Health Bill
Tuesday 16th June 2026
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09:27
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Speaker 2
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Speaker 2
Quietly, please. If our first witness from NHS England could take the chair. Oh, she's not coming. She's on the screen. She's on screen. I beg your pardon?Oh, sorry. I was looking at an empty chair. And you're there. Thank you for joining us. Okay, we're now sitting in public again. Proceedings are being broadcast. Before we start the hearing from the witnesses, do any members wish to make a declaration of interest in connection with this bill?Doctor Caroline Johnson.
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09:31
Speaker 2
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Speaker 2
Anymore?No, thank you very much. Um. If it's relevant to members questioning. It's helpful if they reiterate that those declarations at the start of any speech you make, just to remind everybody. You. Hear oral evidence from NHS England. I'm afraid we have to stick to the timings very rigidly because we've got a lot to get in this morning and we have for this session until 955. So. Could you be very kind and introduce yourself briefly for the record, and make any very short opening remarks you wish to make, please?
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Speaker 3
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Speaker 3
Thank you chair. Good morning, doctor Dash. Um I wonder if you could tell us um what effect is the abolition of NHS England having on its current day to day function. What sort of numbers of people are working solely or mostly on the um transfer. And is that affecting your ability to deliver on your core business?
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Speaker 7
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Speaker 7
Thank you. Um, so I don't believe it is affecting our ability to deliver. Much of the work to date has been led by a joint team of people from across NHS England and the Department of Health and Social Care who are working together, have put together process, um, and have been going through all of the things that you would expect of any integration process. And that's been a fairly confined team as they are starting to look at what needs to happen in each of the different functional areas, the different directorates that we've set out there, working with the, um, director generals or the executive directors leading each of those to understand what should the, what, what different functions do we need to enact within each of those directorates?And what could their teams look like?So they are putting time into that, which is good.
That's what we want them to do, not least because they're also looking at ways of working, not just numbers of people. But I wouldn't say that that is a distraction. And in fact, in some ways, I'd say it's really helpful because it's helping to define what are the core priorities, what are the key things that we need to focus on, and how do we continue on the journey of seeking to improve health and improve healthcare services?So that's, uh, across the, those executive directors and directors general, the team that is putting a lot of time into this, not surprisingly, is are the people working in the HR functions.
So that team is, not surprisingly, spending a lot of time going through the mechanics has been managing things like the voluntary redundancy programme and so on. But I would hope that and I believe that in terms of us focusing on what we need to focus on, I don't see a negative impact.
That's what we want them to do, not least because they're also looking at ways of working, not just numbers of people. But I wouldn't say that that is a distraction. And in fact, in some ways, I'd say it's really helpful because it's helping to define what are the core priorities, what are the key things that we need to focus on, and how do we continue on the journey of seeking to improve health and improve healthcare services?So that's, uh, across the, those executive directors and directors general, the team that is putting a lot of time into this, not surprisingly, is are the people working in the HR functions.
So that team is, not surprisingly, spending a lot of time going through the mechanics has been managing things like the voluntary redundancy programme and so on. But I would hope that and I believe that in terms of us focusing on what we need to focus on, I don't see a negative impact.
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Speaker 3
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Speaker 3
Thank you. Um, just moving on to a question about H sip. You wrote a report about the CQC which wasn't hugely flattering. Um you've also wrote a report about patient safety landscape. Um two questions if I can indulge the chair. One is um why did you choose to roll H into the CQC, given what you said about the CQC and the conflicts of clear on obvious conflicts of interest that it creates, and also you identified in your findings that a large number of clinical nursing staff were being moved into more managerial roles within, you know, within effect on the clinical capacity, um, which of your recommendations or what would you recommend now would deal with that?
09:35
Speaker 7
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Speaker 7
Thank you. Um, so in terms of the first question, my yes, as you say, my first review looked at CQC, um, found that there are a number of considerable challenges there. And I would have hoped that by now many of those challenges had been addressed. Now some of them have been, but some of them have struggled because there's been a a change in the new. You know, they've already gone from the previous chief exec to a new chief exec, and they're now out looking for another chief exec.
Plus, the chair has changed. So that has definitely impeded progress. But as I said, they have or they've made some considerable progress in some key areas, in particular, uh, looking at the use of technology. But they have still got a way to go. And I think we all need to acknowledge that. And I note that the ministerial team within the Department of Health and Social Care have suggested that the integration of H into CQC should only happen when CQC is in a more stable position.
And that sounds sensible to me, and pragmatic in terms of the second review that I did, I was asked to look at the regulatory landscape and the quasi regulatory landscape. I was referred to a report that had been done by Professor Karl McCrea and others that talked about 126 organisations. When I looked, I found more than 150 and listed all of those in in my report. And the observation was. And I spoke to many, many people, well over 200 people who joined various roundtables and so on that we had.
And the very consistent theme was that this is so busy, so confusing, and keeps leading to all sorts of different recommendations from different organisations, but also people having to continually respond to all of these different bodies, asking for people to fill out a form on something, asking questions, doing reviews. Uh, and as a result, our clinical staff actually not just our nurses, but all of our clinical staff are having to spend considerable time filling out those forms, going through tick box exercises. And you will hear people talk about that a lot.
And so the concern is that this very busy landscape is distracting from what it actually is there to do, which is to improve quality of care. So I was asked by, um, Department of Health Social Care to look at this landscape, and I was asked to focus on six organisations that are listed in my report, of which he was one, but across the six and of course, six is small. Out of that 150, I was asked to look at where there were opportunities for rationalisation and simplification, and the observation was that Hscb colleagues in.
Hscb have some great skills and capabilities in carrying out investigations into looking into health care. Highly complementary to the work of CQC, which is equally there to understand how well different organisations are performing to give the public confidence to give ratings and also to identify problems, and therefore putting those two organisations together would create significant synergies and opportunities for them both to work well.
Plus, the chair has changed. So that has definitely impeded progress. But as I said, they have or they've made some considerable progress in some key areas, in particular, uh, looking at the use of technology. But they have still got a way to go. And I think we all need to acknowledge that. And I note that the ministerial team within the Department of Health and Social Care have suggested that the integration of H into CQC should only happen when CQC is in a more stable position.
And that sounds sensible to me, and pragmatic in terms of the second review that I did, I was asked to look at the regulatory landscape and the quasi regulatory landscape. I was referred to a report that had been done by Professor Karl McCrea and others that talked about 126 organisations. When I looked, I found more than 150 and listed all of those in in my report. And the observation was. And I spoke to many, many people, well over 200 people who joined various roundtables and so on that we had.
And the very consistent theme was that this is so busy, so confusing, and keeps leading to all sorts of different recommendations from different organisations, but also people having to continually respond to all of these different bodies, asking for people to fill out a form on something, asking questions, doing reviews. Uh, and as a result, our clinical staff actually not just our nurses, but all of our clinical staff are having to spend considerable time filling out those forms, going through tick box exercises. And you will hear people talk about that a lot.
And so the concern is that this very busy landscape is distracting from what it actually is there to do, which is to improve quality of care. So I was asked by, um, Department of Health Social Care to look at this landscape, and I was asked to focus on six organisations that are listed in my report, of which he was one, but across the six and of course, six is small. Out of that 150, I was asked to look at where there were opportunities for rationalisation and simplification, and the observation was that Hscb colleagues in.
Hscb have some great skills and capabilities in carrying out investigations into looking into health care. Highly complementary to the work of CQC, which is equally there to understand how well different organisations are performing to give the public confidence to give ratings and also to identify problems, and therefore putting those two organisations together would create significant synergies and opportunities for them both to work well.
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Speaker 7
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Speaker 7
Yes. So one of the things that, uh, which I observed when I was doing the review, but I've also observed even more so now that I'm in post, is that we, uh, don't have a effective mechanisms of really learning from patients and patient experience. And if I compare how the NHS works to how other large organisations in our country work, we're not systematically collecting patient information. We're not looking at that in detail. We're not segmenting it into different groups of people, and we're not systematically bringing it into board meetings, which is where it should be in order to drive improvement.
And so we are hoping that the new director of patient experience, or we are expecting that new director of patient experience, will take a real leadership role in this and will both improve the way in which the centre works, but more importantly, will be working with organisations right across the NHS to build those skills and those capabilities, and to put patient experience, feedback and patient improvement in patient experience right at the centre of every discussion on improvement.
And so we are hoping that the new director of patient experience, or we are expecting that new director of patient experience, will take a real leadership role in this and will both improve the way in which the centre works, but more importantly, will be working with organisations right across the NHS to build those skills and those capabilities, and to put patient experience, feedback and patient improvement in patient experience right at the centre of every discussion on improvement.
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Speaker 9
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Speaker 9
Thank you very much, chair, and good morning, doctor Dash. Um, can I return to the issue of Seb?Um, since hearing the evidence that was given to the Health and Social Care Select Committee, have you reflected on the concerns that the driver of confidence in H. Seb, is its operational independence, and what concerns do you have that it will lose that perception of independence and its safe space approach to to learning when something goes wrong.
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Speaker 7
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Speaker 7
So CQC is an independent regulatory body as well. So the hope and expectation is that we have a high calibre, independent regulatory body, uh, which is the primary regulatory body for looking at how well health and care services are delivered and is able, as well as observing how well they're currently performing, is able to, uh, carry. Out specific focused investigations when it spots systematic problems across the healthcare system, or indeed when particular problems are identified in terms of safe space. Clearly confidentiality is important.
Confidentiality is important right across the board. Staff need to feel able to report within NHS organisations and to the CQC, where they have concerns. I have to say I was concerned at that health Select committee to hear an example given, um, I think it was from Jeremy Hunt who gave an example, who said if a midwife is concerned about quality of care in their maternity unit, they need to be able to go somewhere and report that. And within eight Shiv H. Seb would not tell anyone else about it.
I looked at Duncan, who's the, uh, our chief nursing officer who was there with me. We were shocked to hear that. How can that possibly be right?We need to have a mechanism whereby if there are concerns about quality of care, they are properly investigated and they are properly investigated, and there are mechanisms in place to then deal with those problems and to improve services. So yes, we need confidentiality. I was not convinced by what I heard then that we needed a completely separate organisation that was duplicating the work of others.
Confidentiality is important right across the board. Staff need to feel able to report within NHS organisations and to the CQC, where they have concerns. I have to say I was concerned at that health Select committee to hear an example given, um, I think it was from Jeremy Hunt who gave an example, who said if a midwife is concerned about quality of care in their maternity unit, they need to be able to go somewhere and report that. And within eight Shiv H. Seb would not tell anyone else about it.
I looked at Duncan, who's the, uh, our chief nursing officer who was there with me. We were shocked to hear that. How can that possibly be right?We need to have a mechanism whereby if there are concerns about quality of care, they are properly investigated and they are properly investigated, and there are mechanisms in place to then deal with those problems and to improve services. So yes, we need confidentiality. I was not convinced by what I heard then that we needed a completely separate organisation that was duplicating the work of others.
09:41
Speaker 9
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Speaker 9
Thank you chair, and I should have declared that I'm a member of the patient Safety Appg. Um, can I just also, uh. Turn to similar concerns about Healthwatch and its independence?Um, if it's. Absorbed within Icbs locally or within the Department for health at a national level, do you have concerns that those organs will. Organizations will essentially be marking their own homework rather than listening to impartially collected evidence about patient experience.
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Speaker 7
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Speaker 7
As I've just said before, I think we absolutely want, first of all, talk about providers and then I'll talk about the commissioners, the payers, the icbs. So in terms of providers, I. GP practices, community trusts, hospital trusts, we absolutely should be expecting all of them to see patient experience as a crucial part of their role, not to outsource it to someone else. It has to be a crucial part of what they do. They need to get way better at collecting patient experience.
