Health and Social Care Committee
Oral evidence: The work of NHS England, HC 583
Wednesday 20 May 2026
Ordered by the House of Commons to be published on 20 May 2026.
Watch the meeting
Members present: Layla Moran (Chair); Danny Beales; Ben Coleman; Jen Craft; Josh Fenton-Glynn; Andrew George; Paulette Hamilton; Joe Robertson; Gregory Stafford.
Questions 114 - 255
Witnesses
I: Sarah Walter, Deputy Chief Executive, NHS Alliance; Stuart Hoddinott, Associate Director, Institute for Government.
II: Professor Carl Macrae, Professor of Organisational Behaviour and Psychology, University of Nottingham; Rosie Benneyworth, Interim Chief Executive, Health Services Safety Investigations Body (HSSIB); Sir Jeremy Hunt, Former Secretary of State for Health and Social Care.
III: Duncan Burton, Chief Nursing Officer, NHS England; Dr Penny Dash, Chair, NHS England.
Witnesses: Sarah Walter and Stuart Hoddinott.
Q114 Chair: Welcome to this session of the Health and Social Care Committee. Today we are preparing for the NHS reorganisation Bill, which will be read for a Second time in the House on 1 June. As part of the process of preparation for the Committee we will be scrutinising both the process of the merger between NHS England and the Department and how it is going. We will be looking at the functions of HSSIB, and then we will have Penny Dash with us in panel 3.
Panel 1, please introduce yourselves and your organisations.
Sarah Walter: My name is Sarah Walter. I am deputy chief executive of the NHS Alliance, which is the new independent membership organisation representing the healthcare system across England, Wales and Northern Ireland.
Stuart Hoddinott: I am Stuart Hoddinott. I am associate director in our public services team at the Institute for Government, which is a non-partisan think-tank with the mission to make Government work more effectively.
Q115 Chair: On that note, Stuart, from your perspective, how is the merger going?
Stuart Hoddinott: To take it a step further back, we have argued quite consistently that the announcement of the abolition of NHS England and the headcount cuts to NHS England, DHSC and ICBs was handled very chaotically in the initial stages—both the announcement itself and the months following it in which there was little clarity over the purpose of the abolition, the merger, or the ICB cuts. That reached a pinnacle at the end of last year when there was the ongoing discussion about funding for headcount reduction in ICBs. That caused a lot of uncertainty throughout the system, as far as we could tell.
Our view is that, since then, the process has stabilised somewhat. We welcomed, for example, the announcement from Government at the beginning of the year about the timeline for the abolition, including things like when they planned to publish the target operating model, when they planned to have directorates up and running, and obviously when they planned to actually abolish the organisation itself and merge it back into the Department. We think that has helped to bring clarity to staff who were uncertain about what the process would involve. One person described it to me as, “It felt like at the beginning of the year we faced endless uncertainty, and at least now we have some idea that this is going to have an end to it.”
We also welcome having already merged some important functions to have some shared leadership structure. Our work from other mergers and abolitions shows that giving some direction to staff lower down the hierarchy is an important first step to establishing a shared culture in a new organisation. Again, we think that is a welcome first step.
I think there is still a certain amount of uncertainty for staff. There are problems in the merger that we can get into in more detail later, which we hear are still causing certain levels of unhappiness.
Chair: I am hearing morale is through the floor—consistently.
Stuart Hoddinott: Yes, I think that is correct. DHSC had the largest drop in staff engagement scores among Whitehall Departments in 2025 compared to 2024. Admittedly, that did follow the largest increase in 2024 compared to 2023. ICBs have had consistently very large drops in morale in the NHS staff survey. There was a large drop in staff views of leadership and change management in the civil service staff survey as well. Yes, there has been a very large drop in morale. I would say—this is not based on any survey data, polling or anything along those lines—from talking to people within the Department, which we do quite regularly, morale seems to have improved somewhat since the start of the year. Obviously, that staff survey was taken during last year, which was the height of the uncertainty. But I would agree with that assessment that there has been a large drop in morale.
Q116 Chair: The target operating model is welcome but do you have a view of what we should be scrutinising in it?
Stuart Hoddinott: We try not to have a view on the particular functions. There are all different ways you could cut the arrangement of DHSC: you could have it done along policy lines; you could have it done along regional lines. That is up to Government. We would say that it is important to use this period now to think carefully about that structure long term so that it does not require another round of reorganisation in a few years’ time; to make sure that it is well thought through and that it supports wider goals; and that when that is decided, to announce it in a reasonable timeframe to give staff the certainty of what is coming. That is something we would really push: the uncertainty is very detrimental to both morale and the ability to get on with other bits of work.
Q117 Chair: Moving on to the Bill itself, part of the Bill is the absorption of the majority of NHSE’s previous legislative functions. Are there any functions the Department is taking on that you are worried about? I will start again with Stuart, but Sarah, feel free to chip in.
Stuart Hoddinott: The most obvious one is the operational side. They are bringing all operations back into the Department, which is the first time for over a decade that they are going to have direct control. That is not unusual in Whitehall departments; the DWP and the MOJ employ a lot of operational staff. But there is a real question about whether the capability and the capacity will be there on vesting day in April 2027.
That is for a number of reasons. First, the headcount cuts that were announced are incredibly large; 50% headcount reduction is enormous. So far that has not been properly justified by anyone in Government and some people have even admitted that it was a number that was rushed out without much thought. We have seen that there is often a real risk that staffing decisions work backwards from the headcount cut rather than, “What do we need to run an effective department and therefore who do we keep?” There is a tendency at the minute just to get anyone out the door who is willing to go.
As an organisation we are sceptical about voluntary redundancy schemes in the civil service as a way of retaining quality talent, but that is particularly risky in this situation where you just need to get rid of a lot of people. The work we did with the Nuffield Trust on this showed that merging operations and policy within the Department can potentially create tension between them. They both require a lot of people and at some point you might have to make a decision, a trade-off, between the two.
The other function that was brought up quite a lot as being an area that was of particular concern to interviewees was digital and data infrastructure. That is an area that interviewees felt had been a real success for the last few years. The merger of NHS Digital and NHSX into NHS England went very well and created a highly effective area of expertise within that organisation. It also employs a lot of staff in those functions within the NHS, something like 3,500 people; bringing that into the Department with the headcount cuts could lead to quite a lot of loss of expertise. That is the other area we would highlight.
Q118 Chair: Moving on to the ICB side of this and the target of 50%, Sarah, what progress are we seeing with that? Is that figure averaging out across the ICB landscape, with some doing more and some doing less? When we asked Jim Mackey about this number, he said it was going to be an average and it was never totally clear what would be Department and what would be ICBs. What are you seeing from an Alliance perspective?
Sarah Walter: We are seeing progress toward that target. It is worth saying that the 50% is an average to be achieved across all ICBs. Recognising they are working towards new running cost allocations, and some were further from that point than others, the scale of change varies significantly from system to system. The last 12 months clearly have not been smooth. Reiterating some of Stuart’s points around that original announcement in March 2025, ICBs have been responding to a landscape where there is information available, but not always in the—
Q119 Chair: What does that mean operationally? What has this uncertainty and the slashing of headcounts meant for patients on the ground who want to see the NHS improve and are impatient for that?
Sarah Walter: In the short term, inevitably, the scale of change that ICBs have been responding to will take up a huge amount of management capacity, so there is an opportunity cost there in relation to the work that is required from ICB leaders to navigate that scale of change. From the announcement around the 50% cuts, ICBs have been clustering and going through merger arrangements. They have been responding to the model ICB blueprint, which was developed by Penny Dash back in May last year, responding to changes in the expectations around ICBs. The model ICB blueprint sets out quite a clear set of responsibilities for ICBs focused around their role as strategic commissioners.
We have a lot of support from ICBs for that intent, but there are also a number of functions that were identified as potentially transferring out of ICBs that in the short term will remain with those ICBs. That uncertainty around when functions may transfer and how you manage that as an ICB leader has occupied a lot of management capacity. The focus around strategic commissioning and having a more defined role for the ICB is something that people welcome on the whole, but being able to move to that over the course of this year has been a bumpy road and people are still working through their restructures and their new staffing arrangements. We are not through that yet. At the end of that process there is going to be a lot of work needed to ensure that ICBs have the capacity and capability that they need to be able to deliver that strategic commissioning function.
Q120 Chair: Again, just picking up on that disquiet/morale point about ICBs, it is anecdotal and it is just people who I am speaking to, but I keep hearing stories of really good people basically deciding that they are going to take the redundancy; they would rather go and work in the private sector or somewhere else, or some other Department. Are you at all keeping track of that kind of thing? I am even hearing it at leadership level; by the time this is over there are already people preparing to leave. Are you hearing that too and are you tracking any of it?
Sarah Walter: We are not tracking it, no. Lots of individuals at all levels within the system from ICB leadership level across those organisations have obviously been impacted by the uncertainty and some are seeing this reset opportunity for ICBs as a point in time to move into something new, so we have seen really significant turnover.
Q121 Chair: That is such a shame, isn’t it? We want to keep our best people. What do the Minister and Government need to do to encourage those people to stay and play their part in this reboot of the NHS?
Sarah Walter: The real thing that we are seeing is a need to back the role of commissioners within the system. If you look at the 10 year plan there is a really clear vision for the role of ICBs: the part that integrated care boards can play in delivering neighbourhood health, in achieving the shift set out in the 10 year plan, in having that focus on population health outcomes, and in supporting effective local partnerships. There is a really positive future that we can see for ICBs, but we really need to back them. There is a need for the Government, and for NHS England in the immediate term, to be reinforcing and backing the role of ICBs in the system and putting the support in place. There is a strategic commissioning development programme that NHS England is planning to support, which is a really important intervention—
Chair: I assume you are talking about resource, and what they say publicly.
Sarah Walter: Absolutely, and ensuring that within the national team there is that kind of understanding of the role of commissioning. As an organisation we have been calling for the appointment of a director of commissioning development to ensure that that voice is clear within those national conversations.
Q122 Paulette Hamilton: Stuart, you recently wrote that, “ICB reorganisation is turning into a fiasco,” and it has been said that it is emerging that it is even far more problematic than that. Could you tell us how you came to that conclusion?
Stuart Hoddinott: Yes, there were a few things that went into that. First, the process that was just described has been very chaotic, maybe much more so than it needed to be. For example, we have done some work on SEND services looking at how to improve co-ordination of different services around SEND in a local area. While talking to them, we heard of ICBs who have cut their entire SEND function because the ICB blueprint suggested it was a consideration. They have cut their entire SEND function. At the same time, DHSC has said to us that it thinks that ICBs are going to carry on commissioning SEND services and that it is up to NHS England to ensure that those functions are preserved within ICBs. There appears to be poor triangulation between these three different groups about what is actually supposed to be happening, and that undermines the Government’s other reforms on SEND.
Secondly, this is incoherent with the Government’s approach to public service reform. While they supposedly aim to devolve power to local areas, cutting the number of ICBs, reducing their staff and making them cover a geography with an average of 2.2 million people—meaning they are going to have to co-ordinate between, on average, six different upper-tier local authorities, possibly more after local government reorganisation—makes a mockery of the idea that they will be able to effectively design services for local areas, or work effectively with partners in the local area, given the very large remit they have about strategic commissioning. To me, it does not make any sense in terms of the Government’s own stated objectives for either the NHS or public services. That is why, from that perspective, this is increasingly turning into a fiasco that does not even make sense on the Government’s own terms.
Q123 Paulette Hamilton: Having said all that, can you give me one example of something that perhaps would have helped to make this process a little better?
Stuart Hoddinott: First, again working backwards, saying at the beginning, “We think ICBs are too bloated, we need to clearly identify their functions first.” Once you identify that, you can determine the staff needed through a more methodical process. ICBs should have been integrated with other Departments. While we agree with aligning boundaries with MSAs, this did not happen when the changes were announced and since then it has happened in an ad-hoc way. As the Minister warned in Parliament, this risks that they will have to redo the ICB reorganisation in a few years once MSA boundaries are finally decided because that co-ordination never happened. If you look at other public services, they offer a more measured approach. For example, the police launched an entire investigation, which will take a number of years, to determine appropriate sizes, what geographies they should be working across, and how structures beneath the police force will be working. In contrast, the ICB announcement happened in a matter of days with no clear planning behind it. We think it has been very disruptive so far.
Q124 Paulette Hamilton: What are ICB leaders thinking of all this, Sarah?
