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

Public Bill Committee

Thursday 25 June 2026

(Morning)

[Emma Lewell in the Chair]

Health Bill

Before we begin, I remind Members to switch all electronic devices to silent. Tea and coffee are not allowed during sittings. As Members will have noticed, I have taken my jacket off, so please feel free to take yours off—it is hot in here.

Clause 12 Commissioning functions: responsibility

I beg to move amendment 57, in clause 12, page 10, line 10, at end insert— “(4A) Before making regulations under subsection (1)(b) that would alter the range of services or facilities which the Secretary of State is required to commission nationally, the Secretary of State must— (a) prepare and publish a commissioning transition plan in accordance with subsection (4B), (b) consult in accordance with subsection (4C), and (c) lay the commissioning transition plan before Parliament.

(4B) The commissioning transition plan must set out— (a) a description of each service or facility that the Secretary of State proposes to add to, or remove from, national commissioning responsibility under section 3B(1)(b), and the reasons for each proposed change; (b) a description of the body or bodies to which commissioning responsibility for each such service or facility would transfer and the basis on which that body is considered capable of commissioning that service or facility effectively; (c) an assessment of the impact of each proposed change on patients who rely on the affected services or facilities, including— (i) patients with rare diseases or conditions, (ii) patients whose needs cannot be met by a single integrated care board area, and (iii) patients who may face differential impacts on account of a protected characteristic within the meaning of the Equality Act 2010; (d) the transitional arrangements to be put in place to ensure continuity of service for patients during any transfer of commissioning responsibility; (e) the workforce and capacity implications for the bodies to which commissioning responsibility would transfer; (f) the financial arrangements for the transfer of commissioning responsibility, including the funding to be allocated to receiving bodies; and (g) the proposed timetable for implementation of each change.

(4C) Consultation under this subsection must include— (a) integrated care boards that would assume commissioning responsibility under the proposed changes; (b) NHS trusts and NHS foundation trusts providing the services or facilities affected by the proposed changes; (c) patient groups and representative organisations for patients likely to be affected by the proposed changes; (d) clinicians with expertise in the services or facilities affected; and (e) such other persons as the Secretary of State considers appropriate.

(4D) Consultation under subsection (4C) must— (a) run for a period of not less than twelve weeks, and (b) begin no earlier than the date on which the specialised commissioning transition plan is published under subsection (4A)(a).

(4E) Following the consultation period, the Secretary of State must publish a response to the consultation that— (a) summarises the representations received, (b) sets out the Secretary of State's response to the key issues raised, and (c) describes any amendments made to the specialised commissioning transition plan in light of consultation responses.

(4F) No regulations under section 3B(1)(b) that alter the range of nationally commissioned services or facilities may be made until at least 60 days have elapsed after the consultation response required by subsection (4E) has been published.”

This amendment requires the Secretary of State to publish and consult on a commissioning transition plan before making any regulations under the new section 3B of the National Health Service Act 2006 (inserted by Clause 12) that would alter which services are commissioned nationally.

With this it will be convenient to discuss the following: Clause stand part.

Clause 13 stand part.

In essence, the clause confers the commissioning duties of NHS England on to the Secretary of State, because NHS England is being abolished. In that respect, it is quite straightforward. In the existing National Health Service Act 2006, which is to be amended, section 3 sets out the duties of integrated care boards as to commissioning health services, and section 3A similarly. Section 4 is about NHS England’s responsibility for the provision of high security psychiatric services. In essence, clause 12 replaces the references to “NHS England” in sections 3 and 3A with “the Secretary of State”. The ICBs now must act consistently with the discharge by the Secretary of State of the section 1 duty to promote a comprehensive health service. That is consistent with the aims of the Bill. I have concerns, which I have expressed previously, about how the Government ensure that the Secretary of State can make those decisions fairly, on the basis of clinical need, rather than because of pressure from a lobby group, a celebrity campaign or such like, but again, that seems consistent.

The clause also replaces entirely section 3B of the 2006 Act. Under the previous section 3B, the Secretary of State could direct NHS England to commission the service nationally; the proposed new section 3B confers a regulation making power to require the Secretary of State to arrange nationally services for members of the armed forces and their families specifically, as well as such services or facilities as may be prescribed. Perhaps the Minister will comment on what sort of services or facilities might be prescribed under that proposed new section.

In doing that, the Secretary of State must have regard to the number of people needing the service, the cost and the number of possible providers. That reflects a balance. Some services, such as hip replacements, are very common. They occur in all areas of the country, perhaps at different rates, but they are broadly a common service. Accident and emergency is another common service. Some people, however, have the misfortune to have a condition that is rare and requires specialist care, in small numbers. That needs to be commissioned on a more national basis, because of the need for specific expertise among commissioners and health professionals.

In subsection (4), proposed new section 3B(5) modifies section 4 of the 2006 Act so that the duty to arrange high security psychiatric services transfers from NHS England to the Secretary of State, and the Secretary of State gains a new power to direct the providers of those bodies—but only non public bodies—if he is satisfied that the provider is already licensed under the Health and Social Care Act 2012 and would be required by its licence to obey the direction.

In one respect, as I said, it is necessary to transfer powers to Secretary of State, now that NHS England is to be abolished, but I have a couple of questions. NHS England published a direct commissioning update on 2 March, which describes a new commissioning structure. At the moment, NHS England commissions regional NHS England bodies and the ICBs at a more local level. The update suggests that we will have the ICBs commissioning services, and the Secretary of State instead of NHS England, but that each of the seven regions will have an office for pan ICB commissioning, known as an OPIC, to support ICB commissioning services—both standard commissioning and at scale commissioning in some instances.

How is that more efficient than the old structure? Are we just going to see the people working in the regions of NHS England get made redundant, at a huge cost to the state, only to be re employed by the OPIC? What is the estimated cost of that? Is that the intention? We are going to either lose the expertise of the regional advisers in NHS England or end up re employing them having paid them redundancy. Can the Minister explain which she thinks it is?

There is a hugely long list of specialist nationally commissioned services. Can the Minister guarantee that those services will not be moved locally? The ICBs only have so much capacity. It will be a challenge for an ICB to deal with conditions that may affect only one or two people in its area in a given year, particularly given the 50% budget cut; obviously, it will prioritise things that affect more of its population. People who have the rare conditions that are currently commissioned nationally may be worried that they will not get the same level of service that they are getting at the moment.

The direct commissioning update talks about prisoners and the justice system. At the moment, NHS England works directly with the Ministry of Justice to commission healthcare for those in the justice system. That includes adults in the custodial system, children in secure children’s homes, non custodial care, sexual assault and abuse centres, and abuse referral centres.

There are eight high security category A prisons in England. Instead of being specially commissioned as one batch, they are going to be commissioned specially by their local ICBs. Where are the ICBs going to get the advice and expertise to do that? Dealing with category A prisoners is about not only managing the prisoner and providing them with healthcare, but keeping the people providing that healthcare safe while they are working. This is a specialist area. I am interested to understand why the Minister thinks it will be managed best locally. If, under her new system, it is to be managed locally and the prisoner’s home address ICB is different from the prison address ICB, where will the funding move from and to? Will the prison’s ICB be reimbursed by the prisoner’s home ICB or will it bear the brunt locally?

What will happen to the sexual abuse referral centres? It is perfectly possible, particularly in some areas of the country, that an individual is sexually assaulted in one ICB area, lives in another and reports a crime in a third. Will local commissioning have an impact on where the individual needs to go for their pretty intimate examination and assessment? Has the Minister considered that? What is her view?

What happens to healthcare for migrants? That is another area that is dealt with partly by the justice system at the moment. Can the Minister update us on that? There are over 100,000 people in asylum accommodation, including 30,000 in hotels, and many members of her party are keen to welcome even more. Who will be responsible for commissioning their care?

The Government are also delegating the child health information services, which are the record of whether children have been vaccinated and such like. Given that they are planning to have a single patient record and the electronic red book, why do they want the services to be commissioned locally rather than nationally? Do they expect commissioning for a uniform service, such as a screening service, to lead to differential outcomes—and if it does not, what is the rationale for it?

A particular example is blood spot screening. The Minister will be aware that there was a Westminster Hall debate earlier in the week on spinal muscular atrophy, in which blood spot screening was mentioned. Metachromatic leukodystrophy is another condition for which people want blood spot screening. If blood spot screening is to be commissioned on a local ICB level, will ICBs be required to do it in line with Government guidelines, or will they be able to vary the service they provide to those patients?

By delegating more to ICBs, Ministers are creating variation. On one hand, they want local differentiation and variation; on the other hand, they have put in a clause that requires the Secretary of State to limit local variation. Again, there is a tension there. Will the Minister talk about that?

Moving to some technical points, I noticed that “hospital premises” is defined in section 4 of the 2006 Act, but I cannot find it defined in the Bill. Under the original section 3B of that Act, the Secretary of State had to obtain appropriate advice before making regulations about commissioning services; when services were commissioned locally or nationally, the Secretary of State had to take expert advice. That seems like a sensible thing that we want the Secretary of State to do. One would hope that if the Secretary of State were doing his job properly, he would do that, but it seems a little odd that that requirement has been taken out, as though there is an intention for the Secretary of State not to do that. I would appreciate the Minister’s comments on that.

Proposed new section 3B provides that a direction can be given to a person other than a public authority regarding high security psychiatric services. The Minister knows that high security psychiatric services are currently provided at Broadmoor, Ashworth and Rampton, which are still stand alone units run by NHS providers. Does she plan to ask a private provider—someone other than a public authority—to run those facilities? If not, what is the purpose of the clause? There is a secure children’s unit in Sleaford in my constituency. What will happen to those children if it is commissioned locally, and where will the money flow from?

We asked in a previous sitting whether the Minister thought that the new Prime Minister will want to continue with this Bill. When it comes to the OPICs, in essence the Government will be firing staff from one job, paying them redundancy, and rehiring them, potentially on different terms and conditions, to do a similar job in the OPICs. Is the Minister aware that the right hon. Member for Makerfield (Andy Burnham) used to speak out against firing and rehiring staff, and abolishing and recreating organisations? That is essentially what is happening, so will she have to abandon these changes?

We have heard a few times about Conservative fears about redundancy payments and so on. Why did they not add NHS England to the list of organisations covered by the modification order when they had the opportunity to do so? Is the hon. Lady aware of a reason why that did not happen when the Conservatives were in government?

I am afraid I do not know the answer to that question. The key point is that it is not logical to abolish a three tier structure and recreate it with taxpayers’ money to do exactly the same thing. If NHS England is replaced by the Secretary of State, the regional NHS England is replaced by the OPICs and the ICBs are at the bottom—the more local tier—what has changed? The middle tier will be doing the same thing.

The modification order is a piece of legislation that is often used in the public sector. It means that when people from a lot of public sector organisations are made redundant and find alternative employment at another state funded organisation, they are not entitled to a redundancy payment. During their 14 years in power, it would have been entirely possible for the Conservatives to add NHS England to the list of organisations covered by the modification order. That would have prevented the costs that the hon. Lady has mentioned several times. It just seems like they did not take the opportunity to do that, and now they are saying that they should have done that when they were in government.

But we were not planning to abolish NHS England, so we had no reason to worry about redundancy. We were not planning a large scale abolition—the largest that has ever happened in this country.

Amendment 57 would require the Secretary of State to publish and consult on commissioning transition plans before making regulations under proposed new section 3B that alter which services are commissioned nationally. It is a very reasonable amendment that would just mean that people get answers. It would mean that vulnerable people with unusually rare or highly complex conditions requiring regional or even national treatment could understand any changes the Government planned to make. We know that some services are delivered in only three or four centres in the UK. If a patient lives far from a centre, and suddenly that centre is closed, that can have huge travel and service implications, which can create huge distress and worry and make care worse.

Amendment 57 essentially seeks to make sure that, if the Government want to do this—there may be good reason on occasion—they have to be reasonable and take advice from experts and consult those who would be affected, and they must have a plan. This Government are fond of saying that they have a plan but not actually having a plan. Before they came into office, they said they had a plan for the NHS; we saw that they did not. They took a year to write their plan and then it was full of messaging about even more plans, such as the workforce plan, which, despite supposedly being “imminent” for most of the last week or so, still has not been published.

As Members think about their vote, I encourage them to think about what the right hon. Member for Makerfield said the last time a Government undertook a reorganisation of such large scale:

“This is a difficult day, but what makes it harder to stomach for people watching is the manner in which things are happening. People outside will struggle to understand how Members of this House could make such momentous decisions without having carefully considered all the facts and all the evidence…How do they begin to justify that to their constituents, to patients who depend on the NHS and to staff who devote their lives to it?”—[Official Report, 20 March 2012; Vol. 542, c. 655.]

Those comments could be pertinent today, could they not? All we are saying with amendment 57 is, “If you are going to change NHS commissioning from national to local, it could have an effect on patient care, and you need to do it carefully and properly, with a plan that is properly published, and deliver it with timescales and consultations, so that people know what they are doing.”

In summary, clause 12 leaves us an element of uncertainty. Commissioning could move, but it might not; we do not know. Given the chaotic nature of the rest of the changes in much of the Bill, accepting amendment 57 would be an important step to keep patients safe.

Clause 13 introduces the power to confer discretion, which essentially means that if the ICBs are commissioning a service, they can give the provider of that service, which may be NHS or private, the discretion to vary that provision within certain guidelines. To me, that flexibility is a good thing—providers are closer to patients than commissioners, and provided that the limits given by the ICBs are reasonable, the provision seems reasonable to me. Unlike much of the Bill, the provision also aligns with the Government’s stated intent for this legislation, which is more autonomy for local providers. That is a good thing, so I have no particular objection to clause 13.

It is a pleasure to serve with you in the Chair, Ms Lewell. In general, the Liberal Democrats support clauses 12 and 13. We think that local decision making and community empowerment in the NHS, including on commissioning decisions, is the right thing to be doing.

