Health Bill (Second sitting)

Liz Twist Excerpts

Committee stage
Tuesday 16th June 2026 Public Bill Committees

[Helen Morgan]

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

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

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

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

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

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

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

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

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

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

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

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

[Liz Twist]

Q Do you think that there are any good examples we can learn from?

Sir Ciarán Devane: Yes, I do. I was in Epping recently, at St Margaret’s. I talked to the lady who runs the patient engagement: she is a volunteer and is a patient herself. They are a very good example, because they have said, “If we want to provide good services and avoid people turning up at the A&E in Harlow, we can do a neighbourhood diagnostic service.” The patient representatives got in very early. They ran some public meetings ahead of it and said, “We are thinking of doing this: what do you think? We’ll feed it back.”

Everything good is happening somewhere. It is the variability that is causing the problem. We need to make sure that good practices are deployed across the sector. That has to be the expectation: if this reform, which is huge, is to deliver value, that is the value that it has to deliver.

--- Later in debate ---

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

Q I know that in this conversation some have highlighted that patients have stated that their experience has worsened or not improved, but I would argue that is not a Healthwatch failure; it is actually down to the NHS or ICBs not acting on Healthwatch recommendations. It seems to me perverse to give that voice to the organisations that are actually part of the problem through not acting.

As a Minister, I was on the receiving end of some quite sharp recommendations from Healthwatch, but they were always constructive. Whether right or wrong, my fear is that this measure risks a perception among patients that it will be down to NHS managers and ICBs essentially to make recommendations that reflect their priorities, rather than the priorities and voices of patients. Professor, even if the principles that you have enunciated that might mitigate that risk were applied to the new model, are you really confident that they could mitigate the risk to patients’ confidence that their voice is genuinely and independently heard, loud and clear, however unhelpful it is perceived to be by bits of the NHS?

Professor Croisdale-Appleby: I cannot be confident of that, because we are in the foothills, not up the slope, and the details have not been given. ICBs have received something approaching a 50% cut in their running costs. I will not comment on the appropriateness or otherwise of that, but one has to be realistic and think about how high a really informed patient voice—particularly one that seeks out the views of both communities and individuals where the health inequalities are the greatest—will be on the priority list. I would question that, but I will leave it there.

[Liz Twist]

Q You all represent patient organisations in different ways. I would like to put this in the context of the 10-year plan and the shift to involve patients and communities in shaping services. From your patient perspective, how can we best support ICBs, local authorities and other people to drive that change for patients?

James Cooper: It is key that ICBs are given that support. In the conversations that Together for Short Lives and the services we represent have with ICBs, we certainly get the sense that they want support. They want to know how much they should be funding certain services, and they want to know how to plan. A lot of guidance is already out there, particularly in children’s palliative care, where we have service specifications and NICE guidance and quality standards—there is even a legal duty to ensure that ICBs commission palliative care for children and adults. That accountability and support from the centre, and making sure that resource is there, is key.

[The Chair]

Q Do panel members have any further comments?

Professor Croisdale-Appleby: I just want to reassure colleagues here that Healthwatch England and the Healthwatch network are still fully functional—I think that is important for you to know. Although we are sensibly on a reducing trajectory in line with the Government’s abolishment plans, we will maintain that full functionality and the ability to meet our formal mandate right through until the Bill is enacted, and until the guidance that will probably follow is in place. I just wanted to reassure the Committee of that.

--- Later in debate ---

[Dr Johnson]

Q The question was really about trust, and how people can be trusting of figures. For example, with Healthwatch, if you internalise patient experience into an organisation, do people then trust you when you say that it has got better? They will have only their own experience and the experience of their own family to work on; that will be the lens through which they look at things. We know that the waiting list numbers have come down, and there is not widespread trust in those numbers, for all sorts of reasons. If the numbers for patient experience are governed by the Department of Health, or the ICBs themselves marking their own homework, will the public trust them? Whether they should trust them is one question, but will they trust them?

Karin Smyth: I will come back to the waiting lists, but you are absolutely right about trust. In saying that I expect this to be the board’s job, I think it is its job to get this right, and we need to support it to do that. We heard a bit from Penny Dash about the national quality board and the patient experience directorate inside the Department of Health and Social Care reporting directly to the chief executive and the permanent secretary. That has to be part of the wider architecture, which is of course outside the Bill, so we need to be able to tell that story to the wider public.

We know from all the recommendations, reviews and the support that we give as Members of Parliament to our constituents that trust is really important. Getting that right and bringing people on that journey with us will be really important. Independence helps with that, and that it is why it is good to debate it as we consider the Bill—it is good to be able to air some of it—but I think people accept that things are not working and have not been working.

I think your question about waiting lists is about the data and the information that says where we are at. It is really complex. To follow NHS England’s data, of which there is a lot—I commend the amount of data that is available—you need to be quite clever at spreadsheets, and at finding and articulating data, in order to bring it back to your own constituency and local place. These things are complex. It is complex to record, track and recognise how people move through a waiting list, for example.

It is good that we are transparent about that. One thing that I am keen to push out is data on performance in trusts. Making so-called league tables is controversial, but the more information that we have out there, and the more we have honest debates about how complex and difficult it is—I am happy to take your questions around how that moves in order to for us to explain that—the more that helps to build trust.

[Liz Twist]

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

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

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

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

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

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

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

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

[Helen Morgan]

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

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

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

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

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

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

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

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

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

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

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