Public Bill Committees

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

Dr Penny Dash, Chair, NHS England

Sarah Woolnough, CEO, The King’s Fund

Jacob Lant, CEO, National Voices

Dr Jeanette Dickson, Chair, Academy of Medical Royal Colleges

Kay Keane, Chair, Institute of General Practice Management

Dr Rosie Benneyworth, Interim Chief Executive, Health Services Safety Investigations Body

Sir Jeremy Hunt MP

Public Bill Committee

Tuesday 16 June 2026

(Morning)

[Sir Roger Gale in the Chair]

Health Bill

Before we begin, I remind Members please to switch all electronic devices off or to silent. I also have to tell you that tea and coffee are not allowed during the sittings.

We will consider first the programme motion, as on the amendment paper, and then the motion to report written evidence for publication and the motion to allow us to sit in private to discuss questions before the oral evidence sessions begin. In view of the timetable, I hope that we can take those matters formally, without any debate. I call the Minister to move the programme motion standing in her name, which was discussed yesterday at the Programming Sub Committee for the Bill.

Ordered, That— (1) the Committee shall (in addition to its first meeting at 9.25 am on Tuesday 16 June) meet— (a) at 2.00 pm on Tuesday 16 June; (b) at 11.30 am and 2.00 pm on Thursday 18 June; (c) at 9.25 am and 2.00 pm on Tuesday 23 June; (d) at 11.30 am and 2.00 pm on Thursday 25 June; (e) at 9.25 am and 2.00 pm on Tuesday 30 June; (f) at 11.30 am and 2.00 pm on Thursday 2 July; (g) at 9.25 am and 2.00 pm on Tuesday 7 July; (h) at 11.30 am and 2.00 pm on Thursday 9 July; (i) at 11.30 am and 2.00 pm on Thursday 16 July; (2) the Committee shall hear oral evidence in accordance with the following Table:

Copies of the written evidence that the Committee receives will be made available in the Committee Room.

Resolved, That, at this and any subsequent meeting at which oral evidence is to be heard, the Committee shall sit in private until the witnesses are admitted.—(Karin Smyth.)

The Committee deliberated in private.

On resuming—

We are now sitting in public again and proceedings are being broadcast. Before we start to hear from witnesses, do any Members wish to make a declaration of interest in connection with the Bill?

I am a member of the Royal College of Paediatrics and Child Health, a member of the British Medical Association and an NHS consultant paediatrician.

I used to work in a mental health trust for many years, and I am still its employee—I am on an extended career break from the trust.

I am a vice president of the Local Government Association.

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

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

I am a retired ENT surgeon and a fellow of the Royal College of Surgeons.

Thank you very much. It will be helpful if you reiterate those declarations at the start of any speech or question, if they are relevant.

Examination of Witness Dr Penny Dash gave evidence.

We will now hear oral evidence from NHS England. I am afraid that we have to stick to the timings very rigidly because we have a lot to get in this morning, and we have until 9.55 am for this session. Dr Dash, could you be very kind and briefly introduce yourself for the record and make any very short opening remarks you wish to make?

Dr Dash: Good morning. My name is Penny Dash, and I am the chair of NHS England. I thought I was here to answer questions, so—

You are, absolutely. Normally, as a courtesy, I allow a very brief comment if you want to say anything.

Dr Dash: No, thank you.

Q Good morning, Dr Dash. What effect is the abolition of NHS England having on its current day to day functioning? What sort of number of people are working solely or mostly on the transfer, and is that affecting your ability to deliver on your core business?

Dr Dash: I do not believe it is affecting our ability to deliver. Much of the work to date has been led by a joint team of people from across NHS England and the Department of Health and Social Care, who are working together, have put together a process and have been going through all the things you would expect of any integration process. That has been a fairly confined team.

As they are starting to look at what needs to happen in each of the different functional areas—the different directorates—that we have set out, they are working with the directors general or the executive directors leading each of those to understand what different functions we need to enact within each of those directorates, and what their teams could look like. They are putting time into that, which is good—that is what we want them to do, not least because they are also looking at ways of working, not just at numbers of people—but I would not say that it is a distraction. In fact, in some ways, I would say it is really helpful, because it is helping to define the core priorities and the key things that we need to focus on, and how we can continue on the journey of seeking to improve health and healthcare services. That is across those executive directors and directors general.

The team who are putting a lot of time into this, not surprisingly, are the people working in the HR functions. That team are spending a lot of time going through the mechanics, and they have been managing things like the voluntary redundancy programme. I would hope, and I believe, that there is no negative impact on our focusing on what we need to focus on.

Q You wrote a report about the CQC that was not hugely flattering, and you have also written a report about the patient safety landscape. First, why did you choose to roll HSSIB into the CQC, given what you said about the CQC and the clear and obvious conflicts of interest that it creates? Secondly, you identified in your findings that a large number of clinical nursing staff were being moved into more managerial roles, with an effect on clinical capacity. Which of your recommendations would have dealt with that, or what would you recommend now?

Dr Dash: On the first question, as you say, my first review looked at the CQC, and that there are a number of considerable challenges there. I would have hoped that, by now, many of those challenges had been addressed. Some of them have been, but some of them have struggled. It has already gone from the previous chief exec to a new chief exec, and it is now out looking for another chief exec, and the chair has changed too. That has definitely impeded progress. As I said, it has made considerable progress in some key areas, in particular the use of technology, but it still has a way to go, and we all need to acknowledge that. I note that the ministerial team in the Department of Health and Social care has suggested that the integration of HSSIB into the CQC should happen only when the CQC is in a more stable position, which sounds sensible and pragmatic to me.

On the second review that I did, I was asked to look at the regulatory and quasi regulatory landscape. I was referred to a report that had been done by Professor Carl Macrae and others that talked about 126 organisations. When I looked, I found more than 150, and I listed all of those in my report. I spoke to many people—well over 200 people who joined various roundtables and so on—and the very consistent theme was that this is so busy and confusing, and keeps leading to all sorts of different recommendations from different organisations, but also to people having continually to respond to all these different bodies asking for people to fill out a form, asking questions and doing reviews. As a result, our clinical staff—not just our nurses, but all our clinical staff—are having to spend considerable time filling out those forms and going through tick box exercises. You will hear people talk about that a lot.

The concern is that this very busy landscape is distracting from what it is there to do, which is to improve quality of care. I was asked by the Department of Health and Social Care to look at that landscape. I was asked to focus on six organisations, which are listed in my report, of which HSSIB was one. Across the six—of course, six is a small number out of that 150—I was asked to look at where there were opportunities for rationalisation and simplification. The observation was that colleagues in HSSIB have some great skills and capabilities in carrying out investigations into healthcare, highly complementary to the work of the CQC, which is equally there to understand how well different organisations are performing, to give the public confidence, to give ratings and to identify problems, and therefore putting those two organisations together would create significant synergies and opportunities for them both to work well.

Q What about the risks of that—the conflict?

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

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

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

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

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

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

Q I should have declared that I am a member of the patient safety APPG. Let me turn to similar concerns about Healthwatch and its independence. If it is absorbed within ICBs locally or within the Department of Health at a national level, do you have concerns that those organisations will essentially be marking their own homework rather than listening to impartially collected evidence about patient experience?

Dr Dash: I will talk first about providers and then about the commissioners, the payers, the ICBs. We absolutely should expect all providers—GP practices, community trusts, hospital trusts—to see patient experience as a crucial part of their role and not to outsource it to someone else; it has to be a crucial part of what they do. They need to get way better at collecting patient experience, they need to understand it from different groups, wards and medical teams, and they need to be playing that back. Ideally, that should be part of everyone’s appraisals: “Here’s the sort of feedback that we’ve had. Here’s what we’ve heard. Here’s how we’re acting on that.” We need to put that in the places where healthcare is delivered, and that is in those provider organisations.

The ICBs have a different role, which is to commission healthcare services in order to improve health and ensure high quality care, and it is their responsibility to speak to communities. They all have considerable teams of people who are doing that—speaking to different members of society and conducting usually frequent events to get input and hear what people are looking for from their health and care services. When they are looking to design particular services, whether mental health services or children’s services, they go much deeper into that and speak to specific groups, often involving the providers as well.

Those mechanisms are already embedded within ICBs, but we need to continue to ensure that they do those as well as they can. When I was speaking to people, I found some fantastic examples of different healthwatch organisations across the country, but that is not at all consistent and they are often too far removed from what is actually happening in terms of day to day services to have a significant impact on improving patient experience.

