to, and it is different from the 2022 work. I now want to outline the board membership set out in clause 21, but I think we will be discussing this for some time.

Lord Darzi’s review found inconsistency in the roles being undertaken by ICBs and concluded that the health and care system would work better if each organisation had greater clarity and focus on its particular role. That is our starting point, and we set out to do that in the 10-year health plan. In future, all ICBs will discharge their common statutory duties through best-practice approaches, getting better at allocating their budgets to meet the population’s needs and securing the best outcomes. The new focus for ICBs is strategic commissioning. All ICBs will, in future, operate at a minimum efficient scale, with a population of around 1.5 million people covering multiple partner local authorities.

Effective partnership working is core to strategic commissioning and is aided, rather than diminished, by replacing ambiguity in roles with clarity and focus. That is why we are altering the membership requirements for ICBs. We are adding a requirement for strategic authority mayors, or a nominated representative, to be appointed to ICBs operating within their footprint. Strategic authorities will increasingly become key bodies for growth and prosperity in their localities. Mayors, or their nominated representatives, will highlight opportunities to improve health outcomes through a joined-up approach to their other devolved responsibilities, such as transport, housing and employment.

Although we recognise that the coverage of mayors and strategic authorities varies across the country, we will provide guidance to ensure that no area is disadvantaged, regardless of how advanced its local devolution arrangements are. In all cases, ICBs will have an obligation to ensure that their boards have a suitable membership to discharge those functions properly.

Given the larger geographical footprint of ICBs in the future, we are also removing the requirement for ICBs to have at least one member jointly nominated by local authorities. At present, local authorities collaborate with ICBs by sitting on health and wellbeing boards and local integrated care partnerships. The multitude of plans, committees and measures have resulted in confusion, siloed working and, too often, inaction. I think many of us would recognise that in our own areas.

I emphasise that we want to ensure a strong voice for local government in the work of the NHS. Our preferred approach is for local authorities to work with the NHS through health and wellbeing boards, co-commissioning and local authority health scrutiny. Those are likely to be more fruitful forums in which to resolve issues, agree joint approaches and tackle the needs of a local area.

As ICBs become more focused on effective commissioning, it is right that we remove any potential conflicts of interest. That is why the 10-year health plan and the Bill propose removing the requirement for one member jointly nominated by primary medical care providers and one member jointly nominated by NHS trusts and foundation trusts. The clause will provide ICBs with memberships that are best equipped to fulfil their commissioning responsibilities and role in health planning.

On amendment 45, which was tabled by the hon. Member for Sleaford and North Hykeham, I assure her that the Government fully appreciate the importance of general practice and primary care more broadly, and the role that they play in informing ICB decisions. However, as I have said, health and wellbeing boards should be the key forum for resolving local issues and making planning decisions for their neighbourhoods. GPs are well placed to contribute to those discussions and also vital to them. We expect health and wellbeing boards to ensure that they involve relevant stakeholders, including GP practices and primary healthcare providers, in their work.

There is an opportunity for health and wellbeing boards to play a much more proactive and important role in the local economy. To respond to the point made by the hon. Member for Winchester, we absolutely recognise that place is important in those arrangements. Although I agree that the experience of primary care is important, I hope that I have reassured the Committee that having a member nominated by primary care on the board of an ICB is not necessary.

A similar argument applies to amendment 46, which would require a local government representative on the ICB. I should start by saying that I wholeheartedly recognise the important role that local authorities play in the health and care system. As we have discussed, their work in social care and public health, and their influence on the wider determinants of health such as housing and employment, mean that they have a fundamental role in supporting the delivery of our ambitions to improve the health and wellbeing of the population and implement the three shifts identified in our 10-year health plan.

Rather than one local authority attempting to represent the interests of many on an ICB board, however, we think that it is more effective for local government to use health and wellbeing boards to address local barriers to joint working and support the development of neighbourhood health plans, which will shape the commissioning plans of the ICBs. I assure the Committee that we expect ICBs to work effectively with every one of their partner local authorities in the local authority footprint to deliver the neighbourhood health service and progress the integration of health and care services at that level.

I should stress that our changes are not designed to weaken democratic accountability in the NHS. ICBs are NHS statutory bodies that are governed by a unitary board that is jointly responsible for ensuring that the ICB discharges its legal duties. Given that specific role, the ICB board is not the forum in which democratic leaders hold the NHS to account; rather, that is conducted through the local authority health scrutiny functions and Parliament. Again, this is a good opportunity for those health scrutiny functions to be much more robust and proactive at local authority level.

Amendment 46 also proposes retaining provider representatives on the ICB board. As I said earlier, we think that an ICB should have a core focus on commissioning, so it is right to remove the requirement to have providers on them. That will also support the avoidance of potential conflicts of interest.

We debated these issues many times—the right hon. Member for Melton and Syston referred to it—in this Committee Room, or one very similar to it that was not quite as hot, during the passage of the Bill that became the Health and Care Act 2022. These are difficult and complex issues. I mean no disrespect to him—he had a difficult job to do at the time—but the architecture has not worked. It is confusing, and I do not know any area that particularly thinks it has worked. We think that clarifying the roles will make the system much more effective.

I think we agree that adding requirements for strategic authority mayors to make nominations to their ICB boards is a good thing. It will be an effective tool to harness the benefits of joint planning between an ICB and strategic commissioners and strategic authorities, who will have increasingly significant roles in shaping their areas. I ask hon. Members not to press their amendments, and I commend clause 21 to the Committee.

Question put, That the amendment be made.

Health Bill (Fourth sitting)

Karin Smyth Excerpts

Committee stage
Tuesday 23rd June 2026 Public Bill Committees

[The Chair]

I remind the Committee that with this we are considering clauses 2 and 3 stand part.

[The Minister for Secondary Care (Karin Smyth)]

Casting my mind back to before the weekend, we had a wide-ranging debate on clauses 1 to 3 but, I think, substantial agreement about the central proposition to abolish NHS England. I pay tribute to my hon. Friend the Member for Lichfield, who succinctly put his finger on the key issue: it is fundamentally right that people and their elected representatives should be able to hold Ministers to account for the performance of the health service. It is also right that Ministers should have the tools to make the changes that are needed. The abolition is a necessary result of restoring that principle.

The debate raised a number of questions, a substantial number of which we will address during the course of the Committee as we reach the relevant clauses. However, I will pick up a couple now. I reassure the right hon. Member for Melton and Syston that the Government do take the impact of this process on staff seriously. We will treat people with the care, respect and fairness that they are owed through this process, now and in the months ahead. I am also committed to consulting recognised trade unions and I have a joint partnership forum to support ongoing engagement. More broadly, we recognise that change of this type is never easy, but we will need to go through the process quickly, which means, of necessity, proceeding in parallel with the legislation on the detailed internal design work for the new Department. That is in the interests of staff, patients and the public.

The hon. Member for Sleaford and North Hykeham raised the issue of whether the Bill was the cause of delays to the workforce plan. To be clear, it has not been, and we will publish that imminently. She also asked about the opportunity costs for other programmes, and I assure her that the Department, NHS England and Ministers are clear that we are here to deliver the 10-year health plan and other changes that make a difference to patients. We can, should and will do several things at once, and the Bill will help us with that by providing clarity of roles, greater freedom to local organisations and other positive changes.

To take just one example of the real impact, we are already saving on agency costs, and this is the first time in many years that the Department has not had to go back to the Treasury for a further injection of cash mid-year. That is getting a grip on the system. I add that the opportunity costs of not acting are very clear to the public, to staff and to patients in every single staff or patient survey that is issued. Those are the opportunity costs of not doing something; that is why we are acting. Clauses 1 to 3 are a necessary requirement for an NHS that is more effective for patients, delivers better outcomes across the country and achieves the initiatives that are expected of us.

[Edward Argar (Melton and Syston) (Con)]

This brings back memories of being in probably this same Committee Room a few years ago. I made this point during the previous sitting, but is the Minister able to commit that before the Bill leaves the Commons, a full and detailed statistical breakdown of the costs and benefits will be published, given their absence from the impact assessment?

[Karin Smyth]

I can tell the right hon. Member that we expect that NHS England coming into the Department will deliver up to about £1 billion in annual savings by the end of the Parliament, driven primarily by reductions in headcount, calculated using the average staff costs—about £77,000 per staff member in the Department and £94,000 per staff member in NHS England—including all pension and employer costs, which I think should help contribute to those numbers. As I think he knows, we will publish all accounts in the usual way.

I commend the three clauses to the Committee.

Question put and agreed to.

Clause 1 accordingly ordered to stand part of the Bill.

Clauses 2 and 3 ordered to stand part of the Bill.

Clause 4

Reducing inequalities

[Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab)]

I beg to move amendment 13, in clause 4, page 3, line 22, leave out lines 22 to 29 and insert—

“1C Health improvement and health inequalities duty

(1) In exercising any functions relating to the health service, Secretary of State must have regard to the need to—

(a) improve the health of persons in England,

(b) reduce inequalities between the people of England with respect to their ability to access health services, and

(c) reduce inequalities between the people of England with respect to the outcomes achieved for them by the provision of health services.

(2) Health inequalities ‘between the people of England’ means health inequalities between persons, or persons of different descriptions, living in, or in different parts of England.

(3) ‘Health inequalities’ means inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants.

(4) Under subsection (3) ‘general health determinants’ are—

(a) standards of housing, transport services or public safety;

(b) environmental factors, including air quality and access to green space and bodies of water;

(c) employment prospects, earning capacity, and any other matters that affect economic security;

(d) access to public services;

(e) the use, or level of use, of tobacco, alcohol or other substances, and any other matters of personal behaviour or lifestyle, that are or may be harmful to health;

(f) any other matters that are determinants of life expectancy or the state of health of persons generally, other than genetic or biological factors.”

This amendment would amend clause 1C of the National Health Service Act 2006 to introduce a duty on the Secretary of State to have regard to health improvement and health inequalities.

--- Later in debate ---

[Sureena Brackenridge (Wolverhampton North East) (Lab)]

On amendment 13, the shadow Minister asked why my hon. Friend the Member for Stoke-on-Trent South felt the need to table amendment 13. One can only assume it is because health inequalities have continued to widen for far too long. In a 20 or 30-minute drive across my Wolverhampton North East constituency, life expectancy drops by seven years. I accept that tackling health inequalities is not just about health; it is about a wider web of societal issues, including educational, employment and housing inequalities. That very long list is beyond the responsibility of the Secretary of State for Health and Social Care.

Amendment 13 will put the tackling of preventable ill health and health inequalities at the centre of national decision making by ensuring that the Secretary of State must consider not just NHS treatment but wider social and economic factors. Will the Minister assure the Committee that future Secretaries of State will not overlook the wider social and economic factors that drive ill health and unequal life expectancy, and that there will be a responsibility to work across Departments to tackle that wider and growing inequality?

[Karin Smyth]

I am grateful to all hon. Members who tabled amendments in this group, some of which have not been spoken to. I will address the central points that Members have rightly highlighted. I am grateful to the Chair and members of the Health and Social Care Committee for their report and recommendations for the Bill.

Before I turn to the detail of the amendments, I will set out what clause 4 does. As my hon. Friend the Member for Wolverhampton North East highlighted, the wider determinants of health inequalities are important. On the point that the hon. Member for Isle of Wight East made about the Labour party, they absolutely run through our DNA. Clause 4 restates and reaffirms our commitment to tackling health inequalities. It reformulates section 1C of the National Health Service Act 2006, aligning it with the duty imposed on NHS England by section 13G of that Act. It makes plain the need to achieve greater equality between the benefits that people receive and the provision of health services—for their ability to access those services and for the outcomes achieved. Importantly, “outcomes” includes the safety and effectiveness of health services and the quality of the experience undergone by patients. The clause will ensure that the Secretary of State must have regard to reducing inequalities in respect of all those benefits.

The wording of the revised duty more directly encapsulates the benefits that must be taken into consideration and obtained from the health service to support action that reduces or prevents inequalities. Fundamentally, the clause underpins our commitment to improving the health of the population and tackling the stark inequalities that blight the health of communities up and down the land, which have got worse over the past 14 years. That is central to this Government’s ambition, which is why we highlighted it in the 10-year health plan.

We also recognise that this is not a matter for the Department of Health and Social Care alone, which is why we are already working across Government to address the root causes of health inequalities and the barriers to accessing health and care services. We are ensuring that our action on health is embedded in policies that shape people’s daily lives, from the homes they live in to the air they breathe.

[Helen Morgan (North Shropshire) (LD)]

Before the general election, I was the Liberal Democrat housing spokesperson, and one thing that came up regularly was how important housing is, and not just for obvious physical conditions—mouldy houses can cause breathing issues. Temporary accommodation is devastating for the long-term health outcomes of the people who are placed in it. Does the Minister agree that working with MHCLG to improve housing—particularly social housing—is critical to achieving the Government’s objective?

[Karin Smyth]

The hon. Lady pre-empts my next comments. I absolutely agree with her, and so do the Government. That is why we are improving living conditions through the new decent homes standards, which set standards across all rented sectors. Awaab’s law requires social landlords to act promptly to fix housing hazards. Since coming into government, we have launched the warm homes plan, the Keep Britain Working review and the homelessness strategy. In April, we published a renewed women’s health strategy, marking a decisive shift to ensure that women and girls receive the care, respect and outcomes that they deserve. Last November, we published England’s first ever men’s health strategy, to improve the health and wellbeing of all men and boys. Within the Department, we are reviewing the Carr-Hill formula and the Advisory Committee on Resource Allocation to ensure the funding matches need.

However, there is much more to do. The Minister for Public Health and Prevention, my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson), will continue to engage with key stakeholders, including representatives of Health Equals. I have a meeting with representatives of that body this week.

I sympathise entirely with the motivation underpinning amendment 13, which was moved by my hon. Friend the Member for Bury St Edmunds and Stowmarket, and I commend hon. Members for working on this important agenda, but I am not convinced that the amendment is necessary. I note that it draws on the duty that was recently placed on combined authorities by the English Devolution and Community Empowerment Act 2026, with a view to creating a similar duty for central Government.

Fortunately, I can reassure hon. Members that the Secretary of State already has a duty to secure improvement in the health of people in England, and the power to take such steps to improve public health as they consider appropriate. We would not want to narrow the definition of the existing duty, because health inequalities come from many causes, as has been discussed. As I have said, we are already working across central Government and local government to address those wider inequalities, including in housing and air quality, and by getting more people into work.

The hon. Member for Sleaford and North Hykeham said that innovation might expand inequalities across our country, but we have seen a shocking expansion in the inequality gap across our country. That is what we are seeking to reverse, as we have made clear in our 10-year health plan, and the Bill will ensure that that happens. That is why we say that we will take the best to the rest; we are not about taking people down.

Finally, I turn to amendment 34 in the name of the hon. Member for Winchester. He has spoken before about his constituents’ experience, and I have spoken with him about the new hospital programme, his constituents’ reliance on transport to access hospital appointments, and the difficulties experienced in more rural areas, which the hon. Member for Isle of Wight East also mentioned. That is why, in our 10-year health plan, we are very clear about our strong commitment to rural and coastal communities—we are the first Government to do that.

We agree that reducing inequalities in hospital transport is important. The Bill already places a duty on the Secretary of State to

“have regard to the need to…reduce inequalities between the people of England with respect to their ability to access health services”.

Inequalities in access to transport to receive care fall under the scope of that duty. As such, the amendment is superfluous.