Sarah Walter: ICB leaders are wanting to get on with the job. Coming to your point around actually what is the role of the ICB within the system, how do we ensure that ICBs can be delivering those kinds of population health improvements, focusing on the role that commissioning can have in delivering change and improvement across the system? That is what they want to be focused on.
Q125 Paulette Hamilton: Sarah, I am going to be awkward; I did not ask you that. What I said was, what is the thinking among ICB leaders after what was said by Stuart? I will use another word, what are the shared sentiments by ICB leaders?
Sarah Walter: So this last 12 months has been very difficult. ICBs have been incredibly professional in how they have responded to the situation that Stuart has outlined. Going back to the point, there is still a really positive intent to say, “Well, this has happened, this has been the direction that has been set out and we as leaders within the system now need to make the best of this, as far as possible.” To your point earlier, Chair, around how we can retain the best people within our ICBs, trying to focus on actually what we can do within the resources that we have available and focus on the role that they can have and—
Q126 Paulette Hamilton: With almost a 50% cut in budget and more than that in staffing levels, how can you possibly hope to get to what you have spoken about, getting to the best possible service? Do you not think it has tipped over the edge?
Sarah Walter: No, I would not describe it as being tipped over the edge. Despite all the changes there is some fantastic practice still happening; many ICBs that you speak to will have great examples of the work happening within their systems and the commissioning focus around really understanding the needs of their population and how we are going to commission in response to that. So people are keeping on and they are doing their best in what has been a very trying situation, but with a real commitment to their local population. That is not to say that there aren’t implications of the changes, and that has had an impact—
Q127 Paulette Hamilton: Are you at breaking point?
Sarah Walter: No.
Q128 Ben Coleman: ICBs are obviously preparing for their responsibilities as strategic commissioners. How prepared are they at the moment?
Sarah Walter: As I say, there is some really positive practice already in existence within ICBs across the country, but we have seen a loss—not just in this last 12 months but over a longer period of time—in the commissioning capability within the NHS. ICBs would identify a need for that commissioning capability to be enhanced and improved. That is why some interventions that NHS England is currently proposing around supporting the development of strategic commissioning and investing in that commissioning capability is going to be really important. We have lost some of that strength and those skills within the system. So as ICBs are reshaping in response to this clearer focus around strategic commissioning, we need to be looking at some skills that those ICBs are going to need.
Q129 Ben Coleman: You have these seven regional offices for pan-ICB commissioning. I do not know what you call them—OPICs? They are meant to be set up by the end of April; how is that going?
Sarah Walter: We have seen an announcement this week around the lead commissioners for those OPICs. So those are in development and those kinds of conversations are happening locally. I know lots of ICBs have already been developing cross-system relationships. If you take ambulance commissioning for example, many regions have already had effective working relationships for looking at commissioning on a broader scale, so we are not starting at zero.
Q130 Ben Coleman: But as a whole I am hearing you saying that there is not enough understanding of commissioning and it really needs to be bumped up. There was a recent report from the Health Foundation that said that previous attempts to change how commissioning is done “struggled to have an impact on patient care or outcomes.” Do you think these reforms are likely to prove any different, Stuart?
Stuart Hoddinott: I would say that strategic commissioning historically has been very difficult to do. Not just in the UK but internationally the comparisons show that it often does not achieve the goals it sets out to achieve. Here there has been a consistent desire from central Government to shift care into the community to make it more preventative. That has not happened.
Q131 Ben Coleman: Do you expect it to be different this time?
Stuart Hoddinott: It is very difficult to say. One thing I would say is that—
Q132 Ben Coleman: How confident are you?
Stuart Hoddinott: Personally, not particularly confident necessarily. But I would say one thing that would help it would be some stability—some ability for structures to embed, mature, and build relationships with providers with other partners in a local area. This is the third reorganisation, including the establishment of ICBs, that these organisations have been through since 2022. It is impossible to build a high level of capability within any organisation when you face that kind of constant change.
Q133 Ben Coleman: To clarify, is that what the offices for pan-ICB commissioning are aimed at achieving?
Stuart Hoddinott: I have less of a view about those offices.
Q134 Ben Coleman: On those offices, how should we judge whether they have been effective or not, Sarah?
Sarah Walter: Fundamentally you need to judge on whether they are achieving the health outcome improvements that we want to achieve for the population. Fundamentally that is how we judge whether commissioning is effective or not.
Q135 Ben Coleman: Are they measured against targets so we can see that? How will we judge whether they are improving health outcomes?
Sarah Walter: In terms of targets, as the centre sets out expectations for the population there is always a mix of those centrally managed targets and expectations and then outcomes that individual systems will be focused on.
Q136 Ben Coleman: That is what should happen; it is not what there is always. I find these answers of what there is “always” or “usually” to not really be answers; they are just descriptions of a situation. I could probably ChatGPT them. What do you think? Should they set targets? How should they measure the outcomes?
Sarah Walter: It will vary. When you look at OPICs, the range of services that will be commissioned vary significantly. Some are incredibly specialised services as well.
Q137 Ben Coleman: I appreciate that. Specialised commissioning has been carried over into the DHSC. Do you know if the specialised commissioning team within NHS England is going to be retained in the Department of Health and Social Care?
Stuart Hoddinott: I am not sure.
Q138 Ben Coleman: Can I ask about the impact of removing local authority representation from ICBs? What could this mean for ICBs understanding their local populations?
Stuart Hoddinott: We personally think it is a mistake. ICBs are intended to be the drivers of integration in a local area. The NHS is notoriously one of the most difficult organisations to work with in any local area. Local authorities have enormous impact on population health: they run public health services; they commission adult and children’s social care; they are vital partners. It does not make it impossible to work with them because a lot of the integration comes from informal relationships, but removing a formal governance arrangement adds a layer of friction and makes it more dependent on local relationships and ad hoc integration.
Q139 Ben Coleman: I should perhaps declare an interest here: I used to sit as a local authority member of the North West London integrated care board, which Penny Dash chaired at the time. In London, you have recently had the merger of the North West London and North Central London ICBs. You now have one ICB looking after 4.5 million people, 13 local authorities, but there are still only three local authority reps; there used to be three on the North West London ICB alone. Now the idea is to get rid of them and give the power to the London Mayor. Forgive me for talking London—it is a huge area—but the situation in London is that the mayor has no health remit. It is not like Manchester where the mayor has made a success of devolution and has real powers and funding and budget powers. It is not at all the case. You just have London with no remit. Does it make sense to give the London Mayor the remit and get rid of all the local authorities?
Stuart Hoddinott: I would argue no. Even in well-developed MSAs such as Greater Manchester, they still do not have a lot of the powers over services that are particularly important for determining health outcomes. They are not public service delivery bodies still, but in London, yes, I agree with that. When we talk—
Q140 Ben Coleman: Sarah, forgive me for focusing on London, but it is vast. It is a huge difference to give the remit to the London Mayor, the only person who is able to sit on the board, as opposed to local authorities that are responsible for social care, which the London Mayor is not. Does this make sense and has it been properly thought through, or are we just trying to lift and shift the Manchester model and make it work for the country?
Sarah Walter: One thing that we think should be specified within the Bill is what the arrangements are for those ICBs where you do not have a strategic authority because it is a very mixed picture across the country. I absolutely support Stuart’s point around the importance of that local integration between the NHS and local authorities. From our work with ICBs, they are absolutely committed to that.
You have these huge geographies with some ICBs covering multiple strategic authorities. If you look at the North East and North Cumbria ICB or the cluster now covering Nottinghamshire, Derbyshire and Lincolnshire, there are two separate combined authorities as well as a number of upper-tier local authorities. The kind of landscape that ICBs are working in to support that kind of partnership arrangement with local government has become more complex, but it is no less important. I guess there is a question around the role of local authority on the ICB board, and we think that it is important that there is that local authority representation, whether that is through a strategic authority or through other local government representation. There is also what happens underneath that, particularly at a more local level, because those local integration relationships at local authority level are going to be fundamental.
Q141 Ben Coleman: Is there any indication they are going to get the resources? As I say, London Mayor, not responsible for health, a tiny bit of public health. Huge changes would be needed to the mayor, the resources, the expertise. Do you have any indication that that is going to happen? Just a simple yes or no would be good at this stage.
Sarah Walter: No.
Stuart Hoddinott: No.
Q142 Josh Fenton-Glynn: I am mainly going to ask about staffing and shifts to staff. Before I do, Stuart, you talked about ineffectively moving to the three shifts. What changes to the Bill would you make for it to effectively act on the three shifts? I have a blank piece of paper here.
Stuart Hoddinott: I am not so sure that it is about legislation. It is unclear how these structural reorganisations are supporting the ambitions of the three shifts at all. Personally, I do not understand how having fewer ICBs focused on such large populations will be able to strategically commission services at a hyper local level that you need to push care out into the community, for example. I do not understand how abolishing NHS England necessarily supports any of these. There is a stronger argument about clearer lines of accountability and performance management from abolishing NHS England because we agree that having a Department and NHS England means duplication of reporting and increasing numbers of targets.
It has never been clear to me how the structural organisation supports those shifts. If anything, it makes the shifts much harder in the short term. They are enormous systemic changes to how you run the NHS that have been tried for decades and most Governments have failed to do effectively. If you are now going to spend years going through these structural organisations, destroying staff morale, it is unclear to me how those staff are expected to deliver the work that is required for the three shifts in the short term. Potentially over the longer term that makes a difference, but for now it definitely does not help in our view.
Q143 Josh Fenton-Glynn: Okay, I am now going to move on to staff. I am probably going to start with Stuart and then move to Sarah for your reflections. My favourite Institute for Government report is one called “Never Again? The Story of the Health and Social Care Act 2012”. I assume you did not write it.
Stuart Hoddinott: No, I did not.
Q144 Josh Fenton-Glynn: I mean that with the greatest respect. There is a line in it somewhere, and I am doing this from memory, where it says something like the idea is you get rid of the 320,000 staff and make them redundant, but what will happen is their positions will not be redundant and therefore they will slowly be re-recruited, which is in fact what happened. Looking at the way that they are getting rid of staff, particularly through voluntary redundancy, do you think there is a risk of that happening again?
Stuart Hoddinott: Almost certainly. Someone described this to me and it is very accurate: the Government seem to mistake cutting capacity with devolving power. Just a quick caveat; we agree with Government that some duplication existed between the DHSC and NHS England, but the extent is probably beyond that. If you cut capacity and they were doing necessary work, that work is either not done—losing the actual capability of the system—or it is pushed out to local systems. Ultimately you could end up forcing a lot of analytical work on to trusts and other providers that are also facing considerable constraints.
There is a real risk that there is an increase again in these types of roles over the next few years, but you have already gone through a round of cutting those staff. For example, if you look at the police over the last 15 years, it cut 20,000 staff between 2010 and 2015 and then rehired them again, but those staff were less experienced and therefore less effective and there was worse vetting on them. There is a risk that this happens again. The NHS and the entire system is already under-managed and lacks capacity; there is the risk that you just end up having to rehire them in a few years.
Q145 Josh Fenton -Glynn: That is a powerful point and it is never going to be popular to say there are not enough managers in the NHS, but it is probably true. Sarah, just within that, obviously from an ICB level, you talked about defending commissioning but in terms of the way that redundancies are happening voluntarily, do you think that is going to have an impact on your work?
Sarah Walter: It will. I would add that if we are now moving to the system of a smaller number of strategic commissioners operating at a bigger scale, the way in which that commissioning is delivered and the kinds of tools and skills that are required to make that happen will change and have changed. There is also an aspect to this change of ICBs looking at what kind of skills and capabilities we are going to need in order to be able to deliver in this way, particularly now we have some analytical tools and some health economics tools available to us that can support effective commissioning decisions. So there will also be an aspect of, what are some new skills and capabilities that we need to develop and grow within ICBs that may not have been there before?
Q146 Josh Fenton-Glynn: These decisions were announced in March 2025 but it was not until December that they worked out how they were going to pay for it. What have been the practical implications of these funding delays for delivering this 50% headcount reduction?
Sarah Walter: We have multiple examples of ICBs that acted very quickly from the original announcement in March around the 50% reduction—putting in place clustering arrangements, identifying new structures, getting ready and talking to their staff about the consultation process that was going to come—that then needed to press pause on that, essentially because of the uncertainty about how voluntary redundancy was going to be paid. That clearly creates the morale issues for staff that we talked about. Many ICBs have been ready to go but then had to press pause, and then there were some subsequent changes around the scope of what ICBs are being expected to do. There was a shift from what was originally proposed within the model ICB blueprint that was published in May to then, in December, an update on those functions for transfer, and some functions now indicated to stay that had previously been identified for transfer. That has all led to a delay in those kinds of restructure processes getting started and it means they will not all have been completed to the original timeframe that was set out.
