Health Bill (Second sitting)
House of Commons · Public Bill Committees · 16 Jun 2026 · 216 speeches · Official Report
The Committee consisted of the following Members:
Chairs: † Sir Roger Gale, Dr Rupa Huq, Emma Lewell, Sir Jeremy Wright
† Argar, Edward (Melton and Syston) (Con)
† Brackenridge, Sureena (Wolverhampton North East) (Lab)
† Chambers, Dr Danny (Winchester) (LD)
† Daby, Janet (Lewisham East) (Lab)
† Foody, Emma (Cramlington and Killingworth) (Lab/Co-op)
† Irons, Natasha (Croydon East) (Lab)
† Johnson, Dr Caroline (Sleaford and North Hykeham) (Con)
† Joseph, Sojan (Ashford) (Lab)
† Kyrke-Smith, Laura (Aylesbury) (Lab)
† Morgan, Helen (North Shropshire) (LD)
† Prinsley, Peter (Bury St Edmunds and Stowmarket) (Lab)
† Robertson, Dave (Lichfield) (Lab)
† Robertson, Joe (Isle of Wight East) (Con)
† Smyth, Karin (Minister for Secondary Care)
† Stafford, Gregory (Farnham and Bordon) (Con)
† Twist, Liz (Blaydon and Consett) (Lab)
† White, Jo (Bassetlaw) (Lab)
Sanjana Balakrishnan, Rob Cope, Committee Clerks
† attended the Committee
Witnesses
Sir Ciarán Devane, Chief Executive Officer, NHS Alliance
James Blythe, Chief Executive Officer, Royal Berkshire NHS Foundation Trust
Sarah Tilsed, Head of Patient Partnership and Engagement, The Patients Association
James Cooper, Associate Director of External Affairs and Membership, Together for Short Lives
Professor David Croisdale-Appleby OBE, Chair, Healthwatch England
Councillor Megan Wright, Vice-Chair, Local Government Association Health and Wellbeing Committee
Sally Burlington, Chief Executive Officer, Association of Directors of Adult Social Services
Maria Higson, Director of Transformation, South East London ICS
Emily Holzhausen CBE, Director of Policy and Public Affairs, Carers UK
Paul Farmer CBE, Chief Executive Officer, Age UK
Kath Abrahams, Chief Executive, Tommy’s
Dr Michael Cocker, Obstetrician, East Lancashire Hospitals NHS Trust
Dr Towhid Imam, Consultant Geriatrician, Croydon Health Services NHS Trust
Dr Nicola Byrne, National Data Guardian for Health and Social Care
Jon Restell, Chief Executive, Managers in Partnership
Sir Andrew Dilnot
Karin Smyth MP, Minister for Secondary Care, Department of Health and Social Care
Public Bill Committee
Tuesday 16 June 2026
(Afternoon)
[Sir Roger Gale in the Chair ]
Health Bill
Examination of Witnesses
Sir Ciarán Devane and James Blythe gave evidence .
The Chair
We will first hear oral evidence from the NHS Alliance and the Royal Berkshire NHS foundation trust. We have until 2.30 pm for this panel. Gentlemen, I will be grateful if you would be kind enough, from left to right, to introduce yourselves for the sake of the record. Sir Ciarán Devane: I am Ciarán Devane, chief executive of the NHS Alliance. James Blythe: I am James Blythe, chief executive of the Royal Berkshire NHS foundation trust.
Q 60 Good afternoon, gentlemen. My first question is to the NHS Alliance. In a survey published last month, your organisation found that two thirds of trusts and integrated care board leaders are likely to need to cut or reduce patient services to meet their financial plans. Given the financial pressure that ICBs are clearly under, what do you make of their ability to become more strategic commissioners and to innovate? Sir Ciarán Devane: First of all, the ICBs have had their 50% cuts and they are in the middle of reorienting themselves and joining up, so there has been a degree of distraction. The second thing, though, is the idea that the ICBs should be strategic commissioners, working well to commission plans that genuinely reform services. I think we all support that, and the move to give them GP commissioning, pharmacy provision and so on. All of that is good. The challenge will be that the baseline for the current year is not necessarily the outturn of last year, because there were some one-off savings in that, so our members across the NHS are saying that this is the year when the trade-offs have to be made. Some of those trade-offs will be good, in the sense of we can reconfigure this service, move some services into the community and do some good things-I am sure we will hear about some of those-but some of them will require difficult decisions to do with whether we shut down the service in this hospital and double down on the one over there. Making those decisions...
Q The ICBs and trusts are going to operate under the spectre of direct intervention by the Secretary of State, who is taking much more interventional powers in this Bill. What effect will that have on the health system? Sir Ciarán Devane: We are unclear and concerned about what the nature of those interventions could be. In theory, we fully understand that the Secretary of State and the Government need the ability to say, “In the unlikely event an ICB goes rogue, we have to have the right to sort it out,” but we need to guard against the alternative of a Secretary of State who is intervening too much and making decisions on particular services, commissioning decisions or reconfigurations. We want the legislation to prescribe the circumstances in which the board of an ICB can be overruled. That should be transparent, it should be published, and intervention should be rare. We recognise that that backstop needs to be there for the sake of good governance, but we need checks and balances. The powers are needed if somebody is operating outside their licence, but we need to guard against the Secretary of State or the regions or the new departments reaching in and second-guessing local decision making. If this is really about empowering strategic commissioners to do what is right for their populations, working closely with local authorities, interventions that second guess their decisions need to be very rare.
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.
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...
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.
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.
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.
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...
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...
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...
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.
Q This question is to the Royal Berkshire. In response to my colleague, you talked about the benefits of your council of governors. As a foundation trust, you have significant autonomy. The Bill will allow the Government to cap your day-to-day spend, strip away your FT status and make governance changes. What impact will that have on how your boards can carry out their duties? James Blythe: With a lot of foundation trusts, as the NHS has moved into a period of increasingly tight financial control and as we have needed to recover from the covid pandemic, far closer working has been required between all NHS providers and the centre, to manage both the financial implications and the pandemic’s implications for patient access and patient quality. Having recently moved from a senior leadership, board-level role in an NHS trust to two roles as chief executive in a foundation trust, I do not feel that in the day-to-day relationship with the centre and with our local and regional representatives there is an enormous difference in how we balance quality, finance and performance now. Those foundation trust freedoms were most relevant when we were in a system in which expenditure on health could grow and we were not trying to recover from the challenges that we have had recently. Day to day, the relationship between NHS trusts and foundation trusts feels quite consistent now, so I am not sure that the changes proposed in the Bill will necessarily make a huge difference. As I said in...
The Chair
Sir Ciarán and Mr Blythe, thank you very much indeed. Sadly, we have just about run out of time for this session, but we are most grateful to you. Examination of Witnesses Sarah Tilsed, James Cooper and Professor David Croisdale-Appleby OBE gave evidence.
The Chair
We will now hear oral evidence from the Patients Association, Together for Short Lives and Healthwatch England. We have until only 3.10 pm for this panel of three people. Would you be kind enough to introduce yourselves for the record? Let us start from the left. James Cooper: Hello. I am James Cooper, associate director of external affairs and membership at Together for Short Lives. Sarah Tilsed: Hello. I am Sarah Tilsed, head of partnerships and involvement at the Patients Association. Professor Croisdale-Appleby: Good afternoon. I am David Croisdale-Appleby, chair of Healthwatch England.
Q My first question, which is about specialist commissioning, is for James. Your charity is involved with palliative care for children. What effect do you think the changes in the Bill will have on the commissioning of very specialist, low volume and high complexity services? James Cooper: I think that there are both opportunities and threats for families of seriously ill children and the professionals and services that provide them with palliative and end-of-life care. When we talk about seriously ill children, we mean children with life-threatening conditions, life-shortening conditions and severe medical complexity. They have a range of emotional, psychological, social and physical needs that need to be met across health, education and social care services. Part of that care involves specialist children’s palliative care, which is predominantly provided at a regional level by teams led by specialist paediatric palliative care consultants. They often have Grid training, and there are not many across the UK-there are only about 24 whole-time equivalents. They are often based at children’s hospitals or children’s hospices and are often co-located across both. These specialist teams also comprise senior nurses and other specialists involved in emotional, psychological and practical support for families. Our issue is that these services are often quite patchily commissioned at the moment; even though there has been a specialised children’s palliative care specification from...