However, I echo some of the concerns of the shadow Minister, the hon. Member for Sleaford and North Hykeham, particularly on specialist commissioning. I declare an interest as vice chair of the spinal cord injury all party parliamentary group. We are concerned that expertise in low volume, very specialist concerns will be lost if the commissioning is pushed out to multiple ICBs. My understanding is that specialist commissioning sat with NHS England in the first place because of concern that multiple commissioning groups would struggle to deal with low volume, complex issues.

The president of the Royal College of Psychiatrists warned earlier this month that the new commissioning structure lacks mental health experts, with only one senior mental health lead across the seven new regional commissioning hubs taking specialised services from NHS England. Equally, the chief executive of the Derby and Derbyshire, Lincolnshire, and Nottingham and Nottinghamshire ICB cluster has said that it does not look like there will be a requirement for senior mental health expertise in reorganising ICBs. Will the Minister reassure us that when the Department designs which specialist services will be pushed back down to ICBs and which will be retained centrally, it will be minded to listen to representations from experts in the sector?

There are excellent services located geographically by accident—for example, the orthopaedic hospital in my constituency and the veterans service that goes with it. Both are highly valued, but they need specialist commissioning at national level to be utilised properly and to provide the best outcomes for patients. I would be grateful for the Minister’s reassurance on those points.

I agree with much of what the hon. Lady has said. Does she therefore support amendment 57, which would ensure that such a consultation takes place?

Yes, we would support the amendment, which is a reasonable way to get there, but an assurance from the Minister that the Department will consider specialist commissioning and really think that through properly before the powers are delegated to ICBs would be sufficient.

It is a pleasure to serve under your chairmanship this morning, Ms Lewell.

It is right that Ministers are ultimately responsible to the House for the performance of the health service and subjected to the scrutiny of Parliament for its execution, but there is an important distinction between accountability and operational control, which I fear the clause risks eroding in some cases. The national health service has over many years developed a structure that seeks to balance political accountability with operational independence, and that balance exists for a reason. Decisions on what services are commissioned, where they are delivered and how resources are allocated are not purely political judgments; they are complex, technical decisions that ought to be guided—primarily, in my view—by clinical evidence, patient need and professional expertise. Transferring commissioning functions directly to the Secretary of State, as the clause will do, risks drawing those operational decisions more directly into the political sphere, even if that would not happen in every case.

The more that Ministers are involved in determining which services are commissioned nationally and which are not, the greater the risk that over time those decisions will be influenced by short term considerations and short term pressures rather than long term patient outcomes. Even when no such influence is intended, the perception that that could occur will be damaging. As I said in discussions on previous clauses, the NHS depends heavily on public trust, and that trust rests in part on the belief that decisions are being made in the best interests of patients and on the basis of evidence, rather than political expediency. We should therefore be cautious about any measure that threatens to blur that line.

Despite the Minister saying that the stated intent in the Bill is to decrease centralisation, the clause appears to move some parts of the system closer towards centralisation, rather than maintain that balance. I do not believe that the Committee should take that step without careful consideration of the potential consequences.

There is also a practical dimension to this issue. Under the clause, the Secretary of State potentially assumes direct responsibility for any and all decisions currently exercised at arm’s length. That raises legitimate questions about capacity and focus. As I said previously, the health service, as we all know, is vast, complex and complicated, and decisions, especially about specialised commissions, are technical and require detailed expertise and understanding. What is not immediately clear from the clause is that such decisions are best taken by the Secretary of State rather than by bodies with dedicated expertise and a degree of operational independence.

Both my hon. Friend the Member for Sleaford and North Hykeham and the Liberal Democrat spokesman, the hon. Member for North Shropshire, spoke about highly specialised services, where essentially there is a capacity issue and a need to be able to look at the demand as a whole. They both raised the danger that, if those commissioning decisions are taken at local level, those at that level may not have the expertise, the finances or indeed the capacity to truly understand those highly complex, low volume specific needs.

I have some sympathy for the Minister, because the danger that we have seen in the NHS is that everything becomes more and more specialised and the ICBs push it away. I understand why the Government are proposing some of these changes, but we must not throw the baby out with the bathwater. We must ensure that services continue to be commissioned by experts at the national level if they need to be; and that if they need to be commissioned by experts at ICB level or even more locally, it is done through the neighbourhood health schemes that the Government are pushing, which I support in principle.

For those reasons, if the Committee is minded to support the shift in responsibility, I suggest that we put in place some robust safeguards to ensure we have transparency, consultation and evidence based justifications for decisions. Without those safeguards, there is a risk that the centralisation of power on the one hand and the devolution of specialist services on the other will unintentionally make a system that is less transparent and less robust.

That is why I support amendment 57 in the name of my hon. Friend the Member for Sleaford and North Hykeham. The powers in clause 12 need to be bounded by checks and balances, because these are not minor administrative changes, but a significant shift in responsibility. We must ensure that decisions to move service commissioning are made as transparently as possible. In those circumstances, it is entirely right that Parliament should be able to scrutinise those decisions.

The amendment would achieve that. Subsection (4A) would require the Secretary of State, before making regulations, to prepare and publish a commissioning transition plan and to lay that before Parliament. Subsection (4B) would require the plan to set out, in detail, the services being changed and the reasons for the changes. It would also require clarity on which bodies will assume the responsibility and why they are considered capable of doing so. That level of transparency is essential if Parliament is to exercise meaningful oversight. Subsection (4C) would establish a formal consultation requirement, and subsection (4E) would require the Secretary of State to publish a response to that consultation, setting out how concerns have been addressed. That is vital, because there is no point having a consultation if the Government just ignore it. Finally, subsection (4F) would ensure that no regulations can be made until a defined period has elapsed after that response, thereby providing a time for proper parliamentary and public scrutiny.

Those of us who sit on Select Committees, especially the Health and Social Care Committee, often receive responses to our recommendations from the Department that, as my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) said in evidence, give the veneer of acceptance, but then no meaningful action is taken. The amendment would allow meaningful scrutiny and ensure that the Government actually respond to that request.

Taken together, the provisions would ensure that decisions are not only made, but made openly, transparently and accountably to those who are elected in this place to represent our constituents.

I wish to speak on clause 12 in the context of specialised commissioning. In my parliamentary work, I deal with a great number of rare disease communities and other specialised groups. Specialised commissioning is important to them to ensure that they get the service they need and deserve. Will the Minister explain how we can ensure that there is patient involvement in a more dispersed system of commissioning, and that there is national oversight and clinical leadership for all these things? How will she ensure that specialised commissioning groups are monitored and that effective services are being provided to those in the communities who need them?

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

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

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

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

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

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

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

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

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

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

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

Question put, That the amendment be made.

6|0|3|10|The Committee divided:|Question accordingly negatived.||0|0

Clause 12 ordered to stand part of the Bill.

Clause 13 ordered to stand part of the Bill.

Clause 14

Primary care services

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

With this it will be convenient to discuss the following: Clause stand part.

Government amendments 14 to 18.

Schedule 1.

New clause 2—Right to a GP appointment— “(1) The Secretary of State must by regulations, within six months of the passing of this Act, establish a scheme to provide every patient with the right to a GP appointment within seven days of seeking one.

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

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

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

This new clause requires the Secretary of State to introduce a scheme to ensure that patients have the right to see a GP within seven days. Government new clause 21—Dispensing medical practitioners etc. Government new clause 22—Inadequate provision of pharmaceutical services. Government new clause 23—Pharmaceutical services: appeals etc. New clause 30—General Ophthalmic Services: national framework, tariff and protected funding— “(1) The Secretary of State must by regulations establish and maintain a national service specification for the primary ophthalmic services referred to in section 115 of the National Health Service Act 2006 (in this section referred to as general ophthalmic services, "GOS"), setting out the minimum standards of access and provision that integrated care boards are required to secure.

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

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

(4) The Secretary of State must ensure that funding for GOS is allocated to integrated care boards as a ring fenced, protected funding stream, which— (a) may not be applied by an integrated care board to purposes other than GOS; and (b) may not be reduced by an integrated care board in order to meet expenditure requirements in respect of other services.

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

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

Government new schedule 1—Pharmaceutical services: appeals etc. New clause 52—Access to dental provision: Dental deserts— “(1) Within six months beginning on the day on which this Act is passed, the Secretary of State must establish a scheme to improve access to dental provision (“the Scheme”).

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

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

(4) The scheme must make provision to support integrated care boards to— (a) guarantee emergency access to an NHS dentist, (b) provide free dental checks up for— (i) children, (ii) mothers within one year of having given birth, (iii) pregnant women, and (iv) low income households, and (c) guarantee dental appointments for persons commencing— (i) surgery, (ii) chemotherapy, or (iii) transplant procedures.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Finally, I turn to clause 14 and schedule 1. The transfer of responsibilities for primary care services to integrated care boards will deliver on our ambitions to devolve decision making to local systems as part of the 10-year health plan. Since 2022, integrated care boards have had delegated responsibility from NHS England for arranging primary care services, holding contracts and contractual relationships, and making related payments to contractors. That includes the commissioning of primary medical, dental, ophthalmic and pharmaceutical services. However, it is currently a delegated responsibility, with NHS England maintaining oversight and accountability.

Clause 14 and schedule 1 will transfer the statutory responsibility for commissioning services so that ICBs hold the responsibilities in their own right. That relates to my hon. Friend’s question about why the route is through the ICB. This is a key part of giving ICBs the power and responsibilities needed for them to become strategic commissioners of local healthcare services, and allowing them to join up services in the best interests of patients.

I also draw attention to the elements of the clause that give new responsibility to the Secretary of State. In particular, we have been concerned to retain in the centre responsibility for functions that are most appropriately delivered nationally to ensure standardisation, such as setting national contractual and service terms, making regulations and directions, or giving determinations to provide payment terms for primary care contractors.

The Secretary of State will also receive the statutory responsibility for the performers lists from NHS England, along with the power under the Bill to delegate the delivery of functions to appropriate health bodies. The performers list powers allow a practitioner to have conditions placed on them on the grounds of suitability, addressing inappropriate conduct, fraud and the efficiency of the service. The Secretary of State will also receive powers in relation to the removal of a practitioner from the list, including the power to make provision on the grounds for removal. The clause will maintain the framework that upholds patient safety to ensure that practitioners working in primary care are suitable and fit for purpose.

The clause will ensure that stability for contractors and patients is maintained with important safeguards, while further empowering ICBs to create a stronger and more integrated primary care system. I commend the clause and schedule, as amended, to the Committee.

Clause 14 is very straightforward: it states that schedule 1 “confers functions on integrated care boards in relation to commissioning primary care services…transfers related functions from NHS England to the Secretary of State, and”— perhaps most interestingly— “contains other amendments relating to primary care services.”

Schedule 1 essentially makes the following changes to the NHS Act 2006: it makes ICBs responsible for commissioning pharmacy services instead of NHS England; it amends section 99 to make ICBs responsible for commissioning dental services instead of NHS England; it amends section 83 to make ICBs responsible for commissioning primary medical services such as general practice instead of NHS England; and it amends section 115 to make ICBs responsible for commissioning ophthalmic services.

Largely, this change is formalising existing delegation and the risk of disruption is therefore relatively low. Local commissioners can tailor decisions to local need, and it is better if decisions are taken closer to users. However, there are a few other things in there as well. Paragraph 12(2) amends section 97 of the 2006 Act containing local medical committees, which are statutory committees. The way it is phrased, “the whole or part of the ICB’s area”, does not allow for overlap. Is that the Government’s intention? The Government, in a broader sense, talk about the strategic authorities and having the mayoral authority level involved in the ICB. But in Lincolnshire, for example, an area that I represent part of, the local medical committee could not work in conjunction with the mayoral authority under this legislation, as far as I read it, because it essentially covers two ICB areas and two regions.

The mayoral authority is the Greater Lincolnshire mayoral authority. That includes Lincolnshire’s upper tier area, the Lincolnshire county council area. It also includes the areas around Scunthorpe, Grimsby and Immingham, which fall into the Yorkshire region as opposed to the midlands region, and therefore not a whole or part of any given ICB area. I wonder whether the Minister has any comment on whether that was the intention, because it is also the case with paragraph 24(2) of schedule 1, which amends section 113 of the 2006 Act on local dental committees. Again, although the ambition stated and discussed in the Health and Social Care Committee yesterday by the Minister for Care, who is responsible for primary care, was that ICBs were to be covered at strategic level, that would not be possible for local medical committees or local dental committees under my reading of paragraph 12(2).

Does my hon. Friend agree that this Bill would have been the perfect time to align health commissioning services with local government structures and that the fact that these structures are being created totally without the new local government structures is not just an oversight, but a potential problem with the whole Bill? Does she also agree—I think that she was outlining this already, but I want to ensure that the Minister is clear on it—that the Government still have a chance to amend the Bill to ensure that the commissioning structures and commissioning areas outlined in the Bill neatly map out to the new local government areas? In relation to, for example, the current Hampshire and Isle of Wight ICB, Hampshire is potentially being split up into a number of local government areas. I am against the way it is being split up, but if the Government are pressing ahead with it, this would have been the perfect opportunity to align commissioning with those areas. The problem is that we will now have a situation in which they do not match up, and the problems that my hon. Friend has outlined in her speech thus far will come to the fore.

Of course, my hon. Friend is right. One challenge with the Bill is that although not all the measures are a problem individually, the way they are being brought in is a problem. The planning and organisation that has gone into it has not been coherent. A 50% cut has been made to the budgets of ICBs, which has required many of them to merge, but that has been done before the local government reorganisation has been finished, which means that ICBs have been melded together in a way that is not the same as the local government reorganisation.

