Health and Social Care Committee
Oral evidence: Health Bill, HC 219
Tuesday 2 June 2026
Ordered by the House of Commons to be published on 2 June 2026.
Members present: Layla Moran (Chair); Dr Beccy Cooper; Jen Craft; Josh Fenton-Glynn; Andrew George; Paulette Hamilton; Alex McIntyre; Gregory Stafford.
Questions 1 - 98
Witnesses
I: Dr Hugh Alderwick, Director of Policy and Research, The Health Foundation; Sarah Woolnough, Chief Executive, The Kings Fund; and Thea Stein, Chief Executive, Nuffield Trust.
II: Councillor Dr Wendy Taylor, Chair, Health and Wellbeing Committee, Local Government Association; and Dr Victoria Tzortziou Brown, Chair, Royal College of General Practitioners.
Witnesses: Dr Hugh Alderwick, Sarah Woolnough and Thea Stein.
Chair: Welcome to this session of the Health and Social Care Select Committee, which comes the day after Second Reading of the Health Bill and which is part of our scrutiny of said Bill. Would our panel members please introduce themselves and their organisations?
Thea Stein: I am Thea Stein. I am the chief executive of the Nuffield Trust.
Sarah Woolnough: I am Sarah Woolnough, chief executive of the King’s Fund, an independent health and care charity.
Dr Hugh Alderwick: I am Hugh Alderwick. I am director of policy and research at the Health Foundation.
Q1 Chair: Lovely. I will start with the powers that the new Bill will confer on the Secretary of State, which was a matter of debate among parliamentarians in the debate yesterday. Let me simply start by asking you an open question: do you think the Bill is getting that right?
Thea Stein: There are more centralising powers for the Secretary of State in this Bill; that is without doubt correct. It is for politicians to decide whether that is what they wish to see, but it is without doubt the case. In the debate yesterday, it was argued that there is decentralisation, with powers being given to the ICBs. Although that is true, there are many more powers being given to the Secretary of State—for example, directing ICBs at any time, deauthorising foundation trusts and appointing boards. Although it is obvious that a Secretary of State does not have to use those powers, it feels to me like they have been drafted with the idea of there continuously being a good actor in that role, who will use those powers judiciously and with wisdom. I am concerned that this gives the opportunity, at any time, for a less than good actor to make very radical interventions into the health service in a highly politicised way.
Q2 Chair: Can you paint a picture for us of a worst-case scenario? What kind of thing are you concerned about?
Thea Stein: You can appoint every chair of every board. You can get rid of chief execs. You can get rid of directors. You can decide to deauthorise foundation trusts and fire people. You can put limits on spend at particular trusts. You can be in huge national control of the NHS everywhere. We know that politicians are often criticised for cronyism—putting your mates in—and there is an opportunity in this Bill to slip into the temptation of that. I feel sure that the guardrails are not there.
Q3 Chair: Hugh, you have spoken about how some of those powers perhaps do not sit in the right place. Can you elaborate on the Health Foundation’s view? Are some of these powers inappropriate for a Secretary of State to have?
Dr Hugh Alderwick: A bit like Thea, I think accountability for the health system will always rise to politicians in a tax-funded health system. The Secretary of State is right to set the strategy for the health system, but I think that the Bill hands too much power over the day-to-day management of the NHS to Ministers—
Q4 Chair: Sorry to interject, but I remember from when we first came in as new Select Committee members and were briefed about how this very, very complex system works that, while on the one hand, on the face of it, NHS England had operational independence, in reality it never had complete independence. If a Secretary of State wanted something to happen, by and large they found a way of making it happen. Is this not just lifting the veil from our eyes and saying what we have always known, which is that those powers have always lain with the Secretary of State? Is this not just us now writing that into law? What is the issue here?
Dr Hugh Alderwick: The issue is which policy processes or parts of the health system we think it is important should have some independence. We accept the principle, because we have NICE on cost-effectiveness decisions and ACRA on resource allocation. I do not think the debate for this Committee is, “Do you reverse course on scrapping NHS England?” It is, “Is bringing it all back into the Department, and adding some more, the right thing to do?”
You could point to a couple of areas of the Bill. Appointments is one where some more independent checks or safeguards feel important. That is the way it has been managed since 2001.
Chair: Which is what you were worrying about, Thea?
Thea Stein: Yes.
Dr Hugh Alderwick: Another one is data and digital infrastructure, which are really critical functions for monitoring performance of the health system and managing how the health service operates over the long term. Those have often been held at arm’s length but, again, they are being brought back in. That particularly matters, given that trust in digital and data is so important. Healthwatch is another, which I am sure we will talk about.
As you say, politicians are in charge of the health system—they should be, they are and they always have been—but the question is how far you want them to reach in the day-to-day management of the system. That is where some limits and safeguards are needed, not just to ensure trust in the system and to ensure that it runs effectively, but to insulate Ministers from decisions they do not feel they should be taking, as we have done on things like reconfiguration.
Q5 Chair: We will come back to safeguards and other measures that might mitigate some of this, but I want to give Sarah an opportunity to come in on this.
Sarah Woolnough: I agree with everything that has been said. There is potentially some dissonance: if the narrative is that this is a big decentralisation, but in reality you are pulling lots of powers back, what message does that send to the system?
There are a couple of practical things that may not have been said. There is the potential for things to get slowed down or gummed up. Because the Secretary of State can technically intervene on appointments, for example, could that slow the business of Government?
Then there is a cultural point. We have had a history of the system looking up for permission, and sometimes a culture of inaction or this feeling of a lack of agency. Does the signal that this piece of legislation sends make that worse, or not help us tackle it, when what Ministers say is that they want to free up and empower local health organisations to deliver for their populations?
Q6 Chair: Let’s take them at their word on that. They have been saying it successively at the Dispatch Box, which is meant to count for something, although you are pointing out that that is maybe not reflected in what is written in the Bill. Let’s take them at their word: they want to devolve power down into the ICBs, much closer to the communities, and very much in line with that shift-to-community vision they have. What needs to sit where? It would be really helpful for us to tease out, in amendments that we might put down, what powers are appropriate to be sitting with the Secretary of State and what are actively inappropriate. You mentioned appointments—that has been underlined very clearly—but to be clear, what should absolutely not sit with the Secretary of State, and what safeguards need to be put around any that do, so that the Secretary of State actively does push power down to the local level? Do you have a view on that, Thea?
Thea Stein: Perhaps you could go to the others while I try to think whether I have something specific.
Chair: No worries. Specifics are what we are in the market for. I share your view about looking two ways: on the one hand, the Bill is saying one thing and, on the other hand, what the Government are saying at the Dispatch Box is different. If we take them at their word, then let’s help them: what do we need to do to fix this, so that it actually achieves what they want to achieve? Have you got a view, Hugh?
Dr Hugh Alderwick: Ultimately—this is frustrating, I suppose, given what you are asking for—this is about behaviour, and the behaviour always trumps the legislation. The legislation provides a framework, but Secretaries of State will intervene, or not, depending on how they think the health service best improves.
My judgment is focus on which policy processes most need some independent safeguards, and make sure those are in place. Appointments, Healthwatch, and digital and data infrastructure would be different examples. Another would be to give a stronger signal to the system about how these very broad powers—directing ICBs over almost anything, involvement in decision making around FTs—will be used and not used, to avoid the sense that, at any point, there could be top-down intervention, which does not free up local leaders. We have seen this in the past: you have this letting go while holding on ever more tightly, which means that even when you do devolve powers, people are scared to take them, because they think there will be top-down direction. More clarity is needed about when these broad powers to intervene over ICBs and providers might be used and in what sort of cases. But ultimately, this is about behaviour as much as about the legislation, as you illustrated with NHS England. Did that put the NHS at arm’s reach from politicians? No.
Q7 Chair: Do you agree, Sarah?
Sarah Woolnough: I completely agree. We have written extensively about the fact that legislation gets you so far, but it is behaviours, cultures and precedent that often trump that. I think we need probing on how the powers are likely to be enacted—maybe it could be specified in slightly more detail in guidance. But that is the risk.
This point about future-proofing is quite interesting. Thea has already made it, but if there is a different Secretary of State, how do they choose to enact the powers?
Q8 Chair: Is your advice basically to think of the worst possible Secretary of State, and then legislate for that? Is that what we need to do?
Thea Stein: Yes.
Sarah Woolnough: The point is that the legislation only gets you so far. At the end of the day, if the Government are serious about devolving power, and freeing up local health systems and system leaders to do best by their local populations, with sufficient safeguards and direction, they have to think much more broadly than legislation. What are the conditions for success whereby health systems feel they can genuinely act not just on short-term whims and directions, but can take a broader, slightly longer-term view of what creates and sustains good health and is best for populations?
Q9 Alex McIntyre: I am intrigued by the comments about appointments. I totally understand the concern about the risk that a different Secretary of State—certainly not the current one—might want to appoint their mates into key jobs. A challenge that the Government have faced is that they can issue an instruction in the Department of Health, and it has to go through the entire sausage machine of the Department of Health, into NHS England and down to the ICBs. By the time it gets down to individual trust level, that message can look very different. Could an alternative be that they retain these powers of appointments, but that there are then appropriate safeguards in place? Rather than taking those powers away from the Secretary of State again and saying, “The power shouldn’t go there,” an alternative could be to introduce safeguards.