I also offer the reassurance that NHS England has been implementing a range of actions to reduce inequalities in patient transport, including the speeding up of reimbursement for patients eligible for the healthcare travel costs scheme. I also inform the Committee that the cancer plan included a commitment to provide up to £10 million a year to pay for the travel costs for cancer care for children and young people, and their families, as people have long campaigned for.

Some important issues have been raised in this debate, and I am sure that we will return to them. In the meantime, I ask my hon. Friend the Member for Bury St Edmunds and Stowmarket to withdraw the amendment. I commend clause 4 to the Committee.

[Peter Prinsley]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 4 ordered to stand part of the Bill.

Clause 5

Patient involvement and choice

--- Later in debate ---

[Gregory Stafford]

My hon. Friend is absolutely correct. I do not want to go down the cataracts route, but she and the hon. Member for Bury St Edmunds and Stowmarket have both mentioned them. Clearly, cataracts are a relatively low-complexity, high-volume type of operation. My hon. Friend is absolutely right to say that some providers can do five or six operations per list, while other places are doing two or three. That is often about the private sector being able to move more quickly, which is obviously better for patients, as well as for clinicians, who want to do the surgery that they have trained for.

Unlike the hon. Member for Bury St Edmunds and Stowmarket, I think that competition can play an important role in driving improvement. When providers must attract and retain patients, they have a stronger incentive to deliver timely, high-quality services, and to innovate in how they provide care. In that sense, competition is not an end in itself but a means of improving outcomes and responsiveness for patients. If both sides of the Committee support clause 5, because we are interested in choice and competition, amendment 59 is the logical extension of that.

The amendment is also clear about where the new obligation choices would apply. It covers a range of out-of-hospital services, including diagnostics, audiology, hearing-aid care, dietetics, physiotherapy, ambulatory cardiac monitoring and so on. By clearly defining the services in scope, it provides a realistic and workable road map for implementation.

As I said, the amendment is not about ideology—I think we all agree about choice and competition—but about ensuring that patients receive timely care and have a meaningful choice about where that care is delivered. By fostering healthy competition, making full use of the capacity in the system and putting patients at the centre of the decision-making process, it offers a practical route to improving access and raising standards of care. For those reasons, I support it and commend it to the Committee.

[Karin Smyth]

I am grateful to the hon. Member for Sleaford and North Hykeham for bringing this discussion before the Committee. We almost went down a cataract rabbit hole, but I think the points were well made. I will outline the Government’s general approach to choice and then move on to the amendment.

I recognise that hon. Members from both sides of the Committee are committed to protecting and upholding patient choice in our system, as are the Government. That is why clause 5 introduces new duties that require the Secretary of State to promote

“the involvement of patients, and their carers and representatives”

in decisions relating to the prevention or diagnosis of their illness, and their care or treatment. That applies when the Secretary of State is exercising health functions.

The clause also requires the Secretary of State to

“act with a view to enabling patients to make choices”

about the health services provided to them. The Government are committed to involving patients and carers in decisions about their care. We know that supports a better experience of care and, in many cases, better outcomes. Furthermore, if they want to be, patients should be active participants in decisions about their own care, rather than passive recipients of services.

I appreciate the sentiment of the amendment in the name of the hon. Member for Sleaford and North Hykeham, but I do not think it is necessary. It turns a general duty into one with more prescriptive detail, which risks adding complexity. Details on service types and operational details currently sit in secondary legislation, which allows them to be updated and amended as services evolve. I reassure the hon. Member that we will protect and maintain all the existing rights and duties set out in the choice regulations.

In any future consideration of expanding patient choice, which this amendment requests, I hope the hon. Member would agree that we would need to build up and test the evidence base to ensure that any changes were effective and meaningful for patients, before legislative changes were made. I am not sure what problem the hon. Member is trying to solve.

The Government are committed to protecting patients’ rights to choose. It is absolutely right that the duty to involve them in decisions will remain a central principle of the new health system and that patients are empowered to make informed, meaningful choices. I believe that the clause, unamended, does just that. For that reason, I ask the hon. Member to withdraw the amendment, and I commend the clause to the Committee.

Question put, That the amendment be made.

--- Later in debate ---

[Gregory Stafford]

My hon. Friend’s point is correct. There is so little detail in the clause about how these prizes will be awarded and how the committee that will award them will be set up that we have no idea how conflicts of interest will be dealt with. That is another reason that the Minister needs to explain to the Committee how this is going to work. My hon. Friend mentions “Dragons’ Den”. I see her as the Deborah Meaden of our Committee, so I look forward to seeing that play out—I will not say what that makes me.

What I see from amendment 58, tabled by my hon. Friend the Member for Sleaford and North Hykeham— I hope I am not misrepresenting her—is once again an attempt to codify, clarify and strengthen what is fairly woolly wording within the Bill. In particular, her amendment rightly emphasises the importance of

“timely adoption and spread of clinically effective innovations”.

Timeliness is so important to patients. We need innovation quickly. Again, it worries me that the prizes could be given for innovations that could have happened weeks, months, years or decades ago, according to the wording. We also need to ensure that innovation is not in isolated pockets, either in terms of geography or type of service. We need something that is consistently delivered across the healthcare system.

By highlighting the need to address things such as procurement, the regulatory sector and cultural barriers, my hon. Friend’s amendment would support a more proactive and enabling environment for innovation to flourish, not one that shuts it down, as some Labour Members have suggested. Crucially, paragraph (d) of the amendment represents a significant and commendable commitment to fairness and inclusion by prioritising equal access to new technologies, medicines and models of care regardless of geography or socioeconomic background. It would help to tackle long-standing inequalities and move decisively towards ending the postcode lottery that we often see in care quality.

The focus of the amendment would ensure that innovation benefits all patients, not just those in the most advantaged areas. It would ensure that rural and coastal communities are aligned with the urban. As someone who represents a semi-rural seat, I see those inequalities in service delivery, quality of care and innovation. The large towns in my constituency receive far more money and get far better services than the surrounding villages.

I have many concerns about the clause as it currently stands, and I hope that the Minister will be able to clarify some of the Opposition’s questions. I entirely endorse amendment 58.

[Karin Smyth]

I am grateful to hon. Members for bringing this discussion to the Committee. We heard about the excitement in our constituencies around innovation—my hon. Friend the Member for Blaydon and Consett mentioned Newcastle University at the start and the hon. Member for Sleaford and North Hykeham mentioned her visit to Imperial College. Those visits are inspiring. Other universities and centres of excellence are available, but they made the case for why this is so important to the Government’s approach to innovation. I will talk about that and then turn to the amendment.

The Government are fully committed to innovation. It is absolutely central to our ambitious priorities to digitise health and care, support prevention and early diagnosis, and enable a shift to neighbourhood care, to growth in our economy, and to regaining our place in the world as a centre for innovation, which was lost under the Conservatives over those 14 years. That is why clause 6 places a clear duty on the Secretary of State to promote innovation in the provision of health services, including in how services are arranged and delivered.

The clause also incorporates the Secretary of State’s existing power to incentivise innovation and research through the payment of prizes, as we have discussed. That is a flexible tool that will allow him to stimulate breakthrough ideas and reward innovation across the life cycle, including an early-stage report.

On some issues that have been raised, the Conservative party knows that Ministers have to act reasonably as this transfers from NHS England, and we would obviously want to tailor a committee to the matter in question, including membership. The clause will allow that flexibility. The equivalent duty was on NHS England; I understand that it has not actually been used over the past five years, but it was previously suggested as a way of promoting innovation.

In practical terms, the Secretary of State already supports innovation in a number of ways, for example through the work of the Health Innovation Network, supporting workforce developments in schemes such as the clinical entrepreneur programme and providing funding support for developing and evaluating promising innovations.

[Dr Johnson]

The Minister talked about the flexibility of the committee, and my hon. Friend the Member for Farnham and Bordon explained why it is helpful to have some direction. Could the Minister explain why there is no stipulation for the chief medical officer or the chief scientific officer to be part of the committee?

[Karin Smyth]

I am happy to come back to the hon. Lady if I am not correct in this, or if there is another reason, but in the existing duty and under NHS England, the committee’s membership needs to reflect the matter in the question. If there is anything to add to that, I will certainly come back to her. We are also committed to spending more on innovation, raising the NICE threshold to ensure that patients have access to more innovative medicines on the NHS. That is action, not just words.

The Government commend the intent behind the amendment tabled by the hon. Lady, and she spoke well about that. As a clinician, I recognise her support for innovation, but we recognise that barriers remain to the systematic spread of innovation. That is a long-term problem that existed under previous Governments as well, and we seek to rectify it. The ministerial foreword to the “Life Science Sector Plan” published last year says:

“We are clear-eyed about the challenges. For too long, the journey from discovery to delivery has been too slow, too fragmented, and too often held back by outdated systems.”

That is why we need to remove barriers at every stage of the journey; however, the amendment is the wrong way to do that.

The experience of supporting innovation in the NHS suggests that we need flexibility in our approach to tackle emerging barriers as they arise. Specifying several areas of focus in the Bill would limit that flexibility; those are better set out in published strategies and guidance, which is what we are doing. The amendment could also cause unintended consequences. It would create a one-size-fits-all approach, requiring all of England to have equivalent access to innovations. While tackling unwarranted variation is of course vital, we should continue our focus on providing access to innovation that best meets local needs.

Instead of over-defining what we mean by innovation in legislation, we are taking practical measures to drive it on the ground. We are already building the 10-year health plan and the life sciences sector plan to deliver an ambitious set of actions, which address the areas raised by the amendment including procurement, aligned regulation and the alignment of our NHS innovation policy with sector growth policy. That echoes our approach elsewhere in the Bill of devolving power to local levels and giving more opportunity to systems and organisations to innovate, and more agency to use their resources to do so.

The NHS has a strong record of developing and adopting new treatments, technologies and models of care. The clause will build on that record, signalling the Secretary of State’s clear commitment to promoting innovation, and it will do so in a flexible way that will allow us to respond to challenges as they emerge. For that reason, I ask the hon. Member for Sleaford and North Hykeham to withdraw her amendment, and I commend the clause the Committee.

Question put, That the amendment be made.

Health Bill (Fifth sitting)

Karin Smyth Excerpts

Committee stage
Tuesday 23rd June 2026 Public Bill Committees

[The Minister for Secondary Care (Karin Smyth)]

I thank hon. Members for bringing this discussion before the Committee. The Government are committed to ensuring that the NHS has the right people in the right place and with the right skills to care for patients when they need it. We will be publishing our 10-year workforce plan imminently. I cannot give the shadow Minister any more details on that at the moment, but it will set out the action to create a workforce that is ready to deliver the transformed service set out in the 10-year health plan. High-quality education and training for the NHS workforce will be fundamental to that, and clause 7 is in keeping with that commitment.

Before turning to the clause, I will address some of the issues raised during the debate and in the amendments. I understand the intention behind amendment 50, but I cannot accept it. The 10-year workforce plan will set out the staffing needs of the NHS for the next 10 years. That goes further than the amendment calls for and will be updated every two years in line with our manifesto commitment to publish regular, independent workforce planning. It is only because the Government have set such a clear direction for the service through the 10-year health plan that we can credibly set out a sustainable approach to staffing the NHS over the long term.

As hon. Members will understand, workforce planning is a complex topic. It is closely related to the wider service planning, which is why we have engaged so widely with independent experts to develop our forthcoming workforce plan. To divorce the process of workforce planning from service planning in the way that is suggested by amendment 50 would not produce a more reliable or useful set of forecasts. However, it would reduce the potential for innovation and reform of the kind that is needed and which the Government have set out so clearly in the 10-year plan for the NHS. I can only conclude from listening to Opposition Members that they really did learn absolutely nothing from their time in office or, indeed, from the problems with their workforce plan, which focused on headcount but notably did not reform care, did not look at new patterns of care, did not look at retention or training, and created some of the bottlenecks and problems that we have had to deal with.

Our commitment will be guided by the workforce plan, which is why we cannot accept new clause 44. Decisions on training numbers must be guided by workforce need, and that will have to be considered as part of the forthcoming plan. Adding to the point made by my hon. Friend the Member for Bury St Edmunds and Stowmarket, whatever the Government’s position on the number of medical school places that will be required in the future, fixing a number in primary legislation would be unhelpful as it would limit our ability to adjust target training numbers subsequently to reflect any changes in workforce need.

I was asked about correcting the record. The last Government did double places in their 2024 workforce plan, and I commend the movement of medical schools across the country. If the former Secretary of State is reported in Hansard as having said something contrary to the correction of the record by my hon. Friend the Minister for Care, we will of course pick that up.

Amendment 54 and new clause 45 look to reduce flexibility and increase bureaucracy for a workforce that is simply trying to deliver what is best for patients. On amendment 54, I think we can all agree that we need strong leadership and management to deliver national priorities, including the 10-year plan’s three shifts. Having a clinical voice in management positions is vital and many of our board-level and senior leaders are also clinicians. While some choose to carry on with clinical practice, others might prioritise their managerial role, and it is right that they should have that flexibility. Prescribing that all NHS managers with clinical experience must also undertake clinical care risks reducing board capacity and expertise, including clinical leadership, and disincentivising opportunities for management experience at a time when the NHS has seen a reduction in the number of managers per NHS staff from 2010 to 2025. We do not think that simply prescribing that requirement would benefit clinicians, managers or, crucially, the wider health service, so we oppose the amendment.

New clause 45 would require the collection of further data on the proportion of time spent on clinical care. Detailed statistics on the number of staff working for NHS provider trusts broken down by profession and pay band are already published by NHS England on a monthly basis. Adding requirements to that is not simple. There is not a centrally held collection of data about NHS staff time, and setting one up would have costs both centrally and for NHS trusts to collect specific data. It is also not easy to separate out clinical care meaningfully. Clinicians spend time in supervision, education, safeguarding, quality improvement and clinical leadership, and the amount of time they spend on different activities can vary from month to month. The new clause risks putting more burdens on NHS staff if they are being asked to record what they are spending time on beyond existing procedures. We therefore cannot accept it.

I turn to amendment 33, which was moved by my hon. Friend the Member for Bury St Edmunds and Stowmarket, on workforce training. It would require the Secretary of State to intervene in the content and design of healthcare programmes. Standards of proficiency, conduct and performance of registered professionals are the statutory responsibility of independent healthcare regulators, although universities and practice partners develop the specific content and design of programmes to meet those standards. It is vital that the independence of regulators and universities is maintained to respect their expertise in designing standards and curricula that ensure public safety.

We have published our 10-year health plan setting out major NHS reforms, including moving from sickness to prevention. Supporting healthcare workers to address the wider determinants of health will be essential to delivering that shift. That is why we are providing the “All Our Health” e-learning on critical public healthcare topics for people working in the health and care sector, and revitalising the “making every contact count” approach to ensure that every contact that a person has with the healthcare system supports a shift to prevention.

I assure colleagues that our upcoming 10-year workforce plan will set out plans for ensuring that we train the staff we need so that we have the brightest people and the right skills to support patients. For those reasons, I ask my hon. Friend to withdraw the amendment.

Finally, I turn to clause 7. The Secretary of State already has an overarching duty in relation to the education and training of the NHS workforce. Currently, that duty is partially delegated to NHS England. NHS England also has a duty to ensure that there are sufficient numbers of appropriately trained healthcare workers across England. Clause 7 will simply merge those existing duties into a single, robust education and training duty on the Secretary of State.

The Secretary of State will be entirely responsible and accountable for exercising relevant functions with a view to ensuring that there is an effective system for the planning and delivery of healthcare education and training, and that we have enough healthcare workers with the right training to meet England’s health service needs. Bringing those duties directly under the responsibility of the Secretary of State will reduce bureaucracy, streamline oversight and enable the Government to provide national strategic leadership across the NHS workforce.