Q147 Josh Fenton-Glynn: What do you need from Government to be able to catch up some of that time that was lost?
Sarah Walter: At this point, it is around stability now and clarity of focus. More clarity to ICBs, so consistency of messages, would be really helpful—so not saying one thing and then three months later there being a slightly different message. As I say, the focus from ICB leaders that we are working with is that they want to get on with the job, so I suppose an environment where they feel empowered and have the support and the backing from NHS England to crack on.
Q148 Josh Fenton-Glynn: What is morale like?
Sarah Walter: A really mixed bag. It has clearly been really challenging but, as I say, there is still a lot of enthusiasm for the role of ICBs and the role of strategic commissioning in the future. We published a report back in November looking at the state of ICSs and what progress was being made, and you still see a lot of enthusiasm and energy for the kinds of improvements that we can see across the system. There is huge support for the 10 year health plan. People sitting at that ICB level can see the opportunities for improvement, for greater integration, and there is a lot of support for the strategic commissioning focus and the way that could look different in future. Actually, at a leadership level, I would say there is a surprising amount of optimism, but recognising that it has been a really difficult period across the staff within ICBs.
Q149 Josh Fenton-Glynn: Obviously, as politicians, we all have tremendous respect for people who are working in those management roles, and I know it does not always feel like that. My final question is for Stuart, really. There is a big pay discrepancy between DHSC and NHS England. You have looked at several machinery of government changes similar to this. What are the best ways to address that challenge?
Stuart Hoddinott: Thank you for raising that; it is something I wanted to raise. It is very hard. At the minute, the plan is to TUPE in NHS England staff on the same terms they have. What tends to happen is that when staff move into a new role they then move on to a civil service pay grade; there are some risks that are associated with that. There are a few that are more tangible, such as the effect that has on staff’s desire to move. If you are in a very well-paying job, why would you then take a job that entails a large pay cut?
Another is a bit more intangible and that is around culture and staff relations. There have already been some problems such as if you are a deputy director in DHSE, you are paid less in some cases than an analyst working in NHS England. That creates a strange dynamic between staff when they get into the Department. Unfortunately, I actually do not have any good recommendations for how to make that process better, but we can get back to you; I am sure colleagues who work on that have better ideas than me.
Josh Fenton-Glynn: TUPE or not TUPE, that is the question!
Chair: Well done, Josh, for dad joke of the day. That brings us to the end of our first panel. Thank you so much.
Witnesses: Professor Carl Macrae, Rosie Benneyworth and Sir Jeremy Hunt.
Q150 Chair: We are now going to look at the potential merger of the CQC and HSSIB, to get everyone’s head in the right place. Can the panel please introducing yourselves and what you do?
Rosie Benneyworth: Good morning. I am the interim chief executive of the Health Services Safety Investigations Body.
Sir Jeremy Hunt: I am MP for Godalming and Ash, former Health Secretary, and former holder of your esteemed position.
Chair: Indeed, it is a pleasure to have a former Chair with us today.
Professor Macrae: Good morning. I am a professor of organisational behaviour and psychology at the University of Nottingham and a research professor at the Healthcare Improvement Studies Institute at the University of Cambridge.
Q151 Chair: Sir Jeremy, I would like to start with you. You were Secretary of State when HSSIB’s predecessor organisation, with just the one S, was pulled together. Of course, you also chair the APPG on patient safety. This has been an interest of yours for a number of years. Can you talk us through what the rationale was back then for this organisation and why you felt it was so necessary in the landscape?
Sir Jeremy Hunt: Yes. Basically, the comparison in everyone’s minds was with what happens when there is an accident in the air industry. The air industry—actually the travel sector in general—seems to be much better at learning from mistakes than the health sector, not just in the UK but all over the world. In particular, there is an organisation called the Air Accidents Investigation Branch, which does investigations every time there is a crash with fatalities, such as the Shoreham air crash. It will do an instant investigation.
There is a Rail Accident Investigation Branch, which looked into the Croydon tram crash of several years ago immediately. It concluded that there was a problem in the tunnel and the driver was distracted. That knowledge as to what caused the accident was then disseminated throughout the whole light rail industry, or the air industry. We were looking for something similar in health. That is why I originally set up HSIB, and then my successor, Matt Hancock, put it on to a statutory footing.
Q152 Chair: In your view, do you feel it has been a success?
Sir Jeremy Hunt: It has been mixed. It started to do some good reports but, in the early days, I thought that some reports were a bit woolly. What is now functioning very well is the original sense—Rosie will be able to give more detail on this. The safe space concept, where people can speak very openly to HSSIB investigators, is understood and respected, and people think that works well.
However, the big failure—it is not just a failure of HSSIB but a failure across: the Dash report talks about 430 maternity recommendations in five years—is not so much the investigations we do, but our failure to implement the recommendations. If the Air Accidents Investigation Branch says that there needs to be a different type of screw on the second Rolls-Royce engine on the left-hand side of every jumbo jet, airlines do that instantly across the whole world because there is so much at stake. But if HSSIB makes a recommendation that could equally save lives, nothing happens. I am sorry, that is a bit of an exaggeration but broadly speaking, often very little actually happens because hospitals are busy places, and people have other things to do. For me, that is the central problem we have at the moment.
Chair: Before I move to Joe Robertson, I just wanted to point out that we asked the CQC to submit evidence to us on this merger. It is now on our website, if people at home want to see it. I hope the panel has had a chance to look at it.
Q153 Joe Robertson: I will probably direct my questions to you, Rosie Benneyworth. As you have heard, the Dash review has stated that the merger between HSSIB and the CQC would help to clarify roles. Is there any evidence that there is a lack of clarity in roles between the two organisations and that that is a problem?
Rosie Benneyworth: There is not any evidence that there is a lack of clarity between the two organisations. There are a lot of organisations. Carl did a very excellent paper several years ago before we were in existence, talking about the 126 organisations that had a regulatory impact on an individual provider. The whole landscape is cluttered. In many of our reports, we talk about that, we flag that, and we make recommendations about how to simplify that. We have talked a lot about safety management systems and quality management systems that would actually help to support that in terms of accountability.
There is also a lot of evidence about the cluttered landscape with recommendations, and HSSIB did a lot of work on that. We highlighted this in a report in 2024; we raised the issue. However, our recommendations are not the problem. We do not make recommendations to providers; we make recommendations only to national organisations. We have made 37 recommendations in investigations since we launched up to the end of March this year. We make a very small number of recommendations to national organisations such as the Department of Health and Social Care, the CQC, Royal Colleges and NHS England.
We have seen impact from those recommendations. We have lovely examples of impact. For example, one recommendation about aortic dissection has been shown to be saving 300 lives a year. We have data showing the impact of our organisation, which is really exciting and important for us.
In terms of the relationship between us and the CQC, we have very different roles and responsibilities. As you know, the CQC is a regulator; we are an investigatory body. Those are very different functions. If you look at all other safety-critical industries, they have a clear delivery arm, a regulator, and an investigatory body. The roles are distinct and separate. We do not have a regulatory function.
Q154 Joe Robertson: I do not understand quite why bringing the HSSIB into the CQC as an independent branch necessarily declutters the landscape, unless those recommendations are given in the name of the CQC. I do not quite understand how it declutters the landscape.
Rosie Benneyworth: I cannot answer that question either. That was not my recommendation to make, but there is real opportunity to look at decluttering the landscape. For example, the National Quality Board completely agrees with the recommendations in Penny’s review about how that should have a much stronger function, bringing together all parts of the system, really driving that clear strategic direction for safety and quality, and aligning all the different parts of the system. If different parts of the system are aligned, there is a real opportunity to make a much bigger impact on patient safety and quality.
Q155 Joe Robertson: Can I just finish by asking, do you agree with the argument in the Dash review that bringing together HSSIB and the CQC would create a clear link between identifying poor performance and investigating its cause?
Rosie Benneyworth: We do not investigate poor performance; we investigate safety risks. That is very different. There are safety risks in good-performing organisations and in poor-performing organisations. We work very closely with the CQC already, and if it is seeing emerging risks, it will tell us. We listen to those, and we may prioritise those for investigation. That already happens. However, we are not there to be the investigators of poor performance. It is a very different role.
Sir Jeremy Hunt: I just wanted to add that I am also the chairman of the all-party patient safety group. We are unanimously opposed to this merger. The main reason is a very specific legal concern we have about a conflict of interest inside the CQC. The Air Accidents Investigation Branch is completely separate from the people who regulate the airline industry, but the CQC is the health regulator.
The situation that is a concern is let us say that HSSIB, as part of the CQC, received confidential information from a midwife in a maternity unit about something that did not happen that should have happened, and that was a breach of regulation. The CQC’s regulatory branch—a completely separate bit of the CQC—cannot simply have a voluntary Chinese wall; it could be under a legal obligation to use the information that was supplied to another part of the CQC. There is a risk that one part of the CQC could have to go to a High Court to get information out of another part of the CQC and actually be legally obliged to do so, which would be completely ridiculous.
The other risk is that even if you were able to find a way of legally protecting the safe space provisions inside the CQC, the midwife might not believe that existed. They might worry that if they were completely open about something that was actually a regulatory failure in their maternity unit, it could end up with that maternity unit being shut down because that would be the ultimate sanction the CQC has. That is the fundamental legal issue that needs to be resolved if the Government are to proceed, but it is why the all-party patient safety group is against this merger.
Q156 Joe Robertson: It sounds from what you have just said, Sir Jeremy, that actually the merger risks fundamentally undermining the rationale for HSSIB in the first place.
Sir Jeremy Hunt: That is the risk. It is a risk of perception, but it is really important to say that it is actually a risk of reality that you could have this conflict. It may be the case that you can resolve that in law, but I know that the CQC—you can see this from its evidence—does not feel that it has clarity on whether that is actually possible.
Professor Macrae: This is a very, very serious concern, and I certainly agree with Sir Jeremy’s comments and the all-party parliamentary group position on that. To perhaps go even further than that, there is the potential challenge that the invisible part of HSSIB’s role, which is assumed but perhaps not always highlighted, is that it is a systems investigator. It investigates the CQC. You may have a situation where one part of the CQC is investigating another part, protecting that information, and then there is a contest over access to that information.
As Sir Jeremy mentioned, there are examples such as the Shoreham air accident in 2015, where the aircraft crashed on to the crowd with 11 fatalities. The police took the AIB to the High Court to try to release that information, and the High Court declined, saying it would put a chill over anyone’s willingness to speak to AIB in the future. This is a very real risk that is involved. It is precisely why other sectors do not keep them in the same organisation, and they are entirely separate entities with different functions.
Q157 Danny Beales: We started to touch on these issues already, and we discussed the risk of legal proceedings being brought against HSSIB if it is sat within the CQC landscape. How realistic do you think that is? Professor Macrae, you have talked about a different example in another sector, but there are examples in the health sector more broadly. Are there examples of legal action against HSSIB or the CQC for similar reasons currently?
Rosie Benneyworth: Because we are not within the CQC, there has not been any current legal action around this. However, we have a regular conversation about protected disclosure material. There are caveats to the protected disclosure legislation, which means that if there is criminal liability or a significant regulatory breach, we can disclose that information. I can allow that information to be released. We have that conversation not infrequently, but we have a very high bar around what we disclose, and that has built trust with the system.
What we hear from all the providers we work with is that actually they have a high level of trust in us as an organisation that we will not name individuals or organisations. That enables them to speak freely. There is still quite a culture of fearfulness in the NHS that we see in many of our investigations, which means that sometimes people are afraid that they are going to get in trouble with their line manager or their organisation. They think the regulators are going to come in and have a look. We often get told, “We tell you this, but we wouldn’t tell a regulatory body”—rightly or wrongly. We would love to get to a situation where the regulators are able to build that trust with the system, so that we can have that freedom, that speaking up culture, but we are not there at the moment.
We are in the position at the moment where if we launch an investigation, we get lots of organisations contacting us and saying, “Please come and see what’s happening here and really understand the issues.” We need to protect that trust with the organisations at all costs. Patients find it important as well. Patients we speak to say that they are worried about their ongoing treatment with a provider if people know that they have been talking about what has happened to them. It gives patients that level of protection and not just the staff members.
Q158 Danny Beales: Do you think it is possible to create those protections through changes or additional provisions in the Bill? Are there things you would like to see added that would reassure you that those issues could be protected?