Q On that point, Dr Dash, what would you say to concerns that have been raised with me by Healthwatch Wolverhampton that patients and service users will be reluctant to raise concerns from within the system? How will your recommendations help with that?

Dr Dash: I think that we do need to recognise that. I hear that as well and experience it myself; lots of people are often reluctant to come forward, and they think, “If this is my GP, how is this information going to be treated?” That is why we need to really raise the calibre of our directors of patient experience. There are ways in which you can manage that and treat that data confidentially—in fact, you have to treat all data confidentially. There are ways in which you can support people and give them the confidence that their information will be taken seriously and treated confidentially. You can do that often through focus groups, one to one conversations and anonymous surveys. We are hoping to be able to do a lot more of that through the app, to link it directly to people’s care, and to give people prompts as soon as they have had an interaction: “Please feed back.” I think there are ways in which we can overcome that. Bringing this much closer to people’s care, linking it in much more to day to day practice and making sure that feedback goes straight back to our frontline clinicians in an anonymised way to encourage and support them to improve brings a significant benefit, and we can find a way around the concerns about confidentiality.

Q I should declare that I am a member of the all party parliamentary group on patient safety. Apologies, Dr Dash, I have questioned you on this many times, but I am going to continue to do so. When the King’s Fund, the Nuffield Trust and the Health Foundation were in front of the Health and Social Care Committee and they talked about bringing HSSIB into the CQC, all three of them said very clearly: “Don’t do it.”. In fact, I can find almost nobody apart from you and the Department who thinks that moving HSSIB into the CQC is a good idea. Does that give you any pause for thought about whether you are recommending the right thing?

More specifically, if, as you said to the Health and Social Care Committee, the safe space element would be retained and HSSIB would operate as an independent organisation, how can you square the fact that it would remain independent and yet be part of the CQC? If it does remain independent, what is the need to bring it into the CQC?

Dr Dash: The point of bringing it into the CQC, as I said before, is that we are trying to simplify this landscape. There are so many different organisations continually commenting and doing reviews—often replicating the same reviews that other people have done. The concern is that it is distracting rather than enabling. The hope that I had when I made the recommendation, and still have now, is that by bringing HSSIB into the CQC, you can align the work of the two.

For example, if the CQC is going round the country and spotting a particular problem with the way in which anaesthesia is being given or with managing patients post surgery, the CQC could then say to HSSIB—that team of people with specific expertise—“Can you go in and take a look at this? Can you do a detailed focus review of this particular area of care that we are spotting through our visits and which seems to be a particular challenge?” It is that bit about enabling the CQC to identify a problem and then asking HSSIB to review it in detail, and HSSIB bringing its expertise in investigations into the CQC to enable the CQC to go deeper and then come back to the NHS with particular areas, but also to supplement the work of the NHS.

I would like to point out that since HSSIB was established, the NHS has established its own much more rigorous, much more robust investigatory teams and processes. Of course, I am not saying that they are perfect—we can all see that—but I encourage all colleagues here today to look at the work they are doing, the specific areas they are reviewing, the outputs of those reviews and the ways in which those are leading to improving care. That feels to me to be a much more systematic way of addressing the concerns of patients, families and staff in the place where those concerns happen, having mechanisms to escalate those through the NHS so you can bring them to regions—some investigations get done at the NHS England level—and having the CQC as an independent body that can separately review and spot if there are problems but also ensure that those investigations within the NHS are happening well.

Q What happens if the problem is the CQC?

Dr Dash: Well, we then have to deal with that as a problem. That is the same as saying, “What happens if the problem is this organisation or that one?” We have 150 organisations—150. What if the GMC is a problem? What if the Nursing and Midwifery Council is a problem?

Q Dr Dash, you have explained why you believe that the changes to Healthwatch will strengthen patient responses. How do you think that could be strengthened to ensure that the levers really are being pulled for patients? That seemed to be the case.

Dr Dash: There are a few different things. First, we have talked about appointing a director of patient experience. They will report directly to the chief exec of the NHS. That is crucial; it is about emphasising the importance. We are about to do the interviews for that person, so I hope they can be in post very quickly.

Secondly, we are hopefully about to publish the quality strategy. Within that strategy, which has come out of the 10-year plan, we are very clear about the three dimensions of quality. Those are: safety, so ensuring that basic standards are in place; effectiveness, so making sure that patients receive the right care in the right place at the right time and it is delivered to a high standard; and, crucially, patient experience. In the quality strategy, we emphasise that all three of those are crucial. You need to have all three and all three need to be done really well.

We then go on to talk about different mechanisms for improving those dimensions. Crucially, we have a set of 183 metrics, which we will review within the NHS England quality committee while it still exists, and then within the National Quality Board. We also expect every region to review those metrics, as well as others, and every ICB and provider to review the ones that are relevant to them. So the next bit is to have all those different metrics.

Thirdly, we need wider transparency. There are way more than 183 different metrics and we need to have far more on patient experience. They need to be routinely collected in the same way that we do surgical audits or audits of GP work. Those all got in the public domain; that was a big element of the 10-year plan.

Finally, as I said before, we need boards to take full responsibility and accountability for all aspects of quality, which includes patient experience. As I go round and meet individual hospital boards, I ask them about that. I spend quite a lot of time with chairs and new non executive directors coming into NHS providers, and I continually emphasise, “This is a crucial area for you to focus on as a board.” What are you asking your exec colleagues? Who have you put in place as your director of patient experience within the organisation? How are you routinely collecting information from a whole spectrum of users from the whole of society? How are you doing that in a confidential way for the reasons we spoke about earlier, and then ensuring that people are acting on it? I do not think we are doing anything like enough of that, and we need to get much better and do far more of it.

For a final brief question—and a brief answer, please—I call Joe Robertson.

Q HSSIB is obviously an investigator and CQC is obviously a regulator—two different roles. I suspect there was a good reason why you were asked how the CQC can be investigated by a body that becomes part of it. Are you aware that the Air Accidents Investigation Branch and the UK Civil Aviation Authority are separate? If you are, why should that fundamental separation, which benefits air passenger safety, not apply to the safety of patients in the NHS?

Dr Dash: Yes, I am aware. The analogy is continually made—and it has been made several times—and to be honest, 20 years ago, I would have shared the view that healthcare was similar to airlines. Indeed, I did quite a lot of talks about that at the time. However, the more I have looked into it, the more I think there are limits to that analogy.

We are running out of time and this is a much longer conversation, but if I look at the specific examples that people bring up from the airline industry, it is about spotting some very specific things. An example was used at the Health and Social Care Committee about spotting a bolt that is not working properly. The equivalent of that within the NHS is actually something like the MHRA, which is separate. If we spot a drug, an anaesthetic machine or a cardiac device that is not working properly, that is for the MHRA, which is separate from the CQC.

The CQC is there to be the independent regulator of the quality of care more generally, which is more the space that HSSIB has been in. HSSIB has been looking at things like the use of digital triage in general practice and corridor care, and it has done some work on surgical safety and so on. All of that is part of a bigger landscape of quality of care, which the CQC is responsible for. The more that I looked at this issue and the more I spoke to people, I became less sure that it is analogous to the airline industry. It is much broader and more complex, and certainly the airline industry does not have 150 different regulators and quasi regulators.

Dr Dash, thank you very much indeed. The Committee is indebted to you. I am afraid that brings us to the end of this panel and we will now move on.

Examination of Witnesses Sarah Woolnough and Jacob Lant gave evidence.

We will now hear evidence from the King’s Fund and National Voices. Again, I fear that we will have to stick to the timings, as we have very limited time. We have until 10.25 am for this session. Could you please identify yourselves for the record?

Sarah Woolnough: I am Sarah Woolnough, chief executive at the King’s Fund.

Jacob Lant: I am Jacob Lant, chief exec of National Voices.

Q Sarah, the King’s Fund report said that the potential cost savings of abolishing NHS England “would be minimal in the context of the entire NHS budget”.

Many MPs across the House have struggled to get numbers and costings in questions both oral and written, particularly in relation to staff redundancies. We have not received information on the full arrangements of where NHS England’s functions are going to go yet. How can we be sure that its abolition will save any money at all?

Sarah Woolnough: I think, on the basis of the question, we do not know. Our worry has been about the opportunity cost. The Government, when in opposition, said that they would not launch wholescale reorganisation, because they understood the potential opportunity cost on time and other resources. As this has played out, taking longer than anticipated, we have had multiple examples of teams left in limbo about where they will end up in the target operating model. Our ongoing concern has been, “Is the benefit worth the cost?”

Q Yes, although yesterday we received an answer to a written parliamentary question saying that the abolition of NHS England is causing no disruption to the development of new services. That is the Government’s view.