They need to understand it from different groups, from different wards, from different medical teams, and they need to be playing that back. Ideally, that should be part of everyone's appraisals. Here's the sort of feedback that we've had is what we've heard. Here's how we're acting upon that. We need to put that in the places where health care is delivered, and that is in those provider organisations. The Icbs have a different role, which is to commission healthcare services in order to improve health and ensure high quality care.
And it is their responsibility to speak to communities. They, and many of them, well, they all have considerable teams of people who are doing that, who are speaking to different members of society, conducting usually frequent events to to get input, to hear from people. What are they looking for from their health and care services?And when they're looking to design particular services, whether it's mental health services or children's services, then they go much deeper on that. And they speak to specific groups, often involving the providers as well.
So those are mechanisms which we need to well, already embedded within Icbs, but we need to continue to ensure that they do those as well as they can. And what I found when I was speaking to people is, yes, there are some fantastic examples of different Healthwatch organisations across the country, but that is not consistent at all. And they are often too far removed from what's actually happening in terms of day to day services to have a significant impact on improving patient experience.
They need to understand it from different groups, from different wards, from different medical teams, and they need to be playing that back. Ideally, that should be part of everyone's appraisals. Here's the sort of feedback that we've had is what we've heard. Here's how we're acting upon that. We need to put that in the places where health care is delivered, and that is in those provider organisations. The Icbs have a different role, which is to commission healthcare services in order to improve health and ensure high quality care.
And it is their responsibility to speak to communities. They, and many of them, well, they all have considerable teams of people who are doing that, who are speaking to different members of society, conducting usually frequent events to to get input, to hear from people. What are they looking for from their health and care services?And when they're looking to design particular services, whether it's mental health services or children's services, then they go much deeper on that. And they speak to specific groups, often involving the providers as well.
So those are mechanisms which we need to well, already embedded within Icbs, but we need to continue to ensure that they do those as well as they can. And what I found when I was speaking to people is, yes, there are some fantastic examples of different Healthwatch organisations across the country, but that is not consistent at all. And they are often too far removed from what's actually happening in terms of day to day services to have a significant impact on improving patient experience.
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Speaker 7
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Speaker 7
Yeah. So I think that we do need to recognise that I, I hear that as well. Um, and you know, experience that myself, you know, lots of people often reluctant to come forward and they think, you know, if this is my GP, uh, you know, how's this information going to be treated?That's, I think, why we need to really raise the calibre of our directors of patient experience. There are ways in which you can manage that. There are ways in which you can treat that data confidentially.
Well, in fact, you have to treat all data confidentially. There are ways in which you can support people. You can give people the confidence that their information will be taken seriously and will be treated confidentially. You can do that often through focus groups, through 1 to 1 conversations, and indeed through anonymous surveys. We're hoping to be able to do a lot more of that through the app, to link it directly to people's care, to give people prompts as soon as they've had an interaction, please feedback.
So I think that there are ways in which we can overcome that. Um, and that the benefits of almost bringing this, uh, much closer to people's care, much more linking it into day to day practice, making sure that feedback goes straight back, you know, in a, in, in an anonymized way, go straight back to our frontline clinicians to encourage and support them to improve. That brings a significant benefit. And we need to be able to find, and we can find a way around the concerns about confidentiality.
Well, in fact, you have to treat all data confidentially. There are ways in which you can support people. You can give people the confidence that their information will be taken seriously and will be treated confidentially. You can do that often through focus groups, through 1 to 1 conversations, and indeed through anonymous surveys. We're hoping to be able to do a lot more of that through the app, to link it directly to people's care, to give people prompts as soon as they've had an interaction, please feedback.
So I think that there are ways in which we can overcome that. Um, and that the benefits of almost bringing this, uh, much closer to people's care, much more linking it into day to day practice, making sure that feedback goes straight back, you know, in a, in, in an anonymized way, go straight back to our frontline clinicians to encourage and support them to improve. That brings a significant benefit. And we need to be able to find, and we can find a way around the concerns about confidentiality.
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Speaker 10
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Speaker 10
Thank you very much, chairman. I should also declare that I'm a member of the all party group for Patient Safety. Doctor Dash, apologies. I've questioned you on this many times, but I'm going to continue to do so on on h SIB. Um, when we had the King's Fund, the Nuffield Trust and the Health Foundation in front of us, the Health Select Committee, all three of them said very clearly, and I quote, don't do it. When they talked about bringing Hib into the CQC.
In fact, I can find almost nobody apart from yourself and the department who thinks. Moving Habib into the CQC is a good idea. So does that give you any pause for thought about whether you're recommending the right thing?And more specifically, if, as you said at the Health Select Committee, the safe space element would retain it would operate as an independent organisation, how can you square the fact that it would remain independent and yet be part of the CQC?And if it does remain independent, what's the need to bring it into the CQC?
In fact, I can find almost nobody apart from yourself and the department who thinks. Moving Habib into the CQC is a good idea. So does that give you any pause for thought about whether you're recommending the right thing?And more specifically, if, as you said at the Health Select Committee, the safe space element would retain it would operate as an independent organisation, how can you square the fact that it would remain independent and yet be part of the CQC?And if it does remain independent, what's the need to bring it into the CQC?
09:46
Speaker 7
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Speaker 7
So the point of bringing it into the CQC again, as I said before, we're trying to simplify this landscape. There are so many different organisations continually commenting, doing reviews, often replicating the same reviews that other people have done, and the concern is that it's distracting rather than enabling. And so the hope that I had when I made the recommendation, and I still have now, is that by bringing Habib into QC, you can align the work of the two. So for example, if CQC is going around the country and is spotting a particular problem with way in which anesthesia is being given, for example, is spotting a particular problem with managing patients post-surgery that CQC could then say to that team of people with specific expertise, can you go in and take a look at this?Can you go and do a detailed focus review of this particular area of care that we are spotting through our visits seems to be a particular challenge.
So it's that bit about enabling CQC to identify a problem and then ask him to to review it in detail and to bringing their expertise in investigations into the CQC to enable the CQC to go deeper and to then, uh, make. Come back to the NHS with particular areas, but also to supplement the work of the NHS. And I would like to point to. Since H was established, the NHS has established its own much more rigorous, much more robust investigatory investigatory teams and processes.
I'm not saying they're perfect. Of course I'm not, you know, and we can all see that. But they are. I would really encourage all colleagues here today to look at the work that they are doing and to look at the specific areas that they are reviewing and the the outputs of those reviews and the ways in which those are then leading to improving care. And that feels to me to be a much more systematic way of addressing the concerns of patients and families and staff in the place where those concerns happen.
Having mechanisms to be able to escalate those through the NHS so you can bring them to regions. Some investigations get done at the NHS England level, and having CQC as an independent body that can separately review and themselves spot if there are problems, but also ensure that those investigations within the NHS are happening well.
So it's that bit about enabling CQC to identify a problem and then ask him to to review it in detail and to bringing their expertise in investigations into the CQC to enable the CQC to go deeper and to then, uh, make. Come back to the NHS with particular areas, but also to supplement the work of the NHS. And I would like to point to. Since H was established, the NHS has established its own much more rigorous, much more robust investigatory investigatory teams and processes.
I'm not saying they're perfect. Of course I'm not, you know, and we can all see that. But they are. I would really encourage all colleagues here today to look at the work that they are doing and to look at the specific areas that they are reviewing and the the outputs of those reviews and the ways in which those are then leading to improving care. And that feels to me to be a much more systematic way of addressing the concerns of patients and families and staff in the place where those concerns happen.
Having mechanisms to be able to escalate those through the NHS so you can bring them to regions. Some investigations get done at the NHS England level, and having CQC as an independent body that can separately review and themselves spot if there are problems, but also ensure that those investigations within the NHS are happening well.
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Speaker 7
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Speaker 7
Well, you know, as we then have to deal with that as a problem. But you know, that's, that's the same is true of saying what happens if this if you know, the problem is this organisation that we've got 150 organisations 150. What if the GMC is a problem?What if the Nursing and Midwifery Council is a problem?
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Speaker 5
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Speaker 5
Thank you doctor. You've explained about why you believe the changes to Healthwatch will strengthen. Uh, patient. Well responses. Uh, can you just, uh, say. How you think that, uh, that could be kind of strengthened to ensure that the levers really are being pulled for patients?And that's seem to be the case.
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Speaker 7
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Speaker 7
Yeah. So a few things. Sorry. Um, to answer that is. Yeah. Uh, so a few different things. One is we've talked about appointing a director of patient experience. They will report directly to the chief executive of the NHS. I think that's absolutely crucial. It's about emphasising the importance. So that's one piece we've spoken about. And uh, you know, we we're about to do the interviews for that person.
So I hope they can be in post very quickly. The second is that we are hopefully about to publish the quality strategy and within the quality strategy, which has come out of the ten year plan. Uh, we are very clear in talking about the three dimensions of quality. So that is safety. So ensuring that basic standards are in place, it is effectiveness. So making sure that patients receive the right care in the right place at the right time.
And it is delivered to a high standard. And it is crucially patient experience. And in the quality strategy, we emphasise that all three of those are crucial. You need to have all three, and all three need to be done really well. We then go on to talking about, uh, different mechanisms for how we are seeking to improve those and crucially, a set of metrics. So we've got 183 metrics, which we are going to review within the NHS England Quality Committee while it still exists.
And then within the National Quality Board. And we would expect every region to be reviewing those as well as others. And we would expect every ICB and we would expect providers to be reviewing those ones that are relevant to them. So that's the that's the next bit is to have all of those different metrics. The third bit is wider transparency. There are way more than 183 different metrics, and we need to have far more on patient experience. They need to be routinely, routinely collected in the same way that we do a surgical audit, or we do audits of GP work, and those all put in the public domain.
That was a big element of the ten year plan. Um, and then my final bit is we absolutely need boards, as I said before, to take full responsibility and accountability for all aspects of quality. And that includes patient experience. And so as I go around and I meet individual hospital boards, I absolutely am asking them about this. Um, I spend quite a lot of time with chairs and with new non-executive directors coming into NHS providers. And I'm continually emphasising this is a crucial area for you to focus on as a board.
What are you asking your colleagues who have you put in place as your director of patient experience within the organisation?How are you routinely collecting information from a whole spectrum of users, the whole of society, doing that in a confidential way, for the reasons that we spoke about earlier, and then ensuring that people are acting on that. I don't think we're doing anything like enough of that, and we need to get much, much better and be doing far more of it.
So I hope they can be in post very quickly. The second is that we are hopefully about to publish the quality strategy and within the quality strategy, which has come out of the ten year plan. Uh, we are very clear in talking about the three dimensions of quality. So that is safety. So ensuring that basic standards are in place, it is effectiveness. So making sure that patients receive the right care in the right place at the right time.
And it is delivered to a high standard. And it is crucially patient experience. And in the quality strategy, we emphasise that all three of those are crucial. You need to have all three, and all three need to be done really well. We then go on to talking about, uh, different mechanisms for how we are seeking to improve those and crucially, a set of metrics. So we've got 183 metrics, which we are going to review within the NHS England Quality Committee while it still exists.
And then within the National Quality Board. And we would expect every region to be reviewing those as well as others. And we would expect every ICB and we would expect providers to be reviewing those ones that are relevant to them. So that's the that's the next bit is to have all of those different metrics. The third bit is wider transparency. There are way more than 183 different metrics, and we need to have far more on patient experience. They need to be routinely, routinely collected in the same way that we do a surgical audit, or we do audits of GP work, and those all put in the public domain.
That was a big element of the ten year plan. Um, and then my final bit is we absolutely need boards, as I said before, to take full responsibility and accountability for all aspects of quality. And that includes patient experience. And so as I go around and I meet individual hospital boards, I absolutely am asking them about this. Um, I spend quite a lot of time with chairs and with new non-executive directors coming into NHS providers. And I'm continually emphasising this is a crucial area for you to focus on as a board.