Thea Stein: That is where we have been before. We have had safeguards. There has always been the opportunity to intervene. There was the Appointments Commission. We had Monitor. We had other bodies making sure there was something between the Secretary of State and the frontline. History teaches us that you cannot run the whole NHS from Whitehall. You cannot hear every bedpan that falls. It is about ensuring how you get the balance right between having the ability to intervene and having safeguards and checks in place. Maybe I answered too swiftly, but you have to be thoughtful about a political process running with people within it who wish to abuse those powers as well as utilise them for good.
Q10 Josh Fenton-Glynn: Dr Alderwick, how significant are the changes the Government are proposing to make to the governance of foundation trusts?
Dr Hugh Alderwick: That is a good question. They are simultaneously talking about giving powers away—advanced foundation trust status, more autonomy over decisions, the ability to become integrated health organisations—and more tightly gripping controls over spending, appointments and the ability to change the provider licence and deauthorise FTs. They are doing both at the same time. Standing back, that adds up to more central grip. The problem is that we have a highly centralised health system already. This just brings more top-down power.
The question is how those powers are used in practice, as we have talked about before. It just depends on the behaviour and the implementation. I am looking at the rhetoric around the Bill—devolution, handing power to local leaders—and the reality of what is written in it, and there is a mismatch.
Q11 Josh Fenton-Glynn: The explanatory note says the Bill is putting foundation trust governance in line with other trusts. Foundation trust status was given as a bit of a reward to high-performing trusts. Would you say this is an example of the Bill drifting away from the freedom at the local level and being a bit more prescriptive as to what they are allowed to achieve and put in place?
Dr Hugh Alderwick: As I say, it depends a bit on the implementation and what is done with the powers. In reality, the difference between FTs and non-FTs has changed a lot over the period since they were invented. When there was a lot more money in the system, you could do a lot more with your freedoms. When there are performance and financial challenges across the health system, it often becomes a distinction without a difference. I can see some of the logic of wanting to bring some of these powers closer in line, but if the policy intention is to give greater freedom and set high-performing trusts free, looking at the content of the Bill, I would have questions about whether it really does that.
Q12 Josh Fenton-Glynn: I should probably declare that I was one of the governors of a trust. Obviously, they are being done away with. I will be honest: I did not feel at my most accountable when I was a governor of a trust. I was one of the elected officials who was put on that trust, but there were a lot of people who came there. I remember challenging the fact that there were no young parents, for example, apart from me, and I was there in an entirely different capacity. They said, “If they cannot find the time to come, they cannot come.” To me, the governor system was not working terribly well. Do you think it was working? Do you think it could work? What are the pros and cons of that?
Dr Hugh Alderwick: The changes to the FT councils of governors need to be interpreted alongside the other changes in the Bill, particularly around Healthwatch, which look like they diminish the role of patients and the public voice in the health system, rather than strengthen it. That is problematic. The biggest intervention in terms of strengthening the Bill should be around Healthwatch. There has been a mixed experience of the impact of councils of governors.
Q13 Josh Fenton-Glynn: Do you think Healthwatch was universally effective?
Dr Hugh Alderwick: Sarah’s organisation did a fantastic study on Healthwatch, so I will let her comment. It was variable and mixed, but that was often to do with structural factors to do with a big imbalance of power between Healthwatch and the NHS, underfunding and cuts.
Josh Fenton-Glynn: Sorry—that is not what my questions are about. I don’t want to step on anyone’s toes.
Chair: We are going to come back to Healthwatch.
Q14 Josh Fenton-Glynn: More generally, do you think the change to the models makes sense?
Sarah Woolnough: I would echo what Hugh said, in that I think a lot of this is about how you interpret and implement. The legislation is quite light. On FT governors, what is said is, “We’ll allow FTs to develop more dynamic arrangements at local level,” which does not tell you very much about how that will play out. There is a reasonable consensus that governors have operated in variable ways to date, but having a connection to your local community is absolutely critical. Similarly, the Government’s narrative is all, “We’re going to empower patients and local people to have more say in their healthcare.” That feels like an unanswered question about how the new arrangements will work. There is a lot to be stipulated in the regulations.
Q15 Josh Fenton-Glynn: Thea?
Thea Stein: I have nothing in particular to add. Interestingly, I do not think there is any research that demonstrates governors’ effectiveness or otherwise—I had a look. I think it is all about behaviour and involvement. It is much more the principle of how you are going to ensure that you listen to your population, which is why we will overlap with Healthwatch. I do not think that governors were demonstrated as being a particularly good way of doing it. The question remains, how are you going to?
Q16 Josh Fenton-Glynn: Hugh, do you think this is an end of foundation trusts or an evolution of them?
Dr Hugh Alderwick: It looks like an evolution. When I stand back and look at not just the Bill, but the 10-year health plan and the policies the Government have introduced, despite the language being about shifting power and resources out of hospitals, I actually see a lot of power and potential power being held in hospitals, particularly if they are going to get advanced foundation trust status and win contracts to run health services across a whole area. It is an evolution of the model. There might be more grip centrally, but possibly also more power and resources that look like they are going to flow to hospitals, which could be a challenge if we are going to achieve this shift.
Q17 Josh Fenton-Glynn: This is more of a general question. What does the Bill tell us about the Government’s proposals for earned autonomy for high-performing trusts? Everyone is looking to Sarah.
Sarah Woolnough: I wanted to make a point about how you support organisations to develop advanced foundation trust status—something that appears to be different from years ago, when there was a big push on FTs and you had the Trust Development Authority. If we are going to encourage the development of organisations that have more freedoms, what architecture and support will be around them to help organisations act in a high-performing way and take on additional powers?
Josh Fenton-Glynn: Do you have any comment on that, Thea?
Thea Stein: No, nothing to add.
Q18 Josh Fenton-Glynn: Given that the Government’s intention is to give more powers to high-performing ICBs and have them take on a strategic commissioning function, do you think that the Bill puts in place enough accountability requirements for ICBs to ensure that they are performing the role that the Government envisages for them?
Sarah Woolnough: We are supportive of ICBs taking on a stronger strategic commissioning role and felt concerned that they had been being asked to do lots of different things. So often, the short term trumps the slightly longer term. We have heard from lots of ICBs that having to keep an eye on performance and performance manage has sometimes restricted their ability to do the longer-term population health understanding and planning that we hope they will be able to take on as strategic commissioners.
They have had an incredibly difficult operating environment. We have used the phrase “born into a storm”—created several rounds of cuts and efficiencies, asked to do different things. There is a real question about how we set them up for success. Do they have the skills and are people supported in order to be able to genuinely commission strategically over a population?
There has to be a question about their size. Again, this gets into the messiness of the Government’s intention, which is to push power down and it is absolutely about local health systems, with the move to consolidate and pool lots of ICBs together. Government will say that that is a decent size to commission across, but I think there is a tension there at the least.
Q19 Josh Fenton-Glynn: Let me develop that question a little. Where does strategic commissioning from ICBs or local health services look good? What do we want to see mirrored across the country?
Dr Hugh Alderwick: The challenge with strategic commissioning is that we have been trying to do this for a very long time. When you look at the evidence on the repeated changes to the commissioning system since the purchaser-provider split was introduced in the ′90s, there is not a huge amount of evidence that it has had a meaningful impact on care or outcomes.
There are a lot of different reasons for that. Commissioning is super hard to do in any health system. There are big asymmetries of power between providers and commissioners. We also restructure them all the time. We are doing it again now. Do you give them a chance to succeed? We also do not invest in the management capacity infrastructure needed to do it effectively. Strategic commissioning is a bit like world-class commissioning: did it really ever happen?
The question is: what will be different this time around? The only way it will be different is if policymakers actively construct the sort of strategic commissioning they want to see. The problem is they are cutting their budgets and reorganising them again, so there is a lot of challenge and churn in that system.
Actually, I do see a challenge with the direction here. Strategic commissioning sounds fantastic. You look at the content of the Bill and they are becoming more traditional NHS commissioners. The policy intention a few years ago was to try to bring leaders from across the health and care system together to collectively plan where money should be spent to improve health and care, and to collectively redesign services. We are moving back to a sharper split between commissioners and providers. That does pose a risk given that the big challenges facing health really need to be solved through collaboration.
There are some small changes to the Bill that could help—things like looking at the membership of ICBs again, and making sure local authorities have a voice given their role in social care and public health. But if the Government are expecting commissioning to be the thing that transforms the health system, that is hope over experience.
Q20 Josh Fenton-Glynn: You talk about hope over experience. I wonder whether we are almost failing to learn the lessons of the Lansley reforms, when they made commissioning roles redundant and then hired one in five of them back. Is there a risk of that?
Dr Hugh Alderwick: Planning, is really important in a health system. Setting priorities, allocating resources, making sure money flows to the right places—we need this. The question is how you deliver that function effectively. One of the things you don’t do to deliver that function effectively is change it—change its size, change its responsibilities and generate uncertainty—every few years, and that is what we are doing again.
Let’s make sure this time there is some collective commitment about the roles of commissioners so that they have the resources to deliver effectively, and they have the skills—data analytics, actuarial, priority setting—that enable them to do that job effectively. But let’s also recognise that these big challenges at a local level—managing multi-morbidity, preventing disease, shifting resources—require some collective view; they are not going to be solved through the internal market and competition.