Sarah Woolnough: It is inevitable that, in any large scale change in an organisation, there will be opportunity cost. These arguments were very well rehearsed by the previous Secretary of State. He undertook personally that he would not follow this course of action, exactly because these things take longer and cost more, and because the benefit realisation case is not always clear.

It is also quite hard to tell—we have grappled with this as a think tank—whether there is good evidence of what you are delivering at the end, and whether the benefits will be realised as you stated they would be up front. It is harder to get the granular evidence and costings to prove the case, but our ongoing concern has been whether you need to wholescale reorganise to drive the sorts of benefits that the Government have said they want to deliver.

We absolutely understand and agree with those who say, “Let’s reduce duplication. Let’s streamline. Let’s make sure that we’re getting value for money and spending taxpayers’ money wisely.” Do you need to launch a large reorganisation—a mass rearranging of the deck chairs of this nature? Our view has been, “You shouldn’t and you don’t.”

Q Thank you, Sarah. That was also the view of the Darzi report. He said that it was “neither desirable nor necessary”.

Jacob, what effect will the abolition of Healthwatch have on people’s confidence in the independence and reliability of views of patient experiences?

Jacob Lant: First, it is important to note that we know that there are people who are reluctant to come forward and share their poor experiences of care with the NHS directly. They fear retribution if they complain or speak up. Research by Healthwatch has shown that about one in five people experience poor care, so a significant proportion of people are unwilling to come forward and speak to statutory agencies. That will be concentrated in communities who are particularly marginalised—those who already lack trust in institutions. There is a clear case already that there will be a group for whom the lack of independence will be a real concern.

The second point is about the unsolicited feedback that is gathered by the Healthwatch network. Dr Dash and others have talked about how the system does lots of engagement itself, and how it could therefore surely take over those functions. But the system engages on its terms: it is about service reconfiguration that it wants to do, or about trying to gather experiences on a particular topic in which it is interested. Healthwatch allows an opportunity for continual listening and engagement with communities, where they can speak up about anything that is affecting them, from dentistry to patient transport and administration of care. Those issues are not necessarily on the system’s agenda. As I see it, under the changes that will disappear.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q Jacob, how prepared are ICBs and local authorities to take on the healthwatch functions? Is there a concern that splitting the local healthwatch function will lead to a lack of joined up focus on health and on the social care element that resides with local authorities?

Jacob Lant: I will pick up the second part of the question first. The majority of the worst experiences of care—the worst incidents, where people feel most lost—tend to be in the gaps between services. Hospital discharge is a really good example of where the transfer between the NHS and social care services does not always work in the best interests of patients. That sort of insight will be lost entirely under the current structure, unless we build in a requirement for ICBs and local authorities to share the intelligence that they are hearing and to work collaboratively to understand patient and care user experience. That then raises the question, “Why are we splitting them?” If they have to work closely together to comment on the worst experiences of care, I do not understand the rationale for splitting them.

In terms of preparedness, I said earlier that ICBs will not have any additional resource for doing this. They have their own engagement teams at the moment, but even those that have been doing this very well have been leaning on their healthwatch for many years to help them engage with seldom heard communities and build additional capacity. I worry about the capacity of ICBs to deliver once that is cut, particularly given the headcount and budget reductions in ICBs generally.

Local authorities are probably more experienced in doing direct community engagement and more confident about their ability to pick up the responsibilities. Indeed, I suspect that many of them will continue to commission some sort of external support to help them do this, but their budgets will be restricted. They will get only half the money for healthwatch, so that will be a concern.

Q I am an ENT surgeon. Why has there been no effective single patient record in the past? If there were such a thing, who would you give ownership of the data to?

Sarah Woolnough: We have had developments over many years in the direction of a single patient record. We have shared care records; we have attempts in different parts of the country to move in that direction. On the one hand, we have been held back by legitimate concerns about trust, privacy and the right safeguards, but some practical barriers have also held us back. For example—and this is really important to make the single patient record a success—what does it take to ensure that we achieve interoperability, that the data is cleansed and that penalties are followed through if providers are not sharing data? We need to back up any legislative and policy intent with the resource and measures needed to make it happen. That is perhaps a bit of the history of why it has not happened. Sorry, what was the second part of your question?

Q Who would the data belong to? Would it belong to the patient or to the healthcare provider?

Sarah Woolnough: My reading of the legislation is that perhaps this issue is not quite resolved; the legislation does not seek to shift necessarily from having the GP as the data controller. Of course, there will be concerns as the record is brought together nationally. Ultimately, the data should belong to people and patients, but they rightly want to feel that it is protected and safeguarded appropriately through the system.

There are a couple of other points to make as we design this. This is a work in progress, so it is not neat in the sense that you cannot say, “This is exactly what a single patient record is, and this is exactly what it will be for evermore.” I think the policy intent is to build and develop it over time. To give one example, patients and the public being able to understand who has access to their records, and for what purposes, might be really helpful in the process of building trust and belief that their data is being well looked after.

Especially if it were the case that the patient were the data controller.

Sarah Woolnough: Yes.

Jacob Lant: Whoever ends up being the data controller, the most important thing is that patients have a right to express how their data is used. That is where it is really important to keep things like the national data opt out up to date, and to ensure that it is clear and accessible for patients to express how their data is used for secondary purposes.

That becomes much harder in a direct care scenario. If you restrict the sharing of data for direct care, you could inadvertently create a second class system for people who are not in that. It is a really clear distinction. For secondary uses, we need a very clear opt out, where people can understand how their data is used and express a preference.

Q Sarah, when we were at the Health and Social Care Committee, you and your fellow panellists seemed to suggest that the Government could achieve what they needed to in the 10-year plan without this reorganisation. Could you delve into that a bit more and tell us why you think that is the case?

Sarah Woolnough: The Government have an incredibly ambitious agenda, which is partly articulated in the 10-year plan. Our ongoing concern has been that some of the biggest ticket items that the Government rightly want to achieve to fundamentally shift power to patients—delivering a shift towards prevention, moving care closer to home and allowing more digital enablement—do not require this kind of legislation or a reorganisation.

I go back to my first answer: what is honestly the opportunity cost of doing some of this at the expense of more focus and attention on, for example, delivering care closer to home? There is a lot of energy and activity in that area, but the Government want to make really good progress over the next few years. To take that example, if you are really serious, you need to understand what the barriers are to delivering more care in the community, closer to people and patients, and wrapping services around patients. It requires you to flow money differently and to have a different incentive scheme, but that is nowhere near this piece of legislation.

Our worry has been about what is not in the Bill, and what is the rightly and fantastically ambitious agenda to improve health for people and patients, versus the opportunity cost of a largely technical piece of legislation that reorganises some central functions.

Q Would you agree with that, Mr Lant?

Jacob Lant: Yes. I kind of think, as the debate goes on, that—with the changes to Healthwatch in particular—you could achieve so much without legislation. You could beef up the internal functions for listening to a patient and engaging with them without legislation—there is no requirement for that. You could invest more resource in that, and you could do the same with Healthwatch. You could think about the resourcing of the structures and the support they receive, so you could make that whole system better without legislating to get rid of it. As Sarah said, the NHS changes are a distraction at a time when we should be moving on with focusing on patient care.

Q Mr Lant, I am trying to understand a bit more about the patient experience and improvement in care that Healthwatch brings. My understanding is that when a patient raises a complaint with the local provider, it usually gets investigated by a local service manager or a matron, but when somebody is not confident about raising a complaint with the local provider, they go to Healthwatch, and that complaint usually filters down for the same local service manager or matron to investigate it—we have seen that happening. Patient experience is not being improved without local accountability or local change. Can you explain why you are concerned about abolishing Healthwatch and bringing more accountability to local ICBs or local authorities, which may improve patient experience and patient care?

Jacob Lant: The issue is that the system—the NHS provider, the commissioner or whoever is picking up the individual complaint—will treat that as an individual incident to look into. Healthwatch may support the individual to raise that complaint or that individual piece of feedback, but the collective learning across that is more important, and it is pulling out the themes that are consistent across multiple bits of feedback, both positive and negative, that makes the difference. We see that evidence and insight from Healthwatch making a difference in local and national policy. It might not feel like that to the individual patient, but things like the creation of a single patient record exist in part because of a lot of campaigning by local healthwatch on the issue of people having to repeatedly tell clinicians about their experiences.