I reassure colleagues that accountability will not be diluted. Bringing these responsibilities into the Department will create clearer, stronger lines of accountability with the education and training of the NHS workforce. Ultimately, the Secretary of State will continue to be accountable to Parliament for the health service in England, including for the planning of education and training and ensuring sufficient numbers of trained healthcare workers. I commend the clause to the Committee.

[Peter Prinsley]

I am happy with those assurances, so I beg to ask leave to withdraw amendment 33.

Amendment, by leave, withdrawn.

Amendment proposed: 50, in clause 7, page 4, line 32, at end insert—

“(4) After subsection (2) insert—

‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”—(Dr Caroline Johnson.)

This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.

Question put, That the amendment be made.

--- Later in debate ---

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

[Karin Smyth]

Clause 8 will give the Secretary of State the power to direct integrated care boards to exercise his or her functions. This power, similar to that currently employed by NHS England, will promote subsidiarity by enabling such functions to be delivered at the lowest appropriate level. The clause builds on the existing section 7B of the National Health Service Act 2006, which allows the Secretary of State to direct ICBs but only in respect of public health functions.

With our plans to abolish NHS England, the Secretary of State will again have broad powers and responsibility relating to the health service, and so this power encompasses a wider range of functions. Unlike the delegated frameworks set out under sections 65Z5 and 75 of the 2006 Act, which are entered into voluntarily, any integrated care board directed under this power would be obliged to carry out the stated functions.

I reassure the Committee that, while the ICB will be legally responsible for how it discharges a function, overall accountability will remain with the Secretary of State. Furthermore, the Secretary of State might also use directions to place restrictions on the onward delegation of any functions, preventing delegation where it may be inappropriate. Finally, any directions must be published, ensuring transparency and allowing proper accountability.

This measure will empower the Secretary of State to assign functions to ICBs where most appropriate. It aligns with and facilitates our broader direction of travel towards flexibly planned and delivered local services. I therefore commend the clause to the Committee.

[Dr Johnson]

Clause 8 is essentially about the control that the Secretary of State has over ICBs. When we discussed the clause abolishing NHS England, we talked a lot about the balance between democratic accountability on the one hand and independence from political interference on the other.

The Government suggest that the Bill is a decentralising Bill. What this clause does is essentially to recentralise by default. As the Minister has just said, the Secretary of State can change what the ICB is doing if they think that it is inappropriate. What does “inappropriate” mean exactly, and how will that power be used? It may be used very infrequently—perhaps the current and previous Secretaries of State think that the power would be used infrequently—but equally it could be used in response to considerable pressure from MPs, lobbyists and campaign groups. Instead of issuing directions sparingly, we may end up in a position where the Secretary of State is issuing day-to-day instructions.

The Government want ICBs to take greater responsibility for commissioning decisions, but then they want to be able to undermine them by direction from the Health Secretary. The Health Secretary will never have as good a grasp of the situation in the local geographic area as local leaders, but he has the power to tell them what to do and issue blanket instructions with different characteristics. That will be inherently inefficient. ICB leaders will be under pressure, knowing that if they make a particular decision they can be removed or be told to do something different. They have the job and they have the power, but they haven’t really—all at the same time.

There is also the plan, as the Minister outlined, to make directions something that the Government publish. The clause says that directions must be published by the Secretary of State, but only

“as soon as reasonably practicable”.

The intention behind requiring the prompt publication of directions is to reduce the surface area for back-room pressures, but the lack of a clear timeframe makes it rather a weak measure.

We currently have a Government who seem open to greater use of the private sector, whether in financing projects or in delivering out-patient care. Well, our Prime Minister resigned yesterday, and there is no guarantee that the Government of the right hon. Member for Makerfield (Andy Burnham) will take the same approach. Will the Minister confirm whether the powers in clause 8 could be used by a Health Secretary to instruct ICBs to stop using a specific type of provider?

I would not dispute the idea that the Secretary of State needs to be able to exercise some control over the health service now that NHS England is being abolished, but the clause seems contrary to the Government’s stated vision for health management. I am not sure whether it is in the best interests of patients.

[Gregory Stafford (Farnham and Bordon) (Con)]

It is a pleasure to serve under your chairmanship, Sir Roger. I agree heartily with the shadow Minister, and a couple of other things concern me about clause 8.

On the one hand, the clause appears to bring more centralisation, but on the other hand it pushes things down to an ICB level at the same time. I am worried that if we have individualisation of ICBs, we will only exacerbate the disparity of services across regions. I would be interested to understand from the Minister how the Secretary of State’s functions will allow the independence of ICBs and, where an ICB understands its local population well, ensure that patients do not end up in a postcode lottery based on which ICB area they happen to live in.

The danger here is that if the Bill does not deal with those problems and close regional gaps, it is not immediately clear from the clause how the Secretary of State could intervene to ensure that ICBs have the autonomy to make decisions based on their local populations and ensure at the same time that patients do not receive a worse service just because they happen to live in one ICB area rather than another.

[Karin Smyth]

I recognise that this is a subject of some debate; we may discuss it further when we come to the part of the Bill on ICBs. The abolition of NHS England and transferring all its functions to one body has a consequence, which is that the Secretary of State retains that accountability and power. We are keen to have that power clear but flexible in order to empower local systems. That remains the intent.

The power is necessary for the Secretary of State to update national commissioning standards, for example. The ICBs will have wider roles as strategic commissioners. We expect them to take on formal responsibility for a number of services delegated by NHS England. That allows us to issue a common set of commissioning standards, on the point made by the hon. Member for Farnham and Bordon about variability in different places. There need to be common standards across the piece: eligibility criteria, the treatments the provider should use, and national reporting requirements. ICBs having those standards means that there will be a reduction in unwarranted variation in some of these events.

The shadow Minister raised the timetable. The Opposition will recognise that there needs to be flexibility for the Secretary of State and Ministers to respond to unforeseen or changing events. That is why it is purposely broad, because the range of events that can impact the NHS is clearly very broad. We cannot predict the future.

The hon. Member for Farnham and Bordon said that the Bill needs to deal with all these problems. The Bill needs to give enough flexibility to the system and devolve as much power to the system. The Bill needs to make sure that the powers are in the right place, but it is for the local systems to respond to their local needs within that framework. They will be held accountable, for example through the NHS oversight framework and through ICBs’ normal accountability frameworks.

[Dr Johnson]

The Minister is talking about flexibility. I understand that if a Minister is responding to an unforeseen circumstance, he or she may be very busy, but where a direction has been made, it should not take very long for a member of staff to publish it, because it will already have been written and sent. I understand that a Minister might take a day or so to sign it off because they are so busy, but it should not take months. The addition of a deadline is therefore not an unreasonable request.

[Karin Smyth]

With due respect to the hon. Lady, it is not a matter of the Minister being busy, whether that is me or anybody else. It is about the operational running of a £200 billion organisation with 1.5 million staff treating millions of people every day. I am sure we all remember from our own experience incidents and unforeseen events that have happened in the local system, and sometimes very tragic events that have required the Secretary of State to take action. We are trying not to increase the number of reports and documentation and to rid the system of bureaucracy by putting something out in that timeline.

[Dr Johnson]

Will the Minister give way on that point?

[Karin Smyth]

No, I have finished.

Question put and agreed to.

Clause 8 accordingly ordered to stand part of the Bill.

Clause 9

Secretary of State’s power to provide assistance

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

[Karin Smyth]

Clause 9, which will insert new section 12DA into the National Health Service Act 2006, will give the Secretary of State a clear statutory duty to provide financial, staffing or other practical assistance in connection with the health service. The power may be used to support persons providing, or proposing to provide, services as part of the health service or which are beneficial to the interests of the health service. It may also be used to support public authorities where the assistance relates to education or training for people employed, or considering becoming employed, in activities connected with the provision of health services. The assistance may include financial assistance, the services of civil servants or other resources of the Secretary of State, and it may be provided on agreed terms, including terms about payments by or to the Secretary of State.

The clause will support the wider purpose of the Bill by enabling a small centre to act in a supportive and enabling way towards the wider system. Where appropriate, the Secretary of State will be able to provide assistance directly to those delivering or supporting health service activity. The clause is needed because the existing statutory framework does not include a clear power that enables the Secretary of State to provide practical support across the full range of health service activity. Relevant support may be financial, practical, staffing-related or connected with education and training.

Without this clear power, there is a genuine risk of confusion about the basis on which such support may be offered, particularly where the Secretary of State is acting to facilitate the delivery of services by others. The power is permissive and facilitative: it does not require the Secretary of State to provide assistance, and it does not require any person or body to accept it. The power is also limited by its connection to the health service and matters relevant to education, training or activities considered beneficial to the health service. Its exercise remains subject to ordinary public law principles and public financial controls. For those reasons, I commend the clause to the Committee.

[Dr Johnson]

In a system as large as the NHS, covering an area as diverse as England, it is necessary that the Government be able to deal with unexpected situations. The pandemic may be half a decade behind us already, but the Committee will remember that the previous Government had to act quickly and part with a lot of money in a short time. In such instances, it is essential that Ministers have the power to provide financial assistance. It is not only about crises, however; ordinarily, there are occasions when a Government will want to roll out a new prevention programme or address deficiencies in care in particular areas. I know that health policy is always evolving, and the case for flexibility is clear. The Health Secretary may need to be able to provide financial assistance in pursuit of supporting the health service.

I am sure that hon. Members are familiar with the existing legislation. Section 12D of the National Health Service Act 2006 gives the Secretary of State, NHS England, an ICB or the local authority the ability to make direct financial payments as an assistance to persons or bodies. Clause 9 would new section 12DA of the Act, under which the Secretary of State would be empowered to provide assistance to any person or body carrying out, or proposing to carry out, activities that they deem beneficial to the service.

This is where semantics are important. The existing legislation allows the Secretary of State to make payments, but clause 9 is different: it would allow the Secretary of State to provide financial assistance and to make available persons employed by the civil service or any other resources that the Secretary of State has. This is a remarkably open-ended power that would allow the Secretary of State to spend taxpayers’ money while bypassing standard scrutiny. When NHS England spends money, there is transparency: the public can see how much has been spent on different types of care, ranging from hospitals to public health programmes. The public can see how much money has gone into trusts, into the independent sector and into procurement.

Transparency builds trust in the system and disincentivises wasteful spending. Where will parliamentarians or the public be able to see the financial expense of civil servants, or literally any other resource that the Secretary of State may offer in support? For the first time, the Health Secretary will have the power to insert politically directed civil servants into elements of the health service that are not under public ownership.

As clause 9 is drafted, the Secretary of State could provide civil service labour to private or mutual health providers that work within the NHS. Will the Minister elaborate on how that would be used, and how it would be beneficial to the taxpayer and the health service? The number of civil servants taking home more than six figures has increased under this Government. Their time should be focused on delivering public services, not propping up providers, especially ones that are private businesses.

It is also unclear where the legal liability lies under such arrangements. If something goes wrong and the human resources provided by the Secretary of State are responsible, is the Secretary of State responsible or the entity into which those staff have been inserted? Can the Minister clarify that?

It may be politically beneficial in the short term to provide state support, but it can be costly to the public purse and damaging to markets in the long term. By allowing the Health Secretary to issue assistance in the form of free civil servant labour, clause 9 effectively creates a new type of off-the-books subsidy. How can Members of the House or NHS providers tell whether assistance is operational support or a de facto subsidy? It could undermine the idea of a level playing field for firms contracted to deliver NHS services.

There is also the question of when assistance crosses from operational support into running a provider or firm. We do not necessarily want to be in a position where the Bill is used to bail out failing private firms with NHS contracts. I return to the phrase

“any other resources of the Secretary of State”.

It is difficult to understand why the legislation was written in this way, allowing financial assistance, the provision of labour, and then the use of absolutely any other resource at the Health Secretary’s disposal. As with several other provisions in the Bill, it seems another sign that the legislation was rushed. Instead of circumscribing power tightly where it is needed, the Bill gives huge sweeping powers while claiming that it decentralises.

The Minister has described clause 9 as a discretionary power intended to support the effective functioning of the health service and its workforce. Although that may be what she sought to achieve, that is not the reality. The clause paves the way for arbitrary and unaccountable deployments of state resources, and that should concern all hon. Members.

--- Later in debate ---

There are also implications for existing funding and procurement frameworks. The health service operates through established mechanisms designed to promote fairness, competition and value for money. The broad power in this clause to provide direct financial assistance could cut across those arrangements by enabling selective support outside those structures. That may create inconsistencies between providers and reduce confidence in the integrity of any allocation process.

[Karin Smyth]

In concluding the debate on this part of the Bill, the Opposition have helpfully made most of my arguments for me. The hon. Member for Sleaford and North Hykeham opened with reference to the pandemic and the unusual circumstances in which we have found ourselves. It is obviously important that this Government learn the lessons from that pandemic in the round, that we are prepared and that, as NHS England is abolished, those powers come back to the Secretary of State so that we can respond to any eventuality that comes before us.

As the hon. Member for Farnham and Bordon said, there are existing standards and rules of procurement. Any spending that happens through the Department and the NHS will be publicly recorded and published in the Department of Health’s consolidated accounts. Those come before Parliament, so there is direct transparency through the parliamentary process in the usual way and, as we all know and as the hon. Member for Farnham and Bordon said, Treasury rules apply.

The point about the use of civil servants has been made. Again, it is really important that we recognise that we are bringing together NHS England, NHS staff and civil servants in the Department. It is right that the Secretary of State, in whatever eventuality comes before him or her, is able to deploy the right person for the right job, be they a civil servant or someone currently under NHS staff terms and conditions, to support that work going forward. The clause is necessarily flexible and broad to provide for those eventualities, and to enable the necessary assistance to be deployed. I commend clause 9 to the Committee.

Question put and agreed to.

Clause 9 ordered to stand part of the Bill.

Clause 10

Secretary of State’s duty as respects variation in provision of health services

[Dr Johnson]

I beg to move amendment 53, in clause 10, page 6, line 21, leave out from “interests” to end of line and insert “of patients”.

This amendment would only allow the Secretary of State to vary the balance between the public and private sectors in the NHS where it is in the interests of patients to do so.

--- Later in debate ---

[Helen Morgan]

The hon. Gentleman outlines an unintended consequence of the NHS contracting out to private providers. There are ways to get the pricing of those services right, but the clause could introduce that unintended consequence.

Why is this proposal included in the Bill, and what does the Minister see it being used for? Is there a risk that a future Government might use it to bring much more privatisation into the NHS? The general public consensus is that that would be a bad thing. What safeguards can she put in place to ensure that does not happen?

[Karin Smyth]

I will respond to that question before picking up the other comments. If I do not address all the Committee’s comments, I will come back to Members.

Everyone would expect this, but let me be clear: this Government are absolutely committed to a free-at-the-point-of-use, taxpayer-funded service. We also think that unless it is reformed and changed, it is an existential problem for the British public, who will not continue to support the service. As Members know, one Parliament can never bind another one, so I cannot predict what a future Government will do. There is talk from some of our Reform colleagues about an insurance-based system. There are people who were in the Conservative party but have moved over who think that, so obviously I cannot—

[Dr Johnson]

Will the Minister give way on that point?

[Karin Smyth]

I will make some points, and then I will be happy take the hon. Lady’s intervention if I do not address what she was going to say.