Q21 Josh Fenton-Glynn: Is the commissioner/provider spilt working in healthcare?
Thea Stein: Everybody will sigh, but if you were forced to say yes or no, you would say no. You can look at parts of Europe and say that in some places, some of the time, it works, but often it is very focused. They have very clear priorities, not everything everywhere all at once.
Generally speaking—and picking up a point that Hugh made—where you really shift resources or bring people together to transform a care pathway, it is not because of a strong commissioner gripping something and demanding something of providers. We look at the American models far too often, when we should all know in this room that the American models are broken, extremely expensive and the most inefficient in the world. They have a payer model, anyway; they don’t have a commissioner model. Where it works is where you have all parties together around a table with a shared endeavour, making decisions to do something different. You can call it commissioner/provider, you can call it different roles in a system, but we have never got it right in this country and it has never worked.
Q22 Chair: I was initially supportive of the boldness of the reforms, because we all know things need to change, but as the merger has gone on and the Bill has been published, I have become more sceptical. In part—Hugh, I think you said this—I think, did we need to do this reorganisation to achieve the things we need to achieve? I want to ask that question outright. If the Bill and the merger were not happening, could we achieve the shifts in the 10-year plan? Could we do the shift to community prevention and digital without all this stuff that is happening in the background, or are there bits of the Bill that actually are essential to this? I am trying to draw out the wheat from the chaff.
Sarah Woolnough: I think you could get an awful lot of the way, and arguably a lot of delivering the three shifts is nothing to do with legislation. There is a huge opportunity cost of us all scrutinising legislation of this type, but fundamentally, so much of the shift to community and to prevention is about things other than legislation. It is about the levers to direct money differently, to create strategies, to prioritise, to lead differently, to develop people in order that you can support a workforce that is delivering more in the community. So much of that can be done without recourse to legislation. I think we have probably all said in different ways that you can achieve an awful lot through other means.
Governments and others have learned the lesson with health legislation. What the Government may start describing as enabling legislation with much of the detail laid in guidance, can end up getting bogged down in huge amounts of discussion and debate and loads of amendments, not necessarily getting you much further. We urged caution before they took this path. In fact, Labour said in opposition that they would not reorganise in this way because of the opportunity cost, and yet here we are.
Q23 Dr Cooper: It is interesting what you say about whether you would do it or you wouldn’t. I absolutely hear you about reorganisations, having been through several myself. I suppose it is the iterative question: is iterative change possible in a politically led organisation? Have you seen that done effectively? In my experience, I have not seen effective iterative change deliver what we want to deliver over a number of years. That is an open question.
Dr Hugh Alderwick: The change we need is change in how services are delivered and change in the health system. We are largely talking about changes in organograms, responsibilities and structures of the health—
Q24 Dr Cooper: That is fine, but is it possible to do the first thing you are talking about in the situation we are in? There is a whole conversation about whether health should be political or not, which is fine, but given where we are—it is a political situation—is it realistic to say it is possible to do this without this sort of political, legislative change?
Thea Stein: Yes.
Sarah Woolnough: I think it is. If the Government is saying, first, that the landscape is quite crowded and there are some unclear accountabilities or responsibilities, there are ways that you can try to simplify how things get done without recourse to legislation. If the Government is saying, “We want to promote more care in the community”—this shift from hospital to community—we published a report on how successive Governments have had that long-held ambition for at least 30 years, and it fundamentally has not shifted.
To get under the skin and understand the barriers to that and what is getting in the way, it is partly how the money flows—that does not have to be anything to do with legislation. It is partly the status of the workforce—that does not have anything to do with legislation. There is a whole range of other things. I think you can empower local organisations and seek to deliver longer-term shifts without the need to legislate.
Dr Cooper: Which is interesting, in and of itself. I could keep going, but we will move on.
Q25 Andrew George: Thea, I want to dive back into the commissioner/provider split. Clause 10 talks about containing variation between private and public providers within the NHS. Although you have said that, on the one hand, there is a risk that bad actors or malign actors might take control, do you think that that puts a constraint on a malign actor coming in and privatising the NHS, or do you read that in a different manner?
Thea Stein: Interestingly, one of my notes here is about clause 10, because I think it is a bit of a curiosity and I would urge the Committee to dig into it. I do not think that I understand it completely. It seems to make it more possible for the Secretary of State to explicitly set out to increase private or public provision. That is how I read it, but we are uncertain whether we are reading it in the right way. I was going to raise it as something that would be of great benefit for you as a Committee to dig into, unless you already have done. I don’t know.
Chair: Thank you, that is helpful.
Andrew George: I tried yesterday in the debate. It is very helpful that you have elucidated it.
Q26 Gregory Stafford: I look forward to spending five weeks on a Bill Committee that is apparently totally pointless. I feel those opportunity costs. Sarah Woolnough, as was hinted at in a previous question, you have recently published a report on the lessons from Healthwatch, which the Bill essentially abolishes. Do you think the patient voice proposals in the Bill reflect the lessons that you drew out in your report?
Sarah Woolnough: The short answer is that it is hard to tell from what is in the Bill because it is pretty minimal, but our research and the learnings from the Healthwatch model showed that an independent voice in the system is really important, as is the ability to hear unsolicited feedback. We looked across what Healthwatch national and local has achieved, and often it is Healthwatches that have raised issues that the service may not have been thinking about or may not have had front of mind, such as NHS dentistry or NHS administration. We found that the ability to be independent—partly because that helps you form trusted relationships with communities who may not feel they can raise issues in the way that others can, and raise issues that may not be on the to-do list of the centre or the top of the NHS—is crucial.
What is proposed is to create a patient experience directorate within the Department. Our concern would be: how independent is that? How seriously will that be taken? Will the director or the leadership be able to raise issues with the sort of independence and weight that Healthwatch and local Healthwatch have been able to do at times? That is not to say the current system has always worked perfectly. One of the concerns has been that a lot of recommendations have been generated, perhaps sometimes without the ability to follow through and act on them. But our concern is with the Government saying they are going to put patient power in patients’ hands, with the largest transfer of power from the NHS to patients and communities, at the same time as abolishing the independent voice set up to monitor, listen and act on that voice. It is a concern and a worry that we will lose independence and the ability to hear things that the system may not be listening out for.
Q27 Gregory Stafford: To paraphrase you—tell me if I am accurate—Healthwatch is not perfect, but you would rather see improvements to Healthwatch than its total abolition, as we are about to see.
Sarah Woolnough: Yes, I think so. Partly to Hugh’s point, we can forever cut organisations and probably reinvent something quite similar, or we can seek to improve. I am sure there is local variation in how different Healthwatches have carried out their responsibilities. There has also been a pretty severe funding constraint on them.
I sympathise with the idea that it is a really crowded landscape, and the ability perhaps to have fewer recommendations that we know can be acted on is not something I disagree with, but I worry that having spent several years building trust and developing relationships, particularly at local level and sometimes with seldom heard communities, the confidence to raise issues, particularly that the service may not be wanting to hear or listening out for, will be compromised by just abolishing them all and hoping that an in-house patient experience directorate, and ICBs taking on this role, can deliver something enhanced. Ultimately, our report concluded that what follows should enhance where we have been. But to answer your direct question, I worry particularly about the opportunity cost of abolishing 154 organisations and probably ending up recreating something quite similar.
Q28 Gregory Stafford: ’Twas ever thus in the NHS. Specifically on the directorate of patient experience, you indicated that you do not think there is enough information in the Bill. What would need to be in the Bill to get that role to have the significant authority and ability to hold others to account? What needs to be written into the Bill to get there?
Sarah Woolnough: I will add one point and then hand over to others. To come back to what feels really critical, it is the ability to have enough independence or status to say, potentially to your boss, “We’re hearing this and it’s problematic,” and around the top table of the Department, “We’ve heard some really uncomfortable things that we may not have been looking out for. We need to act on them.” I do not know whether that can be written into legislation, but it is particularly that measure of independence. I do not whether you can legislate for this—well, you can to a degree—but you have to have a local link and you have to be able to give powers to develop relationships with all communities.
Thea Stein: I don’t think you can legislate for how people behave. I have worked in systems with directors of patient experience, and people are often very nice to them—very nice indeed—and then they move on to the real business, which is, “Let’s talk about money.” I think it is a bit of performance politics, putting that role in, if I am honest—“Yeah, fine”—but it is all about how you use that role, how you listen to that role and how that role is going. You cannot put that in legislation—
Q29 Gregory Stafford: What are you saying? By virtue of it being in an ICB, for example, the person or people in those roles are not going to be able to speak truth to power, because they are their bosses and—
Thea Stein: I do not have that assurance. As a member of the public, as well as in the role I am in, in my experience that does not give me assurance of that. Sorry—
Gregory Stafford: No, it is very helpful.
Thea Stein: Also, I was listening to yesterday’s debate, and Minister Karin Smyth said that we have had 50 years of patient voice, and it has not achieved the transformational change we want in the NHS, of patients really being embedded and their voice being heard. I have thought about that, and she is right, but this solution is wrong. Both can be right. We have not got it right, but we have not got it right for cultural reasons; we have not got it right for power reasons, for the way in which we train staff, for the way in which we set things up. Abolishing Healthwatch is not the right response to a diagnosis of why it has not worked in the way we all want.