It also could be issues to do with not being able to find a dentist, for example; the system will treat that as an individual incident of helping someone who is trying to find a dentist or not, but Healthwatch could use that insight to petition and push for national change around the commissioning of a service like dentistry. A topic like administration of care, which Healthwatch, National Voices and the King’s Fund have all worked on together, is invisible from the way that the system perceives performance at the moment, but because we listen thematically to patient experience, we can push for a much greater focus on things like the basics of communication and keeping patients up to date on what is happening with their care, which really matter. Healthwatch is thematically looking at patient feedback differently from the way that system does, and that is something I fear may be lost.

Q Ms Woolnough, you have talked about the abolition of NHS England, and, as I understand it, you are dealing with what the position is rather than taking a stand. Beyond the legislation, what are the key things that we should be looking at to get the transfer of functions to ICBs and DHSC right?

Sarah Woolnough: We have talked quite a lot about the culture in the NHS and whether these changes enable the sort of shift that lots of people talk about wanting. Let us be really serious about devolving power and earned autonomy, and about the balance between politicians rightly being held accountable for high level metrics but with enough operational freedom to allow local systems—services close to people and patients—to get on and do the best for them?

We have a slight concern that, even though the Carltona principle should mean that the Secretary of State will enact powers in a way that does not slow things down, because of the broad sweep of powers given back to the Secretary of State, and the quite extensive powers of direction, politicians come under extreme pressure to intervene in certain cases or when there has been a scandal or patient safety issue, and that could lead to things clogging up.

Fundamentally, our worry has been—again, this goes beyond the legislation—how do you genuinely create a system where the culture is not as paternalistic as it has traditionally been, where you are empowering both staff and patients and citizens to have more say in their care, and where system leaders are not constantly looking up for permission, worried they may be held to account for quite a narrow set of metrics? Although managing money and constitutional standards is very important, if we are to deliver the 10-year plan aims and improved patient care, it is more than that. Our worry has been that the abolition of NHS England by the legislation will narrow things. We do not know, because it is broader than legislation, but how do we fundamentally shift the culture? I know that that is the Government’s intention, but it is about more than legislation. Where is the work to make that happen?

And do you think—

Order. We have run out of time again. That brings us to the end of this session. Thank you both very much for joining us; the Committee is indebted to you.

Examination of Witnesses Dr Jeanette Dickson and Kay Keane gave evidence.

We shall now hear evidence from the Academy of Medical Royal Colleges and the Institute of General Practice Management. Once again, I am afraid we have to stick to the timings. This session will end at 10.55 am. Will the witnesses briefly introduce themselves for the record?

Kay Keane: I am Kay Keane, a full time practice manager at Urban Village medical practice in Manchester, and the chair of the Institute of General Practice Management.

Dr Dickson: I am Jeanette Dickson, the current chair of the Academy of Medical Royal Colleges, a past president of the Royal College of Radiologists and a practising consultant clinical oncologist.

Q I should perhaps reiterate that I am a member of the Royal College of Paediatrics and Child Health. Dr Dickson, NHS England has responsibility for workforce and workforce planning. How will the Bill affect that, and what effect is the delayed and delayed and delayed workforce plan having on the ability to plan the workforce now and for the future?

Dr Dickson: I would go back to some of the comments that have been made before. It is the opportunity cost at the moment. We know that the workforce plan is being worked on in the background, but when you are unsure what the operating and delivery model will formally look like, there is a difficulty in seeing what the workforce for that will be. We are also talking about massive changes in the way we think about care delivery—movement into the community and a different way of working—so we need a different workforce.

Therefore, we need to put in some work to look at how curricula drive a different type of workforce, how we train people to work in a different way and how we empower them to see the opportunities to work in that way, when they do not have actual role models. We need a culture shift anyway, whatever is happening, but the abolition of NHS England is in many ways increasing the time. Things need to move, and they are moving, but they are not necessarily moving as fast as they should.

Q So, in essence, the fact that NHS England is being abolished, whether that is the right or wrong thing to do, will have an effect on the delivery of new services?

Dr Dickson: We are delivering services as normal, but that head space and the innovation to see what the future should be and to work towards that future actively are limited by not knowing what that future looks like.

Kay Keane: We do not know what the left shift that we keep hearing about looks like; we do not know what that is for practices. In general practice, we are very practical—we get on with what is in front of us—so the big organisational changes do not have a huge effect on the day to day seeing of patients and organising that, but understanding what is around us does.

Q I want to move on to the single patient record. Do you feel that general practice has had enough information about its role in terms of who is responsible, who is accountable, who will be editing and who will be responsible for checking that the editors are right on this single patient record?

Dr Dickson: The legislation is very much an enabler for a single patient record. The devil in the detail there is not entirely true. In my experience, if you ask most patients if they would like a single patient record, they feel that it is already there. They do not understand that we do not have the ability to share their data in a way that works for them. Therefore, the idea of a single patient record is very much a lodestone for medical practitioners and most patients. When you talk them through the detail of how you achieve that and who owns the data, it is a much trickier issue for many, including the professionals, but also the public.

Kay Keane: I agree. The detail is not there at all. At the moment, we look after the data that is in the GP summary care record. That creates lots of questions for our patients. They will see information in there that they are not sure about or that they want help with. They will perhaps be able to read some of their hospital letters within that record. However, lots of patients have a variety of health inequalities that might mean they cannot access that data. In general practice, our non clinical staff often help them to navigate their way around all that information. We also have patients who will read something in their record on which they want clarity—maybe something that happened a long time ago that they cannot remember and want explaining to them.

All those things take time. Where will the responsibility for that go? It takes an awful lot of resources in general practice to educate and support patients and to help them navigate their appointments and the letters coming through. Where will that responsibility sit? At the moment, it is of course with the GPs, but practically it is practice managers, up and down the country, who take on the day to day responsibility.

Q I have one small question. Dr Dickson, even in paediatrics I have looked after patients who have ring binder after ring binder of notes. Clearly, when seeing a patient for 20 or 30 minutes in clinic, there is not time to read ring binders and ring binders of notes. To what extent will the single patient record oblige clinicians to have read and understood everything for every appointment? Is that really practical?

Dr Dickson: You need to believe that you have found out enough about a patient to deliver their healthcare. I would turn it around and say it is very difficult to deliver appropriate care to somebody on whom you do not have full information.

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

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

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

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

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

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

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

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

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

Q Do you think anything else should be on the face of the Bill to give us clarity so that that GP concern is mitigated?

Kay Keane: The patients need to understand exactly who has access to that record and exactly who is feeding into it. There is a huge amount of trust between a patient and a GP, and a patient and a healthcare professional in a general practice, and we do not want that trust to be diminished so that the patient stops telling us the things that are worrying them—the whole story. We want them to continue their trust, but if they think that information is spreading further and further across the system, we might lose some of it.

Q I want to touch on the single patient record. I declare that I used to work in mental health services. In my experience, mental health patients often navigate between A&E, GPs and mental health services during weekends. Often the clinicians do not know what medication they are on, or what kind of contact patients had on the Friday or Saturday. Also, during the discharge process, getting medication from the GP can be delayed until the discharge notification gets to the GP. Yes, there are concerns about who will own this data, but do you not think that the single patient record will bring a huge benefit for patient safety and continuity of care?

Kay Keane: In the example you gave, the hospital should be giving seven days worth of medication to the patient. That is clearly its responsibility. Within those seven days, the GP practice should get a discharge letter that says what has happened; if appropriate, we then take over the prescribing.

If the information comes and is good quality—if the data is good and timely—the things you mentioned do not happen; they happen when neither of those things are the case. In my experience, information that comes out of A&E is often difficult to understand. A&E might make a diagnosis that it works with, but by the time that gets to the ward it can be different, so the A&E information we act on could be very different from what the patient is discharged with. Timely and good quality information is therefore really important, and that GP record then becomes the centre of the patient’s care.

Dr Dickson: You are talking about transfer of care between services and about a weekend being an important flashpoint, but I think that that transfer of care does not happen appropriately even during the week. It is getting better, with electronic systems, but it is still not necessarily working for the full benefit of patients, especially if they access multiple services. The value of the single patient record is to make that safe, but the question is, will it do that? Can it do that? Is it safe to do that? Will the patient’s data be protected? That is what we are we are worried about. I think that is what patients worry about. They perceive that we do that already, and when they come up against the healthcare service, they realise that it does not happen; they do not realise that it is not a personal thing to them, but a systemic problem. It is about getting patients to understand the systemic nature of the lack of data sharing at the moment.

Q If responsibility for managing and safeguarding the single patient record is to sit with general practice, if that is what the Government want, can you tell us, Kay Keane, as chair of the Institute of General Practice Management, what the implication would be for workload, and particularly workforce, in practice management?