What are you asking your colleagues who have you put in place as your director of patient experience within the organisation?How are you routinely collecting information from a whole spectrum of users, the whole of society, doing that in a confidential way, for the reasons that we spoke about earlier, and then ensuring that people are acting on that. I don't think we're doing anything like enough of that, and we need to get much, much better and be doing far more of it.
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09:54
Speaker 11
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Speaker 11
Um, thank you, doctor Dash. Well, Seb is obviously an investigator. A CQC is obviously a regulator, two different roles. And the reason you were asked, I suspect, why the CQC see how it can be investigated by a body that becomes part of it is a good one. Are you aware that the Air Accident Investigation Branch and the UK Civil Aviation Authority are separate and if you are, why should that fundamental separation that benefits air passenger safety not applied to the safety of patients in the NHS?
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Speaker 7
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Speaker 7
So yes, I am aware and the analogy is continually made and it has been made several times. The more. And to be honest, you know, 20 years ago I would have shared a view that healthcare was similar to airlines. And indeed, I made some talks about that quite a lot at the time. But the more I've looked into this, I think that there are limits to that analogy. Uh. I mean, we're sort of running out of time, but it's a much longer conversation.
But if I look at the specific things and the specific examples that people are going to bring up from the airline industry, it's about spotting some very specific things. You know, I think, again, an example was used at health select committee about spotting a bolt that's not working properly. Well, those are mechanisms, you know, the equivalent of that within the NHS is actually something like MHRA, which is separate. So if we spot a drug that isn't working properly, if we spot an anaesthetic machine that isn't working properly, if we spot a cardiac device that isn't properly, that's MHRA and that is separate to CQC.
So what CQC is there to do is to be the independent regulator of the quality of care more generally, and that is actually more the space where each ship has been going. So each ship has been looking at things like use of digital triage in general practice. They've been looking at corridor care and they have done some work on some areas around surgical safety and so on. But all of that is part of a bigger landscape of quality of care, which CQC is responsible for.
So I'm not sure. The more that I looked at this and the more that I spoke to many people, that it is quite analogous to the airline industry. I think it actually goes much broader and it's more complex. And certainly the airline industry does not have 150 different regulators and quasi regulators.
But if I look at the specific things and the specific examples that people are going to bring up from the airline industry, it's about spotting some very specific things. You know, I think, again, an example was used at health select committee about spotting a bolt that's not working properly. Well, those are mechanisms, you know, the equivalent of that within the NHS is actually something like MHRA, which is separate. So if we spot a drug that isn't working properly, if we spot an anaesthetic machine that isn't working properly, if we spot a cardiac device that isn't properly, that's MHRA and that is separate to CQC.
So what CQC is there to do is to be the independent regulator of the quality of care more generally, and that is actually more the space where each ship has been going. So each ship has been looking at things like use of digital triage in general practice. They've been looking at corridor care and they have done some work on some areas around surgical safety and so on. But all of that is part of a bigger landscape of quality of care, which CQC is responsible for.
So I'm not sure. The more that I looked at this and the more that I spoke to many people, that it is quite analogous to the airline industry. I think it actually goes much broader and it's more complex. And certainly the airline industry does not have 150 different regulators and quasi regulators.
09:56
Speaker 2
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Speaker 2
Well, thank you very much indeed. The committee is indebted to you. That has to bring us to the end. I'm afraid of this session of evidence. We now move on, please. So could we have a quick changeover?And may we have the next witnesses?Thank you for joining us. We're now going to hear evidence from the King's Fund and the national voices. Again, I fear we have to stick to the timings.
We have very limited time and for this session we have until 1025. So from left to right, could you please identify yourselves?For the record?
We have very limited time and for this session we have until 1025. So from left to right, could you please identify yourselves?For the record?
09:57
09:58
09:58
09:58
Speaker 3
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Speaker 3
Thank you, chair. Good morning. Um, my first question is for Sarah about the um report the King's fund did saying the potential cost savings of abolishing NHS England would be minimal in the context of the entire NHS budget. Now, many MPs across the House have struggled to get numbers and costings in questions and written questions, um, particularly in relation to staff redundancies. We haven't got the full arrangements of where everything part of NHS England's functions are going to go yet, so how can we be sure it's going to save any money at all?
09:58
Speaker 12
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Speaker 12
Thank you. Um, well, I think on the basis of the question we don't know. I mean, our worry has been the opportunity cost. The government in opposition said that it wouldn't launch whole scale reorganization because it understood the potential opportunity cost both time, but also, um, you know, other resources. And as this plays out, taking longer than anticipated, we've had multiple examples of, uh, you know, teams. Left in limbo as to where they'll end up in the target operating model.
So our ongoing concern has been, you know, is the benefit worth the cost.
So our ongoing concern has been, you know, is the benefit worth the cost.
09:59
09:59
Speaker 12
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Speaker 12
I think it's inevitable. Any organisation, any large scale change, there is opportunity cost. And these arguments were very well rehearsed indeed by the previous Secretary of State. Uh, you know, he undertook personally that he wouldn't, uh. Follow this course of action. Exactly. Because these things take longer, cost more. And the benefit realization case isn't always clear. It's also quite hard to tell. I mean, it's one of the things we've grappled with as a think tank, you know, is there good evidence of what you're delivering at the end?And, and whether that's, you know, the benefits have been realised, as you stated, they would be up front.
It's harder to perhaps get the granular evidence and costings, uh, to prove the case. But our ongoing concern has been, uh, do you need to wholescale reorganize to drive the sorts of benefits that the government has said it wants to deliver. So we absolutely understand and agree with. Let's reduce duplication. Let's streamline, let's make sure we're getting value for money and spending taxpayers money wisely. Do you need to launch a large reorganisation and mass rearranging the deck chairs of this nature?Our view has been you shouldn't and you don't.
It's harder to perhaps get the granular evidence and costings, uh, to prove the case. But our ongoing concern has been, uh, do you need to wholescale reorganize to drive the sorts of benefits that the government has said it wants to deliver. So we absolutely understand and agree with. Let's reduce duplication. Let's streamline, let's make sure we're getting value for money and spending taxpayers money wisely. Do you need to launch a large reorganisation and mass rearranging the deck chairs of this nature?Our view has been you shouldn't and you don't.
10:01
Speaker 3
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Speaker 3
Thank you Sarah. And and that was also the view of the Darzi report. It was neither desirable nor necessary, he said. Thank you. My second question is for Jacob, which is about Healthwatch. Um, what effect will the abolition of Healthwatch have on the independence of the. And the people's confidence in the independence and reliability of views and patients experiences?
10:02
10:02
Speaker 10
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Speaker 10
Thank you. Um, so I think firstly, um, it's important to note that we know there are people who are reluctant to come forward and share their poor experiences of care with the NHS directly. They fear sort of retribution if they, if they are complaining or speaking up. Um and research by Healthwatch has shown that about 1 in 5 people experience poor care. So it's a significant proportion of people who are unwilling to come forward and speak to statutory agencies. Um, and I think that that is also that will be concentrated in communities who are particularly marginalised.
So those who already lack trust in institutions. So there's a, clear case there already that there will be a group who, for whom the lack of independence will be a real concern. I think the second point is around the unsolicited feedback that's gathered by the Healthwatch network at the moment. So we heard doctor Dash and and others have talked about the system, does lots of engagement itself. And so surely it could take over these functions, but it engages on its terms.
It's about service reconfiguration that it wants to do, or it's about trying to gather experiences on a particular topic. It's interested in. What Healthwatch does is allows an opportunity for continual listening and engagement with communities where they can speak up about anything that's affecting them from, um, dentistry, patient transport, administration of care. All these issues are not necessarily on the system's agenda, and that will disappear under the changes. As I see it.
So those who already lack trust in institutions. So there's a, clear case there already that there will be a group who, for whom the lack of independence will be a real concern. I think the second point is around the unsolicited feedback that's gathered by the Healthwatch network at the moment. So we heard doctor Dash and and others have talked about the system, does lots of engagement itself. And so surely it could take over these functions, but it engages on its terms.
It's about service reconfiguration that it wants to do, or it's about trying to gather experiences on a particular topic. It's interested in. What Healthwatch does is allows an opportunity for continual listening and engagement with communities where they can speak up about anything that's affecting them from, um, dentistry, patient transport, administration of care. All these issues are not necessarily on the system's agenda, and that will disappear under the changes. As I see it.
10:03
Speaker 3
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Speaker 3
Thank you. And the, um, the bill requires that Healthwatch is to an extent abolished, um, and local authorities will be, uh, doing their own patient engagement instead, but they don't seem to be mandated to do so in quite the same way. And local authorities are under financial pressure. Do you believe that this will happen at all, or to the same extent that it is now?
10:04
Speaker 10
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Speaker 10
Well, I think there's a few points under that. So the narrative around the bill is that Healthwatch is being abolished and the functions are lifted and shifted across to local authorities and icbs. And we actually that's not the case. We do lose a number of functions that are important. So, for example, the signposting support that Healthwatch provide at the moment will disappear. So patients won't have that care. Users won't have that to help them understand how to navigate local services.
I mentioned about the unsolicited feedback that's gathered and that that function will disappear. Um, the outreach into communities particularly that will disappear. The voice for patients and communities on health and wellbeing boards disappears. So there's no feed in into those local decision making bodies. So there's a number of places where it's not a direct lift and shift across, which I think is a concern, something the committee should probe further. Um, on the, on the sort of the resourcing point, at least local authorities will be getting, um, part of the existing funding for Healthwatch to support their functions in this space.
ICB is under the impact assessment done by the department will not be getting any funding from the current pot. So there'll be entirely. So that represents a 50% cut in the resourcing for listening to patients and communities. Um which is a concern. Um, so, uh, I'll stop there.
I mentioned about the unsolicited feedback that's gathered and that that function will disappear. Um, the outreach into communities particularly that will disappear. The voice for patients and communities on health and wellbeing boards disappears. So there's no feed in into those local decision making bodies. So there's a number of places where it's not a direct lift and shift across, which I think is a concern, something the committee should probe further. Um, on the, on the sort of the resourcing point, at least local authorities will be getting, um, part of the existing funding for Healthwatch to support their functions in this space.
ICB is under the impact assessment done by the department will not be getting any funding from the current pot. So there'll be entirely. So that represents a 50% cut in the resourcing for listening to patients and communities. Um which is a concern. Um, so, uh, I'll stop there.
10:05
10:06
10:06
10:06
Speaker 12
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Speaker 12
I think as an organisation we've taken the view that, uh we wouldn't necessarily sort of relitigate the decision. I think you can argue it both ways. I mean, I, I understand the um desire to. To reduce duplication and to have clearer lines of accountability. I think our concern has been the opportunity cost and everything you're not doing at the time that you're spending so much energy resource driving this abolition through.
10:06
10:07
10:07
Speaker 10
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Speaker 10
I would echo everything Sarah is saying. I mean, from a from the work that we do, we we see that decision making is taking longer. Programs are taking longer. It's taking longer to secure impact and things, um, that it's very frustrating. And I think that is underpinned by the change, the massive change that's ongoing. If you take, for example, a programme around, um, exploring the experience of waiting for hospital care, so being stuck on waiting lists, and Jim McKee spoke.
About that at Expo last week at the conference, talking about that's a major focus for the NHS right now. And new guidance is expected by the end of the month. But we have been waiting for that since 2021. Um, and the most recent effort to that has been about 18 months. I can only think that drags on because we have so much other change going on in the system. And I wish we focused more on doing things directly for patient care.