The hon. Member for North Shropshire outlined some of the history. This clause seeks to strike a balance. The governing principle behind it is that the decisions of the Secretary of State must not vary the proportion of providers by the type of legal entity that they are. Decisions must be taken according to what serves the health service and the people who depend on it. The clause permits, by way of exception, the balance between sectors to be varied purposefully, but only where doing so would be in the interests of the health service. That would, for example, prevent the Secretary of State from deliberately choosing to grow the proportion of NHS services delivered by private providers for solely ideological reasons.

I understand the concern that drives the amendment. It is that the exception might be relied on to support the convenience of those already providing the service, without taking into account what is best for patients, as the hon. Member for Sleaford and North Hykeham said. That is not the Government’s position, and the clause does not lead to that outcome. The test that it creates is whether the interests of the health services are served.

As the hon. Member for Sleaford and North Hykeham also said, the definition of the health service—as defined under section 1 of the National Health Service Act 2006—is not separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness. A decision to rely on the exception must be justified by reference to that duty; one taken merely because it was easier or more convenient for existing providers or any other group, with no such justification, would be unlawful. The protection that she seeks is, in substance, already secured by the clause.

The amendment would also create another difficulty. Section 1 of the 2006 Act reaches the entire population and includes the prevention of illness before anyone becomes a patient at all. The “interests of patients” reaches only those already receiving care, which is a narrower test than I think the hon. Lady intended, and would allow a Secretary of State who was so minded to provide a landscape that ignores vital preventive health and wellbeing concerns. I hope that she will take from my remarks an assurance that the clause already meets her concerns.

The hon. Lady also highlighted the example of PFI—a subject of much discussion over many years—and of being unable to change her whiteboard. That is absolutely one of the lessons that needs to be learned from the way in which some past PFIs were procured and dealt with. For example, as a new Government, we outlined proposals for a new model of public-private partnerships for neighbourhood health centres, among other things. The previous Government could also have learned the lessons and done something about that, but they chose instead to completely halt the building of any kind of facilities. That is one reason why we are in such a shocking state at the moment. The new proposal outlines, as I think the Opposition know, an 80:20 funding route, exactly to make the point about which is the most efficient way forward. That will absolutely drive measures for growth and create more jobs in the sector.

[Gregory Stafford]

I want to take the Minister back to her rejection of the amendment of my hon. Friend the Member for Sleaford and North Hykeham on the basis that—I paraphrase—she felt the definition of “patients” was too limiting because it would not count people who had not entered the health system at that point. The clause itself, however, refers to the benefit for the health service. Is the Minister suggesting that the health service, as defined in the Bill, includes what happens before people enter what I would describe as the health service? Is it something before that point? She seems to be saying that our definition is too narrow, but her definition in the Bill must apply to those who have entered some kind of formal setting. Or is the health service wider than that?

[Karin Smyth]

I refer the hon. Gentleman back to my comments. The health service is defined under section 1 of the NHS Act 2006 as not being separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness—so, yes.

At this juncture, I will explain a number of other features of the clause. In particular, I draw the Committee’s attention to the fact that it builds on section 12E of the 2006 Act to cover the Secretary of State’s health functions, powers and duties. It recognises that, with the abolition of NHS England, the Secretary of State has a far more substantial role to play—as a commissioner of services, for example—than previously. I also put on the record that whenever the Secretary of State takes a decision in this space, the general NHS procurement requirements and other statutory duties will continue to apply.

Finally, the NHS relies on privately owned providers, as well as charities and community organisations, to provide a range of important NHS-funded services across the country. As such, it is important to ensure that, where there is a mixed-market provision between public and private for providers of a particular service, the Government’s powers are not used to distort the provision and potentially discourage important investment from outside the NHS. Conversely, they should not be used purposefully to favour independent providers over NHS providers for reasons unrelated to the quality or efficiency of NHS-funded healthcare.

[Dr Johnson]

If I heard the Minister right, she said that the clause did not provide for changes on the basis of ideology. However, it says that changes are not to be made

“unless the Secretary of State considers that to do so is in the interests of the health service.”

A Secretary of State whose ideology is that the private sector is bad, good or whatever else could well believe that it is in the interests of the health service to be private or not private. How does the clause prevent an ideologically driven Secretary of State from changing the health service on the basis simply of his ideology, rather than of patient or clinical need?

[Karin Smyth]

The hon. Lady tempts me to delve into the politics of future Secretaries of State. They will respond according to the manifesto on which they are elected by the British public. That is the point of a democratically accountable public service. I think that the clause strikes that balance, as I have said. For those reasons, I hope that the hon. Lady will withdraw her amendment. I commend the clause to the Committee.

Question put, That the amendment be made.

--- Later in debate ---

[Gregory Stafford]

I rise to support amendment 47, tabled by my hon. Friend the Member for Sleaford and North Hykeham, and to ask a few questions about clause 11. I completely understand the thinking behind the clause. The Secretary of State for Health and Social Care is probably the most politically impotent of all Secretaries of State: as my hon. Friend said, they pull levers and not much seems to happen, because they do not have the control over the health service that the public think they do—or indeed, that Members of Parliament think they do, judging by the number of us who stand up and demand that the Secretary of State do things in our local areas.

I understand the Government and the Secretary of State’s desire to change some of that, but there is concern about the potential politicisation of NHS leadership. Integrated care boards were established in various forms under the Health and Social Care Act 2012 precisely to remove politicisation to ensure that decisions in our healthcare service were made for the benefit of patients on the basis of clinical evidence and the needs of the local population, not on the whim of any Secretary of State or Minister. More importantly, ICBs were brought in to make sure that local health systems, local authorities, clinicians and communities made decisions based on local need.

Those politically independent ICB chief executives were expected to exercise professional judgment, make difficult decisions about priorities and resources and sometimes deliver messages that Ministers, and indeed local Members of Parliament, found uncomfortable. If those leaders know that their continued employment ultimately depends on the confidence of the Secretary of State, there is a real risk that the independence of their judgment will be weakened and that patient safety will diminish.

The amendment tabled by my hon. Friend the Member for Sleaford and North Hykeham tackles a core question: should an ICB chief executive focus solely on what is best for patients and the local health economy, or should they have to consider whether their decisions may attract ministerial displeasure? Even if the power is rarely used, and even if, as my hon. Friend said, there are currently some guardrails in the clause, its existence will change behaviour—it must do. Leaders will become more cautious, perhaps more risk-averse and potentially less willing to challenge national policy when local evidence points in a different direction.

ICBs have benefited from the ability to speak truth to power. A system in which senior NHS leaders fear dismissal by Ministers risks discouraging precisely that kind of honesty. Do not get me wrong: there are good ICB chief executives and bad ICB chief executives, ones who understand their role well and ones who feel that they do not need to engage at all with their local communities. I have a very good ICB in what is currently Surrey Heartlands, soon to be a larger organisation, and an ICB that does not do the job as well—I will not name it, but any student of geography will be able to work out which one it is.

Secondly, excessive ministerial power blurs the lines of accountability. The Minister, in her defence, has argued that Ministers need powers because Ministers are accountable. I get that argument, but one of the most important principles of effective public administration is clarity of responsibility. If the Secretary of State gains extensive powers to appoint and dismiss local NHS leaders, it will become increasingly difficult to know who is actually responsible for outcomes. When performance improves, Ministers will claim credit; when performance deteriorates, local leaders may be blamed. If Ministers possess the power to select and remove those leaders, they will inevitably become more directly responsible for those management decisions, so far from increasing accountability, this might dilute it by creating uncertainty about where true authority lies.

Thirdly, there is a constitutional concern. Whether one likes it or not, the previous Act created a balance between democratic accountability and operational independence. Parliament rightly determines the funding, priorities and legislative frameworks, and Ministers rightly set national policy, but operational decisions have been made by healthcare professionals and the statutory bodies established for that purpose. That distinction exists for a good reason. No Secretary of State, regardless of ability or commitment, or indeed their own background in the health service, can personally manage every NHS organisation in England, and I do not think they should. The more powers we concentrate at the centre, the greater the temptation for Ministers to become involved in operational matters that are better addressed through professional expertise and local knowledge. My hon. Friend’s amendment seeks to preserve that distinction in a singular and precise way. It recognises that Ministers should govern the NHS and be held accountable at the top by us as Members of Parliament and our constituents, but should not seek to manage every aspect of it.

Fourthly, there is a practical problem. Supporters of ministerial intervention often point to examples of failure and ask what should happen when an ICB is underperforming. That is a fair question, but the answer is not that the Secretary of State must personally possess dismissal powers. A range of mechanisms already exist: ICB boards have governance responsibilities; NHS England has oversight powers; professional regulators oversee the conduct of clinicians; there are provisions in employment law for procedures when it comes to misconduct and capability issues; and auditors and inspectors can identify failings. It would be far better if the Bill strengthened those provisions to ensure that accountability was brought forward, rather than giving the Secretary of State the ability to fire and hire as he or she sees fit.

Of course, none of those mechanisms of accountability will disappear if amendment 47 is adopted. The amendment would not create any kind of immunity from accountability; it would simply ensure that accountability is exercised through the established governance structures, rather than through direct ministerial intervention on a chief executive. Indeed, one might ask whether a Secretary of State is really the best person to assess the performance of an individual ICB chief executive. Such judgments often require detailed understanding of local service pressures, workforce challenges, demographic factors, financial constraints and so on. Those are matters better evaluated by individual organisations with operational expertise than by politicians operating at national level.

Fifthly, I think the clause as drafted would present a risk to recruitment and retention. The NHS already faces significant leadership challenges. Senior leaders are expected to manage enormous budgets, oversee complex organisations and make difficult decisions under intense public scrutiny. If we create a system in which their tenure can ultimately depend upon ministerial whim, we may deter talented individuals from seeking those positions. As my hon. Friend said, the NHS needs leaders who are willing to innovate, take calculated risks and make difficult long-term decisions. It does not need a culture in which leaders are constantly looking over their shoulder, wondering whether a politically controversial but clinically necessary decision could threaten their position. Strong organisations attract strong leaders when governance arrangements are stable, predictable and professionally driven. They do not attract them through uncertainty and political intervention.

Sixthly, we need to consider the precedent being established. Powers granted to one Secretary of State are inherited by the next, as the hon. Member for North Shropshire said. Members may trust the intentions of the current Minister—I certainly do. They may also believe that these powers would be exercised responsibly—and at the moment I think they would be. However, legislation must be judged not on how it is going to be used by one individual, but on how it could be used by any future holder of the office. Therefore, the question is not whether the current Secretary of State or Minister would misuse the power, but whether Parliament wishes to establish a framework in which future Secretaries of State possess the ability to remove local NHS leaders whose decisions, views or priorities may conflict with their political objectives. That is a much more serious question.

Finally, we must remember what ICBs were trying to achieve, even if we do not think that they have achieved it or performed in the way that we wanted them to. If we go back to the principle of why they were set up, they were designed to encourage collaboration rather than some sort of command-and-control structure. They were intended to bring decision making closer to patients and communities. They were established to support long-term planning across local health systems. Those objectives, I am afraid, are very difficult to reconcile with a model in which local leaders remain subject to direct ministerial dismissal. Partnership working flourishes when organisations have confidence in their independence and responsibilities. It is weakened when authority is increasingly concentrated at the centre.

For all those reasons, I believe that amendment 47 in the name my hon. Friend the Member for Sleaford and North Hykeham raises an important principle. It is not about protecting poor performance or shielding individuals from accountability; it is about ensuring that accountability is exercised through proper governance structures rather than political control. Expanding ministerial powers to hire and fire local NHS leaders risks undermining all of those principles.

[Karin Smyth]

We have a clear political and—as I think the hon. Member for Sleaford and North Hykeham said—philosophical division here. This Government believe in democratic accountability, in politics and in good government. I understand that both Opposition parties were architects of the 2012 Act, which created this huge, independent body to run what has become a £200 billion service that clearly has not worked, and that they want to hold on to some of that, despite not opposing the Bill on Second Reading and, actually, not really opposing the abolition of NHS England—I think we will keep returning to that—but we believe that, ultimately, the Secretary of State needs to be accountable for the service, which is not working as the British public deserve or expect.

The hon. Lady asked me to go into good variation and bad variation. Our drive has been to understand the variation. I know from Members of Parliament who have come to me in the past two years, and we understand from looking in detail at the variation across the service, that there is often no rationale for the variation. Local people do not understand why services work better in one part of their county, even, than in another. The hon. Member for Farnham and Bordon alluded to that when he mentioned some places in his area that are working better than others. That is why—and I personally wanted to drive this very strongly—we are getting more information out, releasing the outcomes framework and releasing information to all Members of Parliament about where and how the current data shows their local systems are performing. That is what local people need, and in my view good local parliamentarians, of whom there are very many, should be able to go back to talk to their local systems and chief executives about why that is—not to berate them, but to understand it. There might be a very good cause for the variation; there might be structural reasons or geographical reasons, and they might be long-standing reasons. That is what we seek to do in order to regain the trust and confidence of the British public, and that is why we are publishing those documents.

I stand by my comments that my approach is more local than centralised. This is about changing the culture, which we seek to do by making that happen more locally. I absolutely get the points about operational freedom and the balance that we will seek when we release the operating model, which is being worked on in the Department, as we bring the new system into being, alongside the Bill.

However, we want to be very clear that when an ICB has failed or is at risk of failure, and that failure is significant, it is right that the Secretary of State has the tools to minimise the impact on patients and the public and to act swiftly to put things right. The public rightly expect that, in such circumstances, Ministers will take the necessary steps to protect patients, taxpayers and the public. In some cases of significant failure, that may include directing an ICB and removing the chief executive.

I am sure that all Members here today will agree that effective performance management of ICBs will continue to be essential once NHS England is abolished, not only to support the provision of a quality service, but to reassure the people served by ICBs that when things go wrong, they will be put right.

[Helen Morgan]

I could not agree more with the Minister that when there is an obvious failure, either in a local system or in a trust, we would hope that the Secretary of State will intervene. She will know from our experience in Shropshire that, when a system is failing or underperforming, that intervention is welcome. But the Bill gives the Secretary of State power to intervene even when things are going well, which is quite an extension of power. Will the Minister comment on that?

[Karin Smyth]

I thank the hon. Lady for that intervention, and I will come on to the power.

As hon. Members are aware, NHS England currently holds similar powers, so it makes sense for these powers to be held by the Secretary of State once NHS England is abolished. I want to be clear—I hope that this will address the hon. Lady’s point—that our intention is to use these significant failure powers rarely and not as a first port of call. It is far better to work closely with ICBs and their leaders to spot issues and work collaboratively to resolve them before they have the opportunity to become significant, but it would be irresponsible not to have the power to intervene as a last resort.

I want to address the other elements of clause 11. The first part of the clause establishes a general power for the Secretary of State to direct integrated care boards about the exercise of their functions. Using that power, the Secretary of State could direct a singular ICB, a group of ICBs or all ICBs, depending on the scope of the direction. This power is a necessary step in restoring democratic control over the NHS. The public rightly expect Ministers to be able to set priorities, drive improvements and set out how they expect the NHS to operate. For example, we expect to use the power to set up and update national commissioning standards.

The power is particularly relevant given the wider commissioning responsibilities ICBs will have in their role as strategic commissioners following the abolition of NHS England. By setting standards for all ICBs, the power will help reduce the unwarranted variation in the way that ICBs discharge their functions. It is also an important tool for enabling Ministers to respond to changing events. The lack of such a power has slowed the ability of NHS England to respond to unforeseen challenges within the health system.