Kay Keane: I think it is impossible, really, for me to understand that. It is a large part of our job already. As Dr Dickson said, we act as a small business. We do all the things that any other small business does, so being able to manage that record on top of that would take a huge amount of investment into general practice.

I would argue that maybe the investment into general practice should not be on data, but should be in the wider workforce. We are really good at looking after our data now. We care about it, we hold it close to the care of the patient and we share it only when appropriate, but in our view to then be the data controller of other information is too much and is unmanageable for a general practice to do.

Equally, our data is very personal to us, and we want to keep hold of that. We do not want our patients worrying about the stories that they tell us, so a model where we feed into something else and have responsibility for the bit that it is fed into sits more comfortably with the Institute of General Practice Management.

Dr Dickson: I do not have much to add to that. The devil is in the detail of where it sits and how we reassure patients that we are trusted with their data—that we are sharing what they have given us appropriately for their health, but not for spurious reasons. I think people’s understanding is that we share an awful lot more than we do, so there is a gap. People perceive that we are going to overshare, whereas actually this will allow us to come up to the level that we should be at.

Q My question is to Dr Dickson and is about education and training policy, responsibility for which will be transferred from NHS England to the Secretary of State. I know that you have a lot of interest in medical training and education, so what do you feel would be the impact?

Dr Dickson: I think the impact could be really positive. At the moment, we train nationally to high standards, so that the product of medical education can be deployed anywhere in the UK, and we are also all trained to develop, innovate, change the service and move forward. What we miss at the moment is parity of esteem for education as a productivity function of the NHS. There is the productivity function of elective care, waiting times, cancer treatment and all those things, but education must sit at that level of esteem for productivity for all professions in order for the service to continue—not to innovate, change and develop, but just to continue. Moving things to the Secretary of State gives us a chance to ensure that that pure parity is seen. The danger is that if you move the function in, it gets lost in the service productivity sphere. There is a huge opportunity to firmly embed the education and strategic development of different roles as a true productivity function of the NHS, which it needs to be.

We have come in under time for a change. Thank you both very much indeed for joining us. Your contribution is invaluable.

Examination of Witness Dr Rosie Benneyworth gave evidence.

We will now hear oral evidence from the Health Services Safety Investigations Body. Again, we must stick to the timings, but we are doing rather well at the moment—let us hope we can stick to that. Would you be kind enough to identify yourself for the benefit of the record?

Dr Benneyworth: Good morning, everyone. My name is Rosie Benneyworth and I am the interim chief executive of the Health Services Safety Investigations Body.

Q Good morning, Dr Benneyworth. There seems to have been a bit of a muddle in how some of this has been expressed this morning. For clarity, could you explain how a regulator is different from an investigatory body, please?

Dr Benneyworth: We are a safety investigator. We have been modelled on other industries that have very successful safety records, and we have learned from those other industries. We investigate patient safety concerns of national significance, and we make recommendations into national bodies about what needs to be improved. We make very few recommendations—only small numbers—into those national bodies, but they are about what needs to change from a systemic point of view to make patient care better. That is underpinned by learning from other industries—the safety science, the human factors and the real knowledge about how you improve safety—and we are trying to embed that in the NHS.

Regulation is very different. That looks at individual providers. I used to the work for the CQC and regulate primary care. It looks at how individual providers are functioning. It makes recommendations to individual providers about what needs to change, and it judges an individual’s performance against a set of regulations. The two functions are completely different.

The other important thing for us is that we do not attribute any blame or liability in our investigations. That is vital, because we learn from what we see. We learn from those investigations, and we are trying to embed a continuous learning environment and culture within the system.

Q Earlier on it was asked what would happen if the HSSIB was rolled into the CQC, yet the problem with the healthcare was a failure of the CQC to properly regulate or investigate. I was a little bit lost for words at that point. How would that work in practice? Or would it not?

Dr Benneyworth: I think it will be very difficult. At the moment, we have the ability, being an independent organisation, to investigate any part of the system where there is a concern. That includes the national system. In several of our investigations we have looked at how the national system, the regulatory system and NHS England are working, and how other parts of the system are working. We are unique in that, because a lot of those bodies do not get the scrutiny from any other part of the system, and they do not get that oversight and ability to look and understand how the national system works together.

If we were a directorate in the CQC, as outlined in the legislation, it would be very difficult for us to comment on how the CQC was looking at different areas and how it was managing certain aspects of safety. I think there is also concern about our ability to make effective recommendations to the CQC if we are a directorate within it.

Q Another question that has been raised about independence is the choice of what to investigate. The Secretary of State can direct, but the impact assessment suggests that the Government intend to direct the vast majority of investigations. Is it currently the case, or has it been the case in the past, that the vast majority has been directed by the Secretary of State, or has that been unusual?

Dr Benneyworth: That would be unusual. We have undertaken one very detailed set of investigations into mental health in patients, which was directed by a previous Secretary of State. We would very much want to hear the patient safety concerns of the Secretary of State to understand what we investigate. We work extensively with stakeholders across the system. We want to be a constructive part of the system. We want to investigate the areas that people are concerned about. We work extensively with all stakeholders to hear their patient safety concerns and make sure that our investigations are informed by that knowledge and by what we are hearing from patients and families, as well as staff working in the system.

However, we need to make sure that we have the independence to investigate what we are hearing about. It is very important that we are not stopped investigating something, and it would be concerning if someone told us not to investigate something. We need to maintain that independence.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q What could be changed in this legislation to ensure that HSSIB can retain trust and independence from the regulatory body?

Dr Benneyworth: There needs to be much more clarity about governance and how that will work in the legislation to protect independence. There are potential compromises that could happen, such as a Healthwatch style model that has its own independent leadership within the CQC, its own governance arrangements and, importantly, its own identity. That would enable it to keep its independence, while being part of a larger organisation. In the legislation, it is vital that there is a legal duty for the CQC to protect safe space.

Q I feel that my question may have just been answered, but you may wish to add something, Dr Benneyworth. Will patient safety accountability be improved when a patient’s care spans different organisations within an ICB?

Dr Benneyworth: One of the things that we see regularly in our investigations is that people fall down the gaps between organisations. We have the ability to look right across the system and understand a person’s journey. As a recent example, we looked at medication errors on discharge from hospital. There are a lot of medication errors, and we looked at the process of how information was being shared and what was happening. Those are the type of things where we see a lot of concerns about patient safety. There needs to be much more clarity about accountability for patient safety.

No one is accountable for the discharge of a patient. There is not one person—no single individual—who is accountable when someone is discharged from hospital to social care. You go through multiple layers of accountability. We are keen to learn from other industries that have effective safety management systems. Part of those safety management systems is having much more clarity about accountability, which is lacking across the NHS. I very much hope that, with the changes to ICBs, they really do think about accountability for patient safety.

Q In her evidence earlier, Dr Dash said that one of the reasons for her recommendations in her second review of changes to the regulatory and investigatory landscape is that it is a problem for the provider landscape that there are so many different organisations making so many recommendations. You have just said that HSSIB makes very few recommendations. Will the merging or folding—however you wish to characterise it—of HSSIB into the CQC lead to any meaningful reduction in the number of recommendations that organisations have to cope with?

Dr Benneyworth: No, we do not make recommendations to provider organisations at all. All our recommendations go to national organisations. I completely agree with Dr Dash that there are too many recommendations. In fact, HSSIB raised that concern through our work two years ago and flagged it to Dr Dash. We wrote a report called “Recommendations but no action”. We are very concerned about the plethora of recommendations going to providers, which create a huge amount of noise but, distressingly for the families involved, do not lead to the changes needed.

I completely agree that there are far too many recommendations. I am leading some work to address that—we are setting up a recommendations hub with the Department of Health and Social Care—but we are not that problem. We have made 39 recommendations since investigations launched and HSSIB started three years ago, and they are all to national bodies. We might reduce the burden on national bodies by taking that away, but it will not have any impact on providers.

Q Dr Benneyworth, you mentioned protected disclosures, and you said that individuals or organisations may have a fear of reprisals. Would you like to say anything more on that? What would you like to see from the CQC or in the Bill?

Dr Benneyworth: Yes, absolutely—we have seen that in so many of our investigations. It can often be exacerbated by different parts of the system working together.

To give you an example, we looked at mental health in patient settings. There is national guidance that says that people should not use risk assessment tools around self harm, but when we looked we found that, on the ground, everyone was using these tools. We asked why that was, and we were given two reasons. One was that the IT systems were set up such that you could not move past the front screen without ticking one of the risk assessment boxes, and the other reason was that people were fearful about being in front of a coroner and asked about risk assessment tools, so we took action on both those fronts.