Let me again give the example of Lincolnshire. Lincolnshire had an excellent ICB, run by chief executive John Turner. That has now merged with Nottinghamshire and Derbyshire. Nottinghamshire and Derbyshire form the East Midlands mayoralty, but Lincolnshire ICB, as was, forms part but not all of the Lincolnshire mayoralty—which, as I said, also includes part of what was the Yorkshire region. Because the cuts were done before the local authority reorganisation, and the left hand does not know what the right hand is doing, we have ended up with an incoherent pattern, which does not help, particularly for social care services that are delivered by local authorities. We will come back to that when we talk about who is on the ICB. The risk is that we end up spending money doing this twice—being forced to do it at short notice, because of the 50% cuts brought in overnight by Government, and then doing it again to try to sort out the mess and bring things back into line with the new local authorities as and when it is decided what they will be.

Going on to the pharmaceutical arrangements—I should probably declare at this point that my brother is a rural dispensing GP—I share the concerns raised by the hon. Member for Bury St Edmunds and Stowmarket in relation to rural dispensing GPs. Let me give the Minister an example from my constituency. The Cliff Villages medical practice was an excellent medical practice. However, there was a doctor retirement and the illness of a doctor, and as a result the service reduced in quality quite substantially.

The ICB was working alongside the surgery and the one remaining practice doctor—not swiftly enough, it must be said. What happened in the end was that the Care Quality Commission came in, found that the service was really not good enough and closed the surgery down overnight, in the middle of the week. It was closed with immediate effect and there were no appointments for any patients in my constituency. Then, because the surgery had been closed, the ICB worked very hard to get a new practice in straightaway, and it got that opened on the Monday, which was pretty quick in the circumstances; but people lost their dispensing GP.

Living in a rural area—I have a dispensing GP myself, living in a rural area—people can go to the doctor’s, see the doctor and, if the doctor perhaps says, “You need some antibiotics,” they can go back to the waiting room and sit there for 10 minutes, be given the antibiotics and then leave. That is significantly more helpful to a rural constituent than having to drive eight or nine miles into the centre of town, park the car, find somewhere to get the prescription and then go all the way home again, which would take much longer. People really value that service—I saw how much when I held a public meeting with the ICB and the new provider to talk about what had happened at the surgery, and 250 people turned up to an evening event in the village hall at short notice. It is hugely important to people.

Will the changes allow the Secretary of State to step in in such circumstances, where the medical contract has been lost due to that cut off by the CQC? Will that sudden loss of service be able to be replaced with a new dispensing service? Could Ministers have therefore given dispensing rights to the new provider? At the moment, those rights are not transferable, and it means that the only way that my constituents who live in that area and attend that practice can maintain dispensing rights is either to move house—perhaps to next door and back again, but they have to move house—or to change practice immediately, that same day, to another dispensing practice. To be honest, that seems ridiculous. Could the Minister make any comment on how the provisions in the Bill will help that situation and what her views are?

I am confused by new clause 23 and new schedule 1; the Minister has introduced them later than the rest of the Bill, but they seem quite significant. They would move pharmacy appeals from the first tier tribunal to an NHS body specified by regulations made by the Secretary of State. I presume the regulations are not yet written, so we do not know what form that would take, but the first tier tribunal is part of an independent judicial system and the appeals will now be under political control, within the Department.

Could the Minister explain why they think that is fair? Why do the Government want to do that? Is it just about saving money? How will the judgments made by that new authority be properly enforceable and give people confidence, given the change from the first tier tribunal in the judicial system to something more politically controlled?

I move on to new clause 2, which would require the Secretary of State to establish within six months a scheme to give patients the right to a GP appointment within seven days of seeking one, or 24 hours if urgent. I would be interested to hear the Minister’s comments on that and how she thinks it could be achieved.

Modelling by the Health Foundation suggests that 6,500 full time equivalent GPs—37,800 in total—will be needed by 2030-31 to meet greater clinical need. We have already talked about the doubling of medical school places; I presume the Minister has sought correction since we last spoke on whether the Government have a plan to double those places or not, but the Government are not on track to have that number of GPs. Is it simply that they do not have the resources to deliver it? I would be interested to hear the Minister’s comments.

With permission, I will explain to the shadow Minister our votes on amendment 57, which she pressed to a vote. I was reassured by the commitment the Minister made to consult widely on those commissioning changes, so the Liberal Democrats switched our vote from support to abstain.

I move on to new clause 2, our amendment in this group, which the shadow Minister was just discussing. It would require the Secretary of State to introduce a scheme to ensure patients have the right to see a GP or another appropriate clinician within their GP practice within seven days.

The NHS constitution currently confers rights on patients when they are considered really important. There are, for example, rights within the NHS constitution around receiving cancer diagnoses and treatment. We felt that there was a gap on access to GPs. Given the Government’s stated aim of transferring more care into the community, which we fully support, and given the observation in the Darzi report that more and more money is being spent on secondary rather than primary care, we think it is really important to confer the right on patients to be able to access primary care when they need to.

As the hon. Member for Sleaford and North Hykeham pointed out, this measure would require a large number of additional GPs and would therefore not be achievable overnight, but over the course of a Parliament. The Liberal Democrat plan includes recruiting and retaining an extra 8,000 GPs, relieving pressure on the rest of the health service and enabling that shift into the community. When patients—

New clause 2 clearly states that everybody should have a legal right to an appointment with their GP “within seven days”, while the current provision is that patients are entitled to see a GP or other professional within 24 hours or two days for urgent care. Would creating this legal burden on GP practices not reduce their ability to prioritise, meaning that the people who need urgent treatment will be delayed further?

We do not consider the right to achieve a cancer diagnosis and treatment to be burdensome on the secondary care providers of those treatments; we consider that important enough to enshrine that right within the NHS constitution, and this would be a similar level of right. I would not imagine that a GP would be worrying about somebody taking them to court, but it would confer upon the Secretary of State the duty to ensure that primary care is adequately resourced in order to be able to meet that commitment.

I am very grateful to the hon. Lady for giving way; she is typically generous with her time. Can I just seek a little clarification in terms of the right to a GP appointment in new clause 2? Is her intention that that is an appointment with the practice—be that any clinically qualified individual within it—or an appointment with a GP, not with a practice nurse? Would, for example, a telephone appointment constitute an “appointment”, rather than specifically an in person appointment? I just want to understand a little more about what is expected here.

The right hon. Gentleman asks an extremely important question, and I am happy to clarify. It would be an appropriate clinician within the GP practice, and it could obviously be a telephone appointment, because that might be more convenient for the patient. Lots of patients are really happy with telephone appointments and we should be using them wherever that is the patient’s choice, because we want—I think we all do—to see an NHS that is patient led and not politician led.

Will the hon. Lady give way?

I am going to make some progress, actually, because I think I am going to be asked the same questions.

I wanted to ask a different question, but okay.

Well, I will just move on a little bit. The important question is: can this be achieved this overnight? Clearly not; we need additional clinicians in the service. The Liberal Democrat view is that the extra—I think 1,000 or 1,500—GPs that the Government have recruited so far is a welcome step forward, but that does not go far enough over the course of a Parliament.

As I was saying earlier, when patients cannot access their GP surgery, they end up, more often than not, in accident and emergency departments. That is no good for anybody. It overburdens the A&E department, leaves people who genuinely need urgent care getting a substandard level of care, and costs the NHS far more. We think it is really important that we put the resource in the right place.

Just to reiterate what my hon. Friend is saying, in Winchester we are now putting an urgent treatment centre in front of the A&E, staffed by GPs to do the triage, because so many people who turn up are only there because they cannot get a GP appointment. So we now have hospital trusts paying for GPs to provide same day GP appointments, and that is coming out of the secondary care budget instead of the primary care budget. That is obviously the most expensive place to treat patients for routine things.

That is exactly what new clause 2 seeks to drive at.

We Conservatives share the hon. Lady’s desire to ensure that patients get their appointments as soon as they need them to be had, but she is talking about a difference between urgent appointments, within 24 hours, and non urgent appointments, within a week. Who is going to make the decision about whether the appointment is urgent? Will it be the clinician? Will it be the patient themselves? Has she thought about where that responsibility lies?

Yes, I have thought about where that responsibility lies. It clearly lies with the triaging process within the GP surgery. I do not think any of us envisage somebody phoning up about a child with a cold and saying, “I consider this to be urgent,” and getting an appointment within 24 hours, but I would imagine somebody from the surgery saying, “Please describe the symptoms to me,” and then, if they detected something more serious, saying, “That is urgent and you do need to come in within 24 hours.” The point of new clause 2 is to clarify in the NHS constitution that some services require parity with others. We have already established legal rights under the NHS constitution for certain types of treatment, and this puts GP access on the same level. We think that that is important.

I am conscious of time, so I will move on to new clause 52, which is about dental deserts. Everyone is horrified by dental deserts and by “DIY dentistry”, a phrase that means—let us face it—people using pliers to extract their teeth and super glue to reattach crowns, and cavities filled with household adhesives. More than 5 million children did not see a dentist at all in 2025. That is a stark failure. Dental care is as important as care for other parts of the body, in particular when most of what goes wrong in dentistry is preventable. We should absolutely focus on prevention, and that is in line with the Government’s aims to move from sickness to prevention.

New clause 52 is about our £750 million dental rescue plan to guarantee access to an NHS dentist for anyone needing an urgent or emergency appointment, which I hope would end that awful DIY dentistry. The plan needs to be achieved through bringing dentists back from the private sector, fixing the contract, using flexible commissioning wherever necessary and introducing an emergency scheme. For example, the emergency dental scheme in Shropshire, operated by the community dental practice, enables people who have urgent need and cannot register with an NHS dentist to get the care that they need when they need it. I urge the Minister to take our new clauses on board and to ensure that people get the care they need when they need it.

I will start where the Liberal Democrat spokesman, left off, with new clause 52 on dental provision. I have a lot of sympathy for what she is trying to achieve with the new clause. In my own constituency, as far as I can tell, looking earlier today, not a single dental practice is taking new NHS patients for dentistry, whether that be children or adults, and that is extraordinarily concerning.

Even more concerning—this somewhat relates to the changes that the Government are making in the clause through bringing the commissioning of dental services to ICBs—I have a fully equipped and fully functional dental surgery in Haslemere hospital in my constituency, but it has remained entirely unused for a number of years, because it sits within the hospital, which is run by the Royal Surrey NHS trust, but is commissioned by the ICB. That seems like an utter waste of resources. That is something that could be clarified through new clause 52 and, I hope, through the clauses tabled by the Government.

On new clause 2, about GP practices, I am disappointed that the hon. Member for North Shropshire did not want to take my intervention because she will not be able to answer my questions, unless she intervenes on me now, which I hope she will. Again, I sympathise entirely with what she is trying to achieve. We want to ensure that people have timely access to their GPs. I am sure that, like me, she has constituents who cannot get a GP appointment in any reasonable time. They can wait numerous weeks, upwards of five or six weeks, for something that they should be seen about.

A lot of questions are unanswered by new clause 2, however. I will not repeat the questions asked by my right hon. Friend the Member for Melton and Syston and by my hon. Friend the Member for Sleaford and North Hykeham, but I have some others. For example, the new clause states that the Government must “establish a scheme to provide every patient with the right to a GP appointment”.

Although the hon. Lady clarified that that could be a telephone consultation, what is not clear is whether that is an appointment at the named GP practice at which the patient is registered, or is just with any GP, through something such as the NHS 111 service.

I would like to clarify that point. We envisage that being at the GP with whom the patient is registered. Our broader policy, which is not included in new clause 2, is to have named GPs for people with complex conditions and complex comorbidities. Absolutely, we would envisage that as being a part of the continuity of care, which is so crucial.

That is a helpful clarification, but it raises a number of other questions. I entirely agree with the hon. Lady that named GPs are most appropriate; all the clinical evidence suggests that even for people with non complex needs, having a named GP whom they can see regularly improves patient outcomes. I therefore support her on that, but does she believe that we currently have sufficient GPs for that to go ahead? Even the six month lag in her new clause would not be enough time to recruit thousands more GPs. If she does not believe that there are enough GPs at the moment, when does she envisage that they would be in post? How much would that cost? Where would she get the money to fund those extra GPs? Rather than just expressing what I would call “motherhood and apple pie” statements about things that we all want, we in this House have a duty to be honest with our constituents about how we would achieve them—and, if we have to achieve them within six months, what funding and impetus will have to be put in place.

Let me clarify. The new clause is about conferring a duty on the Secretary of State to provide that level of care. It would require a significant number of additional GPs, and that would cost a lot of money. The Liberal Democrats’ 2024 manifesto had a fully costed pledge to recruit and retain an additional 8,000 GPs within the course of a Parliament. I think we can all agree that the world has moved on since then, but the hon. Gentleman will be aware that this week we proposed a significantly closer relationship with the European Union, which would grow our economy, increase our tax base and pay for a number of these things without having to subject people to additional, onerous tax hikes.

I think that clarifies that there is no real concrete plan for how to fund this new clause. I do not mean in any way to demean what the hon. Lady is trying to achieve, because she is trying to achieve something important, and which we all want, but we have to be honest with our constituents about how we can do that, and some ethereal money to come through some ethereal plan at some point in the future—

Will the hon. Gentleman give way again?

Let me finish this point. I am not in the mind of the current Prime Minister, and I am certainly not in the mind of the potential next Prime Minister, but even if the hon. Lady is right my understanding is that he—either is probably a he—is unlikely to have changed our relationship with Europe within six months.

Order. We are straying slightly into a debate about European matters. Can we stick to the amendments before us, please?

Thank you, Ms Lewell. You have certainly saved me from myself, if not anybody else. I think I have belaboured the point; I will leave it there. I sympathise with and indeed support the ambition of new clause 2, but I have a real problem with the lack of detail on how it would be achieved.

I turn quickly to clause 14. As my hon. Friend the Member for Sleaford and North Hykeham said, it has bits that we welcome, but there are some concerns about how the ICB structures fit over the local government structures, and cutting ICB administrative budgets by 50%, while asking them to take on more power and responsibility for commissioning services and many other things, is a real problem.