I can also give the Committee an assurance that the clause includes a considered set of limits on the scope of the power. The Secretary of State will not be able to direct ICBs to appoint a particular individual, issue a direction about the services to be provided to an individual, or direct the use of a drug treatment or diagnostic technique where that is inconsistent with NICE guidance or recommendations. Equally, to maintain transparency in the health system, directions made under the general power to direct ICBs as to the exercise of their functions will be required to be made in writing and to be published as soon as reasonably practical. The power will enable the Secretary of State to uphold the standards that patients expect and deserve, while also protecting the principles of fairness and impartiality at the heart of the NHS.

We have already addressed much of the second part of the clause, but I should note that we have purposely placed the powers to intervene in cases of significant failure outside the general power of direction over ICBs. That is because it is important to be clear that those powers are expected to be used only rarely and in situations where an ICB is failing or at risk of failing.

I hope the hon. Member for Sleaford and North Hykeham feels able to withdraw her amendment. I commend the clause to the Committee.

Question put, That the amendment be made.

Health Bill (Third sitting)

Karin Smyth Excerpts

Committee stage
Thursday 18th June 2026 Public Bill Committees

[The Chair]

With this it will be convenient to consider clauses 2 and 3 stand part.

[The Minister for Secondary Care (Karin Smyth)]

Clause 1 formally abolishes NHS England as a statutory body, which is one of the key aims of the Bill. The current structure, with its two centres, has led to layers of unnecessary bureaucracy, duplication and unclear lines of accountability, and has come with significant cost, with the centre growing significantly in size since 2013. Through the Bill, we are simplifying the organisational landscape of the NHS and removing unnecessary complexity and overlapping roles among NHS England and the Department of Health and Social Care. The reform will enable leaders and staff to focus on delivering care, rather than on navigating bureaucratic hurdles. Importantly, it will also restore Ministers’ central role in national oversight and setting strategy, which the public rightly expect as part of a democratic system. The creation of an arm’s length body of this size was a mistake, and we seek to rectify it.

Clause 2 is integral to the orderly abolition of NHS England. It empowers the Secretary of State to establish transfer schemes, which will provide a structured and transparent means of moving property, rights and liabilities from NHS England to the Department of Health and Social Care, the integrated care boards and other relevant bodies. This robust legal mechanism is required to ensure a responsible transfer of NHS England’s assets and staff. It ensures that all necessary legal powers and permissions for the transfer are in place, preventing uncertainty or loose ends for staff, patients, service users and partner organisations as NHS England is abolished. The clause allows provisions to be made similar to those under TUPE to ensure the protection of employment rights for staff who are transferred from NHS England. In addition, the clause allows for the shared ownership or use of property, ensuring that assets can be distributed and used in a way that supports service continuity for patients and the broader health system.

Clause 3, at its core, provides a power for His Majesty’s Treasury to ensure through regulations that transfers from NHSE to the DHSC, ICBs and other bodies are delivered smoothly and on a tax-neutral basis. In particular, it allows HM Treasury to make adjustments to how existing tax legislation applies to transfers of NHS England’s property, staff and liabilities in a scheme made under clause 2. That will ensure that no tax charges arise, and that neither NHS England nor the transferee organisations end up with a different tax position due to the organisational changes. Importantly, the scope of the power is tightly constrained: it applies only to specified existing taxes and only for the purpose of ensuring tax neutrality in relation to transfers made under clause 2. Without the power, there would be a risk that transfers could trigger unintended tax liabilities that would divert public money away from frontline services and undermine the policy intent of the legislation. Clause 3 therefore protects value for money and ensures that organisational change does not come with avoidable fiscal costs.

Without the changes made by clauses 1 to 3 we will not be able to meet the ambitions set out in the 10-year health plan. The abolition of NHS England, delivered in an orderly, proportionate and considered way that safeguards the interests of staff and taxpayers, is a necessary precondition for an NHS that is more effective for patients, delivers better outcomes across the country and achieves the ambitions that the public expect of us. I therefore commend the clauses to the Committee.

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

It is a pleasure to serve under your chairmanship, Sir Jeremy. First, I declare a number of interests. I am a consultant paediatrician working in the NHS, a member of the British Medical Association and a member of the Royal College of Paediatrics and Child Health. Like the Minister for Secondary Care, I got into politics after working in the health service. I am sure she agrees that what you see when working in the health service stays with you when working in the House, and that it benefits the House to have people who have done all different jobs working here.

The NHS constitution says that health services should

“improve, prevent, diagnose and treat both physical and mental health problems with equal regard”,

yet in my work as a doctor—and I worked across several hospitals during my training—the gap between the vision of what should be delivered and the reality of what is being delivered has become apparent to me. The answer frequently given seems to be top-down reorganisation. As I will talk about in a minute, such top-down reorganisation has been done so many times but does not seem necessarily to have delivered in practice what it promised. Indeed, to an extent, we seem to be changing things from how they were to how they are to how they were, backwards and forwards. This Government have decided, in pursuit of better outcomes and cost savings, once again to reorganise the health service, and they seek to do so with this Bill and particularly clause 1.

Clause 1 formally abolishes NHS England. The clause may have very few words, but they represent one of the biggest changes to our health service in decades. Abolishing NHS England is not just a decision about organisational structure or trimming bureaucracy, but a break with the direction of travel the health service has been on since its inception.

Prior to the creation of the NHS in 1948, health services were fragmented: some people used contributory workplace schemes, people who could afford it paid out of pocket, and everyone else relied on very limited state and voluntary provision or went without. In the aftermath of the second world war, the national health service created a state monopoly provider. The Minister of Health had a duty to provide a comprehensive health service free for all at the point of use and a bureaucracy was created to manage it.

There was a tripartite split between hospital services, local authority services and independent practitioner services. The hospitals provided secondary care for those with serious disease and those requiring emergency response. The NHS also took over many cottage hospitals in rural areas that had previously been run by GPs, and larger hospitals that used to be run by local authorities and the voluntary sector. At that time, hospital staff were managed by hospital management committees appointed by regional hospital boards. Those boards implemented Government policies and oversaw the budget. Meanwhile, teaching hospitals kept more independence, directed by their own boards of governors.

Councils, operating as local health authorities, had a duty to provide several personal health services including health centres, maternity care, home nursing, immunisation and ambulance services—some of those are now provided by NHS England. They also had substantial powers to prevent illness and to care for the disabled. Independent practitioners—GPs, dentists, pharmacists and opticians— delivered services to local communities under contract from the health service. Now they deliver under contract from NHS England and the ICBs.

The health service underwent significant reorganisation in 1974, not long before I was born. The main objective at that time was to create a unified, integrated system. Community health services previously operated by councils moved into NHS control. These functions were put under the control of new area health authorities, which took control of most NHS hospitals. Some larger area health authorities had their own distinct management teams, which managed services on the ground—we can look at the current process and ask how it is similar and how it is different. The majority of teaching hospitals lost independent governance, in the way that we, too, are seeing that go back and forth. Above the new area health authorities sat regional health authorities, which were responsible for planning and allocating financial resources. Their members were appointed by the Secretary of State.

In the 1980s, Ministers recognised that the system had become very bureaucratic—perhaps similarly to today—and in 1982, area health authorities and district management committees were scrapped in favour of new district health authorities, with the aim of reducing what was in effect a three-layer structure to two layers. The thinking was that the new district health authorities would be closer to local populations, but primary care was left mostly unchanged. Once again, there are parallels with what is happening now.

From its inception to the end of the 1980s, the NHS had gone through several waves of rationalisation, but the model remained that of a centrally planned public service. However, during that time, there was an intellectual change—the concept of choice. Previously, people had been happy just to get a health service, which they had not had access to before, but that changed and people wanted choice. We now see the benefits of giving patients choice, and we will hear about how the Government’s changes through the Bill will apparently improve patient choice.

Of course, individuals have different values and preferences and live their lives in different ways, which makes it impossible for there to be a single public interest for the Government to pursue. Against that backdrop, the new public management approach to Government administration emerged, advocating for the introduction of market mechanisms and performance metrics—we have heard about the targets that NHS England follows—in public institutions. In theory, if elements of the state could operate more like the private sector, perhaps Ministers could achieve both cost savings and better outcomes.

In 1991 the Government introduced market logic into the health service. They created an internal market by splitting the purchasers—mainly, at that time, the district health authorities—from the providers, which were the hospitals. The Secretary of State gained the power to create NHS trusts—hospitals with the freedom to acquire, hold and dispose of assets; make bids for capital directly to the NHS management executive, in the way they might for NHS England; borrow money within limits; develop their own management structure; and employ their own staff with their own terms of employment. Within three years, almost all providers had become trusts. GP fundholding was established, enabling larger practices to receive budgets to buy secondary care on behalf of their patients, but that was short lived and was shelved in 1999.

When new Labour came to power in the late ’90s, one might have thought that things might swing back the other way, but in some respects the trajectory was similar. Initially, the Labour Government talked critically about the internal market. In 1998 the then Health Secretary told Members that the Government were

“sweeping away the internal market”—[Official Report, 1 July 1998; Vol. 315, c. 314.]

and the NHS plan published in 2000 claimed that

“the internal market introduced competition but failed to bring improvements.”

However, the policy choices of that Government furthered, rather than dismantled, the marketised aspects of the health service. They were saying one thing but, to some extent, doing another. There are similarities with this Bill: we have talked about decentralising power but, as we heard in evidence on Tuesday, many people feel it is more of a centralising Bill than a decentralising Bill.

It was clear that the new public management approach had been adopted across the political divide. The NHS plan promised patients more choice about how to access the NHS—a good thing. It promised a system of inspection, accountability and far greater local autonomy. It said:

“For the first time the NHS and the private sector will work more closely together not just to build new hospitals but to provide NHS patients with the operations they need.”

When GP fundholding went, the Government introduced primary care groups, which meant that GPs, nurses and other staff came together to commission for local populations. Those groups then evolved into primary care trusts, which by 2002 were responsible for spending 80% of the annual NHS budget—a budget that is now distributed by NHS England.

--- Later in debate ---

Ministers have chosen to ignore that warning, as though it were never made. When the Minister responds, can she explain what caused the Government to change their mind about reorganising the health service? They had access to the civil service before coming into Government, they said they had a plan, and they had Lord Darzi’s report, which did not favour reorganisation, so what made them want to reorganise the whole system?

[Karin Smyth]

This is an interesting point, and it is always helpful to have one’s comments put back to one. I am happy to come back to this again. I ask my question again: do the Opposition oppose the abolition of NHS England? I do not think the Opposition oppose the abolition; they think it is the right thing to do. I appreciate that that was confirmed on Second Reading. As I have said before, the previous Government had the opportunity to do this in 2022 and chose not to. The fact that it has not been opposed suggests that it is the right thing to do.

As for what we found on coming into Government, we thought that delivering on our manifesto through the existing powers, flow of funds and priorities would be possible. We were clear that we did not seek this as an initial outcome, but having got into that position, we immediately found, even while developing the 10-year plan and bringing together one team, that it was not possible. I am afraid that the line through which ministerial intentions could be delivered was convoluted, and obstructed by various measures throughout the system. That independence—

[The Chair]

Order. I am sorry to interrupt—

[Karin Smyth]

Sorry, I know that was not an intervention.

[The Chair]

Yes, that was the point I was about to make. I know the Minister is trying to help and answer the point that was raised. As she knows, she has another opportunity to speak at the end of the debate. If she wants to briefly summarise the point now and then come back to it in more detail, she is more than welcome.

[Karin Smyth]

I am happy to come back to it.

[The Chair]

Very well. I call Caroline Johnson.

Health Bill (First sitting)

Karin Smyth Excerpts

Tuesday 16th June 2026 Public Bill Committees

[Helen Morgan (North Shropshire) (LD)]

I am a vice-president of the Local Government Association.

[The Minister for Secondary Care (Karin Smyth)]

I am a member of the Managers in Partnership trade union, which is giving evidence this afternoon.

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

I am co-chair of the Unison group of MPs, which is linked to Managers in Partnership.

--- Later in debate ---

[Dr Johnson]

Q What about the risks of that—the conflict?

Dr Dash: I do not see a conflict. I think they are complementary and this is all about improving the regulatory landscape in the healthcare system.

[Karin Smyth]

Q As you outlined in your review, there are 150 organisations in this area. How do you see the new patient experience directorate in the Department working to give confidence in this area and to try to make sense of some of that and improve it?

Dr Dash: One of the things that I observed when I was doing the review, and that I have observed even more so now that I am in post, is that we do not have effective mechanisms of really learning from patients and patient experience. If I compare how the NHS works with how other large organisations in our country work, we are not systematically collecting patient information, we are not looking at that in detail, we are not segmenting it into different groups of people, and we are not systematically bringing it into board meetings, which is where it should be in order to drive improvement. We are hoping, or expecting, that the new director of patient experience will take a real leadership role in this and will improve the way in which the centre works but, more importantly, will be working with organisations right across the NHS to build those skills and capabilities, and to put patient experience feedback and improvement in patient experience right at the centre of every discussion on improvement.

[Helen Morgan]

Q Good morning, Dr Dash. Since hearing the evidence that was given to the Health and Social Care Committee, have you reflected on the concerns that the driver of confidence in HSSIB is its operational independence? What concerns do you have that it will lose that perception of independence and its safe space approach to learning when something goes wrong?

Dr Dash: The CQC is an independent regulatory body as well. The hope and expectation is that we have a high-calibre, independent regulatory body that is the prime regulatory body for looking at how well health and care services are delivered and, as well as observing how well they are currently performing, is able to carry out specific, focused investigations when it spots systematic problems across the healthcare system, or indeed when particular problems are identified.

In terms of safe space, clearly, confidentiality is important. Confidentiality is important right across the board; staff need to feel able to report within NHS organisations and to the CQC where they have concerns. I have to say that I was concerned in that Health Committee session to hear an example given by Jeremy Hunt, who said that if a midwife is concerned about quality of care in their maternity unit, they need to be able to go somewhere and report that, and to know that HSSIB would not tell anyone else about it. I looked at Duncan, our chief nursing officer, who was there with me, and we were shocked to hear that. How can that possibly be right? We need to have a mechanism whereby if there are concerns about quality of care, they are properly investigated, and mechanisms to deal with those problems and improve services. Yes, we need confidentiality, but I was not convinced by what I heard then—that we needed a completely separate organisation that was duplicating the work of others.

--- Later in debate ---

[Dr Johnson]

Q The Bill requires that Healthwatch be abolished, to an extent, and that local authorities do their own inpatient engagement instead, but they do not seem to be mandated to do so in quite the same way. Local authorities are under financial pressure. Do you believe that such engagement will happen at all, or to the same extent that it does now?

Jacob Lant: There are a few points on that. The narrative around the Bill is that Healthwatch is being abolished and its functions lifted and shifted across to local authorities and ICBs. That is not the case. We lose a number of important functions.

For example, the signposting support that Healthwatch provides will disappear so patients and care users will not have that to help them to understand how to navigate local services. I mentioned the unsolicited feedback that is gathered; that function will disappear. The outreach into communities, particularly marginalised communities, will disappear. The voice for patients and communities on health and wellbeing boards disappears, so there is no feed into those local decision-making bodies. There are several places where there is not a direct lift and shift across. That is a concern, and the Committee should probe it further.

On the resourcing point, at least local authorities will get part of the existing funding for Healthwatch to support their functions in that space. Under the Department’s impact assessment, ICBs will not get any funding from the current pot. That represents a 50% cut in the resourcing for listening to patients and communities, which is a concern.

[Karin Smyth]

Q Accepting what you have said about delays with staff—we absolutely recognise that—do you think that the abolition of NHS England is the right thing to do?

Sarah Woolnough: As an organisation, we have taken the view that we would not necessarily relitigate the decision. I think you can argue it both ways. I understand the desire to reduce duplication and to have clearer lines of accountability. Our concern has been the opportunity cost and everything that you are not doing at the time that you are spending so much energy and resource driving the abolition through.