Another thing that we see is about speaking up. There are definite inequalities at play when people are speaking up. We have seen significant racial discrimination. We wrote a report about temporary workers. We find that people working as locums or agency staff often feel a lot less able to speak up if there are patient concerns. If you are black or from other global majority groups, to be able to speak up is even harder. On the back of that, we made a recommendation to the National Guardian’s Office, and it has done a lot of work with temporary workers, looking at how we can improve their ability to speak up. We still have a huge way to go on culture generally, but particularly on discrimination and the inequalities that we see in every one of our investigations.

Q I reiterate that I am a member of the all party parliamentary group on patient safety. Dr Benneyworth and I have had many conversations about this issue.

I have two questions. The first is about the safe space. We have seen written evidence, and we have heard when others have attended the Health and Social Care Committee, about the fact that if HSSIB is placed inside the CQC, you could have the farcical situation of one set of CQC lawyers, who are representing HSSIB, suing or attempting to sue another set of CQC lawyers, who are looking out for the CQC situation, because they are trying to get information out of part of their own system. Is that parody or is it a possibility and real problem?

Dr Benneyworth: It is a problem and something that potentially could happen. I hope that we would work effectively to try to avoid that. Essentially, and just to reassure the Committee, if we see something of a criminal nature, if there are significant regulatory concerns, we have protocols in place to be able to escalate that. But there is a real risk that potentially, if we held information that the CQC needed in part of its regulatory function, in its enforcement function, we would not be able to share that, because of our legislation, and we would not want to share it, because we want to maintain the trust in the system. It would need to go to the High Court to be able to get hold of it.

Q Just so that I am clear, you have internal protocols that would raise stuff if you saw something criminal, and if you were investigating something and potentially could not share the information, that would not prevent any of the multitude of other regulators that we have out there from investigating on their own something similar. Your investigation would not preclude them from being able to investigate as well.

Dr Benneyworth: No.

Q Dr Dash, in her evidence, said that—I am slightly paraphrasing, so I hope I have not got this wrong—NHS England has a number of investigatory bodies that it has established recently, and that although they were not perfect, they were much better, and they could be doing this job. What is your response to that?

Dr Benneyworth: NHS England has an investigations unit that commissions regional and national investigations, sometimes from private organisations. We work very closely with the NHS England patient safety team. As I said, we have supported their work in rolling out local investigations around the patient safety incident response framework. We have been instrumental in supporting the training and education around that. We are the only safety investigator with protected disclosure. There is no other body that is like us and can do the same type of investigations in this country, and we are internationally looked at. In fact, I am doing a podcast with Canada tomorrow. Numerous countries are looking at us and saying, “We want the same thing.” There is a handful of investigators like us in Finland and Norway, and they have excellent safety outcomes for their patients, but the rest of the world is looking at us and trying to learn from us, and I am frequently asked to speak internationally about this.

Q You are saying that you are a world leader.

Dr Benneyworth: We are—

Very quickly.

I think the answer was, “We are.”

I am afraid we have come to the end of the session. I am sorry and I apologise to colleagues whom I did not manage to accommodate this time. Thank you very much for joining us, Dr Benneyworth. That was most helpful.

Examination of Witness Sir Jeremy Hunt MP gave evidence.

We shall now hear oral evidence from Sir Jeremy Hunt MP. Again, we must stick to the timings and we have to finish at 11.25, so we have got just 15 minutes to put our colleague through the mincer. For the benefit of the record, would you like to identify yourself?

Sir Jeremy Hunt: Jeremy Hunt, former Health Secretary.

Q Good morning, Sir Jeremy, and thank you for coming to the Committee this morning. You are our longest serving Health Secretary and you focused much of your tenure on patient safety. I understand you are still part of the all party parliamentary group on patient safety, so that focus is continuing now. How does HSSIB improve patient safety and what are your thoughts on whether moving it into the CQC is a good idea?

Sir Jeremy Hunt: As the Committee knows, the principle of HSSIB was modelled on the airline industry, where the air accidents investigation branch has a superb track record of identifying safety breaches. There is a very good rail accident investigation branch that does the same for the railway industry, to make sure lessons are learned. My concern was that the NHS and actually health systems across the world are not very good at learning lessons when there are tragedies.

The heart of what the AAIB has is this concept of safe space, where people can talk to it completely without fear that what they say will get passed on or used against them in a court of law, and so they are very open about what may have gone wrong, allowing a rapid conclusion to be drawn. So that was the principle behind it.

I am against the transfer of HSSIB to the CQC for two reasons. First, I am worried that it will undermine that safe space principle. I think the safe space principle is the bit of HSSIB that is working very well and I am worried this will undermine that. Secondly, the Bill does not do anything to address the bit that is not working well, and that bit is that the NHS is still very poor on acting on recommendations that are made, and by the way not just by HSSIB but by public inquiries, prevention of future death notices, by maternity and newborn safety investigations reports.

We are the world champion at doing inquiries and reports. Unfortunately we are also the world champion at allowing those reports to gather dust without anything actually happening. What I would really like the Bill to do is something, whether through the National Quality Board or whatever, so that the public know that when HSSIB or MNSI or a Select Committee or a public inquiry makes a recommendation, the Government have to make a formal decision within a limited time period—“yes we are going to do this” or “no we are not”; no sitting on the fence about “this is under review and we will consider it, come back to it”, but a positive or a negative decision—and then if it is a positive decision, a timeline by when it will be implemented. That is not a party political point, because this is a problem that was not fixed when I was Health Secretary and it has remained outstanding for many years. Families just put their heads in their hands in despair that they get these inquiries, get these recommendations, and nothing changes.

Q We have the Hughes report that is two years from recommendation and we have not got an answer to that one yet. Our previous witness talked about a repository for recommendations—a sort of national hub to put them all into. Do you have any thoughts on that?

Sir Jeremy Hunt: What HSSIB has done is positive but it is still trying to solve a bureaucratic problem with more bureaucracy. What there needs to be is a formal system with a legal obligation on the Government. I felt this when I was chair of the Select Committee as well—that Governments would kick recommendations that were awkward, usually things that cost money that they did not want to spend money on, into the long grass without actually saying whether they agreed or disagreed with them. There is a terrible phrase that is often used: “agree in principle”. I may have been the one who invented it, but it is really bad for accountability because it allows the Government to say, “Yes, we really understand where you are coming from, but we are not going to put any timeline or give you any commitment as to whether we are actually going to make the change”. I think we need a proper system—and if it is the National Quality Board, that would probably be a good place—for formally assessing all public inquiry recommendations, all Select Committee recommendations and HSSIB recommendations, and saying, “Yes, we’re going to do this” or “No, we’re not”, but if it is yes, it will happen by this date with this person being responsible.

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

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

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

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

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

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

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

Q As a former Secretary of State for Health, what are your reflections on the abolition of Healthwatch and the absorption of its functions into the Department of Health, ICBs and local authorities?

Sir Jeremy Hunt: It is not dissimilar to my earlier reflections. It is really important that patients have a voice, but it is even more important that their voice is heard not just through a bureaucratic process that listens to them, and gives them a sense of being listened to, but then nothing happens. The problem with the Healthwatch structure we have is that it is very good at the listening bit, but I do not think people have confidence that things actually change.

Q It is always a pleasure to see you in the Chair, Sir Roger. Sir Jeremy, I want to turn to NHS England’s accountability, or lack thereof. I know you made the point that you did not want clinically advised decisions to be overly politicised, but I had the reverse in my constituency when a decision was made after the lease on a doctors’ surgery ran out. It could not be extended because of some rule in NHS England, but due to that lack of accountability, there was nothing that we could do. The surgery closed, and one in six of its patients was just redistributed to another surgery, so that accountability clearly failed in that space.

If you are concerned that accountability ends up too close to the Department, where else should it land? I am quite comfortable with a Minister being accountable for that decision, because they are accountable to MPs, who are ultimately accountable to the people that it affects. Can you pare back your answer a little bit and talk about where that accountability should lie, and how we can ensure that it works?

Sir Jeremy Hunt: That is a story I think every single Member of Parliament could repeat, and it is a fundamental flaw in the system. Do you not think it is completely ridiculous that you have to go to the Health Secretary, who is responsible for a budget of £160 billion—the largest healthcare system in the world—to sort out something like a GP surgery lease in your constituency? That is a perfect example of a problem that we should be able to sort out locally, and that is why I think the bureaucracy has got completely out of hand.