Rosie Benneyworth: It needs very careful thought about the governance arrangements within the CQC, so that there is very much a separate identity and ring around HSSIB, so that there is a real clarity for people externally and internally about what is within the HSSIB investigatory function and what is within the regulatory function. At present, I am not sure the legislation gives that level of clarity.
Q159 Danny Beales: Do you have thoughts about how board oversight would work? Would having a single board responsible for both be an issue?
Rosie Benneyworth: It would actually put the CQC board at quite significant risk if it had information within its organisation that it was not allowed to be aware of. There are significant risks if there is only one board that oversees both functions. It is quite a conflict of interest for board members sitting on the CQC to be able to manage that.
Sir Jeremy Hunt: Could I just add a very specific example of where there is an ambiguity that is a concern here? If you are a doctor, say you are a surgeon, and something goes wrong with an operation and a patient dies—this is something that could be happening all over the NHS, but it happens to have happened under your responsibility—that could be something that HSSIB investigates. What you are able to do at the moment is say, “Well, look—I did this. I may have made a mistake here. I probably should’ve done that, and I didn’t do that, and I was a bit tired that morning. Maybe I should’ve gone to bed earlier, and I didn’t.” You now can talk about all that stuff with complete freedom, allowing HSSIB to say, “Well, this is the systemic way that we stop surgeons arriving at work tired, etc.”
The problem is if you admit to a regulator something that was actually a failure of a breach of regulation. Some things that the surgeon got wrong could have been a breach of regulations. There may be regulations that say, “You are not allowed to do this,” but they still did it. What hospitals often do—this is where there is a culture of fear—is they just fire the surgeon. They say, “The simple solution here is someone breached the regulations—let’s just fire them.”
The worry here is that the surgeon may decide, “It’s not safe to talk to HSSIB if it’s part of a regulator, and there is a risk that the regulator could find out. Then the hospital, my boss, gets rapped on the knuckles, and because of this regulatory failure, the hospital decides to fire me.” That is the thing that you would have to be incredibly careful to avoid if you were going to proceed with this merger.
Q160 Danny Beales: Do you think that the forthcoming duty of candour rules—the increased requirements on people to disclose and be candid with all parties—would mitigate that risk?
Sir Jeremy Hunt: I am really pleased you asked that question because there is a separate but very specific ambiguity on duty of candour, which I would love this Bill or the Hillsborough Bill to remove, but it is a very big problem at the moment. I introduced duty of candour following Mid Staffs, and again, its results have been mixed at best. The issue is very straightforward. If a mistake is made and a patient dies, with the law as it stands you would think that the hospital has a legal obligation under duty of candour, as in the 2014 Act, to tell the families the truth. However, right now, hospital lawyers tell the hospitals, “Do not say anything at all.”
Lawyers are advising hospitals to do something that is in conflict with their legal duty of candour. However, that is what is happening every single day in the NHS because the lawyers’ judgment is that it is in the hospital’s best interest to say nothing at all because there is going to be a court case further down the road, and they do not want to prejudice it. That needs to be changed. We need hospital lawyers to be advising trusts, “You must tell the truth,” when there has been a tragedy because that was the intention of the law, but it is not happening. If the Committee were able to look into this and make a recommendation as to how that could be resolved in this Bill, it would be transformational for patient safety and for the general candour that we all want to see.
Q161 Danny Beales: Finally, Professor Macrae, you touched upon it already, but you have talked about it being unconscionable for such an investigative body to sit within a regulator. Similarly to my question to Rosie previously, are there any ways that these concerns could be ameliorated through the Bill? Are there further changes in your mind that would mitigate the concerns?
Professor Macrae: I find it very hard to conceive of any ways that the merging of an independent system investigator into a regulator could be finessed in legislation, simply because they are fundamentally different entities that undertake fundamentally different roles. Perhaps just taking a step back from that, the health system has clearly been going through a very long journey around safety and safety improvement. The creation of an independent system-wide investigator was really one of the standout moves that has started to bring healthcare in line with other sectors that pose serious risks to the public.
It has a permanent independent body that can investigate and examine all actors across the system, including the CQC and the Department of Health and Social Care. That is a fundamentally critical separation of functions. The indications at present appear to be that the unit, or the investigation function—it is called slightly different things in different places at the moment—will also be directed by the reformed National Quality Board, which of course will be led by the leaders of the CQC, NHS England and/or DHSC in future.
You have a situation where essentially this is the loss of the independent systemic function of investigation or a huge confusion around it. It appears to unfortunately introduce a lot of complexities and problems when there is already a very simple solution of having a separate entity to do this, as is the case in other sectors.
Q162 Andrew George: Jeremy, you remember that I was around on the Health Select Committee at the time when you introduced the duty of candour. Maybe we will have a moment to talk again about that, but that was the precursor really leading to the investigation body of today. I was unconvinced by the duty of candour at the time, and I am very interested to hear your remarks on that.
In relation to the points already made, I just wonder, Rosie—you indicated it in an earlier answer—whether you feel that the climate is sufficient for frontline staff to feel that there is a genuine safe space, because you implied that people are not necessarily coming forward. Is that cultural, or a legal worry, or is there some other structural reason why you think it is not being used operationally as it could be?
Rosie Benneyworth: In terms of our legislation and safe space, it is being used operationally. My team are out working in providers every day and working with staff on the frontline. We receive a lot of feedback about the protection that brings and the ability of staff to talk freely to us. More generally, there are competing issues that we have highlighted in several of our reports. Sometimes the systemic issues—for example, how the coronial system, regulatory system and other parts of the system impact on providers—actually lead people to be more cautious about what they can say and how they say it across the system. We hear that regularly. For example, we have published a report around learning from deaths in mental health settings, and that was a very big theme in that report.
There is still a lot of work to do, in terms of building the patient safety culture that will deliver good care for patients around psychological safety and the ability for people to speak up about concerns without fear. However, there is no doubt that it certainly is a huge benefit to the work we do. It drives us to be able to really get to the understanding of the problems that exist, rather than the defensiveness that sometimes we encounter within the NHS.
Q163 Andrew George: The classic example is where staff on the frontline are worried about staffing levels. Often these are driven or advised by clinical governance standards, and where they are not mandated, it is down to staff on the frontline to blow the whistle on that. I have often found that the culture is that there is fear. If they speak up to anyone, they fear the consequences, both for their own career and their position within the organisation. Do you not accept that that is still an issue?
Rosie Benneyworth: Yes, it is still an issue. We have reported on that in a number of our investigations and made recommendations. For example, we recently did a report around temporary staff and looked at how temporary staff were able to speak up. We actually found significant levels of racism and discrimination, which were hampering temporary staff being able to speak up effectively, and we reported on that. We made a recommendation to the National Guardian’s Office, which has taken action as a result of that recommendation, to look at how we can improve the ability of temporary staff to raise concerns effectively.
Q164 Andrew George: That is the climate we have at the moment. In its evidence, the CQC expressed real concern about the operational legislative design to ensure that the investigation body retains its independence. It comes to the point that you have really raised, Jeremy, on the critical point of protective disclosure, and all the legal consequences of merging the two bodies, and the risks that that brings. Do you think there are ways, or do you think it will simply be left to the legislative process to provide a legally discreet way in which the investigation body can be protected, as it were, from the body to which it is going to be merged?
Rosie Benneyworth: There are learnings from some other bodies that have sat within CQC, such as Healthwatch England, which has had a separate board, its own quite tight ring around it, and its own identity. That is actually very important. Even emailing a member of staff with a CQC email address will generate a different conversation from if we have our own separate email address. Simple things such as that will make a difference. There is an opportunity to make sure that the governance arrangements with the CQC allow that independence, and to give protection to not only the investigatory function but the CQC board.
Q165 Andrew George: That also applies to the National Guardian’s Office within the organisation. Do you think either of those two examples could provide a safe template? Jeremy, you have been looking at this. Do you feel that is sufficient, or do you think that the merger is simply too much of a risk?
Sir Jeremy Hunt: If you ask the Government this, they will say, “We are going to legislate to make sure that we protect safe space within the CQC.” That will be their answer, but I have yet to see legislation that would actually solve the problems we have been talking about this morning. It is one thing to say it, but in reality, how are we going to properly reassure people who give evidence to the newly located HSSIB that that evidence really is not going to be passed on to the CQC, even though it is part of the same organisation? I have not seen any answer to that.
Q166 Andrew George: Rosie, is this something you have escalated in your concerns to Ministers? How have you articulated this?
Rosie Benneyworth: Yes, we have raised concerns to both our colleagues in the Department of Health and Social Care and our Ministers. We have written with our concerns. The concerns we have raised have been about independence. When we talk about independence, for us that is about being able to decide what we investigate. In particular, it is about making sure there is no facility for someone to stop us investigating something, because that is really important; we do not want a situation where there might be difficult things uncovered through our investigation that someone does not want us to find, and we are stopped from investigating something.
We also need the independence to be able to make recommendations to any part of the system, and not to be told not to make those recommendations. The second area we have raised is around protected disclosure, the safe space legislation, and the importance of that.
Q167 Andrew George: Do you think more can be done to ensure that those within the service on the frontline are aware of your existence, and are encouraged to use the facility in order to effectively whistleblow in a safe space?
Rosie Benneyworth: Yes, there is undoubtedly more that can be done there. We are a small team of about 50 people, and obviously it is an enormous service we are working with, and we cover the independent sector. Raising our visibility has been something we have been working very closely on, and we have increasing visibility. If you think, we have been set up as an arm’s length body since only October ’23, so we are quite new as a body really. We are working hard to raise our visibility and to share the learning. We make recommendations only to national organisations, but we have been doing a lot of work to try to share the learning with local teams, to make sure that patient safety changes can be made so that patients’ care gets safer immediately.
Professor Macrae: I would endorse and expand on those points. The safe space for staff, frontline clinicians, and everyone who works with patients is absolutely critical. HSSIB also provides a safe space for anyone in the system, including patients and families, but also people who work at the regulator, at the CQC, at national bodies. It gives them a space where they can actually point out where there may be inconsistencies, gaps, or deterioration in risk management issues across different parts of the system. HSSIB provides that space as well.
Sir Jeremy Hunt: I just wanted to make one final point about the Dash review, which is tangential to this. I agree with much of the Dash review: not the HSSIB bit, but the rest of it. As we mentioned earlier, the central issue is the observation in the Dash review that over 30 years, we have had 30 public inquiries with 1,400 recommendations. The biggest frustration for people at home, NHS users, is that we are world champions at doing reports that make recommendations, and world laggards at actually doing anything about those recommendations.
One of the things that this Bill should have is a legal requirement on the National Quality Board to consider all recommendations made by public inquiries. By the way, I would say also by Select Committees because how many of your recommendations, and indeed mine, get kicked into the long grass by Government saying, “We agree in principle,” or, “We will review this,” or, “Further work is necessary”? They meet their six-month deadline, but they do not really meet it. They have found a way to basically ignore any Select Committee recommendation.
Chair: We are well aware, yes.
Sir Jeremy Hunt: Sorry to rub it in, Chair, but I have been there, done that. It seems to me that an obvious requirement would be for the National Quality Board to have a legal obligation that within six months of any recommendation being made, the NHS must consider it and decide, yes or no, whether it is going to implement it, and if it is, by when and by whom it is going to be implemented. That is the thing that is really missing more than anything from the patient safety landscape: confidence that recommendations are actually going to be implemented.
Q168 Gregory Stafford: The panel has outlined very clearly the legal and practical challenges of moving HSSIB into the CQC, but let us be frank, the CQC is an absolute mess at the moment. It does not even have a substantive chair or CEO. It is in a right old mess. What risks does coming into an organisation that is in complete turmoil present HSSIB?
Rosie Benneyworth: First, from my team’s point of view, we have worked incredibly hard. HSSIB had a lot of cultural issues that were very well documented. We have worked incredibly hard to change those and deal with those cultural issues, and we have a highly performing team that is working very well. The worry is that going into an organisation where there are cultural issues will have an impact on the morale and culture within my team.
Secondly, probably more importantly, the public confidence about what we actually say needs to be considered. At the moment, we get a lot of contact from the public. People read our reports. We get a lot of positive feedback around our reports from the public, both those whom we work with and the wider public who are interested in patient safety. We need to make sure we hold on to that confidence from the public about what we do.