About that at Expo last week at the conference, talking about that's a major focus for the NHS right now. And new guidance is expected by the end of the month. But we have been waiting for that since 2021. Um, and the most recent effort to that has been about 18 months. I can only think that drags on because we have so much other change going on in the system. And I wish we focused more on doing things directly for patient care.
10:08
Speaker 13
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Speaker 13
Okay. Thank you. Um. Um, can I come on to, um, single patient record, which I think Sarah, you've described as generally transformative. Um, and I think um, national voices have also been really supportive of the opportunity with, with that. How critical do you both think it is that we grasp this opportunity?
10:08
Speaker 12
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Speaker 12
I think it's a major opportunity. Patients generally, if they feel they've got trust in the system, are supportive of a single patient record or joined up records. They often assume one already exists. And of course, we have this patchwork across the country where certain places are further ahead than. Others. So the idea of having more national coordination, more infrastructure to drive progress in this area, I think could be and hopefully will be transformative. I mean, I know from my previous work, um, just how frustrating it is for so many people to, to experience fragmented care, to have to tell their story endlessly.
And whilst we have to be a little bit careful, because I think telling your medical history is a part of, you know, a good consultation, often the idea that care can be more streamlined, that patients and staff can have better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. We know from previous examples and attempts to drive progress in this area. That's so often.
And whilst we have to be a little bit careful, because I think telling your medical history is a part of, you know, a good consultation, often the idea that care can be more streamlined, that patients and staff can have better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. We know from previous examples and attempts to drive progress in this area. That's so often.
10:09
10:10
10:10
Speaker 10
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Speaker 10
And so I've been working in patient and public engagement involvement for about 15 years. And I'd say probably the single most consistent theme over that time has been this, this frustration about constantly having to retell your story. Um, and the fact that notes and information aren't available to provide the care that people need in different settings. So I think there's a golden opportunity with this bill to get the single patient record right and actually meet a long standing patient need, um, for, for that join up of information.
So we're very supportive of the single patient record. And I think the, the debate now needs to move on, not from whether we need one, but actually, as Sarah was saying, what the safeguards are and how we build public trust. Um, and I think two things on that. One, you can't legislate for everything on this, um, but it's important to have a commitment for an ongoing public conversation around, um, the kind. Of the risks and benefits of data sharing. The department's done some really good work in this space on its public deliberative on use of data.
And I think that should continue. Um, and we, and, you know, we understand that that can't all be put into the face of the bill. I do, however, think there are where we do know safeguards and red lines that we already have, those could be put onto the face of the bill. So, for example, not using patient data or non consented data for um, insurance and marketing purposes, that's been clearly talked about in policy for, for many years as a red line that we won't use data for that purpose.
And why we can't put that on the face of the bill to sort of help build public trust. I think that would really help. Um, to be clear on what those red lines are, where we can say things that won't be included.
So we're very supportive of the single patient record. And I think the, the debate now needs to move on, not from whether we need one, but actually, as Sarah was saying, what the safeguards are and how we build public trust. Um, and I think two things on that. One, you can't legislate for everything on this, um, but it's important to have a commitment for an ongoing public conversation around, um, the kind. Of the risks and benefits of data sharing. The department's done some really good work in this space on its public deliberative on use of data.
And I think that should continue. Um, and we, and, you know, we understand that that can't all be put into the face of the bill. I do, however, think there are where we do know safeguards and red lines that we already have, those could be put onto the face of the bill. So, for example, not using patient data or non consented data for um, insurance and marketing purposes, that's been clearly talked about in policy for, for many years as a red line that we won't use data for that purpose.
And why we can't put that on the face of the bill to sort of help build public trust. I think that would really help. Um, to be clear on what those red lines are, where we can say things that won't be included.
10:11
Speaker 13
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Speaker 13
Thank you. And finally from me, sir Roger, um, you highlighted your 15 years in the patient voice and landscape period, which, um, we could discuss at length whether you think it's going well. Um and if it is successful, the situation we've inherited has been a good one. What do you think needs to happen to give patients confidence that the new system will be better?
10:12
Speaker 10
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Speaker 10
I think there are three things on that. So firstly, um, transparency about what what is being heard by the system. So I think it's really important that wherever we put patient voice functions, that it's clear, um, what they've heard from communities that that is made available publicly. Um, both the themes coming through from that, but also the demographics. So we understand who's being heard and who isn't. I think it's really important around the transparency of what's being heard and also how that's being interpreted by the system.
So what's it, what's it understood from the feedback it's received?And does that resonate with what people are actually trying to say?Um, I think the second thing is around accountability. So can people see those voices leading to change?Um, and not just commitments to change, but then following through in, say, evaluating where policy changes implemented as a result of patient feedback have then improved patient experience and drawing that golden thread through for people so they can understand how their feedback is making a difference.
I think that's really missing from the system at the moment. And the last point I would say is around equity. Um, and my big concern is that we might design a system that hears from more people, but whether it hears from the right people and we're hearing, um, we've got equity of voice, um, is a real concern. So I think there needs to be the resourcing and support needs to be put in for, particularly at local level, for them to be able to engage communities who are marginalised and make sure that we're hearing from the people who are basically getting the worst experience and outcomes at the moment.
So if we can deliver on those three things around transparency, transparency, accountability and equity, I think we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it had available. Um, it works out I think is less than 0.00 0.01% of the health and care spend is on Healthwatch. Um, and that generates about 1.4 million interactions every year, either gathering people's experiences or supporting them to, um, navigate the health and care system.
I think that's a really good return on investment. And it's going to be hard to find something more efficient. The challenge is how the system is more culturally open to listening and changing as a result of what people say, regardless of the way that the evidence comes through.
So what's it, what's it understood from the feedback it's received?And does that resonate with what people are actually trying to say?Um, I think the second thing is around accountability. So can people see those voices leading to change?Um, and not just commitments to change, but then following through in, say, evaluating where policy changes implemented as a result of patient feedback have then improved patient experience and drawing that golden thread through for people so they can understand how their feedback is making a difference.
I think that's really missing from the system at the moment. And the last point I would say is around equity. Um, and my big concern is that we might design a system that hears from more people, but whether it hears from the right people and we're hearing, um, we've got equity of voice, um, is a real concern. So I think there needs to be the resourcing and support needs to be put in for, particularly at local level, for them to be able to engage communities who are marginalised and make sure that we're hearing from the people who are basically getting the worst experience and outcomes at the moment.
So if we can deliver on those three things around transparency, transparency, accountability and equity, I think we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it had available. Um, it works out I think is less than 0.00 0.01% of the health and care spend is on Healthwatch. Um, and that generates about 1.4 million interactions every year, either gathering people's experiences or supporting them to, um, navigate the health and care system.
I think that's a really good return on investment. And it's going to be hard to find something more efficient. The challenge is how the system is more culturally open to listening and changing as a result of what people say, regardless of the way that the evidence comes through.
10:14
Speaker 9
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Speaker 9
Thank you chair. Good morning. Can I ask Sarah?Um. The bill transfers a lot of the powers that currently exist within NHS over to the Secretary of State. But do you have any concerns around the additional powers that are conferred upon the Secretary of State?And do you think that some of that goes too far?
10:15
Speaker 12
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Speaker 12
Um, I think probably two concerns. One, one on a couple of different areas. So, um, around appointments and the power of direction, which is very broad. Uh, we, we think that it would be helpful to probe the detail and understand a little more the intention and see whether the legislation could do with amendment. I think there is a more general point that if the narrative is, uh, this is a straight transfer of. Course, you can't legislate for culture and how those powers will be used.
And our concern is that whilst the narrative is actually. It's a straight transfer and we're really empowering local systems and it will be about earned autonomy. Actually, the legislation pulls lots of a lot of power back to the Secretary of State. And you can't legislate for how a future secretary of state may enact those powers.
And our concern is that whilst the narrative is actually. It's a straight transfer and we're really empowering local systems and it will be about earned autonomy. Actually, the legislation pulls lots of a lot of power back to the Secretary of State. And you can't legislate for how a future secretary of state may enact those powers.
10:16
Speaker 9
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Speaker 9
Thank you. Um, and a second question to to Jacob, um, how prepared do you think Icbs and local authorities are to take on the Healthwatch functions?And is there a concern that splitting that local Healthwatch function will lead to, um, a lack of joined up focus on health and the social care element that resides with local authorities?
10:16
Speaker 10
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Speaker 10
Thank you. Thank you. Um, so I think, um, I'll pick up the second part of the question first if I can. The majority of, uh, the worst experiences of care, the worst incidents that happen and where people feel most lost tends to be in the gaps between services. Um, and so for example, hospital discharge is a really good example where, um, the transfer between NHS and social social care services isn't always working in the best interests of patients. Um, and that sort of insight will be lost entirely, I think under the current structure, unless we build in um, a requirement for icbs and local authorities to share the intelligence they're hearing and work collaboratively to understand patient and care user experience.
Um, which then raises the question, why are we splitting them if they have to work that closely together to, to comment on the worst experiences of care?I don't understand the rationale, particularly for splitting them in terms of their preparedness for doing this. Um, you know, I mentioned earlier about Icbs won't have the, um, any resource, additional resource to do this. Um, they do have their own engagement teams at the moment. Um, but largely even the icbs that have been doing this really well have been leaning on their Healthwatch for many years to help them do, um, engagement to, with seldom heard communities, um, with, uh, sort of just building the additional capacity.
So once that's cut, I really do worry about the capacity of Icbs to deliver, particularly given the headcount reductions and budget reductions on Icbs. Generally, local authorities are probably more experienced in doing direct community engagement. I'm probably more confident about their ability to pick up the responsibilities. Um, indeed, I suspect many of them will continue to commission some sort of external support to help them do this. But again, their budgets will be restricted. They're only going to get half the money for Healthwatch.
Um, and so, uh, that will be a concern.
Um, which then raises the question, why are we splitting them if they have to work that closely together to, to comment on the worst experiences of care?I don't understand the rationale, particularly for splitting them in terms of their preparedness for doing this. Um, you know, I mentioned earlier about Icbs won't have the, um, any resource, additional resource to do this. Um, they do have their own engagement teams at the moment. Um, but largely even the icbs that have been doing this really well have been leaning on their Healthwatch for many years to help them do, um, engagement to, with seldom heard communities, um, with, uh, sort of just building the additional capacity.
So once that's cut, I really do worry about the capacity of Icbs to deliver, particularly given the headcount reductions and budget reductions on Icbs. Generally, local authorities are probably more experienced in doing direct community engagement. I'm probably more confident about their ability to pick up the responsibilities. Um, indeed, I suspect many of them will continue to commission some sort of external support to help them do this. But again, their budgets will be restricted. They're only going to get half the money for Healthwatch.
Um, and so, uh, that will be a concern.
10:18
10:18
Speaker 12
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Speaker 12
Well, I think we've had developments over many years in the direction of a single patient record. So, you know, we have shared care records. We have attempts in different parts of the country to move in this direction. Um, what has held us back, I think legitimate concerns about trust and privacy and the right safeguards. On the one hand, I also think there's some really practical barriers that have held us back. So and this is really important in this case to make the single patient record a success.
What does it actually take to make sure that we achieve interoperability, that the data is cleansed, that penalties if providers aren't sharing data are followed through. So we need to back up any legislative and policy intent with the kind of resource and the measures to make it happen. So perhaps that's a bit of the history and why it hasn't happened. And sorry, the second part of your question.
What does it actually take to make sure that we achieve interoperability, that the data is cleansed, that penalties if providers aren't sharing data are followed through. So we need to back up any legislative and policy intent with the kind of resource and the measures to make it happen. So perhaps that's a bit of the history and why it hasn't happened. And sorry, the second part of your question.