Jacob Lant: I would echo everything Sarah says. From the work that we do, we see that decision making is taking longer, programmes are taking longer and it is taking longer to secure an impact on things. That is very frustrating, and underpinned by the massive change that is ongoing. Let us take as an example a programme exploring the experience of waiting for hospital care—of being stuck on waiting lists. Jim Mackey spoke about that at the NHS ConfedExpo last week. It is a major focus for the NHS and new guidance is expected by the end of the month. We have been waiting for that since 2021. The most recent effort towards it has been about 18 months. I can only think that drags on because we have so much other change going on in the system. I wish we focused more on doing things directly for patient care.

[Karin Smyth]

Q Sarah, I think you described the single patient record as “genuinely transformative”, and National Voices has also been really supportive of it. How critical do you think it is that we grasp that opportunity?

Sarah Woolnough: It is a major opportunity. If they feel they have trust in the system, patients are generally supportive of a single patient record or joined-up records—they often assume one already exists. Of course, we have a patchwork across the country, and certain places are further ahead than others. The idea of having more national co-ordination and more infrastructure to drive progress in that area could be, and hopefully will be, transformative. I know from my previous work just how frustrating it is for so many people to experience fragmented care and to have to tell their story endlessly.

We must be a little careful, because telling your medical history is often part of a good consultation, but the idea of care being more streamlined and patients and staff having better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. Previous attempts to drive progress in this area have so often fallen down. Ensuring the right balance of progress, and building trust and sufficient safeguards, will hopefully lead to the most progress.

Jacob Lant: I have been working in patient and public engagement and involvement for about 15 years, and the most consistent theme in that time has been the frustration about constantly having to retell your story, and the fact that notes and information are not available for the care that people need in different settings.

There is a golden opportunity with the Bill to get the single patient record right and meet a long-standing patient need for that join-up of information. We are very supportive of the single patient record, and the debate needs to move on from whether we need one to what the safeguards are and how we build public trust. I have two things to say on that. First, you cannot legislate for everything on this, but it is important to have a commitment to an ongoing public conversation around the risks and benefits of data sharing. The Department has done some really good work in this space, on its public deliberative on use of data—that should continue—but we understand that cannot all be put into the Bill.

However, we know that the safeguards and red lines that we already have could be put into the Bill. For example, using patient data or non-consented data for insurance and marketing purposes is a red line that has been clearly talked about in policy for many year—we will not use data for that purpose. Why can’t we put that in the Bill to help build public trust? It would really help to be clear on red lines and what will not be included.

[Karin Smyth]

Q Finally from me, you highlighted your 15 years in the patient voice landscape. We could discuss at length whether you think that is going well and whether the situation that we inherited was a good one. What needs to happen to give patients confidence that the new system will be better?

Jacob Lant: There are three things there. First, we need transparency about what is being heard by the system. Wherever we put patient voice functions, it is really important that what they hear from communities is clear and made available publicly, in terms of themes and demographics, so that we understand who is being heard and who is not. That is really important for the transparency of what is being heard and how it is being interpreted by the system. What has it understood from the feedback it has received, and does that resonate with what people are actually trying to say?

The second thing is accountability. Can people see those voices leading to change—not just commitments to change, but following through? It is about evaluating where policy changes implemented as a result of patient feedback have improved patient experience, and drawing that golden thread through for people so they can understand how their feedback is making a difference. That is missing from the system at the moment.

The last point is around equity. My big concern is that we might design a system that hears from more people, but whether it hears from the right people and there is equity of voice is a real concern. The resourcing and support need to be put in, particularly at a local level, so that they can engage communities who are marginalised and make sure we are hearing from the people who are basically getting the worst experiences and outcomes at the moment.

If we can deliver on those three things—transparency, accountability and equity—we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it has had available. It works out that less than 0.01% of the health and care spend is on Healthwatch, and that generates about 1.4 million interactions every year, either by gathering people’s experiences or by supporting them to navigate the health and care system. That is a really good return on investment, and it will be hard to find something more efficient. The challenge is in the system being more culturally open to listening and changing as a result of what people say, regardless of the way the evidence comes through.

[Helen Morgan]

Q Good morning. Sarah, the Bill transfers a lot of NHSE’s powers to the Secretary of State. Do you have any concerns about the additional powers conferred upon the Secretary of State? Does that go too far?

Sarah Woolnough: There are probably two concerns in a couple of different areas: appointments and the power of direction, which is very broad. We think it would be helpful to probe the detail and understand the intention a little more to see whether the legislation could do with amendment.

There is more general point. If the narrative is that this is a straight transfer, of course, you cannot legislate for culture and how those powers will be used. Our concern is that, while the narrative is about a straight transfer, empowering local systems and earned autonomy, the legislation pulls a lot of power back to the Secretary of State, and you cannot legislate for how a future Secretary of State may enact those powers.

--- Later in debate ---

[Dr Johnson]

The question is, how do you find it within the way it is structured?

[Karin Smyth]

Q Dr Dickson, can you describe how you think the single patient record could be transformative for patient care, given where we are?

Dr Dickson: Part of it has been touched on by the previous panel, regarding patient experience. Patients come in, they give the same story again and again to different healthcare professionals in different settings, and that frustrates them. Patients are human. I forget what I did last week; patients forget what they did last week, let alone what they did 10 or 20 years ago, although that is still relevant, increasingly. If you go on holiday to Whitby, fall over and break something, have tests done and come back to your house in central London, you cannot see information about that; you cannot share that information.

The opportunity to see everything on a patient across primary care, secondary care and social care is a huge benefit to them in terms of their view of seamless care, but also in terms of safety. I have a chronic health condition; part of my care is delivered by general practice and part by a hospital. At the start of the pandemic I was exceptionally clinically vulnerable; it took the NHS six weeks to tell me that. That is not safe.

[Helen Morgan]

Q Can I also ask about the single patient record? We have heard concern from GPs about their role in being the data controller and what that might mean when data is shared beyond their initial remit. What do you think is most desirable: for the GP to remain the data controller, or for that role to sit elsewhere?

Dr Dickson: I am not a general practitioner. The key thing for data control and data sharing is the trust that patients have in us to share and to hold their data in a way that is beneficial for them as individuals, and potentially sometimes beneficial for the population, but not to share it for what you might call retail use.

One issue with data control is that most general practices are small businesses with a small number of staff working flat out. That legal obligation of a data controller looms large for them, whereas it does not loom as large for large NHS organisations—although, technically, the impact is as hard. I do not mind who controls the data; what we need to do is to find a way to enable that data to be shared safely and with a belief that it is done for patient benefit. I do not think it matters whether GPs maintain data control, with something else happening to support them, or whether it is taken away from them; it is about how we enable that to happen. But I do think that general practice struggles more with resilience.

Kay Keane: I think that is true, in that we are generalists, not experts in a lot of areas. Certainly, we can be very good data controllers of our own data—the stuff that we produce, and that we write and code about our patients. We have to code things to be able to respond to our contract, so we have to be good at that. Things fall down when information comes from other providers, which we have no control of. That would be an area of real concern—that such information would be part of our property and our jurisdiction.

I guess it is about the detail of how that record will be structured. If it is a brand-new thing and we all feed into it, that is very different from all the data coming to the current healthcare record that we hold. I think the detail is not there yet to enable us to describe who should be the data controller, but certainly I do not think that any practice manager would want to control data generated by someone other than themselves.

--- Later in debate ---

[Dr Johnson]

Q Earlier in this session we heard concerns that you keep some information secret. You have the safe space legislation in place. Does that improve or weaken safety?

Dr Benneyworth: There is no doubt that it helps to improve safety. That is something we have learned from 100 years of the air accidents investigation branch, which has had an immense impact on aviation safety, the rail accident investigation branch, and many others. Safe space, or protected disclosures, means that people can talk freely to us about things that have gone wrong without fear of sanctions, being told off by their line manager or losing their jobs.

We hear all the time about people who have ended up losing their jobs or getting into trouble because they have raised concerns. We see in our investigations that we are still working in a culture of fear. In an ideal world, that would not be the case and people would feel able to speak up openly about what has gone wrong, but we are working in a culture where people are not in that place.

This enables staff working in the service and patients to talk to us freely about what they see on a daily basis that they think needs to change. Patients sometimes worry that they will be treated differently and not get the same care after they raise things. This enables patients to talk to us in the knowledge that they will not be named. The patients we work with who have been harmed from healthcare tell us, “We don’t want this happening to other families. We’ve been through this awful, terrible time, and we want to change the system.” This enables them to talk to us.

We do not name individuals in our reports and do not name organisations. We are now in a stage where we are growing that trust. We are coming up to being three years old as an organisation, and we are growing that trust with the system. When we launch an investigation, organisations right across the country say, “Please come and see what’s happening here. Please come and talk to us.” I worry that that might be impacted by the changes ahead.

[Karin Smyth]

Q What are the key things we need to get right to ensure that safety investigations in general and safe space in particular are made to happen in the new arrangements?

Dr Benneyworth: The two key things have been touched on already. The first is the independence to choose what we investigate and make recommendations to any part of the system. The second area is around protected disclosure. The legislation needs to be much clearer around the protection of protected disclosure materials, to give the system confidence in our ability to hold and not share confidential information.

At the moment, the legislation talks about connected individuals having access to the protected materials. The clauses outlining connected individuals mean that anyone working in the CQC could potentially have access to protected materials. That is a very large number of people, and it will create risk. There needs to be a legal duty on the CQC to protect the safe space. There is also something about maintaining an identity that gives people confidence that when they are talking to us, their information will not automatically go into the CQC regulatory functions.

Some of that may be about perception rather than the reality of what is happening, but as we know, perception is very important. People will perceive that we are part of the regulatory system even if we have the same email address, for example.

[Karin Smyth]

Q Those things obviously are manageable in another system, but people need that safe space to come forward. You rightly outlined reality and perception, and perception is often important for confidence.

You talked about the culture of fear, which I think we have recognised over time. We are all constituency MPs, so we recognise that. Can you say something about the opportunities for learning that could arise from working with the CQC, which is in that regulatory space?

Dr Benneyworth: We already work very closely with the CQC. In fact, we meet with them on a very regular basis. They share their learning and concerns with us already. Some of our investigations have come from the learning that they have seen on inspection, so we have a very good relationship with the CQC.

There are significant opportunities for the whole patient safety landscape. We are a tiny part of the patient safety landscape. We need to all work much more collaboratively right across the regulatory space—ourselves, the investigatory bodies and the wider system. The National Quality Board will have a significant role to play in that to share learning and identify key patient safety risks. That is already happening in our work with the CQC. This legislation will not significantly change that.

[Helen Morgan]

Q I re-declare that I am a member of the all-party parliamentary group on patient safety. We have heard this morning about a tension between needing to be able to report when something has gone wrong that HSSIB has become aware of to ensure that it is dealt with—the example given by Dr Dash earlier was a maternity failing—and the importance of a safe space, so that people can report to HSSIB when something has gone wrong and then HSSIB can make the appropriate recommendations to change the problem within the system that has led to that issue. Can you talk a bit more about that tension? What is the best way to manage that?

Dr Benneyworth: First, we do not replace local investigations. If something goes wrong, the local teams are very much responsible for investigating their work. Dr Dash talked about the new processes around PSIRF and the new investigation processes, which we fully support. In fact, our education team have had 40,000 people enrolled over the last three years, free of charge in the NHS, to support them in developing those investigation skills, really supporting that excellence in local investigation. We have a long way to go there, because they are variable in quality.

We do not replace that immediate, “There has been an incident and it needs investigation.” We know that, quite often, the things that need to change are not sitting within one provider. We know that the same things are happening in Cornwall and Cumbria and everywhere in between, and that they often need national solutions to change.

As a recent example, we published a report a few weeks ago looking at the care of people in mental health crisis in emergency departments. That showed that the legislation around the care of mental health patients is not supporting people in emergency departments to look after these people properly. That is not something that can be changed by a regulator. The CQC going to look at that emergency department will not impact that. It is not something that the individual provider can change, but we can make national recommendations about it to change the national system to enable people on the ground working in health and care to do their job properly. We can make sure that the systems and processes really consider how things work, and really change them so that providers and systems locally can do their job.

--- Later in debate ---

[Karin Smyth]

Q You have leant into my next question, Sir Jeremy. You are a former Chancellor of the Exchequer, so you understand some of these tensions. My question is about the number of recommendations and outstanding actions. As you said, honestly recognising that it happened during your time as well, this has all arisen over time. As a result, we are in the situation of having several independent bodies that are not required to take action, but the National Quality Board, which is outwith the legislation, is the place this could happen. Do you want to comment further on that?

Sir Jeremy Hunt: I would just like this to have teeth, because I think people are fed up, as I say, with Governments of all colours receiving recommendations and then nothing happening. I would like the Bill to place a legal obligation on the Government, for a certain category of recommendation, that within a period of time a proper decision will be made with a timescale. If the decision is no, because the money is not available, that is fine, and the Government should say so, but people would prefer to have a decision than for Governments to continually say, “We are reviewing this.” Frankly, I am worried that inertia in the system, and the fact that it is always easier for Ministers to kick things into the long grass rather than give a yes or a no, means that a vague commitment that the NQB will do this job will not be enough. If it is the NQB, I would like there to be a legal obligation that, within six months of recommendations being made by public inquiries, Select Committees and HSSIB, the Government will give a proper yes or no, with a timescale if it is yes.

[Karin Smyth]

Q To move on to the transfer of NHS England’s functions, in your time in office NHS England was a new independent body. What are your reflections on how we can use the transfer of those NHS England functions back into democratic oversight to improve impacts on patients, particularly patient safety?

Sir Jeremy Hunt: I set up NHS England, following the Lansley reforms, and it may surprise you that I have not opposed the Government’s decision to abolish it, for this reason. When it was set up, it did have a very valuable function, which is that it depoliticised a lot of very contentious issues. Typically, those were things such as the closure or downgrading of an A&E that was clinically advised as important, but very difficult politically, or, for example, which drugs are made available through the NHS and which are not. I felt that putting those decisions at arm’s length from Ministers was helpful. However, I think it became too big.

My real problem is that I think the NHS has become the world’s largest health bureaucracy, in which it is very hard to get anything done because 1.5 million people are accountable to one person. The way the DHSC does this, as you know just as well as me, is through the ruthless imposition of targets, so every hospital has 18 monthly operational targets. That makes it very difficult to have any kind of local innovation or local autonomy, because everyone is performance-managed with incredible strictness—their whole career depends on it—by these targets. I felt NHS England was beginning to embody that targets system, so when the former Heath Secretary said he was planning to scrap it, I said, “That’s absolutely fine, as long as this is a decentralising move, and you don’t simply transfer that ruthless central control from NHS England to DHSC.” I have to say I am concerned that that is, in fact, happening—or that we are just getting all those targets recreated by DHSC, rather than NHS England, as I think former Health Secretary Patricia Hewitt has also gone on record as saying.

[Helen Morgan]

Q I am a member of the all-party parliamentary group on patient safety, and one of the things we have heard is that the idea behind HSSIB and the air accidents investigation branch is, in the long run, to reduce the need for public inquiries to save money. Can you elaborate on that a little bit?

Sir Jeremy Hunt: Ideally, when something goes wrong, what you want is for there to be an investigation and for lessons to be learned, so that grieving families can say, “Well, at least we are confident that this wouldn’t happen again.” What happens in the health world is that families still think the only way they can get real change is through a public inquiry, so there is endless demand for more inquiries, rather than for things to actually change. If HSSIB was allowed to flourish, and there was confidence that its recommendations really would be acted on quickly, I think that would reduce the demand for public inquiries. They are very expensive, and the fact that they often take five, six or even seven years also means that there is enormous delay before anything changes.