Q30 Gregory Stafford: Indeed. “We’ve not had enough patient impact with patient voice, so let’s get rid of the patient voice.” That seems to be the solution.
Dr Hugh Alderwick: Thea has made some good points. If we take the Government’s stated rationale that they want to do more to listen to patients and the public, that is really good, but as others have said, you can do that without scrapping anything. The question is, does this help? The public will be losing an independent voice. I would like to see three things in whatever is proposed. First, some independence from the NHS and Government. That does not mean you should not do the other things, such as strengthening the role within Government or within the NHS, but some independence is important, as 50 years of policy have tried to do.
Secondly, we need sufficient infrastructure to gather data locally, and to inform and influence nationally. Thirdly, we need sufficient resources to do that effectively. That is not about the legislation. A lot of this is about power and behaviour, but you can do more in Government to listen to patients without scrapping an independent voice for patients.
Q31 Gregory Stafford: Thea, both personally and as the Nuffield Trust, you have previously argued that the rationale for merging the Health Services Safety Investigations Body with the CQC is unclear, and that it is “difficult to understand the justification for the inevitable disruption and cost of a merger.” The Dash review argued—when Dr Dash was here last week, she argued very strongly—that all that was happening was clarification of roles, strengthening the link between identifying poor performance and investigating. Do you still find those arguments unconvincing, or have you been convinced by Dr Dash’s statements?
Thea Stein: I have not been convinced. I read what she said to this Committee last week very carefully, and I have huge respect for the way in which she is doing a hugely important job. I agree with her on there being a plethora of recommendations on safety, and that they are not implemented. To me, that feels to be absolutely crucial in the safety landscape.
However, I cannot find any evidence that regulation and safety investigation in any other safety-critical industry are recommended to be put together. I heard her eloquence in arguing for it, but I cannot find the evidence for it in any other safety industry, or indeed in any other part of the world, looking at the health service. Slightly remarkably, it has been looking at the growing success of HSSIB. The fact that it should work on systemic issues is something that the Dash report says. My understanding is that it is indeed what HSSIB has been doing. I cannot see how this protected disclosure is going to work within the CQC. I understand that Dr Dash said to the Committee that it is still being explored, but I just cannot see how it is possible to make it work. I do not see a reason to do it. The final point was made by the previous Health Secretary. In a speech a few months before he left, he said that he would be very cautious because the CQC is not a performing organisation.
Q32 Gregory Stafford: Indeed, and we made that point very clearly to Dr Dash last week.
Thea Stein: I would be even more cautious. I would say, “There is a lot on, don’t do it.”
Q33 Gregory Stafford: Very briefly, because I am conscious of time, do either of the other panellists want to touch on HSSIB?
Sarah Woolnough: I agree. There is also something implicit in what has been said, which is how you build trust. HSSIB has been working very hard. People can come and speak without fear or favour, and the worry is that you roll that into the regulator and that completely dissipates. There is something more general, and Penny talked about this in her review and when she gave evidence to the Committee, which is that we have lots of bodies producing lots of recommendations and almost overwhelming the system. It is hard to keep track and act on them.
I am sympathetic to how we bring enough focus. We have the National Quality Board, which can play a role in looking across, but it is also about culture, particularly safety and being willing to hear things from the system, from patient voice, and then acting on it. Over and above legislation, what is the system going to do to say that it is safe to speak up in different workplaces? We should be listening and shifting the balance of power so that people feel they can voice concerns, and that those concerns will be heard and acted on.
Q34 Gregory Stafford: Ms Stein said, “Don’t do it.” Is that what you are saying?
Sarah Woolnough: Yes. Jeremy Hunt talked—
Q35 Gregory Stafford: Sorry, so you are saying, “Don’t do it.” Dr Hugh, are you for “do it” or “don’t do it”?
Dr Hugh Alderwick: Three quick points. I think that if you are going to do it, the question is why. Because as far as I understand it, the commitment is to maintain the safe space model and maybe maintain the branding. Are you running two organisations in one? Secondly, mergers are costly and often take up more time and money than you expect. Thirdly, the challenges at the CQC are well documented. If you are going to do it, why are you doing it if you are going to maintain them effectively as two separate organisations? But the others are right that Penny Dash’s review is completely correct to diagnose the problem of a “cluttered landscape” and too many recommendations that are not implemented. The spirit is the right one, but the question is, “Does this actually reduce any complexities at all, or does it create new ones?”
Q36 Gregory Stafford: Right diagnosis, wrong medicine?
Sarah Woolnough: Yes.
Q37 Andrew George: On the single patient record, if we apply the malign actor test, is there sufficient constraint within primary legislation to control a malign Secretary of State? If there is a benign Secretary of State, do you actually need primary legislation in the first place? Can you not just do this without it?
Sarah Woolnough: You could definitely move forward without legislation on the single patient record, which we are very supportive of in principle. The public and patients tell us—this is in lots of research—that with the right safeguards, privacy rules and so on, they want and expect their records to be joined up. Half the time, they cannot understand why they are not already. It is the same with healthcare professionals.
We are supportive in principle. You do not need legislation to move forward, but there is something about winning the argument in Parliament that might get us further than we have sometimes got in the past. The clauses are enabling, but there is a lot of detail yet to come. To your specific question, it is quite hard to say, because so much of the detail will be set out in regulations.
Thea Stein: I would agree, and we are strongly in favour of the single patient record. It is hard not to be in favour of it, but in terms of being clear on whether there are safeguards—we could talk about the FDP and how it links to that—there are ways in which you could consider things like the advisory group of the HRA, which gives recommendations to the Secretary of State about how you use data. You could maybe make them something stronger. You could put that into law as a safeguard. There is something about making sure that this extraordinary data, which we have the ability to collect in the NHS, is used for the benefit of the NHS, financially and in many other ways, and not for the benefit of big corporations and private business. That could be thought of in the Bill.
Q38 Andrew George: I am not making any assumptions, but what if a bad actor were elected at the next general election? Do you not think that there should be more written into primary legislation, and that it should not all be left to secondary regulation?
Sarah Woolnough: We have to be careful about future-proofing it. In some of the discussions we have been involved in around the Bill, we have said that the world of data and what we will be able to know about our health and might want to share are evolving. The principle is that we should have a single joined-up record that might be available on the NHS app for patients and healthcare professionals, but technology changes over time—we use wearables, and there are other ways that we can learn more about our health—so you don’t want to be too prescriptive in primary legislation about exactly what the single health record is, because I suspect it will evolve over time. The balance has to be quite carefully struck. I do not necessarily think that more has to be put on the face of the Bill, but overall there has to be sufficient assurance that people’s privacy and the right safeguards are in place, not least to maintain trust. That is so often where we have fallen in previous attempts at progressing this.
Q39 Andrew George: So what are the biggest risks of the single patient record?
Thea Stein: I think the fears are. The single patient record is a great thing for patients and will do good things for patient care and research.
Q40 Andrew George: It is more emotion than a real risk, is that what you are saying?
Thea Stein: There is a fear about the selling of data, which could happen. As Sarah is saying, it is about making sure that there are not so many safeguards that it gets completely bogged down. What we don’t want to do is kill the single patient record. We must put enough safeguards in place around the sale of data.
Dr Hugh Alderwick: It is ultimately about trust, so what do we need to see in the debate and the secondary legislation that is to come to give patients, the public and staff the assurances they need that their data are going to be used appropriately to improve their care and the whole system?
There are a few categories of questions. First, how will this actually work? We talk about it as if we know what it is, but we don’t really. We have a very fragmented electronic patient record system, so how is it supposed to work?
Secondly, how will the data be accessed and governed? Who is the data controller? What does that mean for the role of GPs? There are a bunch of questions.
Thirdly, how will patients, the public and staff be involved in the process? We are lucky that we have a long history of failed large national IT programmes to learn from, but the lessons are pretty unsurprising. Often, there was not enough clinical, patient and public involvement from the outset to design them right. Often, there is tension between the political leadership and the technical leadership—for instance, around timelines. The funding and resources needed to implement them properly can be underestimated. The debate now is about whether we trust the thing and what assurances there are.
Q41 Andrew George: Who should be the data controller—GPs or the Secretary of State, or do you manage between the two? Who should do it?
Dr Hugh Alderwick: I think it is about clarity, to be totally honest. What GPs are worried about is not knowing and being liable for somebody else using the data in a way that they would not give consent for and would not find appropriate. What the system needs is clarity. That is more important than deciding who it is.
Q42 Andrew George: What other safeguards need to be put in place, either on the face of the Bill or through regulation—the public interest test on disclosure, reporting requirements to Parliament?
Thea Stein: There are other countries that have done it. Scotland put through their healthcare Bill only last year, which brought in their integration of data. Sweden and France have done it. We should be aware of that and pull in the data. What did they have on the face of the Bill and how did they do it? There will still be a difference, because we have a history in this country and therefore a lot of suspicion, but other countries have managed to pull their data together to allow that integration to work, and we need to learn from them.