10:19
10:19
10:19
10:19
Speaker 4
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Speaker 4
Is, uh, that perhaps this issue isn't quite resolved. So the legislation doesn't seek to shift necessarily from GP as data controller, but, uh, of course, there will be concerns as this record is is brought together nationally. I mean, uh, the data should belong to people and patients, but they want to rightly feel that that's protected and safeguarded appropriately through the system. Um, I mean, there are a couple of other points to make as we design this. You know, this is a work in progress.
So it's, it's not neat in the sense that you can't say this is exactly what a single patient record is. This is exactly what it will be forevermore. Because I think the policy intent is to build and develop it over time. But as one example, patients in the public being able to understand who has access to their records and for what purposes might be really helpful in the process of building trust and belief that their data is being well looked after.
So it's, it's not neat in the sense that you can't say this is exactly what a single patient record is. This is exactly what it will be forevermore. Because I think the policy intent is to build and develop it over time. But as one example, patients in the public being able to understand who has access to their records and for what purposes might be really helpful in the process of building trust and belief that their data is being well looked after.
10:20
10:20
Speaker 2
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Speaker 2
So I think that whoever ends up being the data controller, I think the most important thing is that patients have a right to express how their data is used. Um, this is where things like the national data opt out are really important to keep up to date and make sure it's clear and accessible for patients to express how, um, their, their data is used for secondary purposes. It becomes much harder in a direct care scenario because there are a number of different. If you if you restrict the sharing of data for direct care, you could inadvertently, um, create a sort of a second class system for people who are not in that.
So it's a really clear distinction. But if for secondary uses, we need a very clear opt out where people can understand how their data is used and express a preference.
So it's a really clear distinction. But if for secondary uses, we need a very clear opt out where people can understand how their data is used and express a preference.
10:21
10:21
Speaker 2
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Speaker 2
Thank you very much, Mr. Chairman, sir. You um, when we were at the Health Select Committee, you and your fellow panelists seemed to suggest that, um, the government could achieve what it needed to in the ten year plan without this reorganisation. Could you delve into that a bit more and tell us why you think that's the case?
10:21
10:21
Speaker 4
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Speaker 4
The government has an incredibly ambitious agenda, and partly that's articulated in the ten year plan. I think our ongoing concern has been some of the biggest ticket items that the government rightly wants to achieve, to fundamentally shift power to patients, to deliver a shift towards prevention and care closer to home and, and to, to more digital enablement. Don't require this kind of legislation and don't require a reorganisation. So I think it's back to my first answer in in a sense of what's honestly the opportunity cost of doing some of this at the expense of more focus and attention on, for example, delivering care closer to home.
There is a lot of energy and activity in that area. Um, but, you know, the government wants to make really good progress over the next few years. And if you're really serious, just to take that example, then you need to understand, well, what are the barriers to delivering more care in the community close to people and patients, wrapping services around patients. That requires you to flow money differently and to have a different incentive scheme that's nowhere near this piece of legislation. So, um, yeah, our worry has been really what's not in the bill and what's the fantastically ambitious, rightly ambitious agenda to improve health for people and patients versus the opportunity cost of a piece of legislation, which is largely technical and reorganizing some central functions.
There is a lot of energy and activity in that area. Um, but, you know, the government wants to make really good progress over the next few years. And if you're really serious, just to take that example, then you need to understand, well, what are the barriers to delivering more care in the community close to people and patients, wrapping services around patients. That requires you to flow money differently and to have a different incentive scheme that's nowhere near this piece of legislation. So, um, yeah, our worry has been really what's not in the bill and what's the fantastically ambitious, rightly ambitious agenda to improve health for people and patients versus the opportunity cost of a piece of legislation, which is largely technical and reorganizing some central functions.
10:22
Speaker 2
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Speaker 2
Mr. Lamont, would you agree with that?Yes, I mean, I. I kind of think as the debate goes on, I sort of think about the, um, particularly on the changes of health watch, you could achieve so much without legislation. You could you could beef up the internal functions for listening to patients and engaging with them, um, without legislation, there's no requirement for that. Put more resource in that and you could do the same with, with health watch, you could think about the resourcing and the structures and the support that they receive.
So you could make that whole system better without legislating to get rid of it. And the same, you know, I think that as Sarah said, the NHS changes are a distraction at a time when we should be moving on with focusing on patient care. Thank you.
So you could make that whole system better without legislating to get rid of it. And the same, you know, I think that as Sarah said, the NHS changes are a distraction at a time when we should be moving on with focusing on patient care. Thank you.
10:23
Speaker 9
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Speaker 9
Thank you chair. Um, my question to Mr. Land, I'm just trying to understand about a bit more about the, the patient experience and improvement in care that the health watch is bringing. My understanding is when a patient raises a complaint with the local provider, it's usually get investigated by a local service manager or a matron. And when somebody who is not confident to raise with the local provider, they go to Healthwatch. And that complaint usually filter it down to the same local service manager or matron to investigate.
And we've seen this been happening, not actually bringing any kind of improvement in patient experience. Without that local accountability and local changes made. Um, so can you explain that why you are concerned about that bringing abolishing the Healthwatch and bringing more accountability to the local?ICB or local authority may have an improvement to patient experience and patient care.
And we've seen this been happening, not actually bringing any kind of improvement in patient experience. Without that local accountability and local changes made. Um, so can you explain that why you are concerned about that bringing abolishing the Healthwatch and bringing more accountability to the local?ICB or local authority may have an improvement to patient experience and patient care.
10:24
Speaker 2
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Speaker 2
So I think, um, the, uh, in answer to that question, the issue is that the system, the NHS provider and or the commissioner, whoever's picking up the individual complaint will treat that as an individual incident to look into the role that Healthwatch will play in that is, yes, they may support the individual to raise that complaint or that individual piece of feedback, but it's the collective learning across that that is more important, and it's pulling out the themes that are consistent across multiple, um, bits of feedback, both positive and negative, that make the difference.
And we do see that evidence and insight from Healthwatch making a difference in local and national policy. It might not feel like that to the individual patient, but things like the creation of a single patient record that exists in part because a lot of, um, campaigning by local healthwatch about that issue of people sharing their story. Having to repeatedly tell clinicians about their, their, their experiences. Um, it could be, um, uh, issues or. On not being able to find a dentist, for example, the system will treat that as an individual incident of helping someone trying to find a dentist or not.
Healthwatch could use that insight to petition and push for national change around commissioning of a service like dentistry. Um, a topic like administration of care, something that Healthwatch National Voices and the King's Fund have all worked on together, is invisible from the way that the system perceives performance at the moment. But because we listen to thematically patient experience, we can push for a much greater focus on things like basics around communication basics, around keeping patients up to date with what's happening with with their care that really matters.
So I do see that Healthwatch is thematically looking at patient feedback differently to the way that the system does, and that's something I fear may be lost.
And we do see that evidence and insight from Healthwatch making a difference in local and national policy. It might not feel like that to the individual patient, but things like the creation of a single patient record that exists in part because a lot of, um, campaigning by local healthwatch about that issue of people sharing their story. Having to repeatedly tell clinicians about their, their, their experiences. Um, it could be, um, uh, issues or. On not being able to find a dentist, for example, the system will treat that as an individual incident of helping someone trying to find a dentist or not.
Healthwatch could use that insight to petition and push for national change around commissioning of a service like dentistry. Um, a topic like administration of care, something that Healthwatch National Voices and the King's Fund have all worked on together, is invisible from the way that the system perceives performance at the moment. But because we listen to thematically patient experience, we can push for a much greater focus on things like basics around communication basics, around keeping patients up to date with what's happening with with their care that really matters.
So I do see that Healthwatch is thematically looking at patient feedback differently to the way that the system does, and that's something I fear may be lost.
10:25
Speaker 10
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Speaker 10
Thank you. Uh, question for, um. Miss Wallner, please. Um, you we've talked about the abolition of NHS England, and as I understand it, your position is that you're kind of dealing with what the position is rather than taking a stand. But beyond the legislation, what are the key things we should be looking at to get the transfer of functions to Icbs and to the right?In this legislation?
10:25
Speaker 4
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Speaker 4
Yeah. So we've talked quite a lot about the culture in the NHS and whether these changes enable the sort of shift that lots of people talk about wanting, i.e., let's be really serious about devolving power and autonomy. And what's the balance between politicians rightly being held accountable for high level metrics, but with enough operational freedom to allow local systems services close to people and patients to get on and do the best for them. We have a slight concern that even though the Carlton principles should mean, you know, the Secretary of State will enact powers in in a way that doesn't slow things down because of the broad sweep of powers back to the Secretary of State and quite extensive powers of direction that, you know, politicians come under extreme pressure to intervene in certain cases or when there's been a scandal or a patient safety issue, that that could lead to things clogging up.
But I suppose fundamentally, our worry has been and again, this goes beyond the legislation. How do you genuinely create a system where the culture is not as paternalistic as is traditionally been, where you are empowering both staff and patients and citizens to have more say in their care?Uh, and, uh, that you've got system leaders that aren't constantly looking up for permission, worried they may be held to account for quite a narrow set of metrics, managing the money, constitutional standards, whilst they're very important, if we're to deliver the ten year plan aims deliver, uh, improved.
Patient care. It's more than that. So our worry has been the abolition of NHS England. And this legislation narrows rather than, uh or, you know, we don't know because it's broader than legislation. But how do we fundamentally shift the culture?I know that's the intention from the government. Uh, it's more than legislation. Where's the work to, to, to make that happen?
But I suppose fundamentally, our worry has been and again, this goes beyond the legislation. How do you genuinely create a system where the culture is not as paternalistic as is traditionally been, where you are empowering both staff and patients and citizens to have more say in their care?Uh, and, uh, that you've got system leaders that aren't constantly looking up for permission, worried they may be held to account for quite a narrow set of metrics, managing the money, constitutional standards, whilst they're very important, if we're to deliver the ten year plan aims deliver, uh, improved.
Patient care. It's more than that. So our worry has been the abolition of NHS England. And this legislation narrows rather than, uh or, you know, we don't know because it's broader than legislation. But how do we fundamentally shift the culture?I know that's the intention from the government. Uh, it's more than legislation. Where's the work to, to, to make that happen?
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10:29
Speaker 7
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Speaker 7
Thank you. And I should reiterate, I'm a member of the Royal College of Paediatrics and Child Health. Um, Doctor Dixon um NHS England has responsibility for workforce and workforce planning. Um how do you think the bill will affect this. And what effect is the delayed and delayed and delayed workforce plan having on the ability, the ability to plan a workforce for now, in the future.
10:29
Speaker 15
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Speaker 15
I think I would. Go back to some of the comments that have been made before. It's the opportunity cost sitting at at the moment. We know the workforce plan is being worked on in the background, but. When you're unsure of what the operating and delivery model will will formally look like, there is a. There is a difficulty in seeing what the workforce will be for that. But also we're talking about massive changes in the way we think about care delivery, and we think about movement into the community.
We think about a different way of working. So we do need a different workforce, and therefore we need to put in some work to look at how curricula drive a different type of workforce, how we how we train people to work in a different way and how we. Empower them to see those opportunities to work in that way when they don't have actual role models. So there's a bit about. We need a culture shift anyway, whatever's happening. But the.
The abolition of NHS England in many ways is. Increasing the time. It's that that the opportunity cost of things need to move and they are moving, but they're not necessarily moving as fast as they should do so.
We think about a different way of working. So we do need a different workforce, and therefore we need to put in some work to look at how curricula drive a different type of workforce, how we how we train people to work in a different way and how we. Empower them to see those opportunities to work in that way when they don't have actual role models. So there's a bit about. We need a culture shift anyway, whatever's happening. But the.
The abolition of NHS England in many ways is. Increasing the time. It's that that the opportunity cost of things need to move and they are moving, but they're not necessarily moving as fast as they should do so.