In terms of what we need to make sure that the CQC is fit for us to go there, we need a permanent chair and chief executive; we need to see improvements in the staff survey scores and culture; and we need that confidence that the public is in a good place where they are. If you do not mind, could I just mention some work that we are doing about a recommendations hub? Just to respond to Sir Jeremy because we are—
Q169 Gregory Stafford: Could I just finish the line of questioning on this point? The Health Bill’s impact assessment says, “DHSC will gain assurance that the CQC is fit and ready to take on HSSIB functions in advance of the point of transfer.” Do you have any confidence or understanding of what metrics the DHSC will be using to get its confidence that the CQC is ready to take HSSIB on?
Rosie Benneyworth: No. I have asked that question on a few occasions, and I have not had a response.
Q170 Gregory Stafford: Do any other panel members have any idea what metrics the DHSC is going to use to decide that the CQC is now ready?
Sir Jeremy Hunt: I will just make the point that the metric cannot just be the appointment of a chair and chief executive because the thing we need the CQC to do is to stop another Mid Staffs. What went wrong with Mid Staffs was not that there was a problem in a particular hospital because you are always going to have that; it was that it went on for four years before anyone did anything about it. The CQC is designed to call a spade a spade across the whole system. The worrying thing for the public is whether the CQC is able to do that at the moment. It really needs to focus on that core responsibility, in my judgment
Q171 Gregory Stafford: If I were to paraphrase your comments, at the moment, and certainly for the foreseeable future, the panel could not see any point where the CQC would be ready to take HSSIB on in a competent manner?
Sir Jeremy Hunt: It is several years away before it can make sure it is doing its day job to the standard that we all need.
Chair: I am afraid we are going to have to move on to the next panel. Thank you so much for your time.
Witnesses: Duncan Burton and Dr Penny Dash.
Q172 Chair: This is the third of our three panels; the previous ones have been wide-ranging, and as we put you last, thank you for staying in the room to listen to them; it is much appreciated. Just briefly, for those who might not have seen you before, who are you and what do you do?
Dr Dash: I am chair of NHS England.
Duncan Burton: I am chief nursing officer for England.
Q173 Gregory Stafford: We will pick up where we left off with the last panel. Dr Dash, on reflection, and having listened not only to the last panel but to pushback since your report was published, are you still confident that the recommendation to move the HSSIB into the CQC was right?
Dr Dash: I would like to start with what Jeremy just said. The current system is not as effective as it could be.
Q174 Gregory Stafford: Do you mean that the current system of the HSSIB is not as effective?
Dr Dash: No, it is the current system of our whole quality of care. As you heard, Carl Macrae’s report said that 127 bodies were operating in this space. I was asked to explicitly look at whether we had too many organisations working in this area and, if so, what was the impact of that? I was also asked whether the current system was the optimum way to improve quality of care for the 55 million people in England. My conclusion was no, partly because—as I set out in my report—there are more like 150 or 160 bodies, not 126 or 127. It is a very busy landscape.
Q175 Gregory Stafford: I do not have much time so I want to press you specifically on the merger of the HSSIB and the CQC. Do you still think that is the right recommendation?
Dr Dash: For the reasons articulated by Jeremy and Rosie—that otherwise we have different bodies looking at different things—yes, I do. We are not learning where there are problems in the system because it all sits in these very different bodies.
Q176 Gregory Stafford: You argued that the merger would clarify roles. What do you think was unclear about the role of the HSSIB that is now clarified by bringing it into the CQC?
Dr Dash: You have heard some different examples. The CQC is the regulator for quality of care. It looks first at the three dimensions of quality—outcomes, safety and experience—and secondly at whether an organisation is well-led. That is its responsibility as a regulator. Although you have not asked about it, I would also point out that it is the responsibility of the system to improve quality of care.
Q177 Gregory Stafford: That is interesting. So how do you respond to the point that was made in the last panel, which has been made previously, that quality and safety are not the same things?
Dr Dash: There are three dimensions of quality, which were set out very clearly in the work by Ara Darzi back in 2008; I go into that in detail in my report. First, there is safety, which is about very specific incidents. As Jeremy said, it is exactly the same as with airlines, it is about very specific things. There is a particular bolt that does not work. There is a particular bit of an anaesthetic machine that we think is not working and that we need to highlight. There is a particular problem in the way in which medications are being administered; it might be poor labelling, it might be poor checking of the patient’s number. These are all specific things that lead to problems; that is safety.
Effectiveness is about whether the system is working effectively; that is where quality of care sits. It is what determines the life expectancy of the population, and determines years lived in good health. It is what determines inequalities in health status, which is a really big area. It is all about, are we managing diabetes well? Are we managing heart disease well? Are we looking after children in the best way? Are we looking after older people in the best way?
Q178 Gregory Stafford: You seem to be agreeing with the statement that safety and quality are not the same things. Why therefore do you not accept the argument that was put in the last panel, that to have an essentially investigatory safety body outside the regulatory quality element is not the right way to go about this?
Dr Dash: It all needs to sit together. If you start to separate these things out, you get what has happened in the last 10 years.
Q179 Gregory Stafford: But worryingly—in my opinion— you say in your report, “Most investigations into safety incidents should continue to be managed within provider organisations and commissioners (ICBs) with support from regions where required.” How do you therefore respond to the point that was made in the last panel, that—using the airline example—the widget might not have been screwed into the right bit on aeroplane A, but it is on every single aeroplane around the country. If it is being dealt at a local or even at a regional level, unless you have an investigatory branch that sits nationally, you are not going to be able to make the change.
Dr Dash: That is a really good point; I will let Duncan come in on that as well. We have the National Quality Board. We also have the Quality Committee of NHS England, while NHS England still exists. The outputs of all those investigations—around 3,000 each year, led by local teams, with a lot of scrutiny—go to both the Quality Committee of NHS England and the National Quality Board. This has largely been put in place since 2019, so it postdates some of what Jeremy was talking about and was in response to it.
In any industry it is crucial that you start investigations at the frontline. That is where the clinical staff are. That is where the expertise and the knowledge is. As you say, it is exactly like a missing bolt on an airline; you would hope that if there was a missing bolt in a ventilatory machine, the local teams would spot it and do an investigation to ask, “What happened here?” They would then escalate that, bringing it up to the NHS England Quality Committee through our clinical colleagues. We have a medical director, and we have a lead for patient safety within NHS England. That then comes to the National Quality Board and to the Quality Committee of NHS England.
Q180 Gregory Stafford: The concern that I have, which was raised by the last panel, is that hope is doing a lot of lifting in that sentence. If you had an independent national investigatory body above that, we would be more likely to get there.
Moving on, the other argument we have heard today is around the safe space element, and the risk that the CQC is holding on to information that it cannot act upon. Do you have a plan to mitigate that risk, and what provisions are needed from the upcoming Health Bill in order to do that?
Dr Dash: That is for colleagues in the DHSC, and they are doing a lot of work on it. They have been assuring me and Ministers that they have been working very closely with the CQC to ensure that those protections can remain in place. But it is not my job to do that.
Q181 Gregory Stafford: Even though you are not implementing this yourself, obviously you have a stake in the game. If you felt there was no satisfactory legal mechanism for doing what you have just described, would you speak out and say to this Committee that this organisation is not ready to be brought into the CQC yet?
Dr Dash: Absolutely. I speak out about anything I see that I think is not right. At the moment, we have some significant challenges around quality of care that we need to address, and having this very busy landscape and multitude of recommendations is not helping us or the population of the country.
Duncan Burton: I would just add that although safe space is absolutely important, the cultures that we set within our organisations, within our wards, within our teams, of being able to speak up, of being able to do local investigations and learn from them, are equally important. We need to make sure that this culture is embedded at every single level to avoid needing to get to a safe space in the first place.
Q182 Gregory Stafford: Having worked in the NHS for seven years, I have zero confidence about any learning or sharing of best practice. It happens occasionally, when it is forced to happen; the organic sharing of information is for the birds, to be honest, and that really concerns me.
Dr Dash: We will have to have a separate conversation with you.
Q183 Gregory Stafford: We can, yes. Penny, I know you say it is not for you to implement this, but you must have had in mind some idea of how this was going to happen, otherwise you would not have recommended it. You did not go into detail about what the HSSIB operating as a discrete unit within the CQC would look like. First, how do you envisage the relationship working, and what organisational structures did you have in mind? Secondly, can I ask you very specifically about what you said in the report, that the HSSIB should collaborate with the DHSC through the NQB to agree the scope of any investigations it carries out. Are you concerned that the HSSIB would lose its independence and autonomy if it were being directed by the DHSC?
Dr Dash: On the first question, the CQC was very involved in my review, as was the HSSIB; I deliberately did this in a consensual and inclusionary way, with the DHSC, NHSE and chief execs, medical directors and nurse directors from across the country. Patient groups, National Voices, Healthwatch and so on were all involved. We got to a collective place, as per the review. At the time, the CQC believed that this would be a better model of care. The HSSIB expressed concerns, as Rosie has done today, but Rosie was involved; we worked through it at the time, and the view at the time was that this would get us to a better place.
In terms of your second question, I have a concern; I had it then and I have it now. The areas that the HSSIB is investigating are not the safety concerns that Jeremy articulated. They are looking much more at things such as the recent report on corridor care. None of us want corridor care. Many people have articulated that it is clearly not a good model of care; we know that. We know where the challenges to that sit; they are partly in our current model of primary care, which is suboptimal, does not work effectively with community services, and does not work effectively with social care services. That is a really important thing which is described very clearly in the 10 year plan.
We are doing a lot of work now on starting to develop neighbourhoods, which picks up on the questions you were asking earlier about ICBs. That is a really big area that we need to tackle. We cannot continue having frail older people admitted to hospital in the numbers that they are now. That is one of the biggest challenges in corridor care. It is not a specific issue; it is a much bigger challenge. Now, we know that on the board of NHS England; of course we do. We are looking at the data day in, day out. I would like to come on to data because again, there is an awful lot happening on data and data transparency. We have considerable teams of people right across the country working on this, trying to make it better. There are multiple reports from different think-tanks, different consulting companies, you name it, who have done work on corridor care. I am not quite sure why you would choose that—
Q184 Gregory Stafford: You have used an example to illustrate a point, but the counter argument is that the independence of the HSSIB, which I would argue, and the HSSIB would argue as well, is one of its many strengths, allows it to investigate what it wants. You might stop it investigating corridor care, which I agree with you is wider than its usual scope, but the danger is that in doing so you fetter it from talking about other things which we think it should investigate.
Dr Dash: The NQB is a collective whole. The NQB is not me and it is not Rosie. There is very deliberately a whole group of people on the NQB. The point is to say that all these people, looking at all the data—we have an awful lot of data about quality of care—looking at all the work done by previous investigations and so on, as well as input from Ministers and others, including here, all that taken together ought to allow us to say, “These are the really important things that we need to try to get at,” as well as things that will come up.
For example, we all talk about the number of medication errors. We know it is vast. We know that we have particular problems with medication being dispensed in care homes. We know that we have problems on some wards. That, for me, is a specific safety issue that it would be good to look at. I would look at things such as the surgical checklist. Are we still adhering to that as well as we should? It was brought in a long time ago, so why do we still have some untoward incidents in surgery? Why do we still have swabs left in? That is a real specific safety issue that the HSSIB could be looking at.
The benefit of the CQC is that it is out there looking at quality of care across the whole system day in, day out. Therefore, it has the ability to say, “We are spotting something that doesn’t seem to be working well, we’re looking at serious untoward incidents in every single hospital, we’re looking at what’s happening in GP practices, and we’re looking at what’s happening in care homes, and we think this is something that really needs detailed, deep investigation.” For me, that was the real power of bringing these two together. You could link that much more closely as well as link with what Duncan is seeing or I am seeing come to the board, and so on. Then we can say, “These are things we are concerned about, and we would like the HSSIB to go in really deep, use its expertise, and focus on them.”
Q185 Gregory Stafford: My experience of working in the Getting It Right First Time programme when it was not part of the centralised NHS, and the change that occurred—when it became part of the centralised NHS—regarding what we could and could not recommend once we were inside the system, is that there is a danger here. The system will tell, for very good reasons, what it wants to be investigated and what it can fund. That is my concern.
Finally, your first review identified problems with how the CQC was running; we all agree it is not running effectively at the moment. I will ask the same question I asked the previous panel; do you think that the CQC’s performance has improved significantly, and if not, then what needs to change at the CQC for you to have confidence that the HSSIB is ready to move in?