Q43 Andrew George: I am going to have to move you on to the FDP, since you mentioned it a moment ago, Thea. I know that Sarah is bursting to say something, though. Can you say it quickly?
Sarah Woolnough: We often talk about selling data to big business and so on, but let’s not get away from the worry that data will not be kept safe and that it will be shared inappropriately. When it comes to trust, people expect to see their own record. They expect the healthcare professionals who are treating them to have access so that they are not constantly retelling their story and so that errors are not made. All those things come up in public deliberation. It does not have to be on the face of the Bill, but it is about role-based access. We need safeguards around who can access it, and it must reassure people that their data is not going to get into the hands of somebody for whom it is not appropriate to see it.
I want to underscore the point that legislation only gets you so far. One of the reasons we have not got so far on implementation is because of the resource it takes to cleanse the data and share it appropriately. We need to give as much attention to that.
Q44 Andrew George: On the FDP, we have a session coming up in a couple of weeks’ time. What is the interrelationship between the single patient record and the FDP? How do you see it working?
Thea Stein: I have a very limited understanding of it at the moment, but I understand that the SPR will be on the FDP.
Sarah Woolnough: I don’t think it is entirely clear yet. We do not quite know how this thing is constructed. As this moves forward, there needs to be a very clear way of saying to the public—to patients—that this is what the single patient record is, and this is what it looks like. There could be interaction, but it is not terribly clear yet.
Q45 Andrew George: But what should we be pushing for in terms of ownership, access and control by the public sector?
Thea Stein: We just need to be really clear to the public in saying, “Your data will be kept safe. People will not be able to apply willy-nilly to use your data—to buy your data.” We know, and clearly you are going to have sessions on this, that there is huge anxiety about Palantir. That is going to make some of this debate much more difficult than it could have been, because you have the stories and the narrative about Palantir that have come from America, which is going to get elided and muddled up in this. There will be people who need to make assessments and judgments on that. The most important thing is the ability to give the patient—the public—trust in their data and that there are enough safeguards around it.
Dr Hugh Alderwick: There is a risk of conflating the two. On the FDP, there are a bunch of questions to answer—I know you are having a session. Does the thing work well? Has there been good enough, high-quality, independent analysis of whether it works?
Q46 Andrew George: What is the answer to that?
Dr Hugh Alderwick: I have not seen a lot of high-quality, independent analysis. There has been one commissioned. The first question should be, “Does it work?” Secondly, do patients, staff and the public trust it? However good it is technically, if people do not trust it, it does not really work. Thirdly, are they the right people to deliver it? That is separate from what the single patient record should look like. My understanding is that the federated data platform is more for operational intelligence to support managers on things like discharge planning. That is not necessarily the same thing as what is trying to be done with the single patient record.
Andrew George: Prior to our session in a couple of weeks’ time, you can provide us with your thoughts.
Chair: We are going to have an entire session on this, so could you write to the Committee about that? We are already running over time.
Q47 Dr Cooper: I want to move us on to the local and the regional area. I would like to hear your thoughts on integration in funding, in strategic leadership and between those key interfaces of health and local authorities, on the face of the Bill and in conjunction with the 10-year strategy around neighbourhood health plans. Let us take the first point on financial integration. In the past, we had the better care fund and nods in some places towards social care being better integrated with health. How do you see this legislation and the broader 10-year strategy, if that is more helpful, moving forward with those funding flows?
Dr Hugh Alderwick: I think it is helpful to take them together, because a lot can be done through legislation in a bunch of different places to pool funding between the NHS and local government. That is often in the context of, “Are they planning together? Are they making decisions together?” There are four areas in the Bill and the 10-year plan that are worth looking at in terms of strengthening the legislation. One is on the membership of ICBs. At the moment, we have local authorities as mandatory members or representatives on ICBs. That requirement is going to be removed. The risk is that you will lose the connection with social care and public health at a local level. That is critical for things like managing multimorbidity, and it might make things like pooling budgets more distant or difficult just because the planning together is not as effective.
Secondly, linked to planning, they are scrapping ICPs—the integrated care partnership that went with the integrated care board. It looks like health and wellbeing boards are going to be the main area body for joint planning.
Q48 Dr Cooper: Can I ask what you think about health and wellbeing boards being the main body?
Dr Hugh Alderwick: They have been around for a long time. Evidence suggests a very mixed experience with varied quality, not a lot of teeth and not a huge impact. I would be worried that it is a downgrade of the importance of partnership working.
On the planning, in a sense there are a lot of changes, but in another way, there are not that many. There will be a partnership plan that informs the NHS plan. The question is whether the NHS takes it seriously. That is where the broader policy is important because in the 10-year plan you see a shift away from ICSs being a partnership body for a system working and more towards them being an NHS commissioner. The risk is that it is a retreat for the NHS looking inwards rather than engaging with partners across the health and care system. I have talked around the financing issue, but I think it is because they are all linked.
Sarah Woolnough: I do not have much to add. I think if a big thrust of the Government’s intention is how to improve health closer to home in neighbourhoods, the worry is that you are sending a mixed message into the system and you are doing the reverse of strengthening some of the partnership working.
Q49 Dr Cooper: Broadening it out ever so slightly—I appreciate that you are not likely to know much more than what is available—the ICBs, to the best of our knowledge, more or less map the devolution that is going on in local authorities, with some exceptions where they overlap. But I think the regional hubs are very like the old strategic health authorities. What is your understanding of what the regional hubs would be in a local devolved power base, and what they would be in relation to the central power base? Do you have any sense of where they are going to sit?
Thea Stein: They are linked. They are an arm at the centre. They are from the top down; they are not from the bottom up, and they are very big. They are a long way away, so they are taking on the performance management of local trusts across a very big geographical footprint. I am curious to see how that will operationalise, but they are a direct arm to free up the ICBs locally. I am very unclear how all this works together.
Q50 Dr Cooper: I absolutely hear you. We have talked about some of the central powers and the direct accountability of the Secretary of State. It feels clear in my mind that national standards are absolutely essential. Do you think there is going to be accountability from the ICBs up to regional hubs for national standards or do you think it will go directly to Whitehall? Or is it unclear?
Thea Stein: I think it is wired to be ICBs to regional hubs to the centre.
Q51 Dr Cooper: Let’s see how it goes. To go back to being a bit more local, I wanted to ask about neighbourhood health plans. Obviously, that is within the remit of the 10-year strategy and then we have had this Bill come forward. Neighbourhood health plans have sort of replaced things. Hugh, you talked about some of the previous workings that we have had around local authorities and different partners, such as the third sector. Do you see neighbourhood health plans as broadly a net positive and something that will be able to function within this changing ICB regional hub commissioning landscape?
Sarah Woolnough: I think so much depends on how this plays out. The opportunity and the potential is that this will get together all your local partners. There has been a lot of talk about bringing health and social care closer together, particularly the third sector, really wrapping care and services around people and really understanding your local community. That all sounds good, but the worry is that they are all things to all people if we are not careful. Also, do they default to being NHS-led? That is one of the things we have picked up: when push comes to shove, there is still that power imbalance and dynamic going on.
Thea Stein: I think there is a tension between a neighbourhood being somewhere where you develop integrated, predominantly NHS services—there is nothing wrong with that; they are good things to do, and it is good to have very integrated services for long-term conditions and so on—and whether you are really trying to look at both prevention upstream and bringing all your partners together. I think the policy and its implementation are continuing to show a tension between the two, and they are certainly not picking up the funding implications of either—neither of them is cheap.
Dr Hugh Alderwick: I have three really quick points to add on. You need to have a cross-sector plan that looks at health needs and how services should change to address them that looks beyond the NHS. This is another version of similar things that we have had in the past, and you need them. The second point is that you need people to listen to them. The question is, will they—do they have any teeth, and will anybody care? Let’s see. We should push for these to be important plans that are listened to, but the third point is that you have quite a big difference in the geographical unit of a smaller neighbourhood and a very big ICB, with multiple neighbourhood health plans being created that an ICB will listen to when setting its strategy for the health of the population. The risk is that local needs get lost, and who is really in charge at that neighbourhood level? If that is vague, and it is everybody and nobody’s responsibility, it just risks being talking shops. That would be the concern, but the first point is still important. You need these things, and they have always existed in some variety, but the question is whether you make them matter.
Q52 Paulette Hamilton: Good afternoon. My questions are about patient impact. You started to answer some of it, so I will start with you, Dr Hugh Alderwick.
Dr Hugh Alderwick: My surname is harder than I thought.
Paulette Hamilton: It is just that I get it wrong every time; I am sorry. Given that the Health Bill is largely focused on systems and governance, to what extent will it impact on patients’ experience and health outcomes?
Dr Hugh Alderwick: It is the right question. There are three ways of thinking about it. There is massive potential to improve care from better joining up of data. If the Government can get the single patient record right, and we have a single payer system, those are huge assets in terms of our data. Somewhere down the line, there could be big benefits. The second point is about the organisational changes associated with the Bill. Scrapping NHS England and changing ICBs will cause massive distraction and disruption—it already is. The risk is that that is a cost to patients, because people are focusing on organograms, reapplying for their own jobs and doing the reorganisation rather than improving patient care. I see that as a risk, and it is one that is already happening; this reorganisation is happening already. Thirdly, there are potential risks of a more politicised NHS in future. That depends on the behaviour of future politicians. Without more checks, safeguards and balances, which we have talked about today, the effects could be poisonous, but it depends on how they are used by a future Government.