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10:29
Speaker 12
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Speaker 12
Just really on the kind of left shift that we, we keep hearing about and, um, we don't know what that looks like. We don't know what that is for practices in general practice, we're very practical. We will get on with what's in front of us. So the actual big organisational changes don't have a huge effect on the day to day seeing of patients and organising that. But understanding what's around us does.
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10:29
Speaker 7
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Speaker 7
Thank you. Um, I wanted to move on to, to, to, to ask you about the general, the single patient record and whether you feel that general practice has had enough information about their role in terms of who's responsible, who's accountable, who will be editing, who'll be responsible for checking. The editors are right on this single patient record.
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10:29
Speaker 15
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Speaker 15
I think the legislation is very much an enabler for a single patient record. The the the devil in the detail there is not entirely true. If you ask most patients. In my experience, would they like a single patient record?They feel it's already there. They don't understand. We don't have that ability to share their their data in a way that works for them, and therefore, I think the idea of a single patient record is very much a lodestone for, for medical practitioners and most patients, when you when you talk them through it, the detail of how you achieve that and how you go about it and who owns the data is a much more tricky.
Issue for many, including the professionals, but also the public.
Issue for many, including the professionals, but also the public.
09:10
Speaker 12
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Speaker 12
I would agree that the detail isn't there at all at the moment. We kind of look after that data that's in the GP summary care record. Um, that creates lots of questions for our patients. They'll see information in there that they're not sure about that they want help with. Um, they'll perhaps be able to read some of their hospital letters within that, but there are lots of patients who, who have, um, a variety of health inequalities that might mean they can't access that data.
So our non-clinical staff in general practice are often helping them to navigate their way around all of that information. We also have patients that will read something in there that they want clarity on. Maybe something that's happened a long, long time ago that they can't remember and they want explaining to them. So all of those things take time. And it's where the responsibility for that will go. That does does take an awful lot of resources in general practice, um, to educate the patients, to support the patients, to help them navigate their appointments being on their, their letters coming through in that way.
So it's where that responsibility would sit at the moment. That of course, sits with the GPS, but practically it's practice managers up and down the country that take on that day to day responsibility.
So our non-clinical staff in general practice are often helping them to navigate their way around all of that information. We also have patients that will read something in there that they want clarity on. Maybe something that's happened a long, long time ago that they can't remember and they want explaining to them. So all of those things take time. And it's where the responsibility for that will go. That does does take an awful lot of resources in general practice, um, to educate the patients, to support the patients, to help them navigate their appointments being on their, their letters coming through in that way.
So it's where that responsibility would sit at the moment. That of course, sits with the GPS, but practically it's practice managers up and down the country that take on that day to day responsibility.
09:10
Speaker 7
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Speaker 7
If I may, chair. When Doctor Dixon, we've all. All looked after patients who have, even in pediatrics, have looked after patients who have. Ring binder after ring, binder after ring binder of notes. And clearly, when seeing a patient for 20 or 30 minutes in clinic, there is not time to read ring binders and ring binders and notes. So to what extent to what extent will the single patient record provide an obligation to clinicians to have read and understood everything with every appointment?And is that really practical?
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Speaker 15
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Speaker 15
Has been touched on for patient experience in the previous speakers. Patients come in, they give their same story again and again and again to different healthcare professionals in different settings. That frustrates them. Patients are human. I forget what I did last week. Patients forget what they did last week, let alone, um, you know. Ten, 10 or 20 years ago, which is still relevant increasingly. I think there's a bit about if you travel, if you go on holiday, you go to Whitby, you fall over, you break, you break something.
You have you have tests done. You come back to your house somewhere. Central London. You can't see that information. You cannot share that information. So there's a danger in. There's the opportunity of being able to see everything for a patient across primary care, secondary care. Social care is a huge benefit to patients in terms of their view of a seamless care, but also in terms of, um, in safety. So I have a chronic health condition.
Part of my care is delivered by general practice. Part of my care is delivered by a hospital. At the start of the pandemic, I was exceptionally clinically vulnerable. It took the NHS six weeks to tell me that. That's not safe.
You have you have tests done. You come back to your house somewhere. Central London. You can't see that information. You cannot share that information. So there's a danger in. There's the opportunity of being able to see everything for a patient across primary care, secondary care. Social care is a huge benefit to patients in terms of their view of a seamless care, but also in terms of, um, in safety. So I have a chronic health condition.
Part of my care is delivered by general practice. Part of my care is delivered by a hospital. At the start of the pandemic, I was exceptionally clinically vulnerable. It took the NHS six weeks to tell me that. That's not safe.
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09:11
Speaker 13
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Speaker 13
Thank you very much. Chair. Um, can I ask about the single patient record?Um, we've heard concern from GPS about their role in being the data controller and what that might mean when that data is shared beyond their, beyond their sort of initial remit. Um, what do you think it's what do you think is most desirable?Do you think it's desirable for the GP to remain the data controller, or do you think it's desirable for that control that role to sit elsewhere?
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Speaker 15
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Speaker 15
Okay. I mean, I'm not a general practitioner, I think data I think data control and data sharing, as I say, is absolutely key. The trust that patients have in us to share and hold their data in a way that is beneficial for them as individuals, and potentially sometimes for the population, but not, not for, um, what you might call retail use. And I think, I think part of the issue about data controlling is most general practices are small businesses with small staff working flat out, and that legal obligation of a data controller looms very, very large for them, whereas it doesn't loom as large.
Although technically the impact is as hard for large NHS organisations. So I don't mind who controls the data. What we need to do is find a way to enable that data to be shared safely and with with a belief that it is done for patient benefit, whether that is the GP maintaining the data control and something else happening to support them, or whether that's taking that away. I do not think that matters. I think it's about how we how we enable that to happen.
But I do think general practice struggles more with resilience.
Although technically the impact is as hard for large NHS organisations. So I don't mind who controls the data. What we need to do is find a way to enable that data to be shared safely and with with a belief that it is done for patient benefit, whether that is the GP maintaining the data control and something else happening to support them, or whether that's taking that away. I do not think that matters. I think it's about how we how we enable that to happen.
But I do think general practice struggles more with resilience.
09:27
14:01
Speaker 1
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Speaker 1
When I was sitting in public and the proceedings are being broadcast, we're first going to hear oral evidence from the NHS Alliance and the Royal Berkshire NHS Foundation Trust. We have two until 2.30 for this panel. Gentlemen, I'd be grateful if you'd be kind enough to. From left to right interview. Introduce yourselves for the sake of the record.
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14:02
Speaker 4
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Speaker 4
Thank you, chair and good afternoon gentlemen. Um first question is the NHS Alliance which is in a survey published last month your organisation found that two thirds of trusts and ICB leaders are likely to need to cut or reduce patient services to meet their financial plans. Um, given the financial pressure that icbs are clearly under, what do you make of their ability to become more strategic commissioners and to innovate?
14:02
Speaker 2
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Speaker 2
Thank you. The second thing though, is the idea that the ICB should be strategic commissioners working well to commission plans. The second thing, though, is the idea that the ICB themselves joining up. And we support the move to give them GP commissioning and to give them themselves joining up. So there's been um a level of distraction. The second thing though is the idea that the ICB should be strategic commissioners working well to commission plans, which genuinely reform services.
I think would all support that. And we support the move to give them GP commissioning and to give them pharmacy provision and so on. So all of that's good. Um the, the challenge will be that the, the baseline for the year we're in at the moment is not necessarily the outturn of last year because there was some one off savings in that. Our members across the NHS are saying that the. This is the year when the trade offs have to be made.
Now some of those trade offs will be good in the sense of. We can reconfigure this, move some services into the community and do some good things. And I'm sure we'll hear about some of those, but some of them will require difficult decisions around. Do we um, do we shut down the service in this. Hospital and double down on the one over there and make those decisions that will need political cover and locally as well as nationally. So we're in a in a tricky place.
What what we're saying is, look, we all understand the state of public finances and, um, such. Like, but some capital to allow places to reconfigure and redesign their services, whether it's new, it, you know, AI or, um, new. Um, diagnostic services, those are the things which will then allow the transformations to take place, which is where the productivity and the money will come from. What we're, we're saying, and what chief executives and finance directors and chairs across the NHS are saying is that, look, there's only so much heavy lifting that asking people to run around the hamster wheel a bit quicker can do.
We have to make some of those big decisions.
I think would all support that. And we support the move to give them GP commissioning and to give them pharmacy provision and so on. So all of that's good. Um the, the challenge will be that the, the baseline for the year we're in at the moment is not necessarily the outturn of last year because there was some one off savings in that. Our members across the NHS are saying that the. This is the year when the trade offs have to be made.
Now some of those trade offs will be good in the sense of. We can reconfigure this, move some services into the community and do some good things. And I'm sure we'll hear about some of those, but some of them will require difficult decisions around. Do we um, do we shut down the service in this. Hospital and double down on the one over there and make those decisions that will need political cover and locally as well as nationally. So we're in a in a tricky place.
What what we're saying is, look, we all understand the state of public finances and, um, such. Like, but some capital to allow places to reconfigure and redesign their services, whether it's new, it, you know, AI or, um, new. Um, diagnostic services, those are the things which will then allow the transformations to take place, which is where the productivity and the money will come from. What we're, we're saying, and what chief executives and finance directors and chairs across the NHS are saying is that, look, there's only so much heavy lifting that asking people to run around the hamster wheel a bit quicker can do.
We have to make some of those big decisions.
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Speaker 2
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Speaker 2
Thank you. The, um this is one of the areas that, um, we're we're concerned about in terms of some clarity about what the nature of those interventions could in theory be. We, we fully understand that the Secretary of State and the government need to have the ability to say, in the unlikely event an ICB goes rogue, we have to have the right to sort it out. But understand that, um, but we also need to guard against the alternative, which if um the, you know, a secretary of state was over intervening and making decisions on particular services, particular commissioning decisions, particular reconfigurations.
So. We would be looking for the legislation to prescribe. What are the occasions in which the board of an ICB can be overruled. And that that should be transparent. It should be published. It should be rare. But um, while we, we recognise that that backstop needs to be there, um, for the sake of good governance, it needs to be balanced by some checks and balances which say these are the circumstances. Um it, it needs to be if a um somebody is operating outside their licence say, but um it should we need to guard against and the secretary of State or the regions of the, the new department um reaching in and second guessing local decision making.
So if this is really about empowering strategic commissioners to do what's right for the populations working closely with local authorities, then, um, interventions, which second guess that need to be very rare.
So. We would be looking for the legislation to prescribe. What are the occasions in which the board of an ICB can be overruled. And that that should be transparent. It should be published. It should be rare. But um, while we, we recognise that that backstop needs to be there, um, for the sake of good governance, it needs to be balanced by some checks and balances which say these are the circumstances. Um it, it needs to be if a um somebody is operating outside their licence say, but um it should we need to guard against and the secretary of State or the regions of the, the new department um reaching in and second guessing local decision making.
So if this is really about empowering strategic commissioners to do what's right for the populations working closely with local authorities, then, um, interventions, which second guess that need to be very rare.
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14:07
Speaker 3
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Speaker 3
So I think that Council of Councils of Governors across the NHS have added significant value since they were instituted and brought into foundation trusts. And the Foundation trust councils of governors really play two roles. The first is in relation to the appointment and holding to account of the non-executive directors on the board. And the second is in relation to the um. To securing public and patient involvement and public and patient voice in the organisation and the management of our services. Um, I think that since council governors were instituted, um we have developed increasingly sophisticated ways of getting that public and patient voice into services.
So if you look at innovations like maternity and neonatal voices, partnerships, which really involve service users in how services are developed, sort of on the ground and very close to the teams that are running those services. That now gives us different ways of involving patients in the public, in, in services, in a way that possibly councils of governors haven't been able to do in the past. And so I do think councils of governors have been important. And I do think they've played a really important role in foundation trusts.