Q The safe space principle is arguably under threat by the merging of HSSIB and the CQC. From the evidence you gave to the Health and Social Care Committee, I understand your argument that if you get rid of the independence of HSSIB, staff members who have witnessed wrongdoing and unsafe practices will not feel there is anywhere they can go, when they feel compelled to disclose things they see, where there is no consequence to them. Can you just comment on that?

Sir Jeremy Hunt: Maybe I should just clarify, because I think Dr Dash referred to those comments. The CQC is incredibly important to hospitals and GP surgeries because it gives them a rating—“outstanding”, “good”, “requires improvement” or “inadequate”—and they really care about that. If a staff member is talking openly to HSSIB about a failure of governance in their organisation, and that is the same organisation that could decide whether they get stripped of their “outstanding” rating and downgraded to “good” or “requires improvement”, my concern is that some people may worry and say, “Maybe I shouldn’t be open, because this could affect my hospital’s rating.” Obviously, I would always want staff members to be completely open with HSSIB, but we have to be really careful that people still have confidence in the safe space function if this merger goes ahead.

Sir Jeremy, thank you very much for coming—once again, we are out of time, but we are indebted to you. The Committee will sit again in this same room this afternoon at 2 pm. The room will be locked, if Members wish to leave papers or anything else in here.

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

Adjourned till this day at Two o’clock.

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.

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.

Q60 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 will need political cover locally as well as nationally, so we are in a tricky place.

What we are saying is that we all understand the state of the public finances and suchlike, but we need some capital to allow places to reconfigure and redesign their services, whether that is new IT, AI or diagnostic services. Those are the things that will allow the transformations to take place, which is where the productivity and the money will come from. What we and chief executives, finance directors and chairs across the NHS are saying is that there is only so much heavy lifting that asking people to run around the hamster wheel a bit quicker can do. We have to make some of those big 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 is called, in the Department. If it is not, that could prove very difficult. Not necessarily day to day or in the short term, but in the long term, that bit has to be got right. One of the big risks of the legislation—there is not a legislative solution to this risk—is how day to day management works. We all have views on the relative strengths of the regions, of NHS England and so on, but how is that going to work in the new world? If one loses “grip”—that word is used a lot—then the risk to service delivery is quite high, and the risk to financial control is even higher.

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

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

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 what was good about healthwatches is preserved and is understood by ICBs. There are only 25 of them, so it should be a manageable task for the rest of us.

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

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

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

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

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

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

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

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

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

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

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

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

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 response to an earlier question, it depends entirely on whether the provisions of the Bill are used to set a small number of priorities and let NHS organisations get on with delivering them, or whether they are used more regularly to intervene more directly in our day to day operations. A lot comes down to how the regime is operated.

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.

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 NHS England since 2012, we think that money and commissioning has flowed to these services to only a very limited extent. For example, we have a successful service in the east of England, which provides 24/7 end of life care at home for seriously ill children, supported by nurses and these specialist consultants. But the provision is really patchy across England.

The Bill presents some opportunities through the additional powers for the offices for pan integrated care board commissioning—the OPICs—to mandate ICBs to work together to commission these services. We would like to see that. However, because of the small numbers but highly complex needs of these children, the services often need to be planned and funded at a regional level, although they often are not.

We are concerned by the increased devolution to ICBs because of the extent to which other children’s palliative care services—the core services—are being commissioned at the moment. We have a range of evidence that shows that it is possible in some areas for that care to be commissioned well—for example, 19% of ICBs currently commission end of life care for children at home 24/7, provided by nurses and specialist consultants. However, at the moment ICBs are not taking on their full functions and implementing national guidance.

I would like to see much more rigour and accountability from the centre, the Government, to make sure that such specialised commissioning works for this particular group of complex children and families.

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 us about the problems. I have to ask how that depth and focus is to be replicated under the arrangements suggested in the Bill. That is my extended first point about Healthwatch.

I think we have had a lot of impact, and I use the word “impact” as a researcher myself. Impact is measured by the change that you make. When we produce reports, whether national or local, we include recommendations. The important thing is that we always follow up on those recommendations and ask, “Are they being implemented? Are they being listened to?” Each year, we produce a report that says, “What change has occurred as a result of the recommendations that we make?”

I think that is extremely valuable, because it is about independence and holding organisations to account. Clearly, those organisations report in line function to the Department of Health, NHSE or local authorities, but we are not only the ears of the patient and the carer; at times, we hold feet to the flames over whether something sensible is being done. We do not give up on this; we pursue it down the rabbit hole.

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 who we are listening to, and that services are provided for those who feed back and those who do not—usually, it is those who are not feeding back who we really need to consider.

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 electronic records, as long as they are transparent and patients know what is being done with their data—that is a really important point.

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

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 the listening or the ability to look thoroughly at the impact, and it does not affect the fact that the organisations concerned are held responsible for what happens to the recommendations in terms of implementation. That is uniform across the system—it is just the amount of it that will vary naturally, because of the differential funding.

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

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

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

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

Professor Croisdale Appleby: May I add a short comment?

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 is not always easy for big institutions to go through all the work of evaluating qualitative work. It is easy to look at quantitative statistics, but the patient voice must be highly visible and central to policymaking. That was the basic idea behind the Bill: it would be about the patient and the patient voice, putting the patient right at the centre of the multiple discourses. As my colleagues have said, we should be totally transparent about priorities, impact and holding people to account. If all five of those principles are followed, it will work. If they are not followed, it will not.

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 any more because they are finding that they are getting a worse service of care. That might be a slightly separate issue, but considering that there are so many complaints and that patients are not wanting to complain because they are scared, I do not think that streamlining is the right way. We need an independent voice that will focus solely on the patient voice, which I think we are completely losing at the moment.

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.

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 that seeks out the views of both communities and individuals where the health inequalities are the greatest—will be on the priority list. I would question that, but I will leave it there.

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.

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.

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.

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

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

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.

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?

Is that directed at any particular witness?

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

Let us start with our councillor in the middle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 for social care providers and commissioners. It is worth noting that there are thousands of social care providers, so the implementation of the Bill and subsequent regulations will be important. We are keen to ensure that any approaches are co produced with the social care sector, as well as the NHS. It will be a lot of thinking, a lot of planning and a lot of hard work to get it right, and social care providers will need lots of notice to upgrade their systems in the right, consistent way to enable them to speak to each other, if we are to see the vision of the single person record delivered. I guess it would also be helpful to think about the role of carers as we move into that space, because we know from covid that data sharing among carers was one of the issues that came up.

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?

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 everywhere, but in our borough we have a step down unit called Heathlands, which people quite often go to when they come out of hospital and which does quite a lot of rehabilitation. That already starts the plan to get them home: to go from hospital, to the step down place and then to home. It is about having good systems in place, all of which should hopefully be supported by neighbourhood health, which should have a good knowledge of what is available locally.

Sally Burlington: It should definitely help, if it works well; we should see more capability and capacity available in the community, closer to where people live, to help them when they come out of hospital. There is a lot of good practice and understanding about good discharge and how you plan from the point that somebody is admitted to when they come out of hospital. The emphasis on integrated neighbourhood teams will be important. It would be helpful if we could all remember that those must include social care and wider local government services and connections in to those, not just integration within NHS teams. It is definitely a positive step forward and, if we can try to make sure that the relationships between health, social care, public health and wider services are brought to life in neighbourhood health, that will help us in this way and in lots of others.

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 conversations with ICBs, and a real strategy looking at those health inequalities and what is driving them. It will not purely be access to hospitals; it will also be access to meaningful employment, housing, transport, mental health or social isolation—there will be so much driving those wider determinants of health that are affecting healthy life expectancy. Local authorities are in a prime position to do that, and they need to be listened to. I think the challenge will be how we collectively say, “What needs to be done, other than implementing the Bill? How do we look at the whole health inequality picture and address it?”

Sally Burlington: I would agree with the others: tackling health inequalities is really difficult. Doing it the same way in every area would not work, particularly in a world where there is not enough resource to do everything we would all like to do. You have to tailor how you approach local service delivery and what is needed locally according to local needs, the local community capability, how people work and what their preferences are locally, and the neighbourhood health agenda is our best shot at tailoring in that way.

I think you will come on to Healthwatch, but we would have concerns that, in separating the Healthwatch duties to look at NHS and social care, we risk missing some of those who are most likely to need both, and that that could exacerbate health inequalities rather than make them better.

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.

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.

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.

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.

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 piece in maternity, which will not come as a surprise to you, is that, if you have lost a baby, you end up having to retell your story over and over again and that can be very traumatic. Sometimes that can lead to people disengaging from care, but also in many cases being retraumatised.