Q My second question is for Professor Croisdale-Appleby. The CQC has been reported to be in a relatively difficult place, facing challenges at the moment. It is being asked to take on event healthcare supervision and roll the HSSIB within it. Is that asking too much? Professor Croisdale-Appleby: Obviously, I am not here to speak on behalf of the CQC, although I am a non-executive director of the CQC. You are quite right that it has been in a challenging position, from which it is taking very substantial steps to recover, principally in changing back to a system of having chief inspectors who are very knowledgeable about their particular area of expertise that they can apply. The Department has asked the CQC to take on additional responsibilities in its regulatory capability and, to some degree, in an inspectorate capability. I cannot really agree that it is too much for the CQC to take on, but a substantial amount of work is certainly being added to the CQC.
Q What are your thoughts on the abolition of Healthwatch? Does Healthwatch have teeth? Does it influence people? Is it influencing the decision makers? Could it be reformed or should it be abolished? Professor Croisdale-Appleby: It is quite interesting to think that we have had 52 years of independent organisations representing the patient voice, as well as that of the carer. I think everyone here will be aware of it, but there was a step change in impact after the Mid Staffs situation, when Healthwatch-both Healthwatch England and the 153 local healthwatch bodies-was set up. We have produced over 20,000 reports; if anyone is interested in accessing any of them, we can certainly provide access by the end of the week. Since I joined Healthwatch in 2023, in my view it has been very successful in reaching out to those communities often referred to as “difficult to reach”-diasporas and so on, where we all know the health inequalities are often the deepest. I think Healthwatch has been very successful in ensuring that we have not just listened to the easy-to-reach groups but deliberately sought information and views from those other parts of our society, which form an increasing part of it. The research being done with those communities has recognised that there is quite often an investment of some six months for one of our people go into a particular community-whether a cultural community or an ethnic community-and win the confidence of the people so that they actually talk to...
The Chair
Q Ms Tilsed, you have been very patient. Before I call the Minister, do you want to add anything to what has already been said? Sarah Tilsed: Professor Croisdale-Appleby said absolutely everything that I was about to say, so I will make just a few points without going back over everything. The main thing is that we need to make sure that this does not divert attention from the main priorities, which obviously relate to patients: timely access to care, clear communication and involvement in decisions about their treatment. As the professor said, we need a truly independent patient voice. Abolishing healthwatches creates a fragmentation of patient engagement responsibilities across ICBs and local authorities. The evidence we see every day consistently shows that patients are not feeling informed, involved or treated as equal partners in care. We need to ensure that any replacement model is, as Professor Croisdale-Appleby said, genuinely independent, transparently accountable and resourced equally across the country, to ensure that we do not lose sight of the people it is supposed to serve. Trust is really important here, and patients trust independent organisations. I feel that that trust might be lost in local communities. Lastly, this is, as Professor Croisdale-Appleby said, about reporting. We need to consider the way that patient feedback data is reported, and ensure that that is not getting lost. Themes and demographics still need to be included to make sure that we know...
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.
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?
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...
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?
Q My second question is about Healthwatch. The Committee heard this morning about the variability of Healthwatch’s effectiveness at a local level. What could be done to ensure that the best and most effective Healthwatch practice is rolled out across the whole of England? Professor Croisdale-Appleby: Thank you for that question. One of the reasons there is a difference or variation among the 153 is that the amount of funding is very different. Some of them get 10 times the funding of others, which makes a difference to the scope of what they can do. What it does not allow-and I think Healthwatch England has an important contributory role in this-is a change in the quality of the way in which the research is done. One of the things that I have encouraged very strongly-although it happened before I joined Healthwatch-is the use of qualitative as well as quantitative data. The system is awash with quantitative data, but that does not necessarily cut through to the way that people are, the way they think, the lexicon they use, the concepts they use in communication etc. One of the great strides that Healthwatch England and our 153-member network have made is the intelligent use of qualitative data. That is an art in itself-I would like to think that is a science, but it is certainly an art. It would be easy to remedy that, in the sense that if the funding were more equitable, some of that variation would disappear, but the variation is not in the quality, the effectiveness of...
Q To go back to the single patient record, I see huge potential-at least in my constituency, where we have real challenges with GPs and hospitals not talking to each other or sharing information. Nor do trusts and local authorities across Buckinghamshire, Bedfordshire and Hertfordshire share that information. Sarah has touched on this a bit already, but I am interested to hear from our other witnesses on how they think the single patient record would improve patient experience, and on how we would go about building public understanding and trust in a new system. James Cooper: There are some big opportunities in the single patient record, with the caveats that Sarah mentioned on data governance and consent. For families of children who are seriously ill, it presents huge opportunities, as I said earlier, because of the complexity of their needs. Often, huge amounts of information need to be conveyed to any professional who the children come into contact with, wherever that is across health, education or social care. Many professionals have a long-standing relationship with such families, whether they are NHS community children’s nurses, consultants with a speciality in the child’s condition or children’s hospice teams, but families often need to access emergency unplanned care, perhaps in the middle of the night or at weekends. In those instances, when they speak to paramedics and emergency doctors, it is imperative that they can convey the information as quickly as possible....
The Chair
By all means. Professor Croisdale-Appleby: We have to recognise that a tremendous amount of work is done in the health and social care system with people who have multiple comorbidities-not just one thing, but a number of things that often interact together. Without a single patient record, we can find that a consultant or a GP has access to only one part of that multiple comorbidity, as it were. That can lead to all sorts of unforeseen errors. I think that that is an important point to make about the great advantage that we can get from a single patient record.
Q Professor Croisdale-Appleby, the local healthwatch on the Isle of Wight has proven invaluable in amplifying patient voice, gathering patient experience and helping those who are democratically elected-MPs and councillors-to hold health leaders to account. My concern about that function being folded into the ICB is that the ICB has often been on the sharp end of critical analysis by Healthwatch, and so the ICB will end up marking its own homework. We will lose the critical voice that has, I am sure, led to better decision making. How can we possibly resolve that fundamental issue, if Healthwatch is folded into ICBs? Professor Croisdale-Appleby: You make a pivotal and focused point. The independence is vital, not just because of the quality of what Healthwatch produces, but because of the confidence that it gives people that they are speaking to an independent organisation. In the background, some communities distrust being critical about the care that they receive in case it rebounds on them. If the same organisation is responsible for marking its own homework, as you put it, that problem will be much greater than it has been in the past. In terms of what to do about it, I think that you stick to some basic principles. If we are moving forward positively, we have got to be locally driven. We must reach out to communities. They will not reach into us; we have to reach out to those communities and the individuals within them. I mentioned the value of qualitative evidence. It...
Q Sarah, you mentioned that the patient should be the centre of all this. I do not think that anybody disagrees-including any politicians-that making these changes is in the best interest of the patients. However, many changes have happened over the decades, but data for the last 10 years shows that patient safety incidents and complaints are steadily going up, so those changes have not made any impact on patient care, safety or experience. We need to do something here. After each incident, there is a recommendation or an action plan, but clinical staff or patients do not have much involvement with those and do not see any difference. Healthwatch helpfully finds the issues, but it may not actually go back and see what changes are made following its recommendations. The CQC physically goes into clinical areas to see the difference, and has the power to take action against those responsible, so is it not a good change that more accountability will sit with the providers, and the CQC-or local authorities and ICBs-can take action against them? Professor Croisdale-Appleby: Forgive me; you asked several questions. Which would you like me to start with?
I asked whether it is not a good change to streamline these bodies so that fewer of them have powers to take action like the CQC? Professor Croisdale-Appleby: There is always a danger, if I may say so, in the use of the word “streamline”. We have to think what is lost in the streamlining process. I do not want to repeat what I have said and waste your time, but one thing that is important is whether there is a golden thread running through seeking out and listening to patients’ views, putting those together in a coherent form, making recommendations for improvement-that is what we do all the time at Healthwatch-and then holding people accountable for that. I remember Penny Dash saying that one of the points of the Bill is to bring this closer to those who commission and those who deliver. I am not sure that it necessarily takes it closer to that simply by embedding it-as a colleague asked earlier-within the formal structure. There is a danger in that that the patient voice is often a spiky voice. As a former chair of hospitals and so on, I know that patients do not always say things that are convenient. That point about independence is vital. If I may, sir, I take slight issue with your term “streamlining” and would try to take that apart into the different components that might comprise it. Sarah Tilsed: I cannot comment too much on the CQC, but on the point about a rise in complaints but nothing seems to be happening, we are finding that patients do not want to complain...