But I think that certainly in terms of that patient and public voice function, we have also moved on as a system, and we have now got more sophisticated ways of doing that.
So if you look at innovations like maternity and neonatal voices, partnerships, which really involve service users in how services are developed, sort of on the ground and very close to the teams that are running those services. That now gives us different ways of involving patients in the public, in, in services, in a way that possibly councils of governors haven't been able to do in the past. And so I do think councils of governors have been important. And I do think they've played a really important role in foundation trusts.
But I think that certainly in terms of that patient and public voice function, we have also moved on as a system, and we have now got more sophisticated ways of doing that.
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14:08
Speaker 6
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Speaker 6
To you both really picking up on said events. Comments about um experiences. Being extremely rare. The changes in the bill sit alongside changes going on to the national centre. Um and clarity to icbs with very little change to providers. Um so can you say what you think would be the make the most difference to providers and indeed commissioners as we do this to improve things.
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14:09
Speaker 2
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Speaker 2
I think the, the biggest difference should be that. The, the local providers and the local icbs are incentivized to get together and make these collective commissioning decisions, which mean that what you call it a neighbourhood or a footprint or a local authority area, um, they, that they make those decisions based on population evidence, which is why the single patient record is, is important and that they have the autonomy to do that with a lighter touch centre, which is set in guidance and saying, look, this is this is broadly what we'd like you to do.
And that guidance should be developed in conjunction with the people who actually have to do the job on, on the ground. That's what it it should be. And now there, you know, and if the, um, you know, the potential of the bill allows that, then that's fantastic. The, the second bit is that the, the mechanism and it's not necessarily a legislative thing, but the mechanism by which the NHS is managed day to day will still need to exist. Um who's going to um be keeping an eye on things.
24 over seven, 365 days a week. Um what happens if there's a fire, maybe even a literal fire in a hospital?How is the NHS going to be corralled and brought in to, um, you know, to help out a trust where something like that happens?So that kind of management function, the day to day operational management needs to remain strong enough in the target operating model, as it's called in the department. And if it isn't, then it, it could prove very difficult. Not necessarily day to day, not very.
Um, necessarily, you know, in the short term, but in the long term, that bit has to go. So one of the big risks of the, the legislation, and it isn't a legislative solution to this risk is how is it going to be managed day to day?You know, we all have views on um, the, you know, the relative strength of the regions of NHS England and so on. How is that going to work in the new, in the new world?Um, because, because if one loses grip in the word um that is used a lot, then the risk to service delivery is quite high.
The risk to financial control is even higher.
And that guidance should be developed in conjunction with the people who actually have to do the job on, on the ground. That's what it it should be. And now there, you know, and if the, um, you know, the potential of the bill allows that, then that's fantastic. The, the second bit is that the, the mechanism and it's not necessarily a legislative thing, but the mechanism by which the NHS is managed day to day will still need to exist. Um who's going to um be keeping an eye on things.
24 over seven, 365 days a week. Um what happens if there's a fire, maybe even a literal fire in a hospital?How is the NHS going to be corralled and brought in to, um, you know, to help out a trust where something like that happens?So that kind of management function, the day to day operational management needs to remain strong enough in the target operating model, as it's called in the department. And if it isn't, then it, it could prove very difficult. Not necessarily day to day, not very.
Um, necessarily, you know, in the short term, but in the long term, that bit has to go. So one of the big risks of the, the legislation, and it isn't a legislative solution to this risk is how is it going to be managed day to day?You know, we all have views on um, the, you know, the relative strength of the regions of NHS England and so on. How is that going to work in the new, in the new world?Um, because, because if one loses grip in the word um that is used a lot, then the risk to service delivery is quite high.
The risk to financial control is even higher.
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14:11
Speaker 3
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Speaker 3
So put simply, um. As an NHS organizational leader, there are always a lot of things that you can take your guidance from in terms of what you should be prioritising and focusing on as an organization. Um, if the result of this legislation is that we as organisational leaders have a really tightly defined set of priorities to deliver, and if as much as possible, they can be articulated as outcomes for local people and for population as a whole. In terms of waiting times, in terms of quality, um, in terms of improving population health, then I think that will then allow us to get on at a local level, um, with the partnerships that we already have and that we, we have as a day to day part of running local public services focus on that very small set of things and do them really well.
I think over the last year, there has been that sense of increasing clarity as NHS England and the Department of Health and Social Care have worked more closely together, there has been that increasing sense of clarity over those priorities, and I think the NHS has delivered on those priorities to a large degree. But it does all come down, as my colleague says, to how senior officials and ministers operate that system, because there is going to be significantly more freedom to to set those priorities and design and run the system that essentially delivers them for the NHS.
So I think how that is done and retaining that clarity on the things that that we want to have delivered for the system and to, to empower local systems to do them will be really important.
I think over the last year, there has been that sense of increasing clarity as NHS England and the Department of Health and Social Care have worked more closely together, there has been that increasing sense of clarity over those priorities, and I think the NHS has delivered on those priorities to a large degree. But it does all come down, as my colleague says, to how senior officials and ministers operate that system, because there is going to be significantly more freedom to to set those priorities and design and run the system that essentially delivers them for the NHS.
So I think how that is done and retaining that clarity on the things that that we want to have delivered for the system and to, to empower local systems to do them will be really important.
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Speaker 6
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Speaker 6
Why not?Thank you. Um, because also what you said is that the risk is high about not having financial control. I mean, I would say that the financial control issue over the last few years has been a massive problem. And actually that we have put in much better financial control. Um, so I think your concern is about the future. Yes. Rather than the legislation.
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14:15
Speaker 3
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Speaker 3
Um, so I think that the single patient record has enormous opportunities to improve patient care. Um, we know that we see patients every day who's, whose quality of care and patient experience would be improved through having access to a continuous record that ran through primary care, secondary care, mental health care and other services. And what will be extremely important to this, from my mind, and I have experience in working with systems that have introduced some degree of a single, a single record, or a single care plan is that we take the time to train our clinical staff and adapt our operational systems.
So they use a patient record productively and consistently in the interests of better patient care. If we just put a single patient record into clinical settings without doing anything with the staff or services to make it useful, then at best it will be inconsistently used and sometimes it will just be missed at all. Um, so if we're going to make the investment, which I think is right into a single patient record, we also have to invest in those systems and those human factors around it, and make sure that we're training people to use it well.
Thank you.
So they use a patient record productively and consistently in the interests of better patient care. If we just put a single patient record into clinical settings without doing anything with the staff or services to make it useful, then at best it will be inconsistently used and sometimes it will just be missed at all. Um, so if we're going to make the investment, which I think is right into a single patient record, we also have to invest in those systems and those human factors around it, and make sure that we're training people to use it well.
Thank you.
14:15
14:15
Speaker 7
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Speaker 7
Thank you, sir Roger. Um, I'm a member of the Patient Safety Appg, and I'm also on a vice president of the LGA. Um, can I ask about Healthwatch?Um, we heard this morning that um Icbs will be taking on a chunk of the current operation of local Healthwatch, but they wouldn't have any additional budget to enable them to do that. In fact, obviously we know that their budgets have been significantly reduced. And I just wondered if you could elaborate on how you think that will work and whether that will be as effective as the current system.
14:16
Speaker 2
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Speaker 2
Thank you. Um. Thank you. And they, the icbs have, um, a capitation fee, £19.40, which they have to do everything out of. This is an additional duty placed on them and therefore they have to work out how to do it if there isn't extra um money. Money coming but it will be pressured. They. And I, I hear the arguments that local health watches were variable. And we need to make sure that we don't end up in this situation where this kind of function, which has been slightly outside independent playing back into, um, the decisions that that level of independence remains somehow in how it's constructed and the variability just isn't transferred from local Healthwatch to how they do it within or across icbs.
So again, it'll be the implementation, which needs to be, um, well done. It leads into the question about local authorities and the connection with local authorities as well, about making sure the Democratic voice is brought in. And equally, the local voice. Um, so the. Legislation doesn't stop an ICB doing this. Well, um, and therefore without the legislation, part of what we can be doing collectively is to try and make sure that what was good about Healthwatch is preserved.
It's understood by Icbs, and there are only 25 of them that should be manageable task for the rest of us. Um, but also that the, the effectiveness comes back to whether you believe this is a good thing or not. So one of the things we have to do is to make sure that the benefits of having the patient voice in there, along with the clinical voice, along with the voice of the manager at the same time, so that it isn't. Oh, now we'll go consult the patients on the font size of the report, that it's authentic.
Um, so it, it puts a lot of work onto the icbs and it puts a lot, puts a lot of work onto those of us who believe passionately in engaging the patient voice. Um, but there is a risk because of that, um, that pressure. Done. Well, it will enable strategic commissioning and ensure the quality remains. Um, but, but they're starting from, you know, maybe not scratch, but they're starting from a new place.
So again, it'll be the implementation, which needs to be, um, well done. It leads into the question about local authorities and the connection with local authorities as well, about making sure the Democratic voice is brought in. And equally, the local voice. Um, so the. Legislation doesn't stop an ICB doing this. Well, um, and therefore without the legislation, part of what we can be doing collectively is to try and make sure that what was good about Healthwatch is preserved.
It's understood by Icbs, and there are only 25 of them that should be manageable task for the rest of us. Um, but also that the, the effectiveness comes back to whether you believe this is a good thing or not. So one of the things we have to do is to make sure that the benefits of having the patient voice in there, along with the clinical voice, along with the voice of the manager at the same time, so that it isn't. Oh, now we'll go consult the patients on the font size of the report, that it's authentic.
Um, so it, it puts a lot of work onto the icbs and it puts a lot, puts a lot of work onto those of us who believe passionately in engaging the patient voice. Um, but there is a risk because of that, um, that pressure. Done. Well, it will enable strategic commissioning and ensure the quality remains. Um, but, but they're starting from, you know, maybe not scratch, but they're starting from a new place.
14:18
14:18
14:19
Speaker 2
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Speaker 2
I think we. According to the Icbs we're talking to, which is all of them. Um, what they're saying is, look, we believe in local authority engagement. Um. We will be. Saying that that needs to translate in. You may not be told you have to. But we would be encouraging you to do it. And I'm sure that um should be coming from the department as well. And we know and this is an example of this, um, on to my right that where the NHS has really good local connections, you can get things done in the interests of your patients much more easily.
So the belief is there, what we need to do is make sure the legislation is not seen as a signal that this is unimportant. Um, because that's a risk. Um so therefore we have to be, um, as a kind of a, you know, a representative organisation, we have to be saying to, to people, look what we hear you saying, if you really believe in this, therefore you need to be demonstrating, um, not least to the secretary of State that you are following this through. If forgive me one little addition, which is the, um, in the kind of unitary authority from the mayors being able to um, um, appoint.
Somebody who's the chair of the ICB and also the local health commissioner. Um, that should help. Um, those individuals will have to work out how to serve two masters. Um, but that's okay. Other people learn how to do that too.
So the belief is there, what we need to do is make sure the legislation is not seen as a signal that this is unimportant. Um, because that's a risk. Um so therefore we have to be, um, as a kind of a, you know, a representative organisation, we have to be saying to, to people, look what we hear you saying, if you really believe in this, therefore you need to be demonstrating, um, not least to the secretary of State that you are following this through. If forgive me one little addition, which is the, um, in the kind of unitary authority from the mayors being able to um, um, appoint.
Somebody who's the chair of the ICB and also the local health commissioner. Um, that should help. Um, those individuals will have to work out how to serve two masters. Um, but that's okay. Other people learn how to do that too.
