Health Bill (First sitting)

The Committee consisted of the following Members:

Chairs: † Sir Roger Gale, Dr Rupa Huq, Emma Lewell, Sir Jeremy Wright

† Argar, Edward (Melton and Syston) (Con)

† Brackenridge, Sureena (Wolverhampton North East) (Lab)

† Chambers, Dr Danny (Winchester) (LD)

† Daby, Janet (Lewisham East) (Lab)

† Foody, Emma (Cramlington and Killingworth) (Lab/Co op)

† Irons, Natasha (Croydon East) (Lab)

† Johnson, Dr Caroline (Sleaford and North Hykeham) (Con)

† Joseph, Sojan (Ashford) (Lab)

† Kyrke Smith, Laura (Aylesbury) (Lab)

† Morgan, Helen (North Shropshire) (LD)

† Prinsley, Peter (Bury St Edmunds and Stowmarket) (Lab)

† Robertson, Dave (Lichfield) (Lab)

† Robertson, Joe (Isle of Wight East) (Con)

† Smyth, Karin (Minister for Secondary Care)

† Stafford, Gregory (Farnham and Bordon) (Con)

† Twist, Liz (Blaydon and Consett) (Lab)

† White, Jo (Bassetlaw) (Lab)

Sanjana Balakrishnan, Rob Cope, Committee Clerks

† attended the Committee

Witnesses

Dr Penny Dash, Chair, NHS England

Sarah Woolnough, CEO, The King’s Fund

Jacob Lant, CEO, National Voices

Dr Jeanette Dickson, Chair, Academy of Medical Royal Colleges

Kay Keane, Chair, Institute of General Practice Management

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

Sir Jeremy Hunt MP

Public Bill Committee

Tuesday 16 June 2026

(Morning)

[Sir Roger Gale in the Chair]

Health Bill

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

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

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

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

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

The Committee deliberated in private.

On resuming—

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

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

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

I am a vice president of the Local Government Association.

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

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

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

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

Examination of Witness Dr Penny Dash gave evidence.

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

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

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

Dr Dash: No, thank you.

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

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

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

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

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

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

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

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

Q What about the risks of that—the conflict?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q What happens if the problem is the CQC?

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

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

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

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

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

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

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

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

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

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

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

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

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

Examination of Witnesses Sarah Woolnough and Jacob Lant gave evidence.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sarah Woolnough: Yes.

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

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

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

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

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

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

Q Would you agree with that, Mr Lant?

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

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

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

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

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

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

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

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

And do you think—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examination of Witness Dr Rosie Benneyworth gave evidence.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr Benneyworth: No.

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

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

Q You are saying that you are a world leader.

Dr Benneyworth: We are—

Very quickly.

I think the answer was, “We are.”

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

Examination of Witness Sir Jeremy Hunt MP gave evidence.

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

Sir Jeremy Hunt: Jeremy Hunt, former Health Secretary.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Adjourned till this day at Two o’clock.