Dr Dash: Those are valid questions that we should all be asking. At the moment, there is no chief exec or substantive chair. No organisation is stable without a substantive chief exec and a substantive chair; those roles absolutely have to be in place. We also need to have a stable board. As you have heard my colleagues say, a lot of work is happening on this at the moment, particularly in the DHSC. We are working with the CQC, the HSSIB and with ministerial teams, and we are starting to see some green shoots of recovery. They have certainly done a lot of work on their data and IT systems, which, as my report said, was very much needed. They have started to get into a better place in terms of the assessment framework, which was not good, and was skewed towards looking at certain areas. They are now looking at that more holistically. I would want to see the chief exec, the chair, and the rest of the executive team in a stable position. I want them to get through agreeing what their assessment framework will look like. They also need to get their IT systems in place. I do not think it will take multiple years to achieve that; once they have a chief exec and chair, they ought to be able to do it within a year or so.
Gregory Stafford: Thank you. I apologise, Mr Burton, I have directed most of my questions to Dr Dash, but I am sure my colleagues will have many questions for you as this goes on.
Q186 Chair: Indeed we do. We now need to zoom out and look at the merger itself. In panel 1—you were here for the vast majority of it—we heard how Alliance and its chief of governance feel it is going. Penny, what is your view?
Dr Dash: I feel it is going pretty well. Some parts have gone better than I would have expected.
Q187 Chair: Such as what?
Dr Dash: Agreeing a structure was absolutely key. I have to say I was quite cynical, but I was pleasantly surprised that by last July we reached an agreed overall organisational structure, which was published, and we have been recruiting to that structure since then. One of the comments you heard in the first section was around needing someone to lead on commissioning development. We have made that appointment, but it has not been announced. It was only—
Chair: Okay, so that is a positive.
Dr Dash: Absolutely. We now have a joint director general for finance in place, which is a crucial role. We also have a director general for strategy and policy in place—that was quite painful, with multiple teams and so on—which again is crucial. So that feels extremely positive. We have Duncan, who has a role across both organisations. We have the new medical director for NHS England, who is about to start working closely with the chief medical officer. We are all working very closely with Catherine Frances in our role in prevention, with Sally in social care and so on. We are interviewing tomorrow for the new joint director of delivery, who will be responsible for delivering everything, and the list goes on. The fact is that we have that structure in place and we are appointing to that structure. Yes, it is over a year since this was announced and some corporates might hope to do it within six months, but in Government it takes a bit longer, as we all know. It is not bad, in fact I would say it is very good, and I am pleased with it.
Q188 Chair: Can you give us the other side? What is not going well? Please reassure us by being honest.
Dr Dash: I am very happy to be honest. Since July we have had that big picture structure in place, which is great, and we have been doing a lot of work recruiting into those posts. We wanted to wait for the directors general to be in place before starting detailed work on each of those functional areas. That was the right thing to do. We are thinking about what the teams within strategy and policy will look like. The really big question is where we put all the data and analytics; it would make sense for them to go with strategy and policy, then whether you are looking at equality strategy or a strategy for children’s care, whatever it might be, you can base that on really good data and analytics. That next level down—deciding what we need in each of these teams—will determine the numbers.
I am chairing the transformation board with Alan Milburn, and we do not want to have a top-down approach of cutting 50%. That is not a rational, logical way to do this. In each of these functional areas, with the director general appointed, we are now working bottom-up. What are all the functions that we need to do? What are the tasks that we need to do in each of these different directorates, and how many people do we need to do them? For me, that is the crucial work. I would have liked to have been able to get it done more quickly, because that gives our teams more certainty.
Q189 Chair: Obviously, this all flows down to the ICBs, which have already started making cuts to that level. Over and over again, we hear that many good people are leaving. The Institute for Government has told us that the likelihood is that we are going to end up—as we did with Lansley and a great big organisation that we could see from space—with a situation where we lose good people and they go off somewhere else while this sorts itself out. Maybe they will come back into the system, maybe they will not. Do you recognise that risk, and if so, what are you doing about it?
Dr Dash: I recognise that risk, 100%. It is a risk in any organisation anywhere in the world that goes through a merger or through a change. Good people often go; they decide to be the first to jump. There is a lot of work happening to try to tackle that. Sam Jones and Jim Mackey, the two chief execs, are spending a lot of time with their colleagues, as indeed are the colleagues we are appointing. I am sure Duncan can talk a lot about the work he is doing. They are spending a lot of time with their teams, as are the new people coming in, looking to talk to people about the future direction and so on. There is a lot happening. We are having similar sorts of conversations with the ICBs; I spend a lot of time with Sarah and I meet with the ICB chairs on a regular basis. I have been pleasantly surprised by how many people are choosing to stay; I promise you I am not just saying that for today.
Q190 Chair: I do not want to insinuate in any way that the people who remain are not good; they are, but we know that a large number are leaving.
Dr Dash: They are really good and they are doing some fantastic work. People on the ground are working really hard. You will have heard the announcement last week that we are developing a mental health strategy. We have been doing a lot of work in the run-up to that, looking at the current state of play in mental health services. We have fantastic teams of people working on that, doing really good analysis, thinking, working with the system and so on. Very practically, here today, I do not feel that we are losing all the great people. I feel more confident about the future.
Q191 Chair: Just to make sure that we are clear about it, they are making redundancies, it is happening, and the headcount is going down.
Dr Dash: Yes.
Q192 Chair: The money is there, it has been allocated, and it is not going to be a problem. That is all fine.
Dr Dash: Yes.
Q193 Chair: But we have also heard about some of the opportunity costs. Now, I am sure the argument—I will make it in advance so that you do not have to—will be that, in the long run, this is a 10 year plan and you are pointing towards the future. I will ask Duncan this first: do you accept that in the shorter term, there is going to be turmoil, and that it will prevent some things from happening and being delivered on the frontline? Do you accept that is true?
Duncan Burton: First, we have to recognise that going through a change is difficult for people. While it is progressing well, clearly there are difficulties for people who are worried about their roles, their jobs, and so on in the future. But at the same time, as Penny said, people are absolutely continuing to deliver and to support work on the frontline. With any disruption, of course, there will be periods where that will be difficult, but—
Q194 Chair: Listen—what I am hearing is that things are snarled up, and decisions are taking longer than they need to. No one is sure what they are able to do; they do not know if the person they are going to with a big long-term project is still going to be there. I am just reflecting what people in ICBs and elsewhere in the system are saying. There is a lot of optimism, particularly at the top of ICBs, but when I am talking to the people delivering services—particularly in areas such as neighbourhood health, which we have been looking at recently—things do not feel as if they are moving. In fact, they feel clogged; that is the word I would use. Do you accept that this is happening? I feel you are sugar-coating the issue.
Duncan Burton: I am not sugar-coating it at all. There are variations in this; now that we have teams across both the Department of Health and NHS England, we are seeing efficiencies. I have two women’s health teams who are now working as one. I have two maternity teams now working as one. That enables us to take the best from the civil service, the best from NHS England, and make sure that we are working collectively to streamline things up front for the benefit of people out in the system, and what that does is—
Q195 Chair: People feel that you have put the cart before the horse. You created the structure. You hired the directors. The numbers should have come from that, but as we heard very clearly in panel 1, that is not what has happened. They heard 50% and they started cutting, but it was not clear who should be cut, why, and to what end. We now have to unpick that. We are further hearing, with strategic authorities not yet decided, that we could yet have more disruption in a couple of years’ time, if and when—underline “if”— that gets sorted. It appears that at no point did someone say, “Hold on, wait. Let’s really think this through.” What you have said, Penny, makes a lot of sense. Decide your direction, decide your directors, decide your policy, and then let that flow through the system. It might take slightly longer, but it is going to be done once, and it is going to be done well. Did those conversations happen?
Dr Dash: That is what I have been doing. That is what we have been doing.
Q196 Chair: But it has not happened.
Duncan Burton: It definitely has. From an ICB perspective, we have worked with ICB leaders. I have worked with chief nurses, for example, in ICBs. We have worked with the chief executives; this is where the model ICB framework came from, and the subsequent guidance around what we should do with specific areas within ICBs. That was done jointly to help frame how we should approach the reductions, which would be 50% across the board. It is absolutely reasonable to say that we have done that step back and worked with people out in the system to work that through.
Q197 Chair: I am hearing two different stories. To start with, Penny, you talked about how you recently recruited the directors and that you are waiting until they are set up. I think I can quote you as saying, in the future tense, “Then the numbers will come.”
Dr Dash: Yes, that is right.
Q198 Chair: However, at the same time, ICBs have already been cutting without any of that direction. Can you reconcile this for me?
Dr Dash: We are talking about two different things.
Q199 Chair: But the two are linked, are they not?
Dr Dash: First, let us take the DHSC and the NHSE. Across the DHSC and the NHSE, we agreed the high level structure last July and put that out. We have been recruiting people to it and started work on the bottom-up modelling. As we have the new directors in place, they are doing that work, and my understanding is that in a few weeks’ time a paper will be coming to the transformation oversight board, or whatever we call it, giving more detail. In terms of the NHSE and the DHSC, because there was a lot of duplication as Duncan has just said, there was this sense that 50% was the right number to aspire to. The detailed work will get us to the point of determining what the numbers could and should look like. I would suggest that most organisations—I have done a lot of merger work in other sectors—would go through a similar process. They would start with a high level figure, whether that is 30%, 40%, or 60%, and then do that detailed bottom-up work to achieve it. So we are going through a good, sensible, robust process.
Secondly, we looked in a collective way at the functions we needed the ICBs to do as strategic commissioners. Sarah has been very articulate in describing that process. I would challenge the comments the gentleman from the Institute for Government made about size. If one looks at the functions strategic commissioners need to carry out, scale is required. As Ben said, he and I worked together in North West London covering a population of 2.5 million; that size of population is needed to build the skills and capabilities to be a robust strategic commissioner and improve population health. You also need teams working at the local level, but you can do that within the organisational entity.
I have worked very closely with Sarah and with colleagues from the NHS Confederation—now Alliance—to develop the model ICB. As she said, we described all the different functions that we expect an ICB to perform so that we could consider the scale it would require to enact those functions well. That work was completed quickly, and we published the model ICB document in May. So the ICBs have been further ahead than the centre.
Q200 Chair: I can see that the work has been done. All I am trying to say is that the two parts of the system—at the centre and at ICB level—need to be able to work seamlessly together.
Dr Dash: Of course they do.
Chair: But people are telling me that perhaps it is not working well yet. You mentioned Ben Coleman; I am going to him now.
Q201 Ben Coleman: We are following up on many topics from the earlier sessions, but I would like to focus on the plan for removing local authorities from ICBs. I am concerned that it does not seem to take into account a number of things. Penny, we know each other from the North West London ICB, where the eight local authorities had a fairly robust piece of work in getting proper representation on the ICB; it ended up with three local authorities for, I think, the largest ICB in the country, which was appropriate.
I am concerned about the fact that the plan for removing local authorities from ICBs does not take into account a number of things. Perhaps I could start with London as an example. The Mayor is not responsible for health and social care; the individual local authorities are. My first question is, do you intend to merge all the four ICBs for London and have one representative—the Mayor—or will each of the four ICBs in London have the Mayor representing the population, rather than the local authorities?
Dr Dash: I was here when you were asking these questions earlier, and they are valid questions to ask. As part of the 10 year plan working group there was a working group that included both colleagues from the centre and people from ICBs locally, local authorities and so on, looking at this particular issue. The thinking was more about trying to align the future direction of local government, and in that sense the move in local government is towards combined mayoral authorities.
Ben Coleman: Forgive me; I am talking about London.
Dr Dash: I know that, Ben; I am just trying to explain where it came from. Nationally there was this sense that we are moving towards combined mayoral authorities, and for all the reasons that people would recognise, there was a desire to align the ICB structures with the mayoral authorities more closely across the country. Greater Manchester is one example, South Yorkshire is another where a lot of work is happening in that space and people are looking at aligning more closely. A year ago there were already good examples in different parts of the country where they were working and the sense was that it was more effectively working in the mayoral authorities. That was where it came from.
Q202 Ben Coleman: I appreciate your explanation, but we are short of time. I asked you if the Mayor is going to be in each of the four ICBs, or are the ICBs going to be merged into one?
Dr Dash: None of that has to do with me, and it is not my decision to make for London. We were very clear that people would make decisions locally on what is the right structure for them. We start with the principle of aligning with the mayoral authority because there was a strong sense that it was working most effectively.
Q203 Ben Coleman: Is this an appropriate model for areas outside London, where there is either no strategic authority, or where, unlike for instance Manchester, the Mayor does not have a budget and devolved powers?
Dr Dash: This was not about the Mayor having such powers; there was not a view that this was Manchester or South Yorkshire.