Q On the streamlining point, you have articulated very clearly why you think it is inappropriate, as have members of this Committee, and most of the evidence we have received suggests that it is not appropriate. What do you think is the reasoning behind the Government’s real push for this, when the evidence against it is so clearly strong? Is it simply that they want to save money, in your opinion, or is there an alternative motive? Professor Croisdale-Appleby: If we talk about money- I will be quantitative here-Healthwatch England currently costs £3 million per year and the network receives £25 million per year. To people like me, £3 million and £25 million is a lot of money, but in the greater scheme of things it is not a significant amount, particularly when you think what is being produced for it. I cannot speak appropriately, in my role as chair of Healthwatch, about Government policy. It is not my job to do that; it is the Government’s job. If you want to ask me a question on a purely personal basis so I can step outside of that role, I will be happy to answer, but I always have to draw a very distinct line on anything that I say. Everything so far has been said in my formal position as chair of Healthwatch as opposed to any personal views, because I certainly do not want to comment on Government policy.
The Chair
Let us see if either of your colleagues would like to be less cautious. Mr Cooper? James Cooper: The key here is making sure that the independent patient voice is well-resourced, is held accountable for doing its job and works particularly for those the system finds it hardest to reach. Families of seriously ill children definitely fall into that bracket, so the interest of Together for Short Lives and the children’s palliative care sector is certainly in making sure that those structures do that.
Q I would like clarity on a few views that we have heard, not just in this session but in previous ones. There is one mindset that says that by bringing patient voice into ICBs, they are going to be marking their own homework. Equally, I think about places like Wolverhampton, where we have such baked-in inequalities and we simply have not shifted the dial for far too long, as can be seen in the differences in life expectancy. I have also heard that if you want to bring real change, it is best to bring that change from within the system. I will open that up to you, Sarah. Sarah Tilsed: I disagree with that. It is fine for ICBs to be involved, but it is all about local partnership working-bringing in the voluntary sector and really going into the community, and doing it in partnership. That is the only way of doing it. If you are bringing it into the ICB, consider how much funding there was when Healthwatch was doing it and-I do not want to repeat this point, but I will-the fact that it will be marking its own homework. For me, it is about partnership working going from the community-not within the system and not within the NHS, but going out to the community and feeding inwards.
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...
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.
The Chair
Thank you very much. On that note, Mr Cooper, Ms Tilsed and Professor Croisdale-Appleby, thank you very much for attending, and for your guidance and wisdom-we appreciate it. Professor Croisdale-Appleby: Thank you for the opportunity. Examination of Witnesses Councillor Megan Wright, Sally Burlington and Maria Higson gave evidence .
The Chair
Good afternoon. We shall now hear oral evidence from the Local Government Association, the Association of Directors of Adult Social Services, and South East London ICS. We have until 3.50 pm for this panel. Could you identify yourselves for the benefit of the record, please? Maria Higson: My name is Maria Higson. I would like to state for the record that I am here to bring to the panel the experience of a director of transformation within the South East London ICS. I do not represent the organisation, but hopefully I bring that experience. Councillor Wright: I am Councillor Megan Wright. I am the vice-chair of the Local Government Association health and wellbeing committee. Sally Burlington: I am Sally Burlington. I am chief executive of the Association of Directors of Adult Social Services, which represents directors of adult social care in England.
Q Does removing local authority representation from ICBs weaken the link with local elected representatives, or is it beneficial? Councillor Wright: I assume that was directed at me, as I am a representative in local government. We feel it is going to weaken it. Having someone on the ICB is useful to help shape health strategy and ensure that the wider determinants of health are taken into consideration when planning health. We would like to see some kind of structure where local authorities and other partners involved in determining health from a wider perspective have a voice within the NHS delivering health locally.
Q Thank you. Maria, how do you think the Bill and all the changes around ICB funding will affect local services? To what extent does the process in itself cause disruption-or not? Maria Higson: Whenever we introduce these changes into the system we have to remember that we are talking about a group of professionals who are trying to deliver for the NHS, citizens and patients. This Bill was first announced back in March 2025. It would be fair to say that since then, for an awful lot of people, there have been organisational and personal unknowns. The best intentions to deliver against the agenda and the three shifts can be hindered by that uncertainty. As with everything, implementation is absolutely critical.
Q Thank you. Sally, what would be the impact of the removal of the pooling of better care funding among local authorities and ICBs? Sally Burlington: The better care fund is a really important source of funding for statutory core services. It funds about 80% of social care-in terms of the use of the better care fund by social care, 80% is statutory. While the ability to use it differently could be really valuable, we would be worried about diverting it from those core services into other functions. We have also benefited from the fact that the better care fund is uplifted at the same rate as NHS funding. If we lost that, it would be significant, because social care is systematically less well funded over time compared with some other services.
So you are losing a protection with the Bill. Sally Burlington: Exactly.
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...
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.
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.
Q I am a vice-president of the LGA, and I am also on the all-party parliamentary patient safety group, just to declare that interest up front. I will use the example of my own local authority, Shropshire, which is a unitary authority. It is extremely financially challenged and operates with an ICB in a similar situation. The hand-off that Sally described between continuing healthcare and provision of social care is really problematic because neither organisation really wants to pay for the care for the people who need it because they do not have the funds. It is a really tense relationship between the two. I am really concerned that that will become even more problematic because they cannot work together, given that we are not a combined mayoral authority, that we will not have a mayor sitting on our ICB and that our ICB merged footprint does not fit with our local authority geography. How can the health and wellbeing boards work between the two organisations to deliver good social care?
The Chair
Is that directed at any particular witness?
I am directing it at all three, if that is okay.
The Chair
Let us start with our councillor in the middle. Councillor Wright: It is a challenge. I completely hear that; continuing healthcare is a really difficult one. It is right to say that residents are seen as a financial burden, which should not happen. That is why we need strong health and wellbeing boards. We need strong, honest conversations between local authorities and the NHS for ensuring that good continuity of care. Obviously, I think the overall aim of the 10-year health plan is to move much more to a model of prevention and treatment in the community, where we hope that we could intervene earlier and set up good standards of care before it gets to a stage where it becomes so adversarial. That is what we are aiming for. We have challenges in our local authority and have had to push back on a few cases where we felt the NHS should be helping those people. Sally Burlington: The problem is getting bigger over time. We did some joint work last year with the NHS Confederation to look at those difficult issues on the boundaries between health and social care, including continuing healthcare and mental health aftercare. That identified some good models. We see arrangements for joint commissioning of continuing health care, which can work well. We have seen a little bit of withdrawal from that by some ICBs. Part of the issue has to be that we are seeing a real intention to cut costs, and that leads to lots of reviews taking place that do withdraw continuing healthcare. We have...
Q Do you think that the health and wellbeing boards, as envisaged by the Bill, will be the right structure to deliver those relationships, and how do you ensure that they have the right skills? Councillor Wright: I chair a health and wellbeing board, and everyone comes to those; there are really good conversations and really good reviews of what is happening. I think they are in a really good position. What I worry about is how much influence they will have over NHS wider strategy. I was at a King’s Fund day, and someone said something that I thought was so true: the Health Bill and the NHS 10-year plan is the NHS 10-year plan. The NHS will be judged on how it achieves what it is meant to achieve. Although, as local authorities, we want to help with prevention and those wider determinants of health, ultimately the responsibility sits with the NHS. It is about trying to work out how we have better conversations with the NHS, to say, “We have done neighbourhood health for years; this is what we do as local authorities. We look at all these things and we use public health and our adult social care system to create healthy environments. We need you to be on board with us.” I therefore think there is something about the power dynamics regarding health and wellbeing boards and how we address them. But overall, I feel that they are the best way of ensuring community health. The other thing is about geographies. Health and wellbeing boards might not match neighbourhood health...