Likewise, we have welcomed, and I think both sides of the Committee agree, having neighbourhood health—however we want to describe it—and care closer to home, and having commissioning closer to home. It is therefore strange that my best performing ICB, Frimley ICB, has been abolished or merged with a number of other ICBs that have been performing far less well.

If the Government want to have the principle of place based, locally responsive commissioning, they have to have a real focus on, actually look at, what fits with the current structures and to ensure that those ICBs that are performing best are encouraged and kept and that those that are not are dealt with. I have real concerns about, for example, the superstructure of the new Surrey and Sussex ICB. It is huge and, essentially, entirely antithetical to what the Government were trying to achieve by making stuff local—closer to home.

One thing that my hon. Friend mentions is the Government’s stated intention to bring things closer to home, as opposed to the reality of the Bill as drafted. Does he agree with me that the document that explains what will happen to the commissioning of specialist services, and that talks about seven regions and how ICBs could collaborate within those regions, might imply that the Government are looking forward to having seven areas in which most commissioning takes place? These are even larger areas than have been described in the mergers so far.

It is for the Minister to clarify that point, but I share my hon. Friend’s concern. It is ironic that we seem to be heading back towards the strategic health authorities of an earlier age. Things in the NHS are neither created nor destroyed; they just go round and round and round. I think we may end up being back where we were 15 or 20 years ago, in an ever decreasing cycle of spending money on changes that are perhaps not wanted or needed.

I have touched on dental services, so I will not go any further on that. On pharmaceutical services, I agree entirely with what my hon. Friend said about dispensing GPs. That is a big issue. And I have touched on the Liberal Democrat new clauses. In conclusion, although Conservative Members support a number of the ambitions in relation to the group that we are debating, the questions that my colleagues and I have raised require more clarification from the Minister.

It is a pleasure to serve under your chairmanship, Ms Lewell. My hon. Friends have addressed at some length the Government new clauses and amendments, so the Minister may get a slightly easy ride from me this time, but I want to pick up on new clause 2 and some of the points that my hon. Friend the Member for Farnham and Bordon raised.

The hon. Member for North Shropshire knows that I have huge respect for her. I have worked with her, across the health and social care space in this House, on a number of issues, so I can entirely appreciate where she is coming from on this. She raises an issue that is very important to all our constituents, which is access to primary care when people need it. For example, in Melton Mowbray in my constituency, there have been real concerns in recent months about very long waiting times to access primary care services. That has on occasion caused considerable distress for some patients, who have become more and more concerned.

I have to say that the practice has sought to do a lot to address that. It has brought on board a new annexe and additional services and been recruiting more GPs, but the challenges remain and the concerns are very real and would, I suspect, be shared by all our constituents. One of the key things in how the practice has been seeking to address the issue and how other practices locally, both rural ones and ones in some of the towns in my patch, have sought to address it has been a degree of flexibility and of clinical triage as to what is the most appropriate access point to primary care services for the individual, based on their symptoms and needs.

For me, despite the work being done in Melton Mowbray at the moment to improve waiting times, it remains a very significant concern that despite the integrated care board having a few years ago acknowledged publicly the need for additional GP provision in the town, whether a second GP practice or a new satellite service, it said a few months ago—despite the fact that in the intervening period there has been considerable housing development in the town—that it considers that there is no need at the present time for additional GP provision, and so it does not appear to have a plan to expand that provision. That is obviously concerning. All of us in this House will from time to time have these issues in our constituencies and, I suspect, sometimes get frustrated by the fact that ultimately we can press our ICBs and ask questions of the Minister—who, I have to say, always responds in a courteous and measured fashion—but ultimately the decision maker is the integrated care board’s board and it will do what it wishes to do when it comes to commissioning those services. There is a disconnect there.

My challenge with regard to new clause 2, despite my being in agreement with the need to improve access to services, is that there is a lack of clarity about how that will be done and there is the fear that it may raise expectations that are not necessarily deliverable on in the current context. The Liberal Democrat five year plan for GPs is in their 2024 manifesto, and the hon. Member for North Shropshire alluded to the commitment to 8,000 additional GPs. It is not my usual habit, but I have read the Liberal Democrat website, which sets out the background. I appreciate that this is from 2024 and the hon. Lady may have moved things forward a little bit since then, but it states that the five year plan “gives patients the legal right to see a GP within a week or 24 hours if needed urgently”.

The hon. Lady may wish to respond on that.

I am sure the right hon. Member has enjoyed reading the Liberal Democrat website. If he had delved a little further into the policy paper that sits behind that manifesto commitment, he would see that that is with an appropriate clinician and not with a GP. I appreciate that the wording of the new clause says a GP, but it does indicate a GP practice, and would require the Secretary of State to establish a scheme that would achieve that. I expect that clarification could be made at that point.

I am grateful for that, and the hon. Lady has that on the record. As we all know with political campaigning, the headline on the front page of the website may sometimes, although not always, contain the “conditions apply” caveat in the small print. The hon. Lady has read her explanation into the record of the House, and I, as always, take her at her word and accept that explanation.

My concern is how this measure would be paid for—8,000 GPs, of which half were to be new recruits and half were either through retention or by encouraging returners to the profession, with a costing of about £1 billion. That works out at about £125,000 a head, so it is not outside the realms of possibility. That was not going to be paid for through closer ties with the European Union; if I recall correctly, I think it was tagged against hikes in capital gains tax with three new bandings, rather than EU links.

I am happy to clarify. Clearly, the world has moved on since July 2024 when we put together our manifesto, but this was a fully costed plan with a number of different changes to tax regimes, including a tweak to capital gains tax and changes to the way that banks were taxed and digital services tax. Since then, we have proposed a number of other alternatives, but the principle of changes to capital gains tax, to the way that windfall profits of the big banks are taxed and to digital services taxes still stands. Plus, we also have a fully fleshed out plan to actually grow our economy and deal with this problem in the long term.

I am grateful for that clarification. I am conscious that we have to finish at 1 pm, so I will bring my remarks to a conclusion.

We can all see the intent behind new clause 2; we can all feel that intent in correspondence we get from constituents. Having taken legislation through the House, my concern is that often the challenge is in the drafting of such clauses: while the objective may be honourable, the opacity of them, or the lack of some detail, can risk creating an expectation while not actually setting out how that can realistically be met. My worry here is about the practicalities, in an era where expectations are being set and dashed and that is causing challenges for our democracy.

Even when the right hon. Gentleman criticises, he does so in a charming way.

None of this is moving the discussion to how we keep people healthy and treat them early. He may criticise our funding models and challenge the detail for achieving this measure, but if we flip that round, the previous Government promised 40 new hospitals, which were not hospitals and did not materialise. The entire focus of healthcare has been on treating people once they are sick, while people cannot get GP appointments.

I hope that the right hon. Gentleman would agree that the thrust of the argument is to try to keep people healthy and treat them early, before they end up needing hospital treatment, and that that is what we should all be focusing on. If he wants to help with the details in order to get 8,000 GPs by the end of this Parliament, he can submit his suggestions to the Liberal Democrat website.

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

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

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

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

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

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

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

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

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

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

Question put and agreed to. Clause 14 accordingly ordered to stand part of the Bill. Schedule 1 Conferral of primary care functions on integrated care boards etc Amendments made: 14, in schedule 1, page 60, line 19, leave out sub paragraph (2).

This is consequential on NC21. Amendment 15, in schedule 1, page 60, line 26, leave out “(a), (b), (c) and”.

This is consequential on NC21. Amendment 16, in schedule 1, page 60, line 36, leave out paragraph 46.

This is consequential on NC22. Amendment 17, in schedule 1, page 65, line 5, leave out paragraph 65.

This is consequential on NS1. Amendment 18, in schedule 1, page 75, line 1, at end insert— “(4) In subsection (5), in the definition of ‘relevant area’, after paragraph (b) insert— ‘(ba) in relation to an integrated care board, in a case where a person has at any time provided or performed services by arrangement or contract with the board, means the prescribed area (at the prescribed time).’”—(Karin Smyth.) This adds an amendment to section 259 of the NHS Act 2006 that is consequential on the transfer to integrated care boards of NHS England’s commissioning functions in respect of primary care. Schedule 1, as amended, agreed to. Ordered, That further consideration be now adjourned.—(Emma Foody.)

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, Dr 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

Public Bill Committee

Thursday 25 June 2026

(Afternoon)

[Dr Rupa Huq in the Chair]

Health Bill

Before we begin, I remind Members to switch electronic devices to silent. Tea and coffee are not allowed during sittings, but there are copious amounts of water—blue is still and silver is fizzy.

Clause 15 Public involvement in commissioning by Secretary of State

I beg to move amendment 28, in clause 15, page 11, line 26, at end insert— “(d) in the design of service and arrangement for service delivery (co production).”

The amendment would explicitly require the Secretary of State to make arrangements for the co production of any health service commissioned by the Secretary of State.

With this it will be convenient to discuss clause stand part.

It is a pleasure to serve with you in the Chair, Dr Huq. I am moving this amendment on behalf of my hon. Friend the Member for Oxford West and Abingdon (Layla Moran), who is the Chair of the Health and Social Care Committee. She designed the amendment to explicitly require the Secretary of State to make arrangements for the co production of any health service commissioned by the Secretary of State.

The Liberal Democrats support clause 15 more broadly, and particularly the plans to involve affected patients, carers and representatives in planning and commissioning arrangements. Carers are a priority for our party, so it is really important to us that they have a meaningful say in the design and delivery of their care. I would be grateful if the Minister could elaborate on what that might look like in practice.

The amendment would tighten up the clause to make some of its provisions more explicit, so that we can be confident that anyone involved in an individual’s care has the ability to influence it in an appropriate way.

It is a pleasure to serve under your chairmanship, Dr Huq. I will speak briefly about clause 15 and amendment 28, tabled in the name of the hon. Member for Oxford West and Abingdon, the Chair of the Health and Social Care Committee, of which I am a member.

The amendment is clearly positively intended. We all want the co production of services, and we have discussed it quite a lot on the Health and Social Care Committee. A number of amendments were tabled in the name of the hon. Member for Oxford West and Abingdon but were agreed on by the Select Committee. I think it is fair to say that there are a number of areas that the Committee could not agree on and that are obviously not in front of it, given its political make up, but we all agreed on the ones she has tabled.

That being said, cross party agreement often necessitates fairly non partisan and perhaps non specific wording, so while I agree with the intention behind the amendment, and while it is clearly important to have co production when designing services, I am not entirely comfortable with the way the amendment has been drafted. This goes back to comments I made on the Liberal Democrat new clause 2 about how the requirement would operate in practice or how such an approach would be applied consistently across different commissioning functions. Although I am very keen on the principle, I am concerned about the intention.

I will not detain the Committee for long, and I will speak primarily to clause 15. I am broadly supportive of what the Minister seeks to achieve, as I understand it, with the clause. It is absolutely right that service users and communities are engaged by their integrated care boards—those commissioning services—in the design of services as well in individual care.

As I alluded to before we adjourned for lunch, however diligent an ICB may be in doing formal consultations or conducting surveys, it is all too easy for that to appear to the actual users of the service as a box ticking exercise, with the board none the less determined to follow through with the strategic plan that it conceived and consulted on in the first place. We have seen that challenge on a number of occasions in my Melton and Syston constituency, with the recent closure of St Mary’s birth centre in Melton Mowbray. There was a consultation and engagement with the public, but we always feared that, ultimately, a decision to close was what the ICB wanted and, lo and behold, that is what happened. Similarly, the ICB decided to pull away from accepting the need for a second GP practice or enhanced GP services in Melton Mowbray. There was a consultation and discussion, but ultimately the conclusion that we feared at the outset of the process was indeed what was reached at the end of it.

The clause will not necessarily address all that, but it is a step forward in putting pressure on an ICB, or on those commissioning services, whoever they may be, to engage with local communities in a meaningful way.

My right hon. Friend is making an absolutely correct point, which I made when we were talking about the Secretary of State’s ability to remove, by sacking or otherwise, the chief executives of ICBs. There is a tension between us as Members of Parliament trying to lobby the Secretary of State for changes in our constituencies when he currently has no power to actually make those changes. The clause will potentially give him the power to make those changes, but being able to sack a chief executive is probably a step too far. How does my right hon. Friend see the powers in the clause, which are probably correct, balancing with the local decision making process and clinical expertise? There will clearly be a tension between the two.

My hon. Friend comes to this with significant knowledge from his work on the Health and Social Care Committee. He is absolutely right, but that is a tension and a balance that I fear runs as a thread throughout this legislation, between local decision making and tailoring and the genuine need for a Secretary of State to have effective powers. We lobby Secretaries of State; on occasion I have lobbied the Minister, and she has always been very responsive—she does not always agree with me, but she has always been very responsive to me. As Members of Parliament, we do that on behalf of our communities.

My argument is that ICBs need to be more responsive, even when they do consult, to make it clear that the decision is not predetermined by the board and that they are going through the process. In the context of this clause, that also needs to be true of the Secretary of State: it needs to be not simply a formulaic approach but a genuine engagement and consultation. My question for the Minister, in that context, is about how we make sure of what she is seeking to do in the clause. The Secretary of State or those undertaking commissioning on their behalf must pay heed to something, but how do we make sure that that consultation, engagement and feedback genuinely have some teeth in what emerges in the final decision?

My right hon. Friend the Member for Melton and Syston and my hon. Friend the Member for Farnham and Bordon have covered my points so effectively that I will be very brief indeed. How do we ensure that the consultation is not just well meaning and ticking the legal boxes, but actually listened to, so that people’s voices are incorporated into the plans? Also, I appreciate that amendment 28 is a well meaning intervention, but how do we ensure that all voices are heard in a co production, not just those who are the most articulate or the most able to engage with a process that they see online?