Q204 Ben Coleman: Forgive me; I will explain. When I say the Mayor has the powers, I am talking about responsibilities. The local authorities have responsibility for health and social care; the Mayor does not. In London, the local authorities have some public health responsibility, but it is tangential. Why give this responsibility to someone who does not have the remit for the job, and take it away from those that do and were democratically elected?
Dr Dash: That is because in places such as South Yorkshire where they were already doing this, they already had the mayor part of the ICB.
Q205 Ben Coleman: As I said at the beginning, I am talking about London.
Dr Dash: Yes, but I cannot comment specifically on how this might have been approached in London.
Q206 Ben Coleman: Forgive me, but it is the largest single part of the country. We have 32 local authorities; they have representation of around three to two to one on the ICBs at the moment. They all have a democratically elected responsibility for delivering health and social care. The Mayor does not. Your collective plan for the future of the NHS will sweep away the local authorities and in London, give those responsibilities to the Mayor. Does that seem to make sense to you?
Dr Dash: The Mayor is able, for reasons of having responsibility for a number of functions, including health functions, as you know—
Q207 Ben Coleman: The Mayor has a small amount of responsibility for public health. I am talking about social care.
Dr Dash: Social care is picked up separately through neighbourhood working. We were very clear about ICBs jointly commissioning with local authorities. This is about the positions of those on the board; it is not about jointly commissioning.
Q208 Chair: Are the two not linked?
Dr Dash: Not necessarily, no.
Q209 Chair: Do you think that the board does not help the strategic commissioners make their decisions?
Dr Dash: Yes, it does, but the ICB board is only responsible for commissioning healthcare services. It is not responsible for commissioning social care; that is the responsibility of the local authorities.
Q210 Ben Coleman: The ICB board discusses at great length social care, the Better Care Fund, and many other things that we have mentioned.
Dr Dash: That is all at the health and wellbeing board level; there is a lot in the 10 year plan about the health and wellbeing boards working together to jointly look at neighbourhoods.
Q211 Ben Coleman: When we needed to challenge what was being done to the Better Care Fund, it was local authorities that were able to challenge that. At the ICB board, we will lose that. Many people in the NHS are frightened of challenging at board level, so you need something such as a local authority there. For example, when we were looking at palliative care in North West London—what was being proposed was not appropriate and residents were worried about it—I and my colleagues were able to raise that and have changes made. That is a fact, and it is there in the record.
Dr Dash: But a lot of that is more through the overview and scrutiny committees.
Q212 Ben Coleman: No, not at all, because they do not have the power on the board that the local authority had. It may have been irritating at the time for the NHS, but it was there. When the GPs were worried that the reorganisation of North West London GPs had not been carried out appropriately, I and my colleagues were able to raise that and have changes made, and the outcome for residents was better as a result. That will all go. You will have one mayor who has no responsibility—
Dr Dash: I am afraid that we may have to agree to disagree.
Q213 Ben Coleman: I do not understand how your system will work. The last of our two witnesses said that there is no indication that any preparation or any particular thought has been given to how the London Mayor will take on this responsibility on behalf of 32 local authorities. Can you give us an indication?
Dr Dash: You need to bring in the local team. We have now put in place a regional chair for London—
Q214 Ben Coleman: Is this a question you are asking them?
Dr Dash: Yes.
Q215 Ben Coleman: What are they saying to you?
Dr Dash: We are saying that the regional chair for the NHS needs to work closely with the Mayor of London, needs to work closely with the regional director, needs to work with the ICBs, and needs to work with the local authorities. They are doing that work locally.
Chair: You have one more minute.
Q216 Ben Coleman: The question is, have you discussed with the London Mayor, and have the Government discussed with the London Mayor and the local authorities, what will need to happen for the Mayor to be able to represent, in an expert way, the local authorities once they are removed from—
Dr Dash: I am not the Government. I am the chair of NHS England.
Q217 Ben Coleman: So are you aware of any such discussions taking place?
Dr Dash: I do not know about that.
Q218 Ben Coleman: Do you think they should take place to make it work effectively?
Dr Dash: Absolutely. People are having discussions locally. There is a regional chair for London, there is a regional director for London, both on the NHS side, and they are working—
Q219 Ben Coleman: Are the discussions being had with the local authorities as well?
Dr Dash: You will have to ask the London leadership about that.
Q220 Ben Coleman: Can I ask you to do us a favour; could you ask the question and get back to the Committee on that, please?
Dr Dash: Definitely. We can reach out to them.
Q221 Ben Coleman: If you could clarify the questions that I have been asking about London, that would be great. There is just one other thing I would like to ask you about, which is highly specialised commissioning. The team at the moment sits in NHS England; I have seen that highly specialised commissioning will be transferred into the Department of Health and Social Care. Will there be a specific team in the Department of Health and Social Care responsible for highly specialised commissioning, or will it be diffused?
Dr Dash: That is a good question. Only a couple of days ago it was agreed that quite a lot of highly specialised commissioning is going to the ICBs.
Q222 Ben Coleman: It says in the paper that it is going to the Department of Health and Social Care.
Dr Dash: Some of it is going to the ICBs. There are a small number of highly specialised conditions, and we will need to work through the detail. The structure that was agreed last summer sets out a strategy function, a finance function, and so on. In terms of the cross-cutting, whether you are talking about mental health services, cardiovascular diseases, or specialist services, we want those to be cross-functional. So we want them to have a strategic element, a finance element, and a delivery element.
Q223 Ben Coleman: Will there be a team specifically responsible for highly specialised commissioning, as there is now in NHS England?
Dr Dash: Not as there is now; we are changing because we are going through the integration.
Q224 Ben Coleman: So it might be diffused?
Dr Dash: It may look different, but that work has not taken place yet so I cannot comment on what it will look like.
Q225 Ben Coleman: Could you perhaps write to the Committee with an update on where that stands?
Dr Dash: I will also get them to do that.
Q226 Jen Craft: I will rejig my questions a wee bit based on what Ben was asking because there is a nice segue in there. I understand there is the structure of setting up OPICs—the acronym is continually escaping me—which are regional levels of commissioning bodies. Are you able to clearly set out which services are expected to be commissioned through? I think there is a plan to have seven OPICs set up, rather than individual ICBs.
Dr Dash: What is that about? I do not know what that is.
Jen Craft: Can someone shout out what the acronym OPIC stands for?
Ben Coleman: It is organisational. There are too many acronyms.
Q227 Jen Craft: It stands for Office for pan-ICB commissioning. The plan, I believe, is to set up seven offices for pan-ICB commissioning, and they will be established for services set to transfer to ICBs; so this is looking towards bigger regional bodies. Apparently, by the end of April 2026, one ICB has been identified in each region to host an OPIC. Are you able to clearly set out which services are expected to be commissioned through these OPICs, and which ones are going to be retained by individual ICBs?
Duncan Burton: I would suggest we write to the Committee because I certainly do not have that level of detail with me.
Q228 Jen Craft: Thank you. That is slightly concerning as I believe they are supposed to have been set up last month, but it would be good to have that level of detail so that we can see where they sit within the system. Looking at the right skill set for strategic commissioning, how are ICBs being practically supported to make sure that they have the right skillset for this going forward?
Dr Dash: I mentioned that I have been meeting with the chairs on a regular basis. As part of that, we have been doing some commissioning development support because it is really important that the chairs understand what this is all about. I have brought in a number of different speakers who have done a lot of work on strategic commissioning internationally and in this country; they have been sharing some principles. That is one piece. The model ICB work that we did fairly quickly last May described the core capabilities required for effective strategic commissioning. We are just about to launch a significant strategic commissioning development programme for all ICBs and for colleagues working in ICBs at NHS Alliance on 9 June; I will be part of that launch. That programme will include everything from helping them to build capabilities around population and health analytics through to what good strategy looks like, what good payment reform looks like, and how we should use financial incentives. All of that is intended to improve health and improve quality of care.
Q229 Jen Craft: I note that a recent report from the Health Foundation concluded that previous attempts to change how commissioning is carried out struggled to have an impact on patient care or outcomes; it was quite scathing around proposals in this regard. There is little in the 10 year health plan to suggest that things will be different this time. How will it be different?
Dr Dash: Again, I would challenge what the previous speaker was saying about size. I have already made that challenge, so I am just reinforcing it. Going back to 2010, the PCTs were a good example of developing commissioning. There are good examples of improvements in quality of care that were delivered through PCTs, and there was a lot of focus globally on what they were doing; a lot of countries looked at this and took on some of the expertise from that time. So I do not think it is fully correct to say that this has been a failure since its outset in around 1990 when we first started the principles of commissioning. There were some negatives from GP fund holding, but there were also some real positives. What did not work well—with some exceptions—were the CCGs. They were too small. They did not have the skills and the capabilities, and we had a bit of a lost 10 years.
What are we doing now? First, we are moving towards being very clear that ICBs are strategic commissioners, as we have all been talking about. Secondly, we have been developing that framework since last May and doing the development programme that we are talking about. We have to do a lot to develop the tools to help strategic commissioning. We are in a very different place now in 2026 than we were in 1996. We have fantastic analytical tools, a lot more knowledge, and more ability to think through how to commission for high quality healthcare. All that work will put commissioning in a much stronger stead. We also have a new director of commissioning development, who will hopefully start soon.
One of the key things to think through—we had a board workshop on this yesterday—is how effective commissioning function and expertise works with the provider side. That is the crucial place which you heard a bit about earlier. How do we get the two sides to work effectively together while still having a little grit in there, because you need the commissioners to be focused on population health. They are there for the 55 million people. They are not there necessarily for specific individual interactions. They are there to take a population focus towards improving health.
Q230 Jen Craft: I get that they are meant to have a slightly wider view of what occurs. One reason that has been cited as to why commissioning changes in the past have not had a huge impact is the power imbalance between hospitals and commissioners. We can probably see this as being the antithesis of the concept of, “From hospital to community”. What will be different this time? How do you address that power imbalance?
Dr Dash: Exactly; that is a key thing, and you as a group keep coming back to it. First, we need strong commissioning, being very clear where we are going to commission neighbourhood health services in this way and putting the money behind that. You can see some really good examples of that happening; despite the difficult year that the ICBs have had, there are still some fantastic examples of change. I am very happy to share those.
Secondly, the provider side also needs to play a key role. The principle of looking towards more integrated providers—in other words, hospitals working much more closely with community services and GP services, neighbourhood services, and so on—was set out in the 10 year plan. We have been doing a lot of work on that; it was our board workshop yesterday. We have been looking at international examples of that working and how it has evolved internationally, including how you get financial incentives and management structures in the right place, and what you can do practically on the ground to support those. We are helped by having Jim Mackey as chief exec; he did a lot of that work in Northumbria. Its acute trust runs primary care for some parts of the population, and we have other examples of that around the country. We also have fantastic examples of GP practices working together at scale and increasingly integrating with frailty services that are working across primary care and community care.
Q231 Jen Craft: I am just going to stop you there. You mentioned frailty services; that leads into a concern that Ben picked up on, that there still seems to be a separation between social care and health. In our work as a Committee, it comes up time and again that you cannot do what you want to do on health without doing what you want to do on social care. When we are looking at changing the ICBs it seems that, in a reformed NHS, there will still be that separation. Is it fair to say that this needs to change—that there needs to be a greater integration between social care and health than is currently planned?
Dr Dash: Yes, that is the case for particular groups such as older frail people.
Q232 Jen Craft: I will briefly touch on the wider integration of services. I have a keen interest in SEND reform; one of the big components currently missing is the health component to making sure that any changes work. There have been a number of calls from several organisations for ICBs to have a statutory obligation as commissioners to make sure that they commission the right paediatric services, particularly from paediatric allied healthcare professionals, to make sure that they can support this current system. Do the current proposed structural changes to the NHS support wider Government agendas towards improving outcomes, particularly for young people? If they do not, what needs to change to make that happen?
Duncan Burton: The ICBs continue to be responsible for SEND, and responsible for making sure we are commissioning children’s services in the right way. As Penny has said, we have to improve that commissioning; that applies equally for children and young people. We also have the modern service frameworks; the one for children and young people is a great opportunity to get colleagues across health, social care, and education working collectively on the needs of children and young people.
Q233 Jen Craft: Should there be a statutory obligation on ICBs to meet the needs of children that are either articulated through an EHCP system and an individual support plan system or through the new reformed SEND system?
Dr Dash: They already have a statutory obligation. ICBs are responsible for the whole population, all 55 million people.