Q Having been both a local councillor and a Health Minister, I am very conscious that the real test of any joint working arrangements between different bodies comes when budgets start getting a little tighter. We see that tension growing a little bit with the cuts made to ICBs’ budgets. I was the Minister who created ICBs, and I sat on that Bill Committee with the current Minister for Secondary Care. I am getting a sense of déjà vu-we are on different sides of the Chamber now, but we sat through the Committee stage of the Health and Care Act 2022 together. I deliberately created ICBs to match the geography of upper-tier authorities because health and social care is essentially one system. If one bit does not work, the other bit does not work. Since then, we have seen significant mergers and larger areas, further removing them from that direct relationship and read-across. Although the good ones do, I fear that a lot of NHS ICBs do not fully reflect the intention behind their creation, which was to see them as a genuinely collaborative exercise with equal voices in the room. My question is: if we see ever-larger areas or fragmented areas, whether through neighbourhood health plans or mergers and acquisitions among ICBs, how do we maintain genuine local accountability and the relationships that underpin any structure written in law, on a piece of paper or in guidelines? Notwithstanding what is being done about the health and wellbeing boards’ increasing involvement, do they...
Q Constituents have raised issues with me about when elderly patients or patients with dementia, in particular, come to discharge and the transfer of care, because of the lack of effective data and information sharing. To what extent do the provisions in the Bill on the single patient record allow data to be shared with social care providers? I will ask Councillor Wright to start off. Councillor Wright: At the LGA, we are arguing for a single person record, so that we have a single patient record that brings in social care providers, or at least the local authorities’ social care statutory provision, too. Someone discharged into the community would therefore still have access to records and know what was going on, while others would know what has happened to that person and what they need. Yes, we agree: we hope that a single patient record would make things as smooth as possible from hospital discharge to home and would help when someone comes into hospital, so that the clinicians have a better idea of what the patient’s quality of life was like, what treatments they were on, and so on. We are definitely in support of the single patient record for that, and we would like it to become a single person record. Sally Burlington: We are supportive as well. The Bill itself is unlikely to solve all the problems in this space. A huge number of practical cultural system problems exist in data sharing, so the regulations that follow the Bill will be important to enable that to work...
Q Ms Higson, given that you are a director of transformation, and that this is, in a wider sense, a transformation of the NHS, if you had the money, resources and political capital that the current Government have, would you do this or would you do something else? Maria Higson: Any time we go through an NHS reorganisation, it is distracting-that is the reality of such situations. It is unfortunate that, over the past 15 months, this has been a large distraction for people who are genuinely trying to deliver the three shifts-prevention, digital and neighbourhoods. It is true that it has been a distraction. I am not sure that this Committee is the right space to go into these, as I am aware that we are here to discuss the Bill, but there are probably opportunities to go further on some elements, which may help us in future.
Q Can you give a couple of examples? Maria Higson: To take one example, I would love to see an NHS where we step away from short-term activity metrics, and towards outcomes-that is mentioned in the Bill. The constant firefight on activities is quite challenging, so how can we move that dialogue to ensure genuine transformation? That is an example of where we could potentially go further than the Bill suggests, but I am conscious that I am supposed to comment on the Bill, not give my own random thoughts.
Q One of the concerns of my local healthcare trust is around the release of elderly patients into the community, as it finds that relations with the ICB are sometimes difficult. How can neighbourhood health plans work well and cohesively with healthcare trusts to release patients into community care?
The Chair
I could not hear the question from this end of the room; I do not know if our witnesses could.
I was talking about bed-blocking in hospitals and how neighbourhood health plans can work more cohesively with hospital trusts. Councillor Wright: I think we can answer this together. The whole point of neighbourhood health is to bring in everyone in the voluntary sector, your patient transport and all that, so that your joint strategic needs assessment has a good understanding of what is available to someone in the community when they come home. We talked before about having a strong single patient record so that good communication is there, and neighbourhood health is able to strengthen that. Neighbourhood health should be not just about shifting the need from hospital to community, but about reducing that need in the first place so that fewer people need to go to hospital. At the same time, we are seeing some good developments in the NHS, such as frailty teams and hospital at home teams, all of which help to prevent people from being admitted to hospital in the first place, and to ensure that when people come home, there is a team to visit them. You are right about the communication issue, although it has not been an issue where I am, as we have very good communication with our local ICB about the people being discharged, to make sure that someone is there to meet them and that nurses come out to see them when they come home-I cannot remember the word for that. We have the right systems in place and they are working. I do not know how neighbourhood health will work...
Q Sally, you have said a bit on this already, but could you say a bit more about how the single patient record could change and improve day-to-day experiences of the health and social care system, and the safeguards that you might be concerned about? Sally Burlington: As I understand it, the safeguards around data sharing remain in place under the Bill-they do not change. The part of the single patient record that is really attractive to our world is that people will not have to repeat themselves to every professional they meet; they will not have to tell their story again and again or be retraumatised by explaining the detail of what they have been through. The potential advantages are there, but there are obviously concerns about data protection and how data is used. It is incumbent on us all to take those seriously, think them through and make sure that safeguards are appropriately implemented locally and in all the institutions that have access. That is probably a matter less for the Bill and more for the implementation and supporting regulations, but we and other partners will be keen to be a part of that process to make sure that the safeguards are appropriate.
Q I come from a county with really significant health inequalities-people in the wealthy parts of the county live 10 or 12 years longer than people in some of the more deprived parts of Aylesbury, which I represent. I would love to hear your thoughts on how we ensure that local authorities, ICBs and the voluntary sector continue working well together through this, and specifically how we do that in a way that drives the reduction we need in health inequalities. Maria Higson: I think we are all agreed that working at the neighbourhood level is absolutely the right way to go about that. That is where health inequalities can best be addressed, because that can be most nuanced and tailored. Working on that smaller footprint is really important. You mentioned voluntary, community and social enterprise organisations, and I think that is a hugely important part that has broadly been missed out from the conversation around these changes. We work closely with VCSE partners and we know they deliver huge amounts for the communities and understand the communities in which they are embedded very well, so making sure that the VCSE voice is part of those neighbourhood teams will be important for that nuance and tailoring in the local element. Councillor Wright: I agree entirely. Local authorities are in a good position to engage the voluntary and community sector. But again, we are fighting for a voice with the NHS and they are fighting for a voice with us, so we need some honest...
Q Which organisations or people do you envisage running the neighbourhood health centres? Will they be run out of general practice organisations, or will the local authorities themselves be best placed to run them, so as to join up hospital care with community services? Councillor Wright: That is quite interesting; I was at a session this morning looking at communities, and there was a comment that for the NHS communities are about buildings, whereas for the local authority they are about people. I think it would be the ICBs and whoever they commissioned to provide neighbourhood health centres. I hope there would be enough input from the voluntary sector, the local authority, adult social care and public health-from everyone-but I see the ICBs as the commissioners and the people who organise them.
Q So the ICB will commission it, but somebody will have to run it. Who should run a neighbourhood health centre? Maria Higson: If we want to be as open to change as possible, my argument would be that that should be decided locally. Would it not be fantastic if, for example, some of them were led by VCSEs that worked in close partnerships and had clinics where GPs came in? You can envisage a whole number of different scenarios, led by local communities and local organisations. This plays back to the health inequalities point, but that is how you do it, although it relies on you being open to different models and not trying to do a one-size-fits-all, which is really tricky when you are trying to implement.
The Chair
Last word, Sally Burlington. Sally Burlington: I strongly agree with that. If you were asking who is best placed to run them, the answer would be that it probably looks different everywhere, because it will rely on local leadership and local capability and capacity, which varies across all our sectors, so this is a really good opportunity to make the most of that leadership ambition and skills and capacity locally.
The Chair
Thank you, ladies. The Committee is most grateful to you. I will just explain now, while we are changing over witness panels, that after I introduce the next panel there are likely to be-in fairly short order, because the Minister is on his feet-four Divisions in the House. I shall suspend the Committee from as soon as the first Division is called until 10 minutes after the start of the last Division, when we will start again. I hope that is clear. It does mean, I am afraid, that we will have to ask our witnesses to be very patient. It is extremely tedious and very discourteous, but that is the way this place operates, I am afraid. Examination of Witnesses Emily Holzhausen, Paul Farmer CBE and Kath Abrahams gave evidence.