Q53 Paulette Hamilton: Does anybody else want to add anything before I move to the next question?
Sarah Woolnough: Yes, briefly. I think this is the key question. I have written on this with some tests for the Bill, and this was my first test: does it improve patient care? I will echo a couple of points. The potential of the SPR is a very good thing, and that can make a big difference to how patients experience the health and care system. We publish a lot on how people feel about health and care, particularly NHS administration and co-ordination of care. It can be Kafkaesque to try to navigate the health system: two thirds of people report problems with NHS admin, with appointment letters arriving after the appointment date and so on. It can feel really difficult to navigate the system. An SPR, where you are not having to constantly repeat your story and that you can be in charge of, can really help to shift the power balance. In a way, that is the bit of the Bill that is worth it. That can improve patient care, but the opportunity cost is important, and Hugh has already mentioned it.
I think the point about patient voice is important. The Government have said that they want to fundamentally change the power dynamic. I am very supportive of that, but given that, at the same time, you are abolishing the existing patient voice network, I struggle to see how this piece of legislation strengthens that. I would watch out for that.
We have talked a lot about it—I have already said quite a bit—but there is so much outwith legislation that makes more of a difference in improving patient outcomes. I hope that there is enough focus on that for the rest of the Parliament.
Q54 Paulette Hamilton: Just to move this along slightly, what would you encourage the Committee to focus on?
Sarah Woolnough: I would encourage the Committee to have enough focus on the health of the nation. All our organisations talk about this quite a bit: stalling life expectancy, falling healthy life expectancy, a Government who came to office saying that they were going to deliver a health mission and a prevention revolution. There are lots of signals and metrics flashing red, and if we are really serious about improving patient outcomes, then getting ahead of disease and focusing sufficiently on prevention will be absolutely critical. There is a huge opportunity cost from a massive restructure and reorganisation of the NHS, which, let’s face it, is quite narrow in the part it takes up in creating and sustaining good health. So, there is focusing sufficiently on health.
Secondly, there is the health and care interface, and the importance of good social care—I know that you are very interested in that. We are midway through a Parliament. In terms of the speed at which different processes and reforms are moving, there is a gaping hole in the progress that we are making on fundamental social care reform. Outcomes for people—quality of life, dignity and living as they wish—should be a big priority.
Q55 Paulette Hamilton: Thea, what do you think is missing from the Bill?
Thea Stein: I think there is probably too much in it rather than things missing. That maybe circles back to the point that all three of us have made over and over again: the biggest changes you make are often around culture, partnerships, people, how people work together, how people choose to listen to patient voice. You cannot legislate your way out of the problems that we face.
I think the legislation that is there needs to be thought of and critiqued in many of the ways we have talked about. There are, in addition, a couple of clauses that I would want to pick up. I do not think that we need to legislate for more things; there are more fundamental and much harder conversations about culture, value, training, experience, and they will change things far more than this legislation will.
Q56 Paulette Hamilton: Sarah, do you think that we could add more, or is there too much in there? Do you agree with what Thea says?
Sarah Woolnough: Yes, I broadly agree. I think that there could be something to signal enough focus on prevention or tackling health inequalities, but I have to be careful not to sound hypocritical, because I genuinely believe that legislation only gets you so far. On this idea of promoting health in all policies, the Government have said that they will shift money towards both community and prevention, but we have not seen very much evidence of that to date. Again, that could be looked at through the lens of legislation, but it does not need to be; there are other ways to drive such transformational change.
Paulette Hamilton: Great stuff. Hugh?
Dr Hugh Alderwick: I agree with Sarah. This is a bit about the NHS. The Government need to focus on health and inequalities. A lot of that is about political will and investment. But if you wanted to use the legislation to force that issue, there are a couple of things that you could do. One example is in the new English Devolution and Community Empowerment Act, in which there is a duty on strategic authorities to improve health and reduce inequalities, looking across their functions. At the moment, the duty of the Secretary of State in relation to health and inequalities is narrower, but it could be broadened—that is one example.
There are other examples, but this is about having a cross-Government strategy, investment and things that have as much to do with policy as they do with legislation. That is one specific example, but there are a few others on which I can follow up with the Committee—there are three or four that you could consider.
Q57 Paulette Hamilton: Would you be able to send them in to us? You have given us some good suggestions.
Dr Hugh Alderwick indicated assent.
Q58 Paulette Hamilton: This is my last question—I will start with Dr Hugh Alderwick. Health Equals have argued that the Bill represents a missed opportunity to create a stronger duty to reduce health inequalities. What do you make of the proposals from Health Equals?
Dr Hugh Alderwick: That is what I was just referring to and summarising. Their argument, which is good, is that the big health challenges facing the nation are to do with wider social and economic determinants of health. The Government need to put in place a strategy that goes way beyond the NHS to improve health and reduce inequalities, but the Bill is about the health system and how it is organised. There are some things you could use the Bill to do to force policymakers to consider health more broadly, and the big one is broadening the duty on the Secretary of State to think about the wider determinants of health inequalities, not just about access and outcomes from health services. That is one specific thing.
Q59 Paulette Hamilton: I agree that health inequalities are a major worry within the new Bill. Sarah, I ask you the same question about Health Equals. What do you make of their proposals? Just give me one point.
Sarah Woolnough: I agree with what Hugh said. We have published quite a bit about when we have made more progress on tackling health inequalities, and history shows that it is not dependent on any single piece of legislation. You need energy, political will and cross-departmental working. The other point is that it sits with not just the Department of Health and Social Care. If you are really serious about tackling inequalities, it needs to be much broader, which is why the idea of a cross-Government health mission that genuinely thinks about contributions from different parts of Whitehall, but also regionally and locally, is important. I am absolutely supportive of the idea of prioritising the tackling of health inequalities. Is it worth amending this piece of legislation? You could argue it either way.
Q60 Paulette Hamilton: Finally, Thea, I will ask you the same question.
Thea Stein: I agree with Sarah. It is such a big issue for this Government or any future Government to consider health inequalities and how to tackle them. It will not happen because you put it in health legislation; it will happen because a Government choose to really grip it across Government.
Q61 Alex McIntyre: What if we amended it to say that every Minister across Government should consider health inequalities when announcing major policies?
Thea Stein: That would be good.
Chair: Thank you for your time. Next panel, please.
Witnesses: Dr Wendy Taylor and Dr Victoria Tzortziou Brown.
Chair: Thank you very much, panel two. We are so very nearly on time—I am hoping that we will be. As with the last panel, would you mind introducing yourselves and saying what organisation you are part of?
Dr Wendy Taylor: I am Wendy Taylor. I am the chair of the LGA Health and Wellbeing Committee. I am also a councillor in Newcastle, where for many years I have been the chair of the Health and Social Care Scrutiny Committee. I have also been the vice-chair of the regional ICS scrutiny committee, and I have recently taken on a new role as cabinet member for integrated health and adult social care.
Dr Victoria Tzortziou Brown: I am Victoria Tzortziou Brown. I am a GP in Tower Hamlets in east London, and I am the RCGP president.
Q62 Alex McIntyre: There have been concerns from GPs about what the Bill might mean for their position as data owners in relation to the single patient record. What are the main concerns of GPs?
Dr Victoria Tzortziou Brown: As a GP, when I think about my responsibilities in terms of data, I do not see my role as the data owner; I see my role as the data steward. When I talk about stewardship, it is about the responsibility of recording the data accurately and in a meaningful way so it can be used to guide clinical decision making. It is also about making sure that the data is kept safely, respecting patient confidentiality, and inspiring trust in my patients, so that they come and see me again.
Q63 Alex McIntyre: Sorry, but I must cut you short in the interest of time. That is the data controller role, which is all set out in law, but what are GPs’ concerns about the changes proposed in the Bill?
Dr Victoria Tzortziou Brown: We have not seen how the single patient record will be operationalised and what it will mean for the legal responsibilities of GPs or any other part of the system, so it is very difficult to answer that question. It is really important for us, first, that patient trust is maintained and, secondly, that clinicians are very clear on where accountability and liability lie.
Q64 Alex McIntyre: I guess the point I am trying to pull out is that I know from meeting with GPs in my patch that one of their concerns is about their legal responsibilities as data controllers. Any kind of ambiguity under the new proposals about who has responsibility might leave them open to liability. In an ideal world, do GPs want to carry on being the data controller for the single patient record, or would they prefer for that role to be held by the Secretary of State?
Dr Victoria Tzortziou Brown: That is a difficult question because we have not asked our members, so I cannot respond. We do not have a clear position as a college. What we do have a clear position on is that we want the way our data records are managed to inspire trust for our patients, and we want clarity for clinicians on who is responsible and on when or where liability lies.
Q65 Alex McIntyre: I am a little confused. You said publicly that you would like the Government to provide financial indemnity to protect GPs against breaches.
Dr Victoria Tzortziou Brown: Yes.
Q66 Alex McIntyre: So how is that you have a position on that but not on whether you fundamentally want to be data controllers?