We broadly welcome the single patient record, but with lots of caveats around people feeling able to trust the data and trust that their data is safe. Overall we are very supportive.

Emily Holzhausen: Again, similarly to my colleagues, we are supportive. When we ask unpaid carers what matters to them, sharing of information is really critical, but we have a slightly different perspective here.

First, carers would like to have access to the record, with the right permissions. That is not on the face of the Bill, but it is suggested that that may be covered in regulations, and we would like to see some assurances of that. It would change things, again, because of not having to retell information, which carers call “triggering” and “exhausting”. They will be more able to spot errors or things that are not quite right, which is important for the person they are caring for. As an unpaid carer, when you are responsible for caring for someone, that is a huge weight on your shoulders and you really want to make sure that it is being done right. Finally, most of us care remotely—we do not all live with the person that we care for. This could really help to transform carer’s lives and the pressure they feel.

I have one statistic for you: just under one in eight carers spend over 40 hours a month on NHS admin. If the NHS app and the single patient record can reduce that, that would change things. The only other point I would like to make is that where this tips over into social care, this is something that we need to build with social care and all those people who go across all these different services.

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 groups that are being excluded: older carers, people on lower incomes and people who feel less confident with technology, for a whole range of different reasons.

Some of this stuff is delivered very well through voluntary and community services—I know that Age UK has helped my family locally, for example, but I will stop there, because I am sure Paul will want to come in on that.

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 excluded, but partially excluded. We think people are able to go on that journey, but it does need support. We encourage the Government to think about putting a really thorough programme of digital inclusion alongside the implementation of the single patient record, to support older people, people with long term conditions, people with learning disabilities and other conditions who might need extra help and support to access the NHS app. There is a risk here of people being excluded, but also an opportunity for inclusion.

Mrs B, in Lincolnshire, was helped by Age UK Lincolnshire. She was a carer to her husband, who has had a stroke; she had a home visit from the local Age UK and they were able to set up the NHS app for her. She said she would not have been able to do that without that extra help and support.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 providers and, in particular, in the new world of neighbourhood health?

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

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

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

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

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

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

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

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

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.

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—

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.

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 relied on in terms of people’s confidentiality is something that concerns me very much, as well as people’s trust and confidence in secondary purposes, how the system will be used and what the safeguards around it will be. I would be happy to answer from that perspective when it comes to people’s confidence.

I think you have heard a lot about the potential benefits of this system, but it is important to bear in mind that if people do not trust it, the programme will fail, however great the potential benefits are. As a clinician, I would share the excitement, and I am very supportive of the ambition, but people will not trust it if they perceive the risks to the security of their data and confidentiality to be too great.

With that in mind, I want to draw attention to two things that concern trust. I want to emphasise that trust is not simply important—I know that the word “trust” has come up repeatedly today—but absolutely foundational to the success of this. The question about how demonstrably trustworthy the system is should be the primary foundational question; all other questions, including the technical ones, flow from that one question.

On the confidentiality aspect, I think there is a provision under clause 47 that potentially has very significant unintended consequences. I understand that that is not the intention of the drafting, but I have concerns about it and I have a potential solution to suggest. In clause 47, proposed new section 250E(3) creates the power for the Secretary of State to remove the duty of confidentiality for any processing in the SPR in line with regulations. I need to register my concern about that wholesale lifting of the duty of confidentiality from the entire system.

At a system level, there are two risks. One is to patient and professional confidence in the confidentiality of the data once it is accessed or in a system. Confidentiality is absolutely the cornerstone of all clinician patient relationships. It means that people are comfortable to share the most sensitive information about themselves and often loved ones—it is not just information about ourselves on our records; it is often also information about our loved ones. If people do not trust that that confidentiality is a constant ethical constraint for anyone accessing the record further on, they may be less able to share information about themselves or their loved ones. Clinicians may also be less likely to document that information if they have ethical concerns about who may access it further on if it is particularly sensitive. That will negatively impact on care and the quality of data for any secondary purposes in future.

The second point I will make about that confidentiality provision is that I understand that the drafting intent is to remove any ambiguity in terms of people’s concerns about duty of confidence when allowing access to their data at an organisational level. However, as currently drafted, the provision could be interpreted to remove the duty of confidentiality for not just direct care but secondary purposes. Secondary purposes in future could be dealt with by regulations. That lack of clarity poses a risk.

The solution I suggest is to redraft that provision, drawing on the precedent already set in the Health and Social Care Act 2012. Section 259 prevents disclosure of data from an organisation from being a breach, so people could allow access at an organisational level with confidence. You have removed that ambiguity, but it does not remove wholesale that duty of confidence—that ethical safeguard for the data in the system itself. I think that that is important for people’s own direct care, and, as I said, it is particularly important if there are any questions around secondary uses in future.

Dr Imam: That was a comprehensive answer; I have nothing to add.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 is. It needs to be there for that tool to work. To take you on a slight thought experiment, if it was entirely held within a patient’s control—however loosely we use that term, legally or otherwise—and we could all amend, correct, change or add our diagnoses, findings and treatments, that might be clinically problematic. That may not be the answer you want, but it is the straight answer, if I am honest, from both a clinical and legal perspective.

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.

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.

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 service to the public, the safety of the changes and what will happen to various functions that they are responsible for, if teams get halved and responsibilities are taken to a higher level in that more centralised model.

For example, we have a lot of members working in ICBs who have really hands on roles in the care of individual children, particularly where providers fail. Those kinds of concern are not being properly addressed in terms of risk and continuity of service to those people. We are going to survey our members—we will share the results with the Committee—in the next week or so about what specifically is worrying them about the way that change is being managed. With due respect to the Minister, this was all announced without a plan, and we are now waiting for a plan to emerge, 18 months into the process.

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 managers with enough skills working in the right system to deliver. That is the nub of what we are doing.

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

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

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

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

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

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.

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.

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 care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 funding regime, but while we do not, those costs exist. My sense is that they are second order at the national level, but where they are certainly not second order is for the individuals concerned and their families, for whom this kind of thing is an eruption of anxiety and grief, in the context that families are already under pressures that most of us would find hard to imagine.

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.

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 Act. It even had to be paused mid way through to enact other ways of making things work.

I am sure that you will come back in your second question to decisions about some of the provisions in this Bill. It is true, and a matter of record, that as an incoming Government we did not intend to abolish NHS England as an organisation; in our determination to change the outcomes of the health service, that decision was made some eight months into our being in government. Today, we have not heard a single person suggest that that decision is wrong. Dr Johnson is from the Opposition. The Bill was not opposed in principle on Second Reading. There is overwhelming consensus on the major provision in the Bill—the abolition of NHS England—and on the single patient record.

I am mindful, on a personal level, of the consequences for individual people’s jobs and of trying to get that right. I accept much of the criticism from Mr Restell about how it would be better to do it much more quickly, and about making sure that it is done in a different way, but the consequences of abolishing NHS England are some of the things that we are seeing.

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 make the most of mayoral authorities to allow mayors to be on ICBs, as they are largely determiners of a lot of economic development, transport and indeed the wider determinants of health. We are still going through some of that change; you will recently have been written to for your views on it as local Members of Parliament, along with local government. We need to make sure that that is embedded as quickly as possible so that we can stabilise that side of the system.

On the single patient record, the Bill will provide enabling powers to bring it forward in regulations. There will be further detailed consultation both with clinicians and with patients and the public, as we have heard, because building trust is critical. That will come next, which is usual in parliamentary terms: as legislators we understand that primary legislation makes provision and secondary legislation sets out regulation. I thought Dr Byrne was very helpful earlier on the point about bringing public trust with us and explaining the two stages of bringing this forward.

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 managerial, clinical and patient experience work, is their responsibility. Outsourcing lots of that work to other bodies has not worked, and I think it is outsourcing that responsibility. We have to make boards work at a local level; they have to step up to the plate, and I think they want to. They are certainly equipped to be able to do that—not taking into account that people will need some skilling in some of these areas. There is a debate to be had about independent organisations, and I think we will have a good debate on it in Committee.

As a final comment before you come back, this is a bit of a bugbear of mine, and perhaps as I am speaking on behalf of the Department I should not say it, but I will: none of my constituents are hard to reach—not a single one of them. We know exactly where they are; we largely know what is wrong with them; we largely know what their health outcomes are going to be; we know their ethnicity, demographics and so on. What are hard to reach are the remote organisations that have not served them well, and that is what we are determined to put right. Putting that right in this Bill is the start of doing that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 of doing it now outweigh the risks and that is the only way to make the system change. We heard from the King’s Fund about opportunity costs and that the benefits do not outweigh the risks—we do not think that is true.

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