The Chair
We will now take evidence from Carers UK, Age UK and Tommy’s. Could you introduce yourselves for the record, please? Paul Farmer: I am Paul Farmer. I am the chief executive of Age UK and also the chairman of the Richmond Group of Charities, which comprises 15 of the larger health charities as members. Kath Abrahams: I am Kath Abrahams. I am chief executive of Tommy’s, which is the pregnancy and baby charity looking to stop the heartbreak and devastation of baby loss and make pregnancy and birth safe for everybody. Emily Holzhausen: Hello, everyone. I am Emily Holzhausen, director of policy at Carers UK, representing England’s 4.7 million unpaid carers. I also have lived experience as a carer.
The Chair
Thank you all very much for joining us.
Q My first question goes to all of you. In principle, the single patient record offers opportunity, but people have expressed reservations, as have each of your charities. What are your thoughts on the single patient record? Paul Farmer: From the perspective of older people and people with long-term conditions, the single patient record will be, broadly speaking, welcomed. I will explain very briefly why. If you are an older person with multiple long-term conditions and you find yourself in hospital, you often have to explain your experience and health needs, time and again. That is often because of a lack of join-up between the current data systems. Single patient record means the individual patient does not need to repeat their stories or lived experience-and, more importantly, it allows clinicians to have a clear overview of an individual patient’s health records. There are issues that need to be considered, particularly around making sure that people are not digitally excluded, and I am sure that we will get into those, but at a high level we would welcome the introduction of a single patient record. Kath Abrahams: There are some very similar themes for us. A lack of shared patient record is a particular issue in pregnancy and maternity. You are being seen by your GP, early pregnancy unit and maternity unit. You might have other conditions that affect pregnancy or could affect the outcome of your baby being born. At the moment those systems are very disjointed. The other...
Q I have a question for Emily about digital exclusion and the app. What can be done to help people not to be digitally excluded? How do you see this working in areas of the country with poorer broadband connections, for example? Also, what about the record? Sharing your medical records is not an all-or-nothing thing, is it? It may be that someone is happy to share their current illness or current medical circumstance with their carer, but may perhaps want aspects of their history to remain a secret. Have you had any indications from the Government on how that might work? Emily Holzhausen: Yes. That is a lot of different questions. It has to be done with the right permissions, with the patient being in control of their data-that is a very strongly held principle within the NHS. There will be situations where people do not have capacity and their primary carer, who might be their partner, their son or daughter, might need access. We have lasting power of attorney in England, which could be used as a mechanism, or other assurance mechanisms. As for digital access, that is an issue that I am sure Paul will want to come on to. Especially when digital access costs money and we have people in poverty, we have called for that to be supported by Government to ensure that everybody has digital access. People have to feel confident about it. While we have seen a doubling in the number of carers using the NHS app to manage their own health and care in the past two years, there are key...
The Chair
Paul Farmer, you have been given the floor. Paul Farmer: I would very much like to come in on this subject. We see probably the greatest risk and the greatest opportunity here, in the context of digital exclusion and digital inclusion. The risk of digital exclusion is that older people in particular, although it is not exclusively an older people’s issue, will lack the access to their own care record, as it is electronically based. We need to bear that in mind when we think about the roll-out of that and the availability of the content of that patient record to people who are digitally excluded. I do think, however, that this is a significant opportunity. It is part of a much broader question about digital inclusion more generally, and inclusion into accessing public services more generally, which is a key theme of the work we are doing at Age UK. We had funds from DSIT to support the work of our local Age UKs, where we run a number of digital champions programmes-Members are very welcome to come and visit them at any time. We worked with 8,000 older people in a two-month period; we engaged more than 1,000 of that group into our digital champions programme, and two thirds of people took up the offer of engaging in a training module on accessing the NHS app. In particular, we were able to enable people who are partially digitally excluded. We are publishing a report later, which we will share with the Committee in time, about the opportunities for people who are not fully...
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...
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...
Sitting suspended for Divisions in the House.
On resuming-
Q We have talked a lot about the single patient record, but I want to touch on whether the Bill does enough for people who have historically not been listened to, as we have heard has been the case for carers and women who have suffered in the maternity system. Does the Bill deal with the problem of people not being listened to? What opportunities are there to improve the Bill in a way that improves the situation? Paul Farmer: Listening to patients is an incredibly important part of any health system. It is necessary to make sure that the right mechanisms are in place at both the individual and the systems level. The aspects of the Bill that cover patient experience need careful consideration. Many people were fans of what Healthwatch delivered, and others were not, but it had a clearly established system and mechanism in place to ensure that patient voices were heard. It is important that clear systems are established to ensure that that patient experience is heard. I have operated around the health system for a number of years, seeing a number of incarnations of patient voice organisations and representation; you really have to think about it from the individual and the whole-system level-from top to bottom. It is important that the Committee looks at the provisions in the Bill in that context to make sure that where there are good supports, they not only are preserved but can be built on. For example, how do you make sure that patient voice is heard at ICB level, in...
The Chair
I do not think there are any further questions. I am sorry to have kept you waiting so long for what has been a relatively short period of time, but it was important that all Front Benchers, and any other Members who wished to do so, had the opportunity to question you. Thank you all very much for being so patient and for giving us the benefit of your thoughts and wisdom. Examination of Witnesses Dr Michael Cocker, Dr Towhid Imam and Dr Nicola Byrne gave evidence .
The Chair
If everyone is ready, we will proceed to the next panel; as you will see, one of our guests is on the screen. We have Dr Michael Cocker, from East Lancashire hospitals NHS trust, Dr Towhid Imam, from Croydon health services NHS trust, and Dr Nicola Byrne, the National Data Guardian for Health and Social Care. We will get through this as reasonably swiftly as we possibly can without cutting corners, if that is all right. I will try to bring this to a logical conclusion within- [ Interruption. ]
Sitting suspended for a Division in the House.
On resuming -
The Chair
For the sake of the record, starting with the two people in the room, will you identify yourselves, please? Dr Imam: Hello, I am Dr Towhid Imam. I am a consultant geriatrician, working in Croydon university hospital, where I set up the front-door frailty service. I am also a clinical lead in South West London ICB and an adviser to NHS England. Dr Byrne: I am Nicola Byrne, the National Data Guardian. I am also still a practising clinician, as a consultant psychiatrist in south London. Dr Cocker: I am Dr Michael Cocker. I am a consultant obstetrician in the north-west of England, in Burnley general hospital. I am the clinical informatics officer for maternity at my trust.
The Chair
Thank you all for joining us. Again, I apologise for the disruption.
Q I should say that I also work as an NHS consultant paediatrician. The single patient record offers a great opportunity for doctors, clinicians and patients to all be much more joined up, but I have a quote from the Secretary of State on Second Reading: “rather than data being transferred from where it exists at the moment to a new system, it will remain where it is-in GP surgeries, hospitals and so on-but it will be linked up so that one person, including the patient, can see all that data”. -[ Official Report , 1 June 2026; Vol. 786, c. 890.] How easily will that work in practice? In the trust that I work in, we have different systems for blood results, results, tracking patient appointments, maternity and A&E. Is it realistic to expect someone to be able to log on from one part of the country and to understand all the different systems in all the other parts of the country, or do you think that it needs to work in a different way? Dr Imam: About a month ago, we published some NHS England guidance on best practice for frailty. Included in that are examples of shared care records, where people who are living with frailty who have been assessed by health services can actually view one record. The way those work is to take information from multiple different records and place it into one shared care record, in order for clinicians from various different backgrounds and multidisciplinary teams to work together.
That would be moving it on to a new system. Dr Imam: That is in a separate shared care records system. Dr Byrne: As I understand it, the architecture is not yet decided, so how we solve those technical challenges will be determined by the choice of architecture. Dr Cocker: Similarly, I believe that the technical solution for how that will be delivered has not been finalised. When we did the maternity-based pilot in the north-west, the wireframe prototype that was developed pulled information from all the separate systems-the maternity system, the hospital central electronic patient record system, the GP system. The pilot was based on pulling it from each individual system into one place where it can be viewed, but that is a future aim. The focus is on phased implementation, so it would not all be immediately available like that, but that is the vision.