Dr Victoria Tzortziou Brown: That we want liability cover goes without saying. If we are the data controllers and we have that responsibility, then we absolutely need to be indemnified. Whether we should be data controllers will depend on how things progress with the single patient record. From what I have heard—and again, this seems to be evolving—the GP role in data control will continue, and then there will be a second data controller role for the Secretary of State if the single patient record materialises. But we have not seen the legal detail on that, so it is very difficult to comment.
Q67 Alex McIntyre: I am conscious that we are not necessarily going to have you back, so we must try to drill into this. In a theoretical scenario—although it is not theoretical because it will happen—in which data is shared more widely than it has been in the past, with more partners and on a national scale, does the college have a view on whether it is better for individual GPs or the Secretary of State to hold the legal responsibility to be the data controller in those circumstances and with that kind of model? Or do you just not have an opinion?
Dr Victoria Tzortziou Brown: We do not have a position on that.
Q68 Alex McIntyre: Okay. What information do you need from the Government to be able to make that decision?
Dr Victoria Tzortziou Brown: We will need to see how any single patient record or interoperability will be operationalised. We will need to see the detail of that, including what it will mean for the responsibilities of clinicians in maintaining data safely and ensuring patient confidentiality.
Q69 Chair: I will turn to Wendy on social care. The first report of this Committee looked at social care, the cost of inaction, and data sharing. A lack of data sharing was identified as a massive gaping hole. To what extent, in your understanding, do the provisions in the Bill allow data to be shared with social care providers?
Dr Wendy Taylor: I think they do, but it is going to be a huge problem bringing everything together from different systems, different cultures and different ways of working. It is certainly essential that social care is part of the single patient record; otherwise, we are not going to get proper integration of social care and health.
I think a number of things could be done. Social care has to be an equal partner with the NHS in this. Unfortunately, what tends to happen is that the NHS takes control and then other people come in afterwards, so I think there need to be strict safeguards on what goes in. One of the problems is the fragmentation of the provider market—how we bring in providers to be able to access the records, how we bring the needs of carers into that record so we know that people need support in their caring roles.
It is going to be a problem, but I do not think it is insurmountable. The LGA feels very strongly that we want to see a joint record that has both health and social care information in it.
Q70 Chair: This Committee would agree with a lot of that. You have pre-empted my next question, which was, “What are the barriers?” Is the LGA doing work around the legalities and what is necessary? We have this Bill in front of us. Is this our one and only opportunity, or can all of what you have said be achieved without the Bill?
Dr Wendy Taylor: I think it could, but the Bill probably helps because we want to see national standards on confidentiality, on the safeguards mentioned in your previous session, and so on. That probably needs some legislation to make sure it works.
I think there is a willingness to do that. As was said in the previous session, everything depends on good relationships, and if you have good relationships with the NHS and the local authority, we can make it work, but it will take some time to get all the information together.
Q71 Chair: Are you aware of parts of the country where this is working well?
Dr Wendy Taylor: Some pilots have been done—let me just try to find an example.
Chair: That would be really helpful.
Dr Wendy Taylor: In Cheshire and Merseyside, the ICB and local authorities have worked together on a Marmot-based approach to tackling health inequalities. They have aligned their action on housing, employment and community support with NHS services. The partnership has then supported earlier intervention and more targeted support for deprived communities. That has led to a clearer systems focus on reducing health inequalities and addressing the root causes of ill health, rather than just responding to crisis.
Q72 Chair: That draws us into what the LGA has called for, which goes even wider than this: the single person record. Tell us more about that.
Dr Wendy Taylor: The feeling is that, initially, we need to get health and social care together and make that work before trying to bring in anything else. But our long-term view is that the social determinants of health should also be in the record as well, so that, as you say, it would become a single person record that might have information about employment, housing, environmental concerns and possibly even education or benefits. You then have all the information together to make sure that we are concentrating on prevention rather than just tackling ill health.
Q73 Chair: With that in mind, and if that is what the LGA thinks would be really helpful, is there anything that we should be looking to include in the Bill to enable that to happen? Have you thought about the specifics yet, such as amendments to the Bill or which clauses we should be trying to tie this to?
Dr Wendy Taylor: No, I am not sure that we have got that far. I can certainly check with officers and see whether they have made any progress there, but at the moment I think it is more of an aspiration than a clear view of what needs to be done by way of amendments.
Q74 Josh Fenton-Glynn: I am going to talk a bit more about the move away from local government representatives and Healthwatch. The Bill removes the requirement for ICBs to have members from local authorities and primary care provision on their boards, which both your organisations oppose. Can you give some examples of where the current membership system and structure have had tangible impacts on service delivery?
Dr Victoria Tzortziou Brown: It is difficult to give specific examples because there has not been any research at a great scale to see the impact of individuals on these boards. However, from my personal experience of being on commissioning boards, I very much understand how having a GP representative on a commissioning board can be useful in bringing an understanding of the system and helping to do the strategic commissioning that we mentioned before.
We GPs have a unique view of the whole health and care system because our patients present their experiences of the system to us, so we can identify where the gaps are and where fragmentation lies. We can then transfer all those insights from our patients and colleagues to the board to help to transform services, which can be fundamentally useful at that level. The other very helpful thing is having people from the local authority, including public health colleagues who can provide population health understanding at that level.
Q75 Josh Fenton-Glynn: I will come on to the local authority in a second. I get that you are seeing patients and how they interact with the system every day, so of course you will see where the gaps are, but what does that look like?
Dr Victoria Tzortziou Brown: Do you mean how do we bring that to the board?
Q76 Josh Fenton-Glynn: Yes, but also, what do you see that gives you a unique insight that someone looking from further away or on a spreadsheet might not see, such as something about the patient population or a service that is just not tying up properly?
Dr Victoria Tzortziou Brown: Patient experience of the system is not captured in any data dashboards, but patients do come and say, “I went to this service and got really good care,” and, “I went to this other one and was lost to follow up.” It is about identifying which services really provide good care for patients and which services have gaps, for example, because the patient does not fulfil their very strict criteria for referral. We GPs are very good at understanding how the system and the interface work and where the gaps are, and that is very useful knowledge when we are talking about pathway redesign and transformation.
Q77 Josh Fenton-Glynn: Not to put words in your mouth, but would you argue that having that GP frontline primary care voice on the board helps to deliver care as well as treatment?
Dr Victoria Tzortziou Brown: Absolutely, and it helps with patient advocacy as well.
Q78 Josh Fenton-Glynn: Thank you. Dr Taylor, I should probably declare an interest: I was a cabinet member for social care and worked with the LGA in that capacity, so I have also sat on such a body. Could you outline the LGA’s position on the removal of local government from those boards?
Dr Wendy Taylor: We feel it is very much a backward step. If neighbourhood health is going to work, local authorities have to be at the centre of making it work because they are the convenors of so many services—public health, housing, education—and work with the NHS. You lose that local knowledge going into the ICSs, which are absolutely huge. Even the strategic mayoral authorities are pretty huge—a couple of million people are covered. The mayor is not going to know the local priorities; they will differ between, for example, Workington and Whitehaven or Newcastle and Sunderland. It is only the local perspective that can be brought to the ICS to help to shape the decisions that are made. If the decisions are made outside the local priorities, that is a huge problem.
Q79 Josh Fenton-Glynn: I saw this in West Yorkshire ICB. Obviously, Bradford has very different health problems from Calder Valley, which has very different health problems from Wakefield. Getting the balance right is about understanding those populations, which is why local voices make a difference. If the Government go ahead with this, what would you both like to see in order to mitigate it?
Dr Wendy Taylor: There has to be some role for local authorities, as well as for GPs, in feeding into the ICS. There are a number of options for how exactly to do that, but there must be a clear way for the ICS to get the views of local authorities and the local priorities before it makes its decisions.
Q80 Josh Fenton-Glynn: What would that look like?
Dr Wendy Taylor: It could be a committee. Again, as was mentioned earlier, getting rid of the ICPs is a big problem—that could have been the way it was dealt with. I would ask whether we can, ideally, just go back to having local authority representation. Obviously, it cannot be every local authority—we have, I think, 13 local authorities in our ICS—but we should at least have one or two that would be able to give the local authority perspective.
Q81 Josh Fenton-Glynn: It feels like an upper-tier authority issue rather than a lower-tier one in general. What would the RCGP like to see to mitigate losing that voice?
Dr Victoria Tzortziou Brown: It is bringing it back.
Josh Fenton-Glynn: That is not mitigation.
Dr Victoria Tzortziou Brown: I would say bring it back and multiply it. However, if that is not there, then we need to think how we capture that experience which can be so useful for service redesign. We need to amplify the clinical leadership that we have at ICB level to get those insights into service design.
Q82 Josh Fenton-Glynn: Dr Taylor, I am sorry, but you will need to be quite quick as we are running slightly behind on time. The proposal is to bring some of the Healthwatch function into local authorities. I suspect I know the answer to this, but how well set up are local authorities to take on that role?
Dr Wendy Taylor: We feel that it is a big mistake to get rid of local Healthwatch. There are mixed views and it has not always been effective, but I do not honestly think that splitting patient voice for social care from patient voice for health is going to help anybody. It is just going to cause fragmentation, so that if somebody is using both services they have to go to one person to complain about one thing and somebody else to complain about another. It must be an independent voice, otherwise it does not work.