Patients and the public have a critical role in shaping our health services. I am grateful to the hon. Member for Oxford West and Abingdon for tabling the amendment, as moved by the hon. Member for North Shropshire. I will discuss the amendment with the wider question of whether the clause should stand part of the Bill.

To be clear, the Government are committed to engaging with patients and the public about the services they use. Services shaped together with the people who rely on them are better services. We want to see deep and collaborative ways of working between patients, public and the NHS. Across the country, there are good examples of that from which we want to learn. That is why the clause requires the Secretary of State to involve patients and the public in the planning of commissioning arrangements, the development and consideration of proposals for service change, and decisions that may affect how services are delivered or the range of services available.

The clause is intended to encourage early engagement and meaningful involvement in service change, thereby helping to build legitimacy, trust and better informed commissioning decisions. As a duty, it covers the entire end to end commissioning cycle. I have been a commissioner myself, so although I will not detain the Committee too much on that, it is indeed part of the job of a commissioner to do that at a very early stage.

I also draw attention to the fact that the clause places a statutory duty on the Secretary of State to make arrangements to ensure the involvement of individuals who use or may use health services, together with carers and representatives, where appropriate, in commissioning activity. That duty is purposely broad, covering both existing service users and those who may reasonably rely on services in future, and will support preventive approaches and enable the consideration of wider population health impacts.

We made the deliberate choice to include specific references to carers and representatives, recognising that some individuals may require support to participate effectively in engagement and decision making processes. That is particularly important where barriers such as disability, communications needs, sometimes age, vulnerability or unequal access may otherwise limit participation. We are ensuring that involvement is inclusive and meaningful, which I think is what all hon. Members want to see.

Specifically on amendment 28, I gently caution against creating an implication of different approaches to patient involvement for different parts of the system, leading to a two track approach and unnecessary confusion. Instead, we propose a Government commitment to ensure meaningful consultation. We support co production and will continue to champion it, but we do not think it necessary to put it on the face of the Bill.

The Government support involving patients and the public at every stage, and we recognise that working closely with the people and communities affected by commissioning decisions brings valuable insight into service quality, accessibility, equity and effectiveness. We will use the duties and powers available to Ministers to ensure that that principle is embedded across the work of the NHS. I hope, therefore, that the hon. Member for North Shropshire has some reassurance and will withdraw her amendment. I commend the clause to the Committee.

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn. Clause 15 ordered to stand part of the Bill.

Clause 16 Regulations about commissioning by integrated care boards

I beg to move amendment 51, in clause 16, page 12, line 10, at end insert— “(3) The regulations must ensure that integrated care boards may not impose operational policies requiring patients to wait a minimum number of weeks before they may access treatment.”

This amendment would prevent minimum waiting times for NHS treatment.

With this it will be convenient to discuss the following: Amendment 35, in clause 16, page 12, line 10, at end insert— “(3) Regulations under this section must make provision requiring integrated care boards to make arrangements which ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services.

(4) For the purposes of subsection (3)— ‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”

This amendment would require the Secretary of State to make regulations which would require integrated care boards to ensure that community equipment and wheelchair services are provided within 18 weeks of the date on which a person is assessed as requiring such equipment or services. Amendment 63, in clause 16, page 12, line 10, at end insert— “(2A) Regulations under subsection (2) must make provision requiring integrated care boards to— (a) assess whether sufficient capacity exists to meet current and projected patient demand for cancer treatment, including radiotherapy treatment, (b) maintain plans to ensure that workforce, equipment and estates capacity are sufficient to reduce waiting times for cancer treatment and improve access to treatment, and (c) monitor and address geographical variations in access to cancer treatment, including radiotherapy treatment, with a view to reducing inequalities in patient outcomes the provision of satellite units.”

Amendment 52, clause 16, page 12, line 10, at end insert— “(3) The regulations must include a requirement for the Secretary of State to publish the number of patients validated off of treatment waiting lists each month, and the reason for which they have been removed.”

This amendment would require publication of the number of patients validated off waiting lists each month and the reason for their removal. Amendment 32, clause 16, page 12, line 22, at end insert— “14Z45BA Patient choice: community services substituting for consultant led elective care (1) The Secretary of State must by regulations make provision to enable patients to make choices in respect of non consultant led community services where those services are commissioned as a direct substitute for, or to prevent a referral to, consultant led elective services.

(2) For the purposes of subsection (1), a service is to be regarded as a direct substitute for, or intended to prevent a referral to, consultant led elective services if it— (a) provides assessment, treatment or management for a condition that would otherwise be referred to a secondary care specialist; or (b) is commissioned by an integrated care board for the purpose of reducing or managing demand on secondary or elective care.

(3) Services to which this section applies include, but are not limited to— (a) community audiology services; (b) community glaucoma management and monitoring services; and (c) Minor eye conditions services.

(4) Regulations made by virtue of this section must ensure that— (a) patients are offered a choice of any clinically appropriate provider commissioned under a qualifying NHS contract for the relevant service; (b) no limitation on the number of providers from which a patient may choose is imposed solely on grounds of cost or demand management; and (c) patients are provided with information enabling them to make an informed choice, including information about waiting times and quality.

(5) An integrated care board must not commission a community service of a kind falling within subsection (2) in a manner which has the effect of restricting patient choice below the standard that would apply to an equivalent consultant led elective service.”

Clause stand part.

Schedule 2.

New clause 35—Community equipment and wheelchair services: standards, performance and outcomes— “(1) Each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services.

(2) Each integrated care board must monitor its performance against the standards under subsection (1).

(3) Each integrated care board must publish an annual report including— (a) its performance against the standards under subsection (1), (b) waiting times for the assessment for and supply of community equipment and wheelchair services, (c) the number and proportion of people waiting longer than 18 weeks for such equipment or services, (d) outcomes achieved for people by the provision of community equipment and wheelchair services, and (e) steps taken by the integrated care board to improve the assessment for, and supply of, community equipment and wheelchair services.

(4) For the purposes of this section— ‘community equipment and wheelchair services’ means equipment, aids, home adaptations or appliances provided to support a person’s independence, safety, care or daily living at home or in the community, including hoists, hospital beds, pressure relieving mattresses, commodes, shower chairs, walking frames, grab rails, ramps, specialist seating, postural support equipment, associated mobility equipment, and wheelchairs.”

This new clause would require each integrated care board must publish standards which apply in its area in relation to the assessment for and supply of community equipment and wheelchair services and publish an annual report on their adherence to these standards.

The Government say they are firmly committed to cutting waiting times and meeting the NHS’ 18-week target. It seems odd that, despite that, it is necessary for me to table an amendment to prevent systems from forcing patients to wait artificially longer for their care through the imposition of minimum waiting times.

Last year, The Times reported that at least eight local ICBs had introduced policies to pay healthcare providers for treatments only once patients have waited 12 weeks or more. I cannot think of any clinical reason why someone should wait for 12 weeks before having any treatment. At the time, the Minister said that while there was “no formal national policy supporting minimum waits”, local areas may “choose to include minimum waiting times in Activity Planning Assumptions to ensure delivery of targets within agreed financial allocations…to support commissioners in managing activity to ensure they can sustainably manage within their budgets”.

I do not understand why we would want to make people wait longer than necessary.

The Royal College of Surgeons has expressed concerns and made clear that minimum waits prolong “pain and anxiety” for those made to wait longer, saying that it is “counterintuitive…to give commissioners the green light to impose 18-week waits, while simultaneously working to ensure patients begin treatment within 18 weeks.”

Age UK deemed it a “rationing approach” that is “potentially harmful to the health and wellbeing of older people.”

NHS England has made it clear that ICBs cannot introduce minimum waits of more than 18 weeks—that is longer than the target, so that makes sense—but waits between 12 and 18 weeks are permissible. Will the Minister explain why that is a good idea?

Amendment 51 seeks to ban ICBs from introducing any operational policies requiring patients to wait a minimum number of weeks before they may access treatment. There are safety risks involved in introducing minimum waiting times. They distort clinical priorities and may make patients wait in unnecessary pain and anxiety. Treatment should be delivered when possible, based on clinical needs. If a patient has a high level of clinical need, they might need to be treated earlier than the minimum waiting time because of the suffering they are experiencing.

Minimum waits are not only detrimental to patient experience by forcing people to live in greater pain and discomfort; in some cases, the delay may make the patient’s condition worse, and the treatment they need may be more extensive and even more expensive. Their condition may even become life limiting or life threatening as a result of the delay. The introduction of arbitrary minimum waiting times that do not have any relevance to patient clinical need raises worrying issues, clinically, professionally and ethically.

Minimum waits will also hinder the NHS’ ability to cut waiting lists and get waits to within 18 weeks. Some providers will have a list of people who can be available at short notice for a procedure, who they can call on if there is a cancellation on the day. If that person has not waited the minimum, that may be left as a gap, and that operation or appointment may not happen. That is wasted NHS resource.

Each month that goes by, many people are added to the waiting list, and some are removed from it. We are aware that there seem to be a lot of unexplained removals from the waiting list, and that has spiked recently. Among the people treated by NHS providers in April, around 600,000 were treated within eight weeks of referral, versus 74,000 who were treated between 14 and 18 weeks. The introduction of a minimum waiting time will therefore push back many people’s treatment by as much as 10 weeks.

Minimum waits also worsen and entrench postcode lotteries, because patients who have differential waits, based on whether their ICB has decided to implement minimum waiting times, may experience differential levels of care because of where they live. They are also another way of undermining patient choice, because patients may want to be treated in one area or one hospital because of the waiting time. If they all have different minimum waiting times, that distorts patients’ ability to choose.

Minimum waits are also completely contrary to the 10-year plan for health, in which choice and productivity were considered central features, along with the Government’s wider commitment to keep people healthy. I hope the Minister will agree with amendment 51, which would ensure that minimum waiting times cannot be instituted.

Amendment 52 also concerns waiting times. You will no doubt have seen, Dr Huq, the many newspapers articles about the Government fiddling the figures on waiting times, and there has been a spike in removals from waiting lists. People have found themselves removed from lists or going back on lists, or have suddenly found out that their waiting time started more recently than they thought. Amendment 52 would require the Secretary of State to publish the number of patients who are taken off treatment waiting lists each month and why they were removed. It is important that we are able to explain to our constituents why the Government have decided to remove them.

I want to speak to amendment 63, tabled by my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron). As hon. Members know, he has campaigned passionately and for a long time on the provision of radiotherapy. His amendment seeks to ensure that there is sufficient and equitable access to radiotherapy. Radiotherapy is required by half of all cancer patients, and it is incredibly cost effective, but England has fewer radiotherapy machines than comparable European countries, and thousands of people have to travel long distances and over 45 minutes for their treatment, particularly in my hon. Friend’s Cumbria constituency, as he has noted on many occasions.

The Darzi review noted that radiotherapy services are on their knees. They have some of the longest waiting times for treatment and vast parts of the country are classed as radiotherapy deserts, because of lack of accessibility. Radiotherapy currently has the worst 62-day performance of all main cancer treatments, and if we are serious about ensuring that all cancer targets are met by 2029, then we need the infrastructure, people and equipment to deliver them.

Cancer cases are expected to rise 30% by 2040, meaning that radiotherapy centres must be able to keep pace. Importantly, radiotherapy can also be used at an earlier stage in treatment, potentially saving lives, saving money and meeting important waiting time targets. We really ought to be leading the way on this and keeping pace with our European counterparts so that no one is left without the treatment they so desperately need. I add my support to amendment 52, because we do need to build confidence in the reduction of waiting lists, and more transparency around reductions would be helpful.

Amendment 35 has not been moved, but it is very similar to new clause 35, which may be moved and concerns equipment. I will address both together. I think all in this Committee would agree that ensuring timely access to community equipment and wheelchair services is vital for patient independence, dignity and recovery. I have a number of constituents who believe that they are not getting access to that equipment in the time they would expect.

We also need to ensure that we give proper consideration to the efficiency and management of resources. In particular, we should look more closely at what happens after that equipment has been distributed. Too often, items such as crutches, wheelchairs or Zimmer frames are not reviewed after issue or returned when they are no longer needed. We are already seeing a massive financial consequence of that. It was reported last year that the Royal Berkshire NHS foundation trust is losing around £70,000 a year due to patients retaining unused mobility equipment. That might seem like a drop in the ocean for the NHS, but £70,000 could fund another nurse, if we include the on costs. These things do have consequences.

Despite distributing thousands of items, only 38% of crutches and just 15% of Zimmer frames were returned in 2024. That represents a significant loss of reusable equipment and considerable pressure on NHS resources. It also gets into the mindset of how patients use and value those pieces of equipment and how NHS users think about resources. While I think that we all agree in this Committee that the NHS should be free at the point of use, one of the downsides of that is that patients rarely think about what the cost of their care contributes. I personally think that if people understood how much crutches or medicines cost, they would use them much more usefully. Plenty of times I have spoken to pharmacists in my constituency who tell me that once a patient has unfortunately died, their family then comes to the pharmacy with a sackload of drugs that have never been used. I think that if people understood the cost of those things, they would use them more effectively and with more caution.

This is not an isolated issue but indicative of a wider problem across the system. If we were to introduce firm timelines for provision, we would need to ensure that there is a robust process for recovery, reuse and proper management of that equipment. Therefore, while I am not supportive of amendment 35 or new clause 35, I ask the Government to consider how those proposals could be strengthened by embedding clear expectations about the return and reuse of that equipment so that public funds are used as effectively as possible.

I will now turn to the two amendments in the name of my hon. Friend the Member for Sleaford and North Hykeham. Amendment 51 is important because, while I understand the Government’s intention in clause 16, as my hon. Friend has mentioned, her amendment will prevent any artificial delays in treatment by ensuring patients are seen as soon as clinically appropriate, rather than being required to wait a minimum period. It simply protects the principle that care should be based on medical need—which I think we would all agree on—rather than some administrative target. It helps avoid situations where waiting times are managed on paper rather than reduced in reality. That ultimately safeguards patient outcomes and timely access to care.