Q234 Jen Craft: We are looking specifically at meeting needs. Currently, local authorities have an obligation to meet the needs set out in an EHCP; under the reformed system, they will be looking at an obligation on them to meet that. However, the services they are meant to provide are often not in their gift. They are in the gift of the local ICB or healthcare providers. There is an argument to put that obligation—
Dr Dash: I would strongly caution against any statutory obligation for any particular population group. The ICBs are responsible for the whole population; if you start saying it is this for that, it will be never ending. You will have different groups saying, “Where are our statutory rights?” The ICB is there for everybody.
Q235 Jen Craft: Then how do you get them around the table? We are currently hearing—this is feedback that I receive time and again—that health authorities are absent from the conversation around providing services for disabled children who need to be supported by the SEND system. How do you get them to the table if it is not via a statutory obligation?
Duncan Burton: Again, this goes back to the local leadership working collectively with other services. If you have examples of where that is not happening, I am very happy to pick those up.
Jen Craft: Where it is not happening, it is a whole-system issue.
Q236 Ben Coleman: Do you recognise that it is a whole-system issue?
Jen Craft: It is not sporadic. It is the case not just in my constituency, but across the system, that health is absent from these conversations.
Dr Dash: We have the modern service framework work, which has already started. Again, we will put you in touch with the people leading on that. If you have lots of examples—it sounds as if you do—please share those with the work team so that then we can look at this holistically and work out what is happening.
Chair: So that we are clear, and just to be helpful, we did a one-off session called “The Missing H in EHCPs” where we looked at the system-wide issues. You will know that the Education Committee made a recommendation to put it on a statutory footing, and we endorsed that on the basis of our view that it is a system-wide issue. There is a specific issue, particularly around tribunals. If you haven’t seen that work, I urge you to look at it. This is not a place-by-place issue; it is a huge issue across the country, and I am rather shocked that it is not obvious in this conversation. I am sorry if I have mischaracterised this, but I am really shocked.
Q237 Jen Craft: This goes back to the question around strategic commissioning and what that looks like when you look at a wider commissioning framework. It is not one of the huge issues; time and again in our work as a Committee we see this siloed way of working, which does not deliver health change or wider changes for the population as a whole. It is particularly acute when you look at the paediatric SEND link-up, where health is completely missing. As the Chair has said, it is a systematic issue.
My question is, when you look at the new model of ICBs as strategic commissioners, are you confident that they will have the skillset, the knowledge and the impetus to look at the wider social changes that need to be met beyond the health service and that they will be able to play their role in meeting them, or does there need to be something else? We are looking at an NHS Bill going forward. Does there need to be something in that to put the onus on them?
Duncan Burton: I would go back to what Penny has already said about how we develop our commissioners, the work around how we look at population health analytics, and how we make sure that we have the right people with the right skillset to do commissioning well. It is a really important part of that and, as Penny said, we must make sure we are feeding that view into the work that we will be launching at NHS Alliance.
Dr Dash: We will take your report and we will make sure that it is fed into this fundamental piece of work, which is essentially developing the whole future of children’s health services, recognising—as we all recognise—that the health service needs to work very closely with other aspects of Government and society.
Q238 Jen Craft: Finally, I note that only about 3% of NHS England staff feel that change is managed well. That is probably something you can see throughout the organisation. But on top of this, employees at the DHSC reported a 13 percentage point reduction in their view of how change has been managed since this process began. Penny, do you take responsibility for this drop in morale? Do you feel you should make an apology for how the whole process has been handled?
Dr Dash: This has definitely come up at our oversight board; I am looking at that data and asking for updates all the time. In the same way that you are asking, I have actively asked Jim and Sam as the two chief execs what they are doing about that, and how they are seeking to address it. They are doing work on that through their teams; as a member of the team, Duncan is probably better placed to talk about what he is doing specifically.
Duncan Burton: I absolutely recognise that issue. As I said earlier, change impacts people when they are going through it. We are doing a lot of work to make sure that we are communicating with colleagues and that they are part of the design process that we are going through in terms of shaping the new organisation going forward. At the same time we are doing work to help bring teams together. I have work going on to help facilitate some of my teams, for example the children’s team, in coming together.
Q239 Jen Craft: How are you specifically addressing the concerns that the workforce are raising? There is a pay discrepancy between the DHSC and the NHSE. What measures are you taking to address that? You say that you have ongoing communication about how change is going, but the drop in morale probably reflects that such communication is not as effective as it should be.
Duncan Burton: Every director general, everybody within the Department, is working with their team. Within my team, the nursing directorate, we have a very clear focus on what those surveys—both from the Department of Health and NHS England—have told us about the areas we are working on. We are doing that collectively with staff so that we focus on those key areas. We have programmes of work to make sure that we improve the way in which we are working in the Department of Health and within NHS England, and streamline areas that cause frustration for people. That is one of the things that we have heard back clearly from individuals. There are still things to work through such as pay differentials. That is certainly something that is part of—
Q240 Jen Craft: It is not a minor issue for most people.
Duncan Burton: No, it is not minor; it is one of those key areas that we are focusing on, as well as some comments that have already been made about how we retain talent in the organisation and develop people for the new Department.
Q241 Chair: Penny, I am going to give you another opportunity to answer Jen’s question directly, if that is possible. I do not know if you meant to or not, but it felt like you were dodging it slightly. There were two parts. First, do you accept responsibility for the drop in morale?
Dr Dash: That is an interesting one; do you mean as chair?
Chair: Yes.
Dr Dash: I do not have a formal role in the DHSC.
Q242 Chair: So you do not accept the DHSC part?
Dr Dash: I would like to feel that I am working to support the two parts coming together. But technically, I do not have responsibility there. My responsibility is in NHS England, so let me focus on that. I do at least two things in this regard: I co-chair the oversight group for the integration jointly with Alan Milburn, and as I said before, every single month, we bring up the issue of what we are doing on communications.
Q243 Chair: You made the bringing up and noticing really clear, but you are the chair.
Dr Dash: At that level it is a joint responsibility but there is not the equivalent of a chair in the DHSC and it is very sensitive if you talk about that. So I am only chair of NHS England and we bring it up at that level. Within NHS England, we have a people committee which meets every two months. It is chaired by Louise Ansari, but I sit on it and we have parallel conversations there. We absolutely feel jointly responsible for it in that forum. But it is a joint responsibility because, at the end of the day, there is a limit to what I can do as chair or Louise can do as a non-executive director. We need our executive colleagues to do it.
Q244 Chair: Of course, as a board you are not responsible for the operational decisions that then implement the increase in morale, but the buck is meant to stop with the chair.
Dr Dash: Absolutely, yes.
Q245 Chair: Therefore, do you offer an apology—jointly or otherwise—for the part that you might have played in that drop in morale?
Dr Dash: On 1 April 2025, the first day that I officially started at NHS England, I went up to Leeds and I did an open meeting, which a lot of people joined—we had a video camera for people who could not be there—and I said, “I am sorry.”
Chair: You have done it before and thank you for doing it again. That is much appreciated, I am sure, by the people watching.
Q246 Danny Beales: You have made a robust and forceful defence of the decisions made over the last two years about, as you said earlier, the broader NHS England changes around both scale and efficiency. Those are clearly good arguments to make about the decisions taken. But do you accept that a lot of the challenges that are being put forward about these organisational changes—we have heard from patients, the public, clinicians, ICBs themselves, people in the system, and members of the Committee—are not necessarily saying that those things are not good in themselves but are raising the concern that there may be untoward consequences?
There may be opportunities not being taken around better accountability in the system and patient involvement, particularly locally, with patient involvement being sucked into the Department for Health. There were huge missed opportunities around the integration of public health and social care under the previous reconfigurations. Are you listening to those concerns? From my perspective today, I have not heard anything reflecting those issues and the absence of them in the current reform architecture and the NHS Bill as drafted. If you are listening, what are you doing to respond to those concerns?
Dr Dash: Let me take three areas; they are distinct, even though there are overlaps. First, on accountability, we are doing a lot of work trying to improve accountability in the system. At the chief exec level, Jim is meeting with all the chief execs on a regular basis. One really positive thing he is doing is to bring GP leaders into that group; he is including some GP leaders of big primary care entities within his chief exec forum. He is very clear that that is where the accountability sits, and he is reinforcing that consistently through things such as the new financial model that we are using and through quality metrics. At the chair level, I am absolutely replicating that. I spend a lot of time with chairs; I was at a new aspiring chairs forum yesterday. We have our regional chairs in place and I meet with the chair group on a regular basis.
We are also doing detailed work now with the new set of advanced foundation trusts that are coming through. In all those we are really clear, again, that accountability sits with them for improving operational performance—there is a massive way to go on that—and for all aspects of quality of care. That means patient experience as much as safety or clinical effectiveness. We have to see boards get much deeper into that and take more local ownership and understanding of that. So there is absolutely that sense of accountability. I am very happy to talk more about this, but we probably do not have the time. In terms of closer working with public health, I think that is one of our most significant challenges, as well as the social care issue that we spoke about earlier.
Q247 Danny Beales: A lot of this is just, “Could, should, hopefully.”
Dr Dash: Well, I do not have—
Danny Beales: I suppose the concern everyone has is that those things are absent in the system architecture, in the actual decisions being made, the structures being set up and the legislation coming forward.
Dr Dash: On accountability, they are not. We are clear in the 10 year plan that accountability increasingly sits with local organisations. It has to sit with them. We are doing that through the advanced foundation trusts—
Q248 Danny Beales: There is a difference between responsibility and accountability.
Dr Dash: Both responsibility and accountability have to sit with them. We are really clear on that. The board of a trust is responsible and accountable for the quality of care and the financial and operational performance within its own entity. I do not have the ability to put public health into the NHS. What we absolutely need to do—
Q249 Chair: The point that Danny is making is that this Bill might have been an opportunity to do that.
Dr Dash: That is way beyond my pay grade. But we have to work more closely.
Q250 Danny Beales: There is a suggestion at the moment that the forums—where those discussions were had—have been weakened, not strengthened. To be frank, we are now relying on the health and wellbeing boards, which most people would agree have largely been a failure.
Dr Dash: I would say that we are doing our utmost. I happen to be a public health consultant myself. We have lost a lot in the last 10 years by not having clear directors of public health sitting in influential positions, able to be a part of strategic commissioning, and we need to get back to that. That is where a lot of expertise sits, and we are spending—
Q251 Danny Beales: It would be good if the Bill did that.
Dr Dash: It is beyond my pay grade.
Q252 Ben Coleman: But it is an issue because we are looking at things that we might need to improve in the Bill. Public health is an issue where we had a huge challenge in the ICB, where the role of director of public health was downgraded. It is only when local authorities choose to bring them in and bang them forward that they achieve what you are trying to achieve.
Dr Dash: Yes, because they need to work at a bigger, macro level. As an example, I have looked at the work of the public health team in London on the London Million Hearts and Minds campaign, which has the potential to be very impactful. But you asked about patient and public involvement, and I would like Duncan to fill you in on what we are doing on that.
Duncan Burton: We are strengthening patient involvement and patient experience right at the centre of the Department of Health. We are recruiting at the moment for a new director of patient experience nationally, who will report into the chief executive of the NHS.
Q253 Danny Beales: Is that any different to what happened at NHS England level?
Duncan Burton: This individual will be reporting into the chief executive and myself, and we will be making sure there is reporting regularly to the board. One of their jobs is to make sure that we are effectively using the enormous amount of data that we already have around patient experience. In order to make sure that we are using that effectively, we are building mechanisms to bring it through—
Q254 Danny Beales: One of the concerns we have is that with the loss of Healthwatch, is this going to be independent and challenging enough? We do not yet know what the exact structure will be; as you say, most responsibility or accountability is now at local provider and ICB level. There is no clear provision for PPI—patient and public involvement—in that structure. The draft structure that we have seen has patient and public involvement below the system and right at the top, but no detail of what it looks like in the whole function of the middle of the system.
Duncan Burton: ICBs have a responsibility to engage with their public and with patients, and they are doing that in many ways. We have good examples of that, but it needs to continue to be strengthened. We have talked a lot today about safety—
Q255 Danny Beales: Perhaps you can write to us about the requirements for an engagement at ICB level; does it require co-design, engagement, involvement? It is unclear.
Duncan Burton: I would be very happy to do that. But I would add that we are listening to the voices of people who are saying that they have concerns about how we build in the new patient experience function in the Department. It is important that we hear those voices and use them to help shape that. Just to give you some level of assurance, I have been meeting with lots of people—as have Penny, Jim, and others—to make sure that we get this right.
Chair: Thank you very much.