Health Bill (Second sitting)

Karin Smyth Excerpts

Committee stage
Tuesday 16th June 2026 Public Bill Committees

[Dr Johnson]

Q Mr Blythe, what value does your council of governors add to your trust?

James Blythe: Councils of governors across the NHS have added significant value since they were instituted and brought into foundation trusts. The foundation trust councils of governors play two roles. The first relates to the appointment and holding to account of the non-executive directors on the board. The second relates to securing public and patient involvement and voice in the organisation and the management of our services.

Since councils of governors were instituted, we have developed increasingly sophisticated ways of getting public and patient voice into services. If you look at innovations such as maternity and neonatal voices partnerships, which really involve service users in how services are developed on the ground and are very close to the teams that are running them, that gives us different ways of involving patients and the public in services where possibly councils of governors have not been able to do in the past. Councils of governors have played a really important role in foundation trusts, but certainly in terms of that patient and public voice function, we have moved on as a system and developed more sophisticated ways of doing that.

[The Minister for Secondary Care (Karin Smyth)]

Q To pick up on Sir Ciarán’s comments about experiences being extremely rare, the changes in the Bill sit alongside changes to the national centre and clarity for ICBs, with very little change to providers. What would make the biggest difference to providers and commissioners to improve things?

Sir Ciarán Devane: The biggest difference should be that the local providers and ICBs are incentivised to get together to make collective commissioning decisions. That means that, whether you call it a neighbourhood, footprint or local authority area, they make those decisions based on population evidence, which is why the single patient record is important, and they have the autonomy to do that with a lighter-touch centre that is set in guidance saying, “Look, this is broadly what we’d like you to do.” That guidance should be developed in conjunction with the people who have to do the job on the ground. That is what it should be; if the Bill allows that, that is fantastic.

The second bit is that the mechanism—it is not necessarily a legislative thing—by which the NHS is managed day-to-day will still need to exist. Who is going to be keeping an eye on things 24/7, 365 days a year? What happens if there is a fire—maybe even a literal fire—in a hospital? How is the NHS going to be corralled and brought in to help out a trust where something like that happens? That management function—the day-to-day operational management—needs to remain strong enough in the target operating model, as it is called, in the Department. If it is not, that could prove very difficult. Not necessarily day to day or in the short term, but in the long term, that bit has to be got right. One of the big risks of the legislation—there is not a legislative solution to this risk—is how day-to-day management works. We all have views on the relative strengths of the regions, of NHS England and so on, but how is that going to work in the new world? If one loses “grip”—that word is used a lot—then the risk to service delivery is quite high, and the risk to financial control is even higher.

James Blythe: Put simply, as an NHS organisational leader I think there are always a lot of things from which you can take your guidance on what you should be prioritising and focusing on as an organisation. If the result of this legislation is that we as organisational leaders have a really tightly defined set of priorities to deliver, articulated as far as possible as outcomes for local people and our population as a whole in terms of waiting times, quality and improving population health, I think that will allow us locally to get on with the partnerships that we already have as a day-to-day part of running local public services. We can focus on that very small set of things and do them really well.

Over the last year, there has been a sense of increasing clarity about those priorities as NHS England and the Department of Health and Social Care have worked more closely together. The NHS has delivered on those priorities to a large degree, but it all comes down, as my colleague says, to how senior officials and Ministers operate the system, because there is to be significantly more freedom to set priorities, and to design and run the system that essentially delivers them for the NHS. How that is done, retaining clarity about the things that we want to have delivered through the system and empowering local systems to do them will be really important.

[Karin Smyth]

Q Sir Ciarán, may I clarify a point with you? I think you are not objecting to the abolition of NHS England—yes or no?

Sir Ciarán Devane: No, we are not.

[Karin Smyth]

Q Because you also said that the risk of not having financial control is high. I would say that, over the last few years, financial control has been a massive problem, and we have put in much better financial control. I think that your concern is with the future rather than the legislation.

Sir Ciarán Devane: Yes, completely.

[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.

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[The Chair]

Thank you. Those opening comments were extremely helpful, but I now ask for brevity in your answers, as several Members wish to put questions to you.

[Karin Smyth]

Q As we have heard, despite 52 years of independent patient voice, 20,000 reports and many hundreds of recommendations, we have some of our worst ever patient satisfaction. We are also now more than 10 years on from the Francis report, but recommendations are not being followed through locally or nationally. It is pretty clear that the landscape does not work. Like many other Committee members, I represent communities that are not in that space and need to be represented in new way. What are the barriers to that? How can the single patient record, and the information we can create in different ways, help to reverse what is a shocking landscape for patient experience and patient voice?

Professor Croisdale-Appleby: Sorry, I had some difficulty in hearing the question, but I hope I heard it correctly. Was it about the patient record?

[Karin Smyth]

Yes.

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

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

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

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

[Helen Morgan]

Q Sarah, 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?

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[Dr Johnson]

So you are losing a protection with the Bill.

Sally Burlington: Exactly.

[Karin Smyth]

Q Councillor Wright, the Bill will essentially abolish NHS England. Do you have any comments about how that works at the moment in terms of local government? How can we unlock some of the potential in the Bill, with the changes to NHS England, with regard to local government, particularly on health and wellbeing boards and the entire place agenda?

Councillor Wright: The main problem the abolition of NHS England has caused is upheaval and uncertainty with our health partners. Many of the health partners at our health and wellbeing board meetings or our place committee meetings are almost saying to us, “I don’t know if I will be here at the next meeting.” Such turmoil in the changeover creates instability from a lack of being able to plan what will happen next. That is one of the challenges that we feel. We are working with our health partners and getting assurances that there will be continuity, but it is quite hard when the person we are working with is changing.

We are really excited about neighbourhood health sitting under health and wellbeing boards. We love the idea of neighbourhood health looking at the wider determinants of health and having a very localised health response to the issues that that community needs to help it. One of our anxieties is that a lot of ICBs have become bigger and have less connection with the place. They are also shrinking; I think NHS England is losing 30%—

Maria Higson: Larger geography, fewer people!

Councillor Wright: Exactly. We have had a letter from our ICB giving us the heads-up that they might not be able to guarantee that they can send the right person to our health and wellbeing committees, which will obviously make it difficult to plan neighbourhood health.

The other challenge we find in neighbourhood health is that local authority boundaries might not necessarily match neighbourhood boundaries. I will give an example from Bracknell, where I live. Bracknell is very clearly a neighbourhood, but the south of the borough, which is within the Bracknell Forest council area, probably sits within Bracknell and Wokingham and a little bit within Reading. It will be hard to bring in true neighbourhoods with the current structure, but that is something we are working around, and we are hopeful that we will be able to sort it out.

[Karin Smyth]

Q May I come to you, Sally, particularly on social care and the opportunities that might arise from it?

Sally Burlington: Health and wellbeing boards will probably become even more important following the removal of local government representation from the ICB. It will be the only place we have NHS and local government partners with the specific statutory responsibility to work together on social care. As others have noted, they are at place level and will therefore be crucial for connecting with the neighbourhood.

The other factor that is helpful to note is that there is a huge amount of pressure on systems at the moment, and the cuts to ICBs are having a profound effect on the relationships they have with local government partners. We are hearing from our members that continuing healthcare is a real point of concern, with reviews leading to the withdrawal of that care, placing challenges on local authorities. In that context, making sure that we are supporting health and wellbeing boards to be as effective as possible for neighbourhood health, and in that strategic joining-up role, becomes even more important.

[Karin Smyth]

Q Can you say a little more about what those opportunities might be, particularly for social care, with better focus on health and wellbeing boards?

Sally Burlington: Neighbourhood health is a really important vision that we strongly support. In a way, it is obviously the right thing to do to move services closer to the people they serve and to work very closely with communities. Health and wellbeing boards have an opportunity to drive that neighbourhood health agenda because they are responsible for neighbourhood health planning and have the connection to local government, to the voluntary sector in many cases, and to the NHS. It feels like that is a real space of opportunity to drive neighbourhood health and realise the benefits that it could offer.

[The Chair]

Q 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.

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[Dr Johnson]

Q As a Lincolnshire MP, I am delighted to know that that is operating, if not necessarily in my constituency, then certainly in the county. I have a question for Kath: how does the single patient record apply to maternity in terms of safeguarding and access to that sort of information? As an aside, this Bill allows the Secretary of State to set targets. How would you see that working in maternity care?

Kath Abrahams: On digital exclusion, the same risks apply, although there is a different age demographic. If you have somebody who has a particular disability, has English as a second language, or has difficulty reading, we need to ensure that alongside the single patient record we are not excluding people without meaning to. Having said that, there are real opportunities to reduce inequities as a result of this change, such as by ensuring that everyone’s information is there, and that people do not have to retell their story if they find it difficult to speak to their clinician.

What the single patient record will not do is solve all the problems found in the national maternity and neonatal investigation. An action plan will come out of that investigation, and it must be looked at really seriously. A single patient record does not replace compassionate care or somebody really being looked after well, but it can potentially provide a safer environment—I am very happy to go into detail on that.

The national maternity ambitions have expired, but we are pushing very hard for them to be restated. There is potentially an opportunity to use the data at a broader level to measure progress. If it was possible to use the single patient record to understand how things were going towards improvement, that could be very helpful.

[Karin Smyth]

Q I will follow on from Dr Johnson’s questions. You have all expressed support for the single patient record, which is great, but that is not universal. Obviously, the Bill has to be enacted for that measure to go forward. It would be helpful to hear about your current experiences in your different areas—older people, maternity and carers. Your examples gave a bit more detail on why not to have this, Ms Abrahams—let us not assume, because although the process of the Bill is to make this happen, we have heard some concerns today from people who do not want that. What is happening in your world that this will help with?

Kath Abrahams: Right now, the situation is really tricky and people are being failed in their pregnancy and maternity care. Women report constantly having to retell their story—highly sensitive or traumatic experiences of loss—and that repetition can happen across the early pregnancy unit and maternity services. There is a common misconception that the NHS is one system, so when they find that people in another bit of the system do not know something, that can be really frustrating and annoying, because they assume that it exists.

There is also a lack of continuity. A clinician can be completely unaware of a sensitive or traumatic experience that somebody has had, and there can also be genuine dangers in outcomes. We know from the reports into Morecambe Bay, Shrewsbury and Telford that the lack of joined-up sharing of information and good communication between different parts of the system has led to some really difficult outcomes, particularly if somebody also has gestational diabetes, for example, or another condition and they are taking a particular medication that could cause harm to an unborn baby.

There are lots of situations in which not having the complete history is preventing people from getting not only really good, compassionate care, but the safe care they need. If someone is in an emergency situation and they are bleeding out, or their baby is not moving as much as they should, there is not time to start from scratch; they might not be in a position to explain what is happening to them and what their history is. They might not even know all the relevant bits of their history. Having that complete record, if it was done really well, would give clinicians the information that would allow them to make really timely decisions. Maternity can often be high risk—I do not need to say that to you; you know that—but these are often fast-moving situations where time is absolutely of the essence.

Emily Holzhausen: To build on what I said earlier about the amount of co-ordination and admin that people do, I will just refer to some carers’ words. One said that if they had to phone, they would end up in a long waiting queue or having to travel to the GP in person. There are people juggling work and care, so this has real, everyday impacts on their lives and their time.

When I refer to errors, I mean things such as medication errors or diagnosis errors. When you care for someone with very complex conditions, you can have health appointments every week—sometimes twice a week—and it is so hard to stay on top of it. When I say it is so hard, and talk about unpaid carers, we know that caring is a social determinant of health: in itself it is a single factor for poorer health outcomes. We know that 600 people a day give up work to care.

We have done a report on the tipping point: what tips carers out of work? One such thing is social care; another is how they are treated in the health system. If we reduce the pressure on carers and put information at their fingertips to help them to manage care, we improve outcomes for everybody: the health and wellbeing of the carer and the safety of the person that they care for. People are trying to do their best in quite a difficult situation.

One of our members, Norman Phillips, has talked about that a lot. He was in contact with more than 24 professionals, knitting up care around his wife who had advanced multiple sclerosis and dementia. That is an incredible amount of co-ordination of care. You can see how a single patient record, as it is envisaged in the future, could really help to support people who provide care. It is critical, given that we have an ageing population, that we recognise and support families in what they do.

Paul Farmer: I would start by talking about people with long-term conditions. Let us bear in mind that by the time we are 65, 82% of us will have one long-term condition, and half of people aged 70-plus have more than one long-term condition. Most of those long-term conditions are diagnosed within primary care, but of course they have a huge impact on access to secondary care services. For a clinician not to be able to see that whole picture and for the individual to have to explain again and again their physical health issues, and potentially their comorbid mental health issues, creates a huge challenge for people in getting access to the right help and support in a timely manner.

I would build on that to think about two areas that particularly affect older people: frailty and dementia. In this context, we know that assessment for frailty can make a big difference to ensuring people receive the right kind of help and support. That should be done in primary care, but often, sadly, people with frailty will present in hospital with a range of conditions. Understanding the frailty assessment score and what help and support is needed is key. For people with dementia and their family carers, having access to the right information for the clinician and for the individual concerned can make a huge difference. A disjointed experience just exacerbates what can often be a very challenging time.

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[Dr Johnson]

Q Does it surprise you that the Bill is being brought forward before it has been properly and completely designed? We have tabled some amendments to clause 47; I appreciate that you will not have had a chance to look at those yet, but we would be interested in your thoughts if you could provide them to the Committee afterwards.

We keep hearing that it is difficult for people to have to repeat their story. I understand that stories can be traumatic and repeating them can be unpleasant, particularly if it must be done many times, but is there sometimes a clinical value in asking people to go through their story? If so, what is it?

Dr Imam: My specialty is frailty, which is a medical condition characterised by a loss of independence. Although it is associated with ageing, it is not an inevitable part of ageing. The treatment that I deliver as a clinician is called a comprehensive geriatric assessment. It is evidence-based and we know that it improves patient outcomes and maintains independence. What it describes is a multidisciplinary team approach to a holistic assessment that focuses on what matters most to the patient.

One of the issues that we have right now, however, is that the NHS does not consistently identify people who are living with frailty right across the system from community to hospital. If we are identifying people and diagnosing them with a condition, you would expect treatment options to be offered, yet we do not consistently do that across the country. That is essentially driving ineffective and inefficient care. Sometimes, therefore, when a crisis sets in—we have seen this in other reports around corridor care—that can ensue in older people living with frailty.

In my day job, where I look after people in a busy A&E department, I see people who have may have had a fall or become confused, or where there has been a breakdown in their social situation. My practitioners and I are spending hours trying to piece together information from multiple different sources. Those could be paper-based, digital or telephone—we could be trying to phone people to get up-to-date information. As you can imagine, sometimes they do not pick up the phone, so we are sometimes working from incomplete information and things that are not up to date.

Once we have done that, we try to create a care plan for a patient that allows them to be looked after in the community. However, that care plan may not follow the patient, because everyone uses different electronic patient record systems. Some important partners in that care, like social care or ambulance services, cannot actually see the care plan that I have developed for my patient.

Unfortunately, if a patient with frailty then succumbs to a crisis of some kind, the default setting is, in many cases, to trigger an admission to hospital. If a patient does not need to be in a hospital environment and they are frail, they can end up becoming more frail and weak, and lose their independence. That means that they will need even more social care than would otherwise have been required.