Q Of course, it would need to be viewable across the whole country for people who travel around. What about the security of this data? Lots of people have expressed concerns about the security of the data, both from people who are a bit nosey and who want to have a look, and from people who would wish to do the country harm, hacking large volumes of data. How do we keep it safe? Dr Cocker: That is a pertinent question. I know that that has been the focus of a lot of concern since the Bill was publicised. I believe that the structure of the SPR would be recognised as a critical national infrastructure-type of project, so it would have access to more resource to protect it. But there will always be inherent risk, when you have something centralised, that it is a single target rather than multiple targets that could be attacked-for example, in a cyber-attack. Role-based access would be important-for example, having an understanding that the information should be accessed only for the provision of clinical care. How it would be delivered on a technical level would have to be finalised; that was not the type of the prototyping work we did, because it was more about a proof of concept than those more minute technical challenges. Dr Byrne: I am glad that Dr Cocker took that question first, because he has given you a helpful technical answer. As National Data Guardian, my mission and concern is primarily around public and professional trust. Trust in whether this system can be...
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...
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...
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...
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,...
Q My other question is about digital exclusion. This is particularly for Dr Imam, because we associate older people with being digitally excluded, although I know it is not exclusively older people who are digitally excluded: how would you envisage the digital record interacting with something more analogue for people who cannot use the NHS app for whatever reason? Dr Imam: That is a really important question; it is something that needs to be thought about very carefully when it comes to the implementation. From my previous NHS England experience, where we have had digital innovations implemented in the older age group, or among those who are perhaps traditionally digitally excluded, that has included partnerships to enable people to have the option of someone coming around, and there has been a thought process regarding people who perhaps cannot engage with technology as easily. That could involve people from the voluntary, community and social enterprise sector-for example, we had Age UK in the previous panel. There are lots of good examples of that type of work to ensure that people are not disadvantaged. Dr Byrne: There is an opportunity here in the context of digital exclusion. In a digital-first NHS, it is really helpful to think continually about what the analogue version of the system is in the event of further cyber incidents and outages of the system. We need to continually build and maintain a resilient system for the times when digital-first is not available. It...
Q I was listening to Dr Byrne’s concerns about confidentiality and trust. I want to declare that I have worked in the NHS in the mental health sector for many years. I worked in one of the biggest mental health trusts, Kent and Medway mental health NHS trust. We use an electronic patient record called Rio. As Dr Cocker said, before anyone is given access to the record, they have to have training on information governance and data protection, and access is given based on their role. That system creates an audit trail, so patients can request to see how many people have accessed their information in the last month or two-there are facilities on the system to check that. Is staff training and raising awareness among patients important for creating trust and confidentiality? Dr Byrne: Those things are very important, yes. There are some technical solutions. Again, the SPR is an opportunity to look at that across the system, because systems vary greatly in the sophistication of their audit function, for example. Even when there is an audit function, if someone has legitimate access through their role as a doctor or a nurse, it can be difficult to know whether their access in any particular case is legitimate. These are not common occurrences, but it is extremely distressing for patients if their confidentiality is breached for any reason. It is not simply a matter of technical controls. We need to look at how we build stronger, more effective deterrents across the system by...
Q I am an ENT surgeon. What do you think about giving the patient ownership of the single patient record as well as discretion over whether the information in that record is revealed to the clinical team? Dr Byrne: It is an interesting idea, but I am not sure. I heard your question earlier about data controllership specifically in this regard. You will not necessarily like my answer. There are two ways of answering the question; perhaps straightforwardly, legally, but also clinically. I will start with the legal answer, which in some ways is easier. Data controllership in data protection law is a very technical term; it is determined by who is making the decisions about processing the means of the data. An organisation running and controlling an electronic patient record would be the data controller. Obviously, this is ultimately a question for the regulator and the Information Commissioner’s Office to determine, but that would be the legal position, nevertheless. Clinically, we have to come back to thinking about what a patient record is for. Primarily, it is to provide good care in the context of the clinician-patient relationship. If you prioritise the needs of either side of that relationship, I think it is problematic; the needs of one must not outweigh the needs of the other. The clinical record is there to enable clinicians to record what someone is presenting with, the difficulties they are having, what investigations are appropriate, the findings and what the plan...
Q I would love to amend the figures in my bank account-I would like to be able to go into my Lloyds bank account and add a nought to the end of the balance figure-but I cannot, because the bank controls that. But I am the one who has access to the data. Dr Byrne : I totally support that ambition. Patients and the public having more agency in their care, strengthening that relationship, and them being able to access their information through the NHS app is a great thing. That is hugely helpful, and there is real potential with the SPR to strengthen that. We have landed on agreement.
Q Do you have any thoughts on the separation of elements of the record such as safeguarding records and sexual health records? We have heard about carers being able to see parts of the record. Surely there are circumstances where we may want people to see parts of the record but not others, or people may wish to share some parts and not others. Are you aware of any provision being made for that? Dr Byrne : At the moment, I think it is too early to say. Those are absolutely important questions that will have to be addressed in the design. At the moment, I am not sure how the programme intends to deal with those questions, but clinically, that needs to be thought about. There are complications that need to be thought about very carefully in terms of the record and the access. Sometimes that is clinically complicated, but I am not aware of what the plans are for that.
Thank you. You are nodding, Dr Cocker. Dr Cocker: I was just going to say that we did do some exploratory work in relation to safeguarding, because that is quite a key part of safe maternity care, but because of the issues with confidentiality for other involved parties-say, a mother’s partner or someone else in the family-and the risk of that information being pulled through to someone else’s single patient record, it was felt that we could not include any information that contained information about anyone else. That aspect has been considered, but as Dr Byrne said, it would need careful consideration of all those different sources and whether there would be any option to change what feeds in. The only one I am aware of that we have looked at specifically was safeguarding, and it was primarily due to confidentiality issues for other involved parties.
Q Presumably, the obstetrician may need to be aware of previous pregnancies, but the patient may not want their current partner to know about them. Dr Cocker: Yes, and those are concerns with the existing systems. There are multiple sources of information we record on a clinician-facing basis that might be deemed sensitive or confidential that are not available from a patient-facing perspective. It might be sexually transmitted infections or previous pregnancy history that a mother does not want someone else to be able to access on the patient-facing aspect of the record. Being able to provide that is very important in realising the end product of the SPR.
The Chair
Dr Byrne, Dr Imam and Dr Cocker, thank you very much indeed for your patience and for affording us the benefit of your experience and wisdom. The Committee is most grateful to you. Examination of Witness Jon Restell gave evidence.
The Chair
We will now hear oral evidence from Managers in Partnership. We have until we have exhausted ourselves-I will say that for the moment-for this session. Would you be kind enough to introduce yourself for the record? Jon Restell: I am Jon Restell, the chief executive of Managers in Partnership.
Q Good afternoon, Mr Restell. When the NHS has been reorganised in the past, it has become more centralised or less centralised. Which do you think this Bill does? Jon Restell: There are lots of different ways to answer that. Obviously, some functions of NHS England moving into the Department, with powers going to the Secretary of State, feels like a centralising measure. I know that the ambition of Government is to give local NHS bodies more freedom and autonomy, but the Bill is very careful and goes into a lot of detail to leave powers with the Secretary of State to intervene in the running of those local bodies. On the whole, it is probably more of a centralising measure. Another way that some changes outside the Bill process are centralising is through the merger of ICBs and, arguably, quite a lot of providers. Whereas before you might have two or three ICBs covering an area, you now have half the staff covering much bigger geographies. I would argue that that centralises decision making to a higher level than formerly.
Q What effect is that having on managers and their ability to do the day job and deliver care? Presumably, a lot of time, effort and energy, and perhaps a lot of worry, are going into the process of reorganisation. What effect does that have on the delivery of services and the development of new ones? Jon Restell: This, for us, is the crux of what is going on. The Bill is the Bill, but there is a finite management resource in the health service. I think that, internationally, it is considered to be quite low. Certainly, Lord Darzi, the Institute for Government and Institute for Fiscal Studies have all pointed to a shortage of management being one of the potential weaknesses of the NHS, so what is going on right now is knocking another big hole in an already limited resource of managers in the health service. That has the potential to create very large workloads for people in the new system, such that, inevitably, certain things will not get done or will not get done well enough. It certainly feels like we have gone into an environment where we are cutting a management cost without thinking about the management capability the health service needs to innovate, deliver reform, and do basic safety and resource management.