Moving on to amendment 52, I add my strong support to this amendment, because it goes to the heart of trust, transparency and patient safety in the health system. I have been speaking to constituents and individuals from across the country who have contacted me after a video I posted on my social media that contributed to the exposure of the removal of 351,000 patients from waiting lists in March of this year. The stories I have heard are deeply troubling. Those include patients who have waited years for potentially life changing treatment only to receive notification late—or in some cases not at all—that they have been removed from the list. For many it came as a shock, while for some it came after months or years of uncertainty. This is not some trivial administrative matter. I would sum up the Minister, when responding to questions on this point, as: “Nothing to see here, this is what always happens.”

There has been such a significant jump over a period of two months that there has to be something going on here. The experiences of patients who have spoken to me about this suggest that that is happening. For those patients it is the difference between treatment and deterioration, between hope and abandonment. It is also undoubtedly affecting more vulnerable and less technologically savvy pockets of society, such as the elderly.

I should say that I am on a waiting list for treatment myself. The validation process seems to involve phoning people to check if they still need treatment, which after a long period is perhaps not an unreasonable thing to do. However, if they then say yes, they are phoned again a few weeks later; and if they say yes again, they are again phoned a few weeks after that. That puts pressure on people to say, “Okay”. If they are then asked, for example: “Would you be happy to see the consultant so that he can check that you are still listed for the right procedure, given that your condition may have changed and you may want to do something else?” it feels entirely unreasonable to say anything other than “Yes” to that. Would my hon. Friend be surprised to hear that when some people do that they find that they do indeed need the same procedure, but that their waiting time has now gone back down to zero?

My hon. Friend makes two important points. First, of course there has to be a validation process. There has been for a long time, and I do not think that anyone is objecting to that. However, it is a question of how it is being articulated and the people it is focused on. It is being focused on vulnerable people. I have anecdotal evidence from conversations with a significant number of people since I posted that social media video that they feel pressured into coming off the lists. It does not help that trusts have financial incentives to take people off lists. Earlier this month, the Health Service Journal said that three trusts are earning more than £1 million in having people taken off lists. There is no problem with giving trusts a financial reward to do due diligence and validate the lists, but there is potentially a perverse incentive for trusts to try to knock people off them.

I am not entirely clear why there is a problem with the financial incentive. People coming off lists that they have been on for a long, long time may well have a clinical condition that is changing. In my practice, I deal with the management of children with glue ear, who need to have grommets. From time to time, the condition fluctuates and the glue ear goes away.

Equally, the reason that we do a tonsillectomy is that people get recurrent acute tonsilitis, but it is actually quite a good idea for people to wait some time because often the recurrent acute tonsilitis simply settles down and they do not need their operation. Sometimes, when a patient comes into hospital for an operation on their tonsils and I ask them, “When did you last have an attack of tonsilitis?” they say, “I can’t remember.” We have to take account of the fact that the condition of the patient may fluctuate.

The hon. Gentleman is entirely correct, and I think I said some moments ago that I am not against a validation of the list—I think I even said that I am not against some sort of financial incentive to clear the list. My concern is the extraordinary jump in the baseline in the last month or so: 351,000 people have been removed from the list for no apparent reason.

While I have been having anecdotal discussions with patients, my hon. Friend the Member for Sleaford and North Hykeham has been doing something a little more robust. It would be interesting to see the outcome of her endeavours and researches and to find out exactly what is happening in those areas. Anyone with a modicum of inquiry and common sense would say that the significant jump that we have seen in a single month deserves at least a level of interrogation, which the hon. Member for Bury St Edmunds and Stowmarket is not allowing in his comments.

Does my hon. Friend agree that when somebody—particularly a vulnerable person—receives a call asking them whether they would be prepared to see a consultant to see whether they still need treatment, they are aware of all the noise in the media? They are aware that other people are waiting. People do not want to waste NHS resources. The first time, they may think it is a routine process but, when they receive the second or third call, they may start to think to themselves, “They are trying to tell me that they want to do something else. Maybe I don’t need it as much as other people.” They feel obliged and pressurised into saying they do not need the procedure when they do.

My hon. Friend is absolutely right. The danger in this process—especially the multiple instances of chasing within a period of weeks, which sometimes happens—is that pressure is put on patients. Again, I know anecdotally from patients who have been speaking to me that those who are most compliant—if I can put it like that—and do not want to make a fuss are generally older and vulnerable people, who feel that they are perhaps causing an inconvenience to the system. They see people with, in their view, more serious conditions or a greater need. We need to be very careful about creating perverse incentives, financial or otherwise, to try to take some of those people off the list. As I say, the significant jump that we have seen deserves more scrutiny and inquiry, and that is why I am very supportive of my hon. Friend’s amendment.

We need to understand whether patients are being removed because they no longer require treatment, as the hon. Member for Bury St Edmunds and Stowmarket said—which is, of course, entirely appropriate—or just to improve targets, present an improved picture of waiting lists, and unlock the financial benefits tied to performance metrics. There is a troubling echo here. We saw similar practices in the 2000s when patients were removed or reclassified in ways that reduced waiting list numbers without genuinely improving access to care; it damaged confidence in the system then and it risks doing so now. What concerns me most is that we may be repeating that pattern. If the Government find they cannot meet their waiting list targets, there is a real danger that the pressure to do so will translate into decisions that, intentionally or not, compromise patient safety and fairness.

We are in 2026. Social media and the media scrutinise everything that we do. Will the hon. Member confirm if there has been any report in the media that somebody, anywhere in the country, has had their condition made worse, or died, or did not get treatment?

There have been a number of reports of situations where people have not received care and have died because of that, so I do not see the hon. Member’s point. I think that, with amendment 52, my hon. Friend the Member for Sleaford and North Hykeham is trying to ensure that when the statistics are published, we can scrutinise the reasons behind them. The hon. Member for Ashford may be entirely right; let us imagine that is the case, and there is no gamifying or pressure going on. Why not allow the public to see that? Why not put to bed the HSJ stories that say there is something fishy going on? He should welcome that level of transparency and scrutiny to back up his argument if he is correct.

The hon. Member for Ashford talks about social media and social media comments. I wonder if, where the DHSC or the Government have put that waiting lists are falling, my hon. Friend has read any of the comments that come in from the general public below such proclamations.

My hon. Friend tempts me to be political; I will rise to that briefly. Yes, I have seen them and she is right. There is a clear concern that when the Government make all these proclamations about how brilliant the NHS has suddenly become, the reality on the ground does not meet that for many patients. However—I am being gentle now—that is probably not exclusively a problem with this Government. My right hon. Friend the Member for Melton and Syston might kill me, but I am sure other Governments have done something similar.

I will go back to amendment 52 because I think it is really important. Let me be clear: it would not prevent people being removed where appropriate; it would simply require the Government to be honest about why. It requires the Secretary of State to publish the number of patients removed from waiting lists each month and, crucially, the reasons why. If everything is being done properly there should be nothing to fear from such transparency, but if there are problems, sunlight is the best disinfectant and the amendment is exactly what we need. We owe it to our constituents and to every patient in the country to ensure that waiting lists are not improved just on paper, or in a press release, or in a social media tweet, or at the expense of the care of real people but actually improved.

If we are to strengthen patient choice, particularly in relation to community services that substitute for or prevent hospital admission and treatment, there are some good measures in clause 16. However, as my hon. Friend the Member for Sleaford and North Hykeham said, there are concerns, so I hope the Minister will be able to pick those up in her comments when she winds up.

There are a number of amendments in the group. Amendment 35 was not moved but as the hon. Member for Farnham and Bordon spoke to it, I will comment on that amendment, which is in the name of my hon. Friend the Member for Bexleyheath and Crayford (Daniel Francis). Community equipment and wheelchair services are really important to us and—to allay the concerns of the hon. Member for Farnham and Bordon—that is why the medium term planning framework requires that, from this year, all ICBs and community health services must actively manage and reduce waits over 18 weeks and develop a plan to eliminate all 52-week waits. I assure the Committee that we will hold the ICBs for their performance. The community health services situation report has a specific monitoring line, covering children and young people and covering adults, for the wheelchair, orthotics, prosthetics and equipment category. We intend to continue that work following NHS England’s abolition. Consistent national standards will help us to identify the best and the weakest performing areas, to identify what improvements need to be made and to tackle the longest waits.

Amendment 52 was tabled by the hon. Member for Sleaford and North Hykeham. We are committed to ensuring that all patients receive the NHS care they need in a timely manner, and I recognise the importance that Committee members have placed on that matter. The NHS constitution sets out that patients should start consultant led treatment within 18 weeks of referral, and it is imperative that the system continues to work towards returning to and then upholding that standard.

I listened with great care to the comments from Members on the Opposition Benches, but I was here—as were you, Dr Huq—during the last couple of Parliaments; I was here as waiting lists rose and rose after 2012, under the previous Government’s stewardship, until they reached 4 million people, all waiting an inordinate amount of time. That Government had no kind of approach to reducing the numbers; they were quite content to have 4 million people on waiting lists, and to never bring forward measures to change that. They were quite content not to challenge NHS England or trust boards about why people across the country in all our constituencies were languishing on those lists. We are determined to resolve that situation.

Will the Minister give way?

I will move on. It is absolutely right that integrated care boards, as local commissioners, retain the ability to manage their services and waiting lists effectively, given the shocking numbers that they have inherited. This is complicated, difficult work: commissioners have to balance demand, capacity and clinical need, and a prohibition such as the one set out in the amendment would threaten to remove legitimate flexibilities that are required at the local level to ensure that services are delivered safely and efficiently.

We are clear that systems should not be setting minimum wait times that exceed the 18-week constitutional standard, but hon. Members will appreciate that not all elements of waiting are inappropriate. In many cases, they reflect clinical pathways, sequencing of care or the need to prioritise the most urgent patients. It is imperative that clinical judgment and urgency remain the key drivers of prioritisation, which is something the amendment threatens to remove.

Turning to amendment 52, I recognise that Members across the House are committed to ensuring that all patients receive the NHS care they need in a timely manner. Validation is a routine and long standing part of waiting list management by providers. It ensures that patient records are accurate, that patients are on the best pathway to meet their needs and that they still need their appointments. Routinely validated waiting lists will support a return to the 18-week NHS constitutional standard.

Reasons for removal as a result of validation include a patient no longer needing their appointment or there being a duplicate appointment. The previous Government left behind some systems and trusts in such a poor condition that they give out duplicate appointments, and we need to resolve that as part of our work. Other reasons for removal include a patient’s record not being properly updated following treatment or a clinical decision—another sign of the inefficiency that the previous Government left behind.

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

Once again, my hon. Friend is absolutely right. He is expert on this issue and has outlined to us some excellent clinical examples. I look forward to debating the single patient record further in Committee.

Importantly, any patient removed from a waiting list should be notified alongside their GP. Data on the total number of removals from waiting lists is published by NHS England. That data includes, but cannot separately identify, patient pathways removed as a result of validation. The Department remains committed to the transparent publication of official waiting list statistics following the abolition of NHS England, although there are no plans to publish more detailed breakdowns. NHS staff are delivering record levels of elective activity, which has enabled us to meet our interim target of 65% of patients being seen within 18 weeks.

If a person has been waiting more than 18 weeks, the trust calls them and asks them to see a consultant to check whether they still need the appointment or whether they need a different treatment. If, after having that appointment, they are told that they still need the treatment, that same day they go back on the waiting list as if it were day one. Therefore, they have not waited less than 18 weeks, even though the Minister’s statistics might suggest they have. Does she accept that?

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

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

Amendment 63 was tabled by the hon. Member for Westmorland and Lonsdale and spoken to by the hon. Member for North Shropshire. Improving timely access to cancer treatment including radiotherapy is a firm priority for the Government. That is why we published the national cancer plan in February this year. The plan is driven by evidence and shaped by the voices of more than 11,000 patients, charities and professionals who responded to the call for evidence. I am very grateful to them for their contribution.

The plan makes specific commitments to improve radiotherapy services’ productivity, including by using artificial intelligence to streamline treatment planning. We have allocated £70 million of funding for state of the art radiotherapy machines and to streamline, improve and incentivise the use of the latest treatments. Both of those commitments are due to be delivered in 2027. The plan also commits to delivering 5,000 learning opportunities each year and rebalancing cancer training places to remote, rural and coastal regions to address inequalities in cancer care. I know that the hon. Member for North Shropshire works very hard on that. We continue to recruit in priority medical specialties, including clinical oncologists, medical oncologists and clinical radiologists. We are reforming training to support rapid development for radiologists. We are also tackling poor performance and serious variation through the Getting It Right First Time programme and national interventions to address these issues at local level.

We are well aware that radiotherapy performance is below that of other treatment types. There is much work to do, and we are committed to it, but I hope that the hon. Member agrees that it is important not to duplicate efforts already in train to improve oversight of cancer treatment and radiotherapy services. I hope that gives the hon. Member for Sleaford and North Hykeham the reassurance she seeks.

Before I finish, I draw the attention of the Committee to other aspects of clause 16 and associated schedule 2. Clause 16 allows the Secretary of State to make regulations to inform the commissioning activities of ICBs. Those regulations can cover matters relating to waiting times, patient choice arrangements, the enforcement of patient choice regulations and the appeals process against the individual commissioning decisions of ICBs.

New section 14Z45A of the National Health Service Act 2006 will allow the Secretary of State to continue to set regulations to impose duties on ICBs in relation to waiting times for the treatment or other services that they arrange as part of their commissioning functions. That provides a clear statutory mechanism to set and maintain waiting time expectations, helping to ensure that patients receive timely care. The regulations may also require ICBs to put arrangements in place to address cases where a specified treatment or service is not provided within a specified period. That helps to ensure that delays to patient care are identified and managed consistently, and that patients receive appropriate follow up and support.