Q83 Josh Fenton-Glynn: The theory behind the single patient record is to stop people having to tell their story again and again. You do not really want people to have to do that when trying to get recourse after bad situations.
Dr Wendy Taylor: I think losing that independent voice is a big problem, and my committee certainly discussed that at our last meeting and concluded that local Healthwatch should not be disbanded unless an alternative independent voice was put in place. We feel very strongly that that is needed, as are its enter-and-view powers to go and look at any services that it likes to ensure the residents are actually getting the services or to visit the care home or whatever. It can go in and talk to the residents and get those views. I think it is a really important role.
Q84 Chair: Jen is going to talk about neighbourhood health plans, so please save any comments for Jen’s questions. However, as you will notice from the Bill, the health and wellbeing boards themselves are mentioned and form part of the wash up—if you want to put it in a nice way—and the bits of the system that are not assigned end up there. Reflecting on my local board as an MP, and people’s understanding of it and to what extent it has teeth in the face of the dictating trusts, I am not totally convinced that those boards work as well as they could. I am therefore concerned that the Bill is putting a lot of weight on organisations that probably could use a bit of beefing up. Would you agree with that, Wendy?
Dr Wendy Taylor: Yes, very much so.
Q85 Chair: Can you help me be a bit more specific in my thinking: what should we recommend the Government do to make a success of the beefed-up roles of health and wellbeing boards?
Dr Wendy Taylor: I think that the funding and support that the health and wellbeing boards get will be an issue. We will need more staff to be able to support the health and wellbeing board to make those decisions and stop the NHS taking over neighbourhood health. That is unfortunately the way that things are going in some areas where it is very much the NHS moving in and saying, “We have localities and primary care networks, and we know what we are doing.” It could be that the local authority then gets left out of that. We certainly have a very different view of neighbourhood health.
Dr Victoria Tzortziou Brown: If the aim is to better integrate health and social care at a local level, then the health and wellbeing boards should have an important role to play. To do that role well, they will need to bring in representatives and clinical leadership from both the health and care spaces along with the analytic capability so that they understand the population and can use the data to underpin any decisions about how any shared funding will be used.
Q86 Jen Craft: That leads me on to your broad view of the changes that the Bill makes to service planning and integration. I think that you have covered some of it there with regards to not wanting the NHS to take over neighbourhood health. Can you speak a little bit more about that?
Dr Wendy Taylor: Certainly, there is a lot more to be done on integrated funding. Continuing healthcare is an example of where it is really not working at the moment. We actually have ICBs commissioning consultants to go in and look at their health plans and say, “We do not need to support that one any more”, and then trying to hand the costs back to the local authority. It then goes to appeal, and there is a poor person stuck in the middle wondering what on earth is happening with their care. That is the sort of area where we need much more joint funding to be able to do the job properly.
It is also about how you look at neighbourhoods. To be honest, in a city 50,000 people is not a neighbourhood. If it is not based on genuine neighbourhoods, I do not really see how it is going to work. We would be looking at it as a local authority, asking what services we have. What services does the NHS have? What services does the voluntary sector have? Where are they based? What is working? How do we bring them together in libraries, community centres, church halls, etc, to try and make that work? The NHS is much more top-down. Bringing that together and how we best do that is really going to be the challenge for neighbourhood health.
Q87 Jen Craft: Is your experience more that the NHS almost looks at how it can make neighbourhoods work for it rather than the other way around?
Dr Wendy Taylor: I think that is a risk. I am not saying it is necessarily going to happen, but it is a risk.
Q88 Jen Craft: Is that based on past experience working with NHS bodies?
Dr Wendy Taylor: For me, it is based on the initial plan for our neighbourhood that came forward for scrutiny. It was very much based on the NHS localities, which are massive. I have to say, I did not really think that was going to work.
Q89 Jen Craft: Is it a pure numbers thing? So looking at population size? Or is it more nuanced than that?
Dr Wendy Taylor: It is a bit more complicated. There are areas where you might have 50,000 people who could call themselves a community. With a small town that would be fine. But in other areas you can have very different communities within quite a small area. You can have a very deprived area just a few miles away from somewhere that is very affluent. Their needs could be very different.
Q90 Jen Craft: We all know that as constituency MPs. I do not think any of us have a pure homogeneous constituency. Are there any aspects of the previous joint forward plans and joint capital plans that you would like to keep?
Dr Wendy Taylor: I have not really been involved with the health and wellbeing board in my previous role, so I am not sure I can really answer that. Certainly, that is something that I will take to the LGA to talk about.
Q91 Jen Craft: You have spoken about your concerns, but what would you like to see done differently in the production and focus of neighbourhood health plans? What would make it really work for you?
Dr Wendy Taylor: It is really thinking about how you can best provide the service without starting to build shiny new buildings at great cost. We have the services there. There is good work going on. We have some excellent services. It is just about bringing it all together with the NHS and making sure that we can actually provide the services close to where people are.
Q92 Jen Craft: It is interesting the way that you put it. We have just finished a trip to Cornwall looking at the neighbourhood health infrastructure that was in place. I do not think it is out of place to say that it seemed that there were two very distinct views of NHS estate. One was from the NHS, which was the bricks and mortar building, which you can build big and shiny. That was versus local authority VCS, which is that the estate should be wherever you can provide healthcare, such as village halls, libraries and anywhere you have got a spot. Do you think that having more detail of that, either in the Bill or in guidance, would allow neighbourhood health plans to achieve what they are supposed to be doing?
Dr Wendy Taylor: I would hope that the pilots will start to give some information on what works and what does not. There are some very interesting things coming forward. I remember a talk at our committee in which somebody said that providing a service in the cricket club did not work, but providing it in the football club across the road did. It is just simple things like, where will people actually go to get their service? And how do you make sure that people who are underserved or socially deprived actually use the service? They are the people we really need to get to sort out health inequalities.
Q93 Jen Craft: Victoria, anything to add?
Dr Victoria Tzortziou Brown: We need to have clarity on what we are trying to improve with neighbourhood health. It should be about improving health outcomes for our population. Bringing together health and social care and the voluntary sector is really important in working with our communities. While we do that, we need to remember that, if the aim is to bring more services closer to home, resources need to follow. A lot of the time, we expect community services, general practice and local authorities to work together, while forgetting that those are the least well-funded parts of our health and care system. Unless resources are transferred at the same time, it will not be easy to transform the services that we provide and deliver more care in the community. It is very important that any transformation is well resourced in order for it to succeed.
Q94 Jen Craft: Do you think some of that under-resourcing is that siloed thinking from either NHS or—I hesitate to say—local authorities thinking, “This is my remit.” You gave the example of continuing healthcare, where you have the patient there but two organisations battling about who should pay. At the end of the day, the patient is not first in that. Does the Bill address enough that current way of working, or does there need to be something more in it about joint planning and joint commissioning that would actually enable that to happen?
Dr Victoria Tzortziou Brown: The Bill could ask for more accountability locally on how this resource is going to happen and who is going to report on not only how much activity is being transferred out of hospital and closer to home, but also how much funding is being transferred and workforce as well.
Dr Wendy Taylor: I would agree with that, certainly.
Q95 Chair: Can I ask about section 75 arrangements? The Committee, on at least a couple of occasions, has suggested that the Government strengthen those as the basis on which funding could be shared and flow better to the neighbourhood. Wendy, do you have experience of section 75 arrangements in the places that you have been a councillor?
Dr Wendy Taylor: No.
Q96 Chair: I would be curious to know if the LGA has specific things that we might want to add to those funding arrangements. It seems so self-evident to me that, with all the will in the world, there are two things that need to change, one of which we probably cannot do in the Bill, but one we might be able to. One is culture—I think that was made extremely clear in our first panel—but the other is funding arrangements and funding flows. There is an opportunity in the Bill to embed some of this as potentially part of these neighbourhood health plans, but I am searching for clarity about what exactly it is we need to be searching for. Victoria, do you or the Royal College of GPs have any idea?
Dr Victoria Tzortziou Brown: As I said before, we are expecting already very poorly funded parts of our health and care system to merge budgets and contribute to something together. Unless we fund these parts of the system better, they will not have the ability to pool the funding in a meaningful way to deliver something better. It is about better transparency on when care is being moved closer to the community or when we are expecting more to be delivered in the community. We need to have more transparency on how the resource will follow and report on that.
Q97 Chair: Where exactly do you feel should that sit?
Dr Victoria Tzortziou Brown: We are asking for the primary care investment standard, and we are asking for this to be reported both by the Secretary of State and at ICB level. Whatever commissioning arrangements will be in place in the future, there has to be transparent reporting on how much funding is being allocated at local level for these sorts of initiatives.
Q98 Chair: That answers my last question, which is about what we should be looking actively to include. That is one. Wendy, do you have any others?
Dr Wendy Taylor: I think we are all aware of the dire state of local council funding at the moment. We need to work on that. The better care fund, for example, is working very well, and the NHS and local authorities have come to sensible decisions about how that could be spent. That could be expanded or a similar scheme introduced to make sure that the funding for neighbourhood health is there, so that we can implement what we want to do. I know we are not talking about social care, but ideally, moving social care away from local government funding would be a great step forward, because it really is a drain on local council resources.
Chair: Thank you very much for your time. Thank you also to our first panel.