Q That does not sound very good. The Government said that they were going to regulate NHS managers. What impact do you think that would have? Jon Restell: Our members have been on a bit of a journey on this one. I think that they would broadly support the regulatory proposals that the Government will bring forward after the consultation. I think the real impacts will be very limited, covering a relatively small number of people and being used in very exceptional circumstances, so I do not think that they will transform management culture and deal with the management capability issue we have. They are a very personal form of professional regulation that will have very limited impact.
Q We have heard a lot today about things not being quite finalised yet; we are not quite sure where the destination is. Is it difficult for managers to be asked to transform from a current service to a new service if there is no well explained vision and understanding of what “new” looks like? Jon Restell: That is probably driving most of the anxiety and uncertainty that people are experiencing, and it is why, for some members, this is becoming psychologically very difficult. You have a change programme that started in March last year with the announcement by the Prime Minister of the abolition of NHS England and the halving of the staff of NHS England and ICBs. For 18 months, that process has dragged on, with lots of design decisions still to be taken about how the organisation will look, what functions it will have, what will be going to the Department and what might be going elsewhere, and what will potentially go to trusts from ICBs and from ICBs to regions. Despite all that uncertainty, people are being told to make decisions about voluntary redundancy and the future where they do not understand where that future potentially sits for them. That is undoubtedly driving a lot of people to feel psychologically unwell and distressed, and they are leaving. People are beginning to leave, because they need to protect themselves. There is another part to this. Obviously, that is a very personal issue for our members, but the other thing is that they are really worried about the...
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.
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...
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...
Q If I may ask a related question, one element of the Bill is the reorganisation of who sits on the ICB. We have seen the removal of local authority representatives and their replacement by a mayor or his or her appointee. What concern does that cause to your members-or do they think that is the right way to go? Jon Restell: A lot of the concern is to do with the political make-up of mayoralties in the future and what that might mean; if mayors have an ever-growing responsibility and say in the who, what and where of health services, that is probably different from the more representative, advisory function that they have had. That really needs to be thrashed out: is that the new democratic accountability for health services, or does it remain, as now, with the Secretary of State, accountable to Parliament, making provision for healthcare? It feels a little unclear how much decision-making power those new local government voices will have on ICBs. Have people raised that as a concern? Of course they have; it is uncharted.
Q I am a vice-president of the Local Government Association. With changes to the better care fund pooling and the link-up with local authorities, are there concerns at ICB level that the partnership with social care will start to become more difficult? Jon Restell: I cannot comment specifically on the BCF, but a general theme coming out of what our members are telling us in surveys, and in the regular surgeries and meetings that we have with them, is the sense that policy at the moment is trying to get you thinking in terms of your own organisation again, and thinking less about system-wide transformation, innovation or co-ordination. ICBs are getting bigger and providers are getting bigger. It is some of the system stuff, where I think a lot of our members would say the innovation will come in the way different organisations try to solve problems around patients and populations, that they feel is at risk, by the way-not just from the Bill putting things together, but from the stripping out of resource to do anything different.
The Chair
Thank you very much indeed, Mr Restell. Thank you for your patience, thank you for coming and thank you for the evidence you have given. It is greatly appreciated. Examination of Witness Sir Andrew Dilnot gave evidence.
The Chair
We shall now hear oral evidence from Sir Andrew Dilnot. Sir Andrew, for the benefit of the record, could you identify yourself, please? Sir Andrew Dilnot: I am Andrew Dilnot; it is great to be here.
Q Good afternoon. Social care is one area that is absent from this Bill. To what extent is it possible to make the health service more efficient without tackling problems in adult social care? Sir Andrew Dilnot: It is largely absent from the Bill-indeed, when I was asked to come and give evidence to this Committee, I was initially somewhat puzzled, since it is so largely absent. The question you ask is absolutely to the point: certainly, we can improve the efficiency of the NHS without doing anything about social care, but we cannot really address many of the fundamental problems facing the NHS if we do not sort out social care. That is partly because not having a good social care system means that we are not achieving the levels of human flourishing that are the objective of the health service and the social care system. It is also the case that the social care system is now under such pressure that it is leading to direct challenges for the NHS. We hear a lot about delayed transfers of care, which are an important part of this, but it is not just those; it is people who end up needing healthcare because they have not had appropriate social care support. The short answer to your question is that we can make the NHS a bit more efficient without reforming the social care system; but until we address social care we have at least two hands, and probably one foot, tied behind our back. It seems pretty astonishing to me that we have a 10-year NHS plan but no real plan for social...
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...
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...
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...
Q I will put words in your mouth, and you can disagree with me. Do you think the Bill should tackle the point about having a properly funded care service so that the transition from hospital to the community can actually take place? As you have just said, if people are not cared for properly, they end up back in hospital, and everyone here agrees that is what we are trying to avoid. Sir Andrew Dilnot: Yes, it is very odd. It is worth doing the odd thought experiment: imagine that the bit of healthcare that was underfunded and available only subject to a means test, and not free, was for heart disease. We cannot imagine it. The fact that it is dementia and severe arthritis means we have drawn an arbitrary line, and while that line still exists and there is still inadequate funding, even in a means-tested system, we are hamstringing the NHS. Now, that is not the most important problem, which is that we are failing to give people flourishing lives and allow them to live to the full, but it is now so bad that it is actually making it hard for the NHS to work.
Q Hospital pressures on the Isle of Wight are particularly severe, and part of the way of dealing with so-called corridor care is for the hospital and local authority to look at discharging some frail patients to the mainland, including those living with dementia, which is plainly not a solution by anyone’s normal interpretation. Is there anything in this Bill, notwithstanding that it does not deal with the fundamental problems of social care, not only that can help to resolve those sorts of situations, but that could help to resolve them if it went a little further? I am looking for opportunities to use the Bill to try to do a little more in and around discharge and social care. Sir Andrew Dilnot: That is a very good question, to which I do not have a very immediate answer. Well, I do have an immediate answer, which is that, as far as I can see, it is nothing very substantial. The single patient record offers some prospects here, and it is terribly important for people receiving social care, which again reflects how much longer we are living. There is much more multiple morbidity now. Many of the people who can and are benefiting from social care will have quite complicated medical experiences and histories. That is the kind of group that could particularly benefit from a single patient record, so that we are not having inappropriate prescription and so on. That is going to help, but it will be a second-order issue. Let me be very blunt. There are two fundamental challenges...
Q You have talked a lot about adult social care in terms of the very elderly and frail and people with dementia, but it also affects younger people. For example, Swallow Lodge, which is a facility for working-age adults in my constituency, is under threat of closure. I and others have made the arguments about how it is a lifeline that allows the families to have a break and the individuals using the service to flourish and enjoy life, but there is an economic argument too. How well do you think that is understood? Closing such a place could lead to higher costs for the NHS in mental health or physical health support, further social care admissions and the like. Sir Andrew Dilnot: You are absolutely right to emphasise the importance of non-elderly adult social care, which is roughly half of all of the expenditure and growing. One reason that we see particular pressures in the elderly care sphere is that the less-elderly need has grown very dramatically, again because of the scope for increased human flourishing. On the whole, as far as I can see, there is very little understanding of the integrated nature of these costs between social care and the NHS, so I think there is very little thinking in budgetary terms about the consequences of the squeeze on social care leading to increased expenditure and needs elsewhere in the NHS. That is not easy to resolve. Moving to a system that properly integrates those trade-offs will be difficult, and it requires a different sort of...
The Chair
Thank you very much indeed, Sir Andrew, for affording us the benefit of your considerable knowledge in this area, and thank you again for your patience. We are most grateful to you. Sir Andrew Dilnot: Thank you. I am delighted that you are thinking about social care in the context of this Bill. Examination of Witness Karin Smyth gave evidence.