New section 14Z45B requires regulations to be made for the arrangements that ICBs must make when exercising their commissioning functions to enable people to make choices in relation to specified treatments or services. The regulations may make other provisions for ICBs to protect and promote patient choice rights, including rights created by the regulations themselves and rights described in the NHS constitution. That provides a clear signal that patient choice must continue to be delivered within the integrated care system.

New section 14Z45C makes provision for the enforcement of patient choice requirements. It enables the Secretary of State to investigate whether an ICB has failed or is likely to fail to comply with regulations made under section 14Z45B. It also enables the Secretary of State to accept an undertaking from the ICB to take specified steps to prevent, mitigate or remedy any failures. With supporting schedule 2, it sets out the procedure for undertakings. The Secretary of State’s powers of direction over ICBs are set out in sections 14Z61 and 14Z62A of the 2006 Act. The new measures retain the patient choice enforcement powers of that Act, ensuring that accountability for patient choice is maintained.

New section 14Z45D allows the Secretary of State to continue to set regulations creating a formal appeals process, so that patients can contest decisions about their care made by their ICBs. It enables the creation of independent panels to review cases, sets rules for how appeals work, including timelines and the power of panels, and makes provision for administrative support for the process. That power allows clear, consistent rules for appeals to ensure that all patients are heard.

Taken together, these four powers provide the basis for a number of key regulations underpinning the operation of ICBs, and as such I commend the clause and schedule 2 to the Committee.

Question put, That the amendment be made.

7|0|3|9|The Committee divided:|Question accordingly negatived.||0|0

Amendment proposed: 52, in clause 16, page 12, line 10, at end insert—

“(3) The regulations must include a requirement for the Secretary of State to publish the number of patients validated off of treatment waiting lists each month, and the reason for which they have been removed.”—(Dr Caroline Johnson.)

This amendment would require publication of the number of patients validated off waiting lists each month and the reason for their removal.

Question put, That the amendment be made.

8|0|4|9|The Committee divided:|Question accordingly negatived.||0|0

Clause 16 ordered to stand part of the Bill.

Schedule 2 agreed to.

Clause 17

Duty to have regard to impact on services in border areas

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

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

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

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

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

The hon. Member for North Shropshire makes the point very well. Back when I was a Minister, and subsequently shadow Secretary of State, she raised that point with me. The clause is sensible. The Minister articulated concisely and reasonably why it is necessary. It is the nature of any devolution arrangements that a little bit of cross border co operation is required along the border to make sure that services work effectively for people. This may have changed, but in my experience the majority of those crossing the border were people from Wales coming for secondary care services in a hospital on the English side of the border, so I think the clause is entirely reasonable.

I echo the hon. Lady’s request: I would be grateful if the Minister updated the Committee on what conversations she has had, particularly with the Welsh Government, but also with the Scottish Government, to ensure that there is reciprocity and that they will put an equivalent provision into their laws to ensure that patients in England are taken into consideration in their healthcare planning.

The clause imposes a duty on ICBs to have regard to the likely impact of their commissioning decisions on areas of Wales and Scotland close to the border. In some respects, this is like other parts of the Bill—a statement of the obvious regarding a person’s job. Are we suggesting that the Secretary of State, and in particular ICBs, would not consider the effect of their decisions? I hope that they would, but, given that the clause is there, what teeth does it have? What if they do not? Is there any consequence in the Bill if they do not? As others have said, will the Minister confirm whether there is a reciprocal agreement with Wales and Scotland? If there is not, what negotiations has she entered into and what progress are they making?

As an MP in Bristol, which is not quite on the border, but is pretty close, I absolutely understand. We have relationships with our Welsh colleagues and I have been involved in debates on this matter. The clause ensures that, with the abolition of NHS England, regard is had to to arrangements with our colleagues across the border. We all understand that devolution means that different arrangements will be made in the constituent parts of the United Kingdom. It is not for the UK Government to determine what those are, because they are devolved. However, I assure members of the Committee that across the piece in the Department, and indeed across the Government, regular meetings and conversations on these and other matters with regard to the devolved functions are a regular part of the work that we do.

Question put and agreed to. Clause 17 accordingly ordered to stand part of the Bill. Clause 18 Transfer schemes in connection with integrated care boards Question proposed, That the clause stand part of the Bill.

The clause gives the Secretary of State the powers to make transfer schemes where an ICB is being abolished or established, or where the area covered by an ICB is being amended. A transfer scheme ensures that all the staff, property rights, responsibilities and liabilities, other than criminal liabilities, of the ICB being abolished are transferred to another ICB. That ensures that the ICB taking over has the appropriate information and resources to continue to arrange healthcare services for their population. In the past, that has been used to support the restructuring of ICBs to achieve geographical boundary alignment with strategic authorities, as set out in the 10-year health plan. The power also allows transfers to the Secretary of State and, when a new ICB is established, allows the transfer of staff from an NHS trust or foundation trust or from a special health authority.

Following the abolition of NHS England, we expect that Ministers will continue to need to be able to make transfers between ICBs. The clause allows that as needed. I therefore commend the clause to the Committee.

I have one question for the Minister. Which ICBs does she envisage being abolished, or is this just a precaution for the future?

It is precautionary to give the power in the event—future proofing the Bill.

Question put and agreed to. Clause 18 accordingly ordered to stand part of the Bill. Clause 19 Integrated care boards: power to provide assistance Question proposed, That the clause stand part of the Bill.

The clause relates to the power for integrated care boards to provide assistance and support in relation to the health service. It replaces section 14Z48 and, in part, section 12ZA of the National Health Service Act 2006 with a clearer and more flexible power. At present, the various ICB assistance powers are narrower and more confusing. Section 12ZA provides for certain forms of practical assistance in connection with ICBs’ commissioning functions, while section 14Z48 provides a more limited power to make grants or loans. Other specific assistance powers sit elsewhere in the legislation, including in sections 96, 112, 124 and 147, which allow assistance and support for primary medical services, dental, ophthalmic and pharmaceutical services.

Clause 19 replaces all those separate powers with a general power for ICBs to provide assistance or support. The clause will make it clearer when an ICB may support providers, prospective providers or other activity connected with the health service. It will allow an ICB to provide assistance or support to a person who is providing or proposing to provide services as part of the health service. It will also enable an ICB to support a person who is carrying out or proposing to carry out activities that the ICB considers to be conducive to the health service. The assistance may include financial assistance, making available the services of ICB staff, or making available any other ICB resources. The clause also allows assistance to be provided on agreed terms, including terms about payments by or to the integrated care board.

The clause supports ICBs in their role as strategic commissioners. ICBs need to be able to support the development, improvement and resilience of services for their populations. They need to be able to cultivate their provider sector to meet the needs of the people they are responsible for, and they need to be able to do so in innovative and flexible ways. The clause gives them a clearer statutory basis for doing so. This is only an enabling power; it does not require an integrated care board to provide assistance and it does not create any entitlement for a person to receive assistance, nor does it disapply the ordinary legal and financial controls that apply to integrated care boards, or any other element of the usual way in which NHS bodies are overseen and regulated.

The clause should be read alongside clause 9, which creates a broadly analogous assistance power for the Secretary of State. In combination, the clauses support the move to a simpler, more flexible statutory framework that enables everybody, from the centre to ICBs, to discharge their responsibilities in ways that can be adapted to the complexity and multiplicity of circumstances they will inevitably encounter. I commend clause 19 to the Committee.

The Government’s explanatory notes state that the clause is intended to give ICBs the ability to provide a broad range of support to those involved in providing or administering the health service. The flexibility there aligns with the Government’s stated vision for more autonomy across the system. I have a couple of questions. If the ICB were to provide support in a way that was out of line with good practice or what is expected by the Department, what would be the recourse? Where will it be possible for right hon. and hon. Members to see the financial expenditure that ICBs make in any such circumstance?

I thank the shadow Minister for her questions. ICBs are part of the accountability outcomes framework, so they will be monitored in the usual way, and any expenditure by the ICB—and, indeed, by the Department—is recorded in the departmental accounts.

Question put and agreed to. Clause 19 accordingly ordered to stand part of the Bill. Clause 20 Performance assessments of integrated care boards Question proposed, That the clause stand part of the Bill.

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

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

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

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

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

I recognise the right hon. Gentleman’s expertise as a former Minister in this role. I do not want to mislead him, so I will come back to him in writing on both those points, if that is acceptable. He tempts me to be more prescriptive than I think we intend to be at this point, but I will ensure that he gets a proper answer to both questions. I commend the clause to the Committee.

As has been said, the clause replaces the part of the NHS Act that requires NHS England to carry out performance assessments of the ICBs and rewrites it so that the Secretary of State has to carry out those assessments. That makes some sense, but, as the Minister said, it takes out the criteria against which the ICBs will be assessed.

I accept what the Minister says—she wants those criteria to be set out more flexibly than can be done in primary legislation—but it is not reasonable or fair to assess people against criteria that they do not know in advance. It will be important, will it not, that ICBs know in advance what those criteria will be? Given what she said to my right hon. Friend the Member for Melton and Syston about writing to him, will she commit to writing to us to say not only what the criteria will be at the moment, but how far in advance ICBs can expect to receive them before they are expected to work to them and then be assessed against them?

Will variation be a factor in whether an ICB is deemed to have been performing well or not? We know that there is a tension in the Bill between the Secretary of State’s need to equalise provision and the ICBs’ desire and intention to vary it and innovate. Given that the Secretary of State is a political individual, how will the assessment process be conducted in a way that gives ICBs and their leaders confidence that there will not be political interference in it?

Of course ICBs will know how they are going to be assessed; that will be in guidance in the usual way. In the last two years, in planning terms, we have brought forward all that work for the system—including on the finances—in order that the system works more efficiently, and we will continue to seek to do that.

The hon. Member, as she has several times in the Committee, returned to the question of variation. When there is devolution and local systems are different, there will be a degree of variation, as I have said. In performance management terms, where there is unwarranted variation, we will seek justification and understanding of that. Sometimes, there is variation for geographical reasons. There may also be historical structural reasons in a local system, or temporary reasons why performance is variable. We would look at that as part of that general work.

Question put and agreed to. Clause 20 accordingly ordered to stand part of the Bill. Clause 21 Membership of integrated care boards

I beg to move amendment 46, in clause 21, page 15, leave out from line 33 to line 6 on page 16 and insert— “(2) The constitution must provide for the ordinary members appointed as mentioned in sub paragraph (1)(b) to include— (a) at least one person nominated by one or more NHS trusts or NHS foundation trusts which provide services under arrangements made by the integrated care board, in accordance with regulations made under sub paragraph (2A); (b) at least one person nominated by a body representative of providers of primary medical services whose area falls wholly or mainly within the area of the integrated care board, in accordance with regulations made under sub paragraph (2A); (c) at least one person appointed by a local authority whose area falls wholly or partly within the area of the integrated care board; and (d) at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with, or includes the whole or any part of, the integrated care board's area (if any).

(2A) The Secretary of State may by regulations make provision about the nomination of ordinary members under sub paragraph (2)(a) and (b), including provision about which NHS trusts, NHS foundation trusts or representative bodies are entitled to make nominations.

(3) The constitution must set out the process for making nominations under sub paragraph (2).

(4) A person making a nomination under sub paragraph (2) must have regard to any guidance published by the Secretary of State as to the selection of candidates.”

This amendment modifies Clause 21 so that, rather than replacing the existing mandatory membership requirements in Schedule 1B to the National Health Service Act 2006 with a requirement for mayoral representation alone, the new sub paragraph (2) reinstates and consolidates the full range of required ordinary members.

With this it will be convenient to discuss the following: Amendment 25 in clause 21, page 15, line 38, at end insert— “(2A) The constitution must also provide for the ordinary members appointed as mentioned in sub paragraph (1)(b) to include at least one member nominated jointly by the local authorities whose areas coincide with, or include the whole or any part of, the integrated care board's area.”

This amendment would require integrated care boards to have a member jointly nominated by local authorities from within the board's area, as is currently the case but would otherwise be removed by clause 21. Amendment 45, in clause 21, page 15, line 38, at end insert— “(2A) The constitution must provide for the ordinary members as mentioned in sub paragraph (1)(b) to include at least one member nominated by local primary care providers.”

This amendment would ensure that ICBs have to have representation from primary care providers. Amendment 26, in clause 21, page 16, line 3, leave out from “mayor” to “sub paragraph (2)” on line 4 and insert “or local authority nominating an ordinary member as mentioned in sub paragraphs (2) and (2A).”.

This amendment is consequential on amendment 25 and would require a local authority involved in nominating a member of an integrated care board to have regard to guidance published by the Secretary of State. Amendment 27, in clause 21, page 16, line 9, at end insert— “‘local authority’ has the meaning given by section 2B(5);”.

This amendment is consequential on amendments 25 and 26 and defines the term “local authority”. Clause stand part.

At present, integrated care boards will have a chair, a chief executive and at least three further ordinary members. Those three ordinary members will include a representative of the NHS trusts and NHS foundation trusts in the area, someone from the primary medical services in the area and someone nominated by the local authority areas within the ICB area. Under the clause, the requirement for those individuals is replaced with a requirement to have someone from each of the mayoral authorities.

Because of the order in which the Government have done this—removing half the budget from the ICBs, which has caused them to merge in a way that is not coherent with the Government’s not yet complete local government reorganisation—we have a situation where representation is not even. For example, in my ICB area the Mayor of Greater Lincolnshire and the Mayor of the East Midlands will each be able to choose someone to represent them on the board, but the proportions of the population are not even. Lincolnshire will be over represented, which is not an issue for my constituents, but it may be for those from Nottinghamshire and Derbyshire. Likewise, the northern part of Greater Lincolnshire, which is in a different region, has a small population relative to its ICB. Some mayors will therefore have representation that is not proportionate to their population size.