Where the solution comes in is that a nationally rolled-out single patient record system could fundamentally reshape this form of care, because we would be moving it from the fragmented, reactive model that I just described to one that is proactive, co-ordinated and truly centred around a patient. Another thing about frailty is that there are so many different people involved in that person’s care, so we need to try to restore the continuity of care for that type of patient, which has become eroded over time. The SPR addresses that with a single up-to-date view of a patient. It enables earlier risk identification, faster clinical decision making and that whole-system integrated response I have been describing, which is lacking at the moment.

There is often duplication; one of the other issues is that assessing patients in this manner can take a long period of time—up to two and a half hours is often quoted by the British Geriatrics Society. You can imagine that if you had an electronic record that could be auto-populated or could rely on the most recent, up-to-date plan done by someone else, that would avoid reassessment as we would be working from contemporaneous information.

Over time, you can see how, for frailty and many other conditions, that could lead to a more preventive approach that is more community based, that reduces the need for admissions, and that provides a better overall experience for staff and patients. Importantly, there needs to be a shift towards neighbourhood working on frailty, and this allows the multidisciplinary team to work towards one plan. You have also heard today about patient voice and carer voice, and this type of care plan also gives them the opportunity to become partners in looking after themselves.

Dr Cocker: The brief answer to the original question would be that communicating and getting a history from a patient are the cornerstone of the patient-doctor relationship. I do not think that the SPR is ever intended to replace that. Where I see its value within maternity, although I am sure that this is the same across all specialties, is that it would form a reliable means of cross-referencing information and being able to get information that—as we have alluded to previously—is often held on many separate systems. As a clinician, you will often not have the ability or the credentials to access that.

For example, in maternity care at my trust we use a certain piece of software. If you do not work in maternity, although you might be able to get generic access to it, you might not be able to navigate that system. The idea of the SPR is that it would pull out those key bits regarding current concerns about the pregnancy or what follow up has been arranged—all those kinds of things. That would not rely on the ability to use lots of different systems; instead, the information would be available. If there is information that requires cross-referencing or checking, it would also give you the ability to do that rather than replacing the process of taking a history and working out what is wrong with someone.

Dr Byrne: It is a terrific question. Healthcare is a relationship; it is not simply a transaction of facts. At its best, it is a working relationship between a clinician and a patient, but that is also why it is so hard sometimes. Our stories are a combination of two things: the facts and the interpretation of those facts. We heard a moving example earlier of someone saying that they had had five miscarriages and those facts were then not known and how distressing it was that they were not. That is a good example of why getting the facts from conversation to conversation could be really helpful.

Our life story changes over time, however, as does the interpretation that comes up in a conversation. As a doctor in the moment with a patient, I am sometimes as interested in what they are choosing not to tell me at a particular time as what they are choosing to tell me. For all of us, the story changes and is fluid. I think that is a potentially helpful distinction to make.

[Karin Smyth]

Q My questions around the benefits that you might see have been really well answered, so I will not go back to that issue. Dr Cocker and Dr Imam, in your work on maternity and frailty, what early lessons have you picked up on how this might work for you?

Dr Cocker: Having seen the maternity-focused prototype that NHS England developed in the north-west, we learned that it is technically difficult because there are lots of systems. There needs to be a level of interoperability that allows you to pull the data or it is not going to be much use as a reliable system.

The other thing was about trying to ensure that we design those systems for the patients most in need. That might be social or medical need, and there are many different facets to that. That was one of the other challenges. A lot of the focus went into trying to determine a set of theoretical patients who were very high need, and ensuring that you have encompassed all those possible needs, so that if you design the systems for those in most need, they will cater for as many people as possible.

Dr Imam: To expand on Dr Cocker’s point about the identification of problems, people living with frailty often have multiple under-identified issues. In the prototype we have been shown, the SPR has the potential to analyse the wealth of data on a person and summarise it in a manner that makes sense to the clinician logged into the record. It can also piece together a timeline of what has been happening with a person.

As I said earlier, we often follow a manual process to try to understand what has been going on recently for a person. The SPR will not only enable the automation of that process, but give us the ability to know who the key individuals involved in that person’s care are, so when that person is in a crisis or emergency situation, we know exactly who to call and who the last person to touch the patient was.

There are other important functions. It is not only about sharing information across an entire pathway and having the whole-system approach that I described—from community to hospital, and vice versa. Importantly, many people living with frailty require multiple different referrals and the involvement of multiple different people in their care. The SPR will be able to streamline some of those processes and make recommendations for certain referrals that a clinician, who, under an earlier version, would have logged into the record, may not have otherwise thought about, so it may even improve outcomes for patients by providing solutions to improve their care that we would not have come up with otherwise.

[Karin Smyth]

Q Dr Byrne, you 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.

--- Later in debate ---

[Dr Johnson]

Q We do not have a plan of where we are going, but you have been asked to go somewhere.

Jon Restell: Obviously, we have the 10-year health plan, which most people broadly see as a good vision for the service, but there are too many key design questions around the new department, the role of the department’s regions, what ICBs will be doing and what trusts will take on as part of this reorganisation. Behind it, there is a lot of capacity and resource organisational memory being taken out of the system.

We do not talk nearly enough about the work of the commissioning support units staff, who are providing internal consultancy and a huge range of business services to the health service, including overseeing child immunisation programmes in some cases. It is really unclear what the future of those functions is. We are taking out a lot of staff who have skills, expertise, organisational memory and commitment, but we do not quite know yet what the precise form of those organisations will be. It is a very difficult change to manage.

[Karin Smyth]

Q 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.

--- Later in debate ---

[Dr Johnson]

Q We have heard evidence today that the Bill weakens links between local authority working and the ICB. Does that help social care, or could that actually make it worse?

Sir Andrew Dilnot: I would not claim to be expert here, but I have read the Bill and the briefings. The role of local authorities in social care is a very interesting one. If we were to stand way back and honestly answer the question, “Why is social care managed by local authorities at the moment?”, we would say, “Because it was forgotten in 1948, when the rest of the modern welfare state was created.” At that stage, social care was a pretty small activity, and it was just left with local authorities. What has happened since then is that it has grown and grown, and it is now putting enormous strain on at least many local authorities.

I think we should draw a clear distinction in something that is definitely appropriate—that is, care being provided within a local context. The kind of care that is appropriate in Camden will be different to the type of care that is appropriate in the highlands of Scotland. Local delivery seems relevant, but whether local financing makes sense in 2026 is a very big question. That is the context.

On its own, it is hard to see the potential reduction in the role of local authorities in ICBs making things better. It will not necessarily make things significantly worse, but I do not think it will help local authorities and the NHS in trying to integrate these two essentially non-integrated functions.

[Karin Smyth]

Q 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.

Compassionate Use Medicine Schemes: VAT

Karin Smyth Excerpts

Thursday 11th June 2026 Commons Chamber

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

(Urgent Question): To ask the Secretary of State for Health and Social Care if he will make a statement on the effect of VAT on the availability of medicines through compassionate use schemes.

[The Minister for Secondary Care (Karin Smyth)]

It is very important for patients to have access to innovative medicines as quickly as possible, especially where there is unmet clinical need or no alternative treatment. We are working to streamline the decisions of the National Institute for Health and Care Excellence and the Medicines and Healthcare products Regulatory Agency so that NHS patients benefit from the latest medicines as soon as they are proven to be safe and effective.

Early access and compassionate use programmes can play an important role in enabling patient access to medicines ahead of routine commissioning decisions. However, we should be clear that these programmes are commercial decisions taken by pharmaceutical companies: companies choose whether and how to provide medicines free of charge to patients and the NHS before the medicines go through licensing, post-trial access or a funding decision.

The tax system is, as Members know, a matter for the Chancellor, so I will not get into details about that at the Dispatch Box, but under long-standing VAT rules, supplies of goods free of charge can still be treated as taxable “deemed supplies” where input tax has been recovered. That means that VAT can apply even where no payment is made, reflecting established principles of the tax system. We recognise the concerns raised by industry and others about the potential impact of this treatment on the provision of free-of-charge medicines. We are working closely with the Treasury and His Majesty’s Revenue and Customs to explore options to address these issues, as witnessed by my hon. Friend the Exchequer Secretary to the Treasury, who is here with me on the Front Bench. We will carefully consider the legal, fiscal and operational implications of any potential changes. Until then, we will continue to engage constructively with industry, the NHS and all our partners to make sure that British patients, who we have in our thoughts at all times, have access to innovative medicines.

[Dr Johnson]

I declare an interest as a consultant paediatrician. One of the worst moments as a paediatrician is when all treatments have failed and there is no suitable clinical trial. At that point, in those dark moments, compassionate use schemes can be a glimmer of hope, and new unlicensed medicines with clinical potential have been provided free to the patient, and free to the NHS. Last year, however, the Government started charging VAT on the deemed value of those drugs, meaning that companies had to pay tax to give the drugs away. When hearing that “every meeting” with Labour MPs was about

“who can we tax in order to pay benefits to others?”

few would have imagined that that would include potentially lifesaving, charitably given drugs for sick adults and dying children.

Following lobbying by my hon. Friend the Member for Hornchurch and Upminster (Julia Lopez), the Government have paused enforcement while they review the situation, but they have said that liabilities remain, and they are taking too long. Bayer has now withdrawn from the scheme, and others could follow. Patients are at risk. Does the Minister recognise that that makes trials in the UK less attractive, and that HMRC’s pause is not enough? How much money do the Government expect to raise with this VAT? How did the Government find time to reduce VAT on fairground rides at Alton Towers, but not to sort out this problem? How many patients have missed out so far? Does the Minister recognise that this delay could cost lives, and who was the Minister who signed this off? Was it the Health Secretary when he was a Minister in the Treasury?

I understand that the Government say this situation is not new, and that it may apply to a law dating back over 30 years. I gently point out, however, that the application is new, and that the levers to change it—and change it quickly—lie in this Government’s hands. Patients need them to act swiftly.

[Karin Smyth]

I pay tribute to the hon. Lady’s service as a clinician, and she is right to say that, at times, for patients facing such situations, compassionate use schemes are a glimmer of hope, but I think the rest of her comments were ill deserved. I understand the desire of the Opposition to attack a new Secretary of State because he was in the Treasury, but I will move on to the actual issues, because patients care about this. The rules had been in place for a long time when this Government took office, and we have not changed them. We have inherited this system, and we are looking at how we can improve it.

The previous Government could have abolished VAT on such medicines, but they chose not to do so. What is more, since we have been in office, we have struck a deal with the USA that not only guarantees 0% on pharmaceutical tariffs, but changes the old formula that we use for medicines. For the first time in 20 years, the Government are spending more to ensure that our patients are first in the queue for innovative medicines. The previous Government could also have raised the threshold, but they chose not to do so. Now, for example, patients facing Duchenne muscular dystrophy, children as young as 12 who need a brain cancer drug, or those who have a type of rare and aggressive stomach cancer, are being treated.

We recognise the importance of the UK remaining a leading location for life sciences, investment and innovation. That is precisely why we are engaging with industry and partners across the Government to understand and address concerns, including the issue of VAT payable on donated medicines. In considering a way forward, it is important to safeguard the robust and fair system by which routine access to medicines commissioned by the NHS is determined. A range of options are being considered. No decisions have been made at this stage, and I will not pre-empt any.

[Dr Scott Arthur (Edinburgh South West) (Lab)]

I thank the Minister for her response—I am sure she is working hard to resolve this issue. As the hon. Member for Sleaford and North Hykeham (Dr Johnson) explained, a pause was introduced. That was welcomed by charities such as Sarcoma UK, which asked for that pause to be made permanent. If the Minister is working hard to get the Treasury to understand the impact that the VAT charge is having on patients, will she invite a Treasury Minister to meet charities such as Sarcoma UK to hear first hand about the impact of charging VAT?

[Karin Smyth]

I commend my hon. Friend’s work in this area on behalf of patients. As I said, no decisions have been made and we are continuing to work on this issue. The Exchequer Secretary to the Treasury is with me on the Front Bench and will be happy to keep engaging with all interested parties.

[Mr Speaker]

I call the Liberal Democrat spokesperson.

[Helen Maguire (Epsom and Ewell) (LD)]

I was deeply shocked to hear about the change in HMRC’s policy. It is extremely worrying that pharmaceutical companies must now pay VAT on drugs available through compassionate use and early-access schemes. In April, HMRC told the pharma industry that it would pause enforcing VAT bills while the Government considered measures to support the industry in supplying patients who desperately need these drugs. The changes have been mired in uncertainty and misunderstanding, and there has been poor communication from HMRC from the start.

The Government must ensure that they create a workable long-term solution for the pharmaceutical industry to support these patients who are in desperate need. Patients must not lose access to medicines as a result and HMRC must communicate with pharma and patients effectively. For patients of all ages with rare cancer types, schemes such as these are the only way to access potentially life-extending treatment. Has the Minister spoken to cancer charities about the real-life effects that the changes will have? We should be making it easier for patients to access life-extending drugs, not harder. Will the Minister confirm that patients will not be denied lifesaving drugs as a result of these changes?

[Karin Smyth]

I thank the Liberal Democrat spokesperson for her comments. She knows that we engage with the sector all the time and, as I said in my earlier response, we will continue to work with bodies across the life sciences sector and with patients, the NHS, HMRC and the Treasury. A range of options are being considered and no decisions have been made.

[Jerome Mayhew (Broadland and Fakenham) (Con)]

The Minister is responding to this urgent question because the Government have decided to charge VAT on donated medicines used for compassionate EAM schemes. The Minister says, “Well, that is not our fault—the scheme has been around for 30 years”. That may be true, but they have decided to apply the rules for the first time. Why have the Government decided to impose VAT now?

[Karin Smyth]

It is important for hon. Members to recognise the deep concern caused to patients with unmet clinical need, who rely on the glimmer of hope provided by these medicines, when they hear these sorts of exchanges. These are long-standing rules and we continue to engage on the issue.

[Sir Ashley Fox (Bridgwater) (Con)]

It is utterly shameful that this Government are presiding over the imposition of VAT on drugs donated for compassionate use. The Minister referred to the previous Government. VAT was not put on those drugs under the previous Government, but it is being put on them under this Government. Was it the Health Secretary who signed this off when he was in the Treasury?

[Karin Smyth]

The hon. Gentleman’s last comment reveals exactly why he is raising this issue.

[Jim Shannon (Strangford) (DUP)]

Hon. Members have raised concerns for compassionate reasons and on behalf of their constituents who feel the pain. Compassionate access schemes are a critical lifeline for terminally ill patients, often stepping in when the NHS has exhausted all standard funding avenues. Any move by HMRC to levy, to barter or to impose deemed supply VAT on free clinical treatment places an unacceptable risk on voluntary patient provision. I say this kindly, but will the Minister ensure that the Treasury works collaboratively with the devolved health Executive to create a permanent and water-tight VAT exemption, so that no patient, regardless of their postcode, is left behind and compassion is a UK-wide attribute, not a postcode lottery?

[Karin Smyth]

The hon. Gentleman works very hard in this area. He is right to use the word “compassion”, because that is exactly how we must approach the issue for patients who have an unmet clinical need and are desperate for innovation. That is why we are putting our collaboration and work with the life sciences sector front and centre and working closely with HMRC. My hon. Friend the Exchequer Secretary to the Treasury is on the Treasury Bench listening attentively to the issues and we will continue to work together. They are long-standing rules. As the hon. Gentleman would acknowledge, we have made huge progress in this area for patients in this category, particularly with our revision of the National Institute for Health and Care Excellence threshold, and we will continue to do so, on behalf of the patients we all want to help.