The Chair
Minister, for the sake of the record, would you identify yourself, please? Karin Smyth: I am Karin Smyth, the Minister of State at the Department of Health and Social Care.
Q Minister, you have previously said: “The reorganisation of health services always distracts from people’s jobs, destroys morale and wastes money”. -[ Official Report , 22 September 2020; Vol. 680, c. 809.] In response to a written question this week, though, which asked what assessment you have made of the disruption of development of new services caused by the abolition of NHS England, you said: “The abolition of NHS England is causing no disruption to the development of new services.” I wonder which of those statements you agree with the most and whether you want to change your mind in the light of any of the evidence you have heard today. Karin Smyth: I do not know exactly what year you are quoting from, but I am happy to take that full on. Of course, change, reorganisations and changes in legislation have consequences at different times depending on what they are. That will determine changes to some services at local level. I think that quote probably relates to the 2012 changes, which, as I have often said, brought me into Parliament. The entire infrastructure of the health service was destroyed and changed in order to bring forward that legislation. I can never find anybody-I think I have heard Lord Lansley say this-who thinks that was a good thing. I am very happy to say that part of the rationale was the fact that, despite lots of warnings about the damage to that infrastructure, that lesson was not learned. We will not go through the history of the passage of that...
Q May I press you on the answer to my first question before I move on to the next? In the light of what you have heard today, do you want to correct your statement this week, in response to a written question, that the abolition of NHS England is “causing no disruption”-yes or no? Karin Smyth: In terms of service delivery-I think the written question was about delivering services- I stand by that.
Q My next question is about the vision. My right hon. Friend the Member for Melton and Syston spoke earlier about his reforms of the past, and there was a coherent vision to those, but today we have heard that there is not really a plan. On the single patient record and other aspects of the Bill, lots of decisions have yet to be made. You are asking people to move from here to there without specifying where “there” is. Is this ready? Are you trying to get to a landing place that you understand as a coherent vision, or are you just trying to unpick things that somebody did before and that you did not like? Karin Smyth: Do you mean the future state of ICBs?
No, I mean the system as a whole. My right hon. Friend the Member for Melton and Syston spoke earlier about how ICBs were designed to link in with upper-tier local authorities, and he gave a reason why. Under these reforms, Lincolnshire ICB, which was part of a mayoral authority, will now link in with Derbyshire and with Nottinghamshire, which are part of another mayoral authority but not a complete mayoral authority. You have things jumbled up. I wonder whether that is because, rather than having a vision, you have started to unpick somebody else’s work because you did not like it. Likewise, with the single patient record, we have heard that lots of necessary decisions were not made before the Bill was introduced, so people are being asked to deliver things that have not been properly considered. Is that fair? Karin Smyth: I think they are two separate things. On the provision made in the Bill, abolishing NHS England brings with it a lot of technical detail to ensure that the legal responsibilities and duties are placed, rightly, on the Secretary of State and into ICBs. It clarifies the landscape on very technical matters such as licences and foundation trusts, and there is a large chunk of detail on the consequences of abolishing NHS England. Alongside that, there is a move to give ICBs a larger footprint, in parallel with the Government’s agenda on devolution. I accept that that is a lot of change in all our constituencies and for all our areas. We are making sure that we...
Q We have heard a lot about independence: the independence of HSSIB, its ability to independently investigate and independently recommend, and Healthwatch’s ability to independently describe patient voice without interference from those whose homework it is marking. Do you have any reflections on the Bill and what it contains in the light of what you have heard? Karin Smyth: There is a fundamental philosophical, and perhaps political, difference in the approach that this Government are taking compared with what has gone before, in terms of the notion of responsibility and accountability for both commissioning and delivering services, and the position of independence. We talked earlier today about perception and reality. The system has not worked. To my earlier question- I think I said this on Second Reading-we have had what is called an independent voice in some of these bodies for over 50 years, and we have had numerous recommendations. I disagree with Jeremy Hunt on this. Under his stewardship of the new NHS England, we had a plethora of recommendations and new organisations, and layer upon layer of bureaucracy, totally remote from any kind of democratic accountability or oversight. That is not working, and I do not think that anybody is really defending that. It is the job of the NHS-both providers and commissioners-to include patient voice and patient experience in their work. I think Ciarán Devane from the NHS Alliance said that getting boards right, in terms of their...
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....
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...
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...
Q I have a technical question about foundation trusts. The 10-year plan says that foundation trusts could be given population health responsibility for commissioning and budgets. I do not understand how that fits in with the Bill. Could you clarify whether that is not envisaged for now or if it is lurking somewhere in the Bill that I have not spotted? Karin Smyth: I will need to come back to you on the detail of that. In much of the Bill, we are trying not to over-prescribe. However, we need to get foundation trust licensing right. There are some things that are needed in the Bill, which is what we have put in as far possible, and some things that are not. Can I come back to you on that specific point if that does not answer your question?
indicated assent.
Q You are speaking with tremendous passion and I can tell that you see this as an opportunity to make the NHS function far better. You mentioned at the very beginning that it took eight months to make the announcement that you were going to abolish NHS England. How quickly did you realise that NHS England was malfunctioning, far too bureaucratic and not delivering on the priorities for people in this country? Karin Smyth: That is a good question. When I was in opposition, I spoke frequently about accountability and democracy, as the hon. Member for Sleaford and North Hykeham was trying to highlight-I am sure that we will hear some more quotes. I cannot speak for the former Secretary of State, as he is not here, but it did surprise us going into the financial year when, despite very clear direction and expectation about the financial situation that the Government inherited and what needed to happen, we were still faced with a very large projected deficit. The duplication meant that there were a lot of people in the room and clearly things were being handed off and that was not working. Ultimately, this is a question that always lurked. I know that the right hon. Member for Melton and Syston is here, and during the passage of the Bill that became the Health and Care Act 2022, we said to the Department that that might have been the opportunity to act. I think that previous Secretaries of State, as was alluded to earlier, thought that they might do that. Ultimately, the benefits...
The Chair
That brings us to the end of the time allocated for the Committee to ask questions. On behalf of the Committee, I thank the Minister for her evidence. Ordered, That further consideration be now adjourned .-(Emma Foody.)
Adjourned till Thursday 18 June at half-past Eleven o’clock.
Written evidence reported to the House
HB01 Ryan Sutton
HB02 Steve Sellwood
HB03 Dr Michael Ellis
HB04 Mike Derry, CEO, Healthwatch Richmond
HB05 Alan Metherall
HB06 John Bache OBE FRCS, Lead governor / public governor, Mid Cheshire Hospitals NHS Foundation Trust
HB07 Helen James
HB08 National Lead Governors Association (NLGA)
HB09 Picker
HB10 Local Healthwatch Working Together
HB11 Healthwatch Nottingham and Nottinghamshire (HWNN)
HB12 UNISON
HB13 One Cancer Voice
HB14 Mrs J Melling
HB15 Healthwatch Birmingham and Solihull
HB16 Dr Chad Byworth
HB17 ISC2
HB18 British Healthcare Trades Association (BHTA)
HB19 Brian Toner, Lead Governor, ROH (Birmingham)
HB20 Tandem Health
HB21 Healthwatch Brighton and Hove CIC
HB22 Healthwatch Worcestershire
HB23 Royal College of General Practitioners
HB24 Stephen Hall, Founder, Digital Narrative Care
HB25 Impact on Urban Health
HB26 Action for ME
HB27 Jean Flanagan
HB28 Specsavers
HB29 Stephen Hickey, Chair, Healthwatch Wandsworth
HB30 Asthma + Lung UK
HB31 County Councils Network (CCN)
HB32 Association of Directors of Public Health (ADPH)
HB33 Health Equals
HB34 Dr Eric Valentine, Lead Governor, Newcastle Hospitals Foundation Trust
HB35 Healthwatch in Devon, Plymouth and Torbay
HB36 Optical Fees Negotiating Committee (OFNC)
HB37 NCHA - The Association for Primary Care Audiology Providers
HB38 Catharina Savelkoul and Professor Sophie Park, Nuffield Department of Primary Care Health Sciences, University of Oxford
HB39 Yorkshire Cancer Research
HB40 Newmedica
HB41 Leeds Health and Wellbeing Board and Leeds City Council