There is surely a risk that the next step will be for the Government to say they want to make things more even, with ICBs working in relation to mayoral authority areas. Yesterday, the Minister for Care suggested at his appearance before the Health and Social Care Committee that the ICBs should be aligned with strategic authorities, but the only way in which that can happen once the Government have decided where the strategic authorities will be is if things are changed once again.

That brings ongoing costs—financial costs, opportunity cost for service development, and cost to the people delivering these services. The people working hard to try to deliver the Government’s plan find themselves and their jobs threatened and chopped and changed all the time. We heard evidence that the concentration on reorganisation rather than service delivery, provision and development is causing distress to those people.

We also heard about the effect on social care, which, certainly in Lincolnshire and in other places, is delivered by the upper tier local authority, but not all mayors have any responsibility for health—our mayor does not. We will therefore have someone who is not responsible for health on the ICB while someone responsible for delivering social care will have their seat on the ICB removed. I am afraid that I simply do not understand that. I watched through several times the Minister for Care’s Select Committee appearance, and I still do not understand the rationale. I will be grateful if the Minister for Secondary Care could explain that.

In essence, our amendments 45 and 46 would reinstitute representation on the ICB, so that the people can work together and understand each other’s roles more effectively. We could then get an integrated and joined up system, rather than a system where the social care people talk to the local authority, which talks to a health and wellbeing board, which passes a message on to the ICB, which makes a decision—perhaps with the approval of the mayor, who might not have any health responsibility—and that decision then goes back down. We all know about Chinese whispers—we all played the game as children—and passing message after message is not as effective as having direct representation on the board. Social care has been put on the back burner by this Government. I do not want to make this a political point, particularly, but we have seen the report taking a long time, and nothing really happening in the meantime. That is very much this Government: they are writing plans, reviews and glossy brochures, but what people need is delivery.

Others will have a lot to say, so I shall take no more time, other than to commend amendments 45 and 46 to the Committee. They would ensure that we have good representation on the ICB, particularly of social care, and that we get a co ordinated, joined up and well delivered commissioning process.

We have a few concerns about the clause in general, especially about the removal of local authority and primary care representation on the ICB. Some ICBs are already stepping back from joint commissioning arrangements with social care and the health and wellbeing boards, and it is vital that social care has a seat at the table. We have talked about this extensively in many Committees and in the Chamber, but the Liberal Democrats have been emphatic that we cannot solve any of the problems in the NHS without solving social care. At any given point, our hospital in Winchester certainly has 160 people in it who are well enough or would be better cared for in the community with a social care package; instead, they are stuck in a hospital, obviously affecting flow through the whole hospital and even affecting A&E waiting times.

Combined with the changes to the pooled budgets that will affect the better care fund, we are seriously concerned that the Bill is increasingly separating the NHS and social care just at a time when the service and experts are screaming out for greater integration and collaborative working. We discussed GPs this morning. They have long standing concerns about getting their voice heard, given their unique place in the health system. They are the front gate to the NHS and they have the most patient contact of any NHS service. Removing the duty seems to be a step in the wrong direction in that regard.

Finally, the change will leave in limbo areas such as Hampshire that do not yet have a fully functional mayoral authority—our elections will be in the next couple of years. There has not yet been sufficient clarity about what the interim arrangements will be.

The clause will replace the constitutional requirements contained in paragraph 8(2) to (4) of schedule 1B to the 2006 Act so that “ordinary members” must now include at least one member nominated by the mayor of each mayoral strategic authority whose area coincides with or includes the whole or any part of the ICB’s area. The ICB’s constitution must set out a process for making such a nomination, and a mayor nominating an ordinary member must have regard to any guidance published by the Secretary of State, following the abolition of NHS England, as to the selection of candidates.

The definition of a local authority in paragraph 8(7) of schedule 1B to the 2006 Act will be replaced with the definition of a mayoral strategic authority. Sub paragraph (1), outlining the process to determine the appointment of an ordinary member, and sub paragraph (6), specifying that one ordinary member must have knowledge and experience in mental health services, are both retained. The clause therefore represents a clear shift in the structure of integrated care boards and, in my view, an unwelcome one, by removing the requirement for representation of GPs, local authorities and NHS trusts, while introducing a requirement for representation from mayoral authorities.

Those are not minor features of the system. The inclusion of local authorities in particular was designed to ensure that decision making reflected local needs and supported genuine integration between health and social care.

For as long as I can remember, Governments of all colours have talked about bringing health and social care together. Some have been more successful at that than others, but there should be agreement across the House that much more needs to be done. With this clause, the Government seem to be taking at least one step back—I would say numerous steps—from trying to bring health and social care together. Like my hon. Friend the Member for Sleaford and North Hykeham, I watched the Health and Social Care Committee’s discussions with the Minister for Care yesterday, and I too cannot fathom why the Government are doing it. I hope that it is an oversight and that, once the Minister goes away and reflects on it, she will look to table some amendments further down the line—I am sure that she will vote against ours today—so that we can bring these matters back.

I am especially concerned about the removal of local authority representation. We are effectively asking local authorities to continue to deliver vital services while removing their voice in the room where strategic decisions about health and social care are made. That raises a fundamental question about how the integration is intended to work in practice. There is also a broader concern about the direction of travel. We are moving away from place based representation towards a model that places greater emphasis on these mayoral structures, yet the legislation is not prescriptive about who the mayors appoint, and colleagues within and without this Committee have already raised concerns that there is a gap in the understanding at the centre about how local authorities operate in practice.

That brings me to the point raised by my hon. Friend the Member for Sleaford and North Hykeham and the hon. Member for Winchester. I apologise; the Minister said that she did not want a geographic tour of our constituencies, but I am afraid that she will get one now. Part of my constituency sits in Hampshire in the Hampshire and Isle of Wight ICB, and as the hon. Member for Winchester said, we may or may not have mayoral elections in a year’s time. Hampshire county council has launched a judicial review against the proposed local government reorganisation; if that is successful, or even if it delays the process, this Bill will come into effect without our having a mayor, and there will be no representation for anybody on this board. We need clarity from the Minister on who will represent the people on the board if there is no mayoral authority. I would say that local authorities—Hampshire county council in this case—should remain on that board, at least until there is a mayoral authority.

Where a mayor is from one political party and local authorities are run by different political parties, the mayor, as part of the ICB, will be able to make decisions about spending done by authorities that are run by different parties. That will surely create a political conflict, or at least the potential for one.

My hon. Friend makes an interesting point that I had not considered before, but she is absolutely right. The upper tier authorities and strategic mayors might be from different parties, and, where the mayor does not have an actual responsibility for health, there essentially could be democratic deficit there that I had not thought about. My hon. Friend makes an interesting point.

That democratic deficit will potentially be exacerbated in the other half of my constituency, which is in Surrey. As I have already alluded to, the Surrey ICB has taken on Frimley but is also now merging with Sussex. As far as I can tell, the Government have absolutely no plans to introduce a mayoral authority in Surrey; however, my quick googling suggests that there will be a mayoral authority in Sussex in 2028, so the mayor of Sussex could be sitting on a board where there is no representation from the Surrey side. That is a complete democratic deficit. There would be the Surrey and Sussex ICB, with representatives for the people of Sussex but not for the people of Surrey. That must be an unfairness. I hope the Minister, if she cannot answer now, will at least go away and think about how that democratic deficit will be avoided. I suggest that she dumps the whole idea and goes back to having the people who actually run health and social care in our country on the board.

That is why I am very supportive of amendments 45 and 46, tabled by my hon. Friend the Member for Sleaford and North Hykeham. Reducing the representation to a single mayoral representative is a problem. Reinstating and consolidating the full range of required members and thereby giving the breadth of representation within ICBs that we have all talked about, is essential. It would strengthen the legislative framework, ensuring decision making remains multidisciplinary and balanced and that it incorporates both the clinical expertise, which we are going to lose, and the local authority political input, rather than having a one sized, over politicised mayor in charge.

By maintaining that membership, the amendments would help safeguard overdominance by a single actor, support a much more informed and locally responsive decision making process and, crucially, reinforce the collaborative foundation between health and social care that I thought was a given among all parties in this House. I urge the Minister to reconsider what she is proposing in this clause. She should, at least, give us some clarity on what will happen in the interim period or, at best, go back to the drawing board and ensure proper representation of the people who are actually delivering health and social care in our constituencies.

I agree entirely with my hon. Friend the Member for Farnham and Bordon. At risk to my political career, such as it is, I also agree entirely with the hon. Member for Winchester, who made a very good point in drawing the Committee’s attention to something that should not need to be said, which is that the provision of healthcare and social care go hand in hand, and if either part of that equation does not function, the other part will not. He highlighted a good example, and I visited Winchester hospital when I was a Minister.

If we do not have a functioning social care system, or a social care system that is closely integrated in and working closely with the NHS, we see the knock on effects pretty swiftly in terms of the large numbers of people medically fit for discharge who are unable to be discharged, which then impacts on the flow through an acute hospital setting. That is one of the big factors we see in A&E backing up, because people cannot be discharged, people cannot get into beds because the beds are full and then the ambulances are queuing up outside. The hon. Gentleman illustrated that point extremely well.

On the economics, it costs around £850 a night to keep someone in a hospital bed and a fraction of that for a social care package. This is an absolute false economy, even if we ignore patient experience and patient recovery.

The hon. Gentleman is absolutely right from the financial perspective. As he mentioned, there is, of course, the human perspective and the impact on someone’s recovery and their health, as well as their psychological health, if they are in hospital when they simply want to get home, because they have no medical need to be in hospital.

My worry about clause 21 is that it essentially seeks to undermine the whole concept that ICBs rest upon. ICBs were conceived to bring together all the NHS services in a particular area, but also, as my hon. Friend the Member for Farnham and Bordon highlighted, to make sure that the NHS footprint mapped on to the geographical footprint of the upper tier local authority delivering social care, so that the ICB is looking at the same geographical area for the two key parts of the system and they neatly map on to one another.

With changes, mergers and acquisitions—as well as a whole range of other changes—that link is already breaking and weakening, as ICBs start covering larger areas and look in different directions. As my hon. Friend the Member for Farnham and Bordon set out, and as I think the hon. Member for Winchester highlighted in an earlier sitting, because we do not know what local government reorganisation will look like in the years to come, we increasingly run the risk of creating something that again will not map on to a geographical footprint and may have to change.

In a number of areas—take my area, Leicestershire—we do not have a mayoral authority. At present, there is no plan or proposal before us for one. Yet the ICB is merged with Northamptonshire, which does not have one either. We will see a real gap in representation.

We are moving away from what we sought to do with ICBs. During the passage of the 2022 legislation, I always used the phrase—the Minister probably heard it until she wished to hear it no more—that we were seeking to be permissive, not prescriptive, where we could be. However, this was one area where it was not just us in the then Government who were trying to put a bit of a guardrail around the membership of ICBs. We were pushed by the now Government, then Opposition MPs, to go further in what we prescribed for the membership of an ICB.

The risk with the changes is, first, that we lose the local authority representation, that link with social care and that voice. As my hon. Friend the Member for Farnham and Bordon, from the Health and Social Care Committee, highlighted, we also lose the voice of those who are actually delivering care in our communities, who are at the coalface and who bring valuable insight to the workings of an integrated care board. The risk that we run, which we sought to mitigate in how the system was originally conceived, is that, once again, an integrated care board becomes essentially a board of NHS management, that looks at things dispassionately but is without that frontline voice—that grit in the oyster, that voice of social care to challenge the decision making within the board. That risks creating a system that moves away from being focused on integration and on those who provide the service and what they see at the frontline, and back towards simply being an internal board of the NHS. There was always going to be an element of the latter, because it is an internal accounting and decision making mechanism of the NHS, but we felt it was important that there was that alternative voice or voices within it to ensure that it was not simply an echo chamber.

My genuine fear—quite apart from local government reorganisation, the lack of mayoral authorities in some areas and the risk, highlighted by my hon. Friend, that a mayor coming from one part of the system but not reflecting the views of another part of the geography could be the representative—is that we lose the central link between health and social care on a local footprint.

I am listening carefully to what the right hon. Member has to say. I wonder whether he could present us with a concrete example of where precisely elected local government involvement in the commissioning of services in ICBs has been essential, because it seems to me that what an ICB needs is expertise in commissioning. We need people who know how to commission services. Although I understand the importance of representation, I think that what we really need is expertise in commissioning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Question put, That the amendment be made.

9|0|5|9|The Committee divided:|Question accordingly negatived.||0|0

Amendment proposed: 25, in clause 21, page 15, line 38, at end insert—

“(2A) The constitution must also provide for the ordinary members appointed as mentioned in sub paragraph (1)(b) to include at least one member nominated jointly by the local authorities whose areas coincide with, or include the whole or any part of, the integrated care board's area.”—(Helen Morgan.)

This amendment would require integrated care boards to have a member jointly nominated by local authorities from within the board's area, as is currently the case but would otherwise be removed by clause 21.

Question put, That the amendment be made.

10|0|5|9|The Committee divided:|Question accordingly negatived.||0|0

Amendment proposed: 45, in clause 21, page 15, line 38, at end insert—

“(2A) The constitution must provide for the ordinary members as mentioned in sub paragraph (1)(b) to include at least one member nominated by local primary care providers.”—(Dr Caroline Johnson.)

This amendment would ensure that ICBs have to have representation from primary care providers.

Question put, That the amendment be made.

11|0|5|9|The Committee divided:|Question accordingly negatived.||0|0

Clause 21 ordered to stand part of the Bill.

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

Adjourned till Tuesday 30 June at twenty five minutes past Nine o’clock.

Written evidence reported to the House

HB79 Angela Moreton, Founder, The Full Impact

HB80 Glaukos UK

HB81 National Data Guardian (supplementary)

HB82 Carers UK (supplementary)

HB83 Adam Cooper

HB84 Dr Stephen Watkins