14:21
14:21
Speaker 3
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Speaker 3
I mean, I would focus on a slightly different part of the bill in terms of how I think this needs to work. Um, there are. 25 Icbs now, so that that's going to be quite, they're quite large footprints in my experience of delivering really meaningful collaboration and joint working between health and local government. It tends to happen at a more local level than that. Um, the neighborhood health plan in the bill, I think becomes extremely important. And I think as a system, we should be very ambitious for those health plans.
I think they should go a lot further than just describing what should happen in terms of improving health outcomes at a local level. But I think that we should set an aspiration as a system, that there should be a responsibility on health bodies and local government bodies to describe how changes will be made. And and actually, I think the role of Icbs is to enable groups of providers and other organisations in local areas, of which most icbs will have several sort of places to, to, to come together and to not just work out what a local population needs, but actually to do it.
Um, which will mainly be about relationships on the ground between an acute hospital team, a community services team, a mental health team, and a social work team. Um, so I think the role of Icbs is very much to, to give the, the sort of contractual tools and the mechanisms to at local NHS organisations to work really effectively with their local authorities to have really good neighbourhood health plans, and most importantly, not just to write them, but actually to see them through.
I think they should go a lot further than just describing what should happen in terms of improving health outcomes at a local level. But I think that we should set an aspiration as a system, that there should be a responsibility on health bodies and local government bodies to describe how changes will be made. And and actually, I think the role of Icbs is to enable groups of providers and other organisations in local areas, of which most icbs will have several sort of places to, to, to come together and to not just work out what a local population needs, but actually to do it.
Um, which will mainly be about relationships on the ground between an acute hospital team, a community services team, a mental health team, and a social work team. Um, so I think the role of Icbs is very much to, to give the, the sort of contractual tools and the mechanisms to at local NHS organisations to work really effectively with their local authorities to have really good neighbourhood health plans, and most importantly, not just to write them, but actually to see them through.
14:22
14:22
14:22
14:22
Speaker 2
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Speaker 2
Um. I suppose I'd go back to. You we have to convince people. Many people are convinced that's probably the best first thing to say, but convince people of the benefit of doing this. If, if one's going to deliver these, um, ambitious neighbourhood health plans that, um James describes then, um, that will only happen if everybody is in the room and doing it now, I don't, I, I don't think necessarily that the legislation can mandate that belief and mandate the way, um, to do it, but setting an expectation on the ICB that in the development of their plans, they will be able to demonstrate that they have engaged with the local authorities, with the patient organisations and the public local to them that they're using, um, population evidence to, to make the right commissioning choices that if there are reconfigurations to happen, which may well be locally contentious, that that engagement is happening beforehand and that the, um, if you will all know, um, from, uh, being elected members that you start those conversations early and you don't just bounce your local population into something.
So I think it will be incumbent on the new department to set those expectations with the Icbs that this new way of working, which is the only way we're going to create the NHS, which will be able to cope with the, you know, the number of frail elderly people with multiple morbidities, which is. A consequence of success as a consequence of the success of the NHS over decades, that people are living longer with um, you know, cancer, prevalence of cancer, the number of people alive with cancer doubling in 20 years.
But that means there are 4 million people now who are not necessarily well. The only way to be able to do that is to, to do a significant and radical change to these neighbourhood health plans and to bring the public with us doing that. And that will only happen by proper patient and public engagement.
So I think it will be incumbent on the new department to set those expectations with the Icbs that this new way of working, which is the only way we're going to create the NHS, which will be able to cope with the, you know, the number of frail elderly people with multiple morbidities, which is. A consequence of success as a consequence of the success of the NHS over decades, that people are living longer with um, you know, cancer, prevalence of cancer, the number of people alive with cancer doubling in 20 years.
But that means there are 4 million people now who are not necessarily well. The only way to be able to do that is to, to do a significant and radical change to these neighbourhood health plans and to bring the public with us doing that. And that will only happen by proper patient and public engagement.
14:25
14:25
14:25
Speaker 2
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Speaker 2
I was, um I was in um Epping. Uh, recently in Saint Margaret's and um, talking to the lady who runs the patient engagement, uh, and um, who was a volunteer, you know, she's a patient herself. Uh, and they are a very good example of saying if we want to provide good services and avoid people turning up at the A&E in Harlow, we can do a neighbourhood diagnostic service. You know, the, the patient, um representatives got in very early. They ran some public meetings ahead of it and saying, we're thinking of doing this, you know, what do you think we'll feed it back.
So absolutely everything good is happening somewhere. Um, it's just that we need to make sure that those good practices are, are deployed across its the variability which is causing the problem. And therefore that has to be the expectation. If this reform, which is huge, um, is going to deliver value, that's the value it has to deliver.
So absolutely everything good is happening somewhere. Um, it's just that we need to make sure that those good practices are, are deployed across its the variability which is causing the problem. And therefore that has to be the expectation. If this reform, which is huge, um, is going to deliver value, that's the value it has to deliver.
14:26
14:26
Speaker 9
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Speaker 9
Thank you very much. This question is to the Royal Berkshire. Um in response to my colleague you talked about the benefits of your board or council of governors. So as a foundation trust, you have a significant amount of autonomy. The health bill will allow the government to cap your day to day spend, strip away your feet status and make governance changes. So what impact do you think this will have on how your boards are able to carry out their duties?
14:26
14:26
Speaker 3
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Speaker 3
Um, I think that in reality um for. The, for a lot of foundation trusts, we have seen that um as the, as the NHS has moved into a period of increasingly tight financial control and as we've needed to recover from the Covid pandemic, that actually it's required far closer working between all NHS providers. Um, and, and the centre in order to manage both the financial and the patient access and the patient quality implications of that pandemic. So moving recently from a senior leadership or board level role in an NHS trust to then a two roles as chief executives in foundation trusts, actually, in terms of that day to day relationship with the with the the centre and with our local regional representatives in terms of how we balance quality finance and performance.
I have to say, I didn't feel that there was an enormous difference between doing that in an NHS trust and a foundation trust context now, because I think that those foundation trust freedoms were most relevant when we were in a system where sort of expenditure on health could could grow, and we weren't trying to recover from some of the challenges that we've had recently. So I think that on a day to day basis, um, that relationship feels quite consistent actually now between NHS trusts and foundation trusts. And so I'm not sure that I can necessarily see at the moment that, um, that necessarily these changes proposed in the bill will make a huge difference to that.
As I said earlier, responding to a previous question, that entirely depends on whether the provisions within the bill are used to set a small number of priorities and let NHS organisations get on with delivering them, or whether they are used on a more regular basis to to intervene more directly in our day to day operations. So I think a lot comes down to how the regime is operated.
I have to say, I didn't feel that there was an enormous difference between doing that in an NHS trust and a foundation trust context now, because I think that those foundation trust freedoms were most relevant when we were in a system where sort of expenditure on health could could grow, and we weren't trying to recover from some of the challenges that we've had recently. So I think that on a day to day basis, um, that relationship feels quite consistent actually now between NHS trusts and foundation trusts. And so I'm not sure that I can necessarily see at the moment that, um, that necessarily these changes proposed in the bill will make a huge difference to that.
As I said earlier, responding to a previous question, that entirely depends on whether the provisions within the bill are used to set a small number of priorities and let NHS organisations get on with delivering them, or whether they are used on a more regular basis to to intervene more directly in our day to day operations. So I think a lot comes down to how the regime is operated.
14:28
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14:29
Speaker 1
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Speaker 1
We've got three people. There with us. We think we're one person short. Afternoon. Um, we now hear oral evidence from the Patients Association together for short lives and Healthwatch England. And we have only until 310 for this panel for three people, starting from the left. Would you be kind enough to introduce yourselves for the record, please?Camera left your.
14:30
14:30
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14:31
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14:31
Speaker 11
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Speaker 11
I think there are both opportunities and threats for families of seriously ill children, and also the professionals and services that provide them with palliative and end of life care. So when we're talking about seriously ill children, we mean children with life threatening conditions, life shortening conditions, and children with severe medical complexity. And they have a range of emotional, psychological, social and physical needs which need to be met across health, education and social care services. And part of that care involves specialist children's palliative care, and that is predominantly provided at a regional level, um by teams led by specialist paediatric palliative care consultants.
They often have good training. There are not many of them across the UK, only around 24 whole time equivalents. And they're often based at children's hospitals or in children's hospices, and often co-located across both. These specialist teams also comprise senior nurses and other specialists involved in um, emotional, psychological, practical support for families. Now, the issue that we have is that often these services are quite patchily commissioned at the moment. So even though there is a specialist children's palliative care specification for this from NHS England, which has been in existence since 2012, there's only a very limited extent to which we think money and commissioning has actually flowed to these services.
So, for example, we have a successful service in the East of England, which provides 24 over seven end of life care at home for children who are seriously ill supported by nurses and specialist consultants. But it's really patchy across England now. I think the bill presents some opportunities because of the additional powers that are put through the offices of ICB commissioning the opex um to mandate Icbs to work together to commission these services. We would like to see this, but because of the small numbers but really highly complex needs of these children, these services often need to be planned and funded at a regional level.
But they aren't. Um, we are concerned by the increased devolution to icbs because of the extent to which other children's palliative care services, the core services are being commissioned. At the moment. We have a range of evidence that shows that it is possible in some areas to see some of that care commissioned well. So, for example, 19% of Icbs currently commissioned end of life care for children at home, 24 over seven provided by nurses and specialist consultants. But at the moment, we're not seeing icbs, uh, taking on their full functions and implementing national guidance.
So I would like to see much more rigor and accountability applied from the centre, from government, to make sure that this specialised commissioning works for this particular group of complex children and families.
They often have good training. There are not many of them across the UK, only around 24 whole time equivalents. And they're often based at children's hospitals or in children's hospices, and often co-located across both. These specialist teams also comprise senior nurses and other specialists involved in um, emotional, psychological, practical support for families. Now, the issue that we have is that often these services are quite patchily commissioned at the moment. So even though there is a specialist children's palliative care specification for this from NHS England, which has been in existence since 2012, there's only a very limited extent to which we think money and commissioning has actually flowed to these services.
So, for example, we have a successful service in the East of England, which provides 24 over seven end of life care at home for children who are seriously ill supported by nurses and specialist consultants. But it's really patchy across England now. I think the bill presents some opportunities because of the additional powers that are put through the offices of ICB commissioning the opex um to mandate Icbs to work together to commission these services. We would like to see this, but because of the small numbers but really highly complex needs of these children, these services often need to be planned and funded at a regional level.
But they aren't. Um, we are concerned by the increased devolution to icbs because of the extent to which other children's palliative care services, the core services are being commissioned. At the moment. We have a range of evidence that shows that it is possible in some areas to see some of that care commissioned well. So, for example, 19% of Icbs currently commissioned end of life care for children at home, 24 over seven provided by nurses and specialist consultants. But at the moment, we're not seeing icbs, uh, taking on their full functions and implementing national guidance.
So I would like to see much more rigor and accountability applied from the centre, from government, to make sure that this specialised commissioning works for this particular group of complex children and families.
14:33
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14:34
Speaker 13
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Speaker 13
Well, obviously I'm not, uh, not here to speak on behalf of CQC, although I'm a non-executive director of CQC. And you're quite right, it has been a challenging position from which it has taking very substantial steps to recover, principally in terms of changing to a system or changing back to a system of having chief inspectors who are very knowledgeable about their particular area of expertise that they can apply. Um, the department has asked. CQC to take on additional responsibilities in terms of its regulatory capability and to some degree, in terms of inspectorate capability.
Uh, I can't really agree that it is too much for CQC to take on, but it is certainly a substantial amount of work that is being added to seek.
Uh, I can't really agree that it is too much for CQC to take on, but it is certainly a substantial amount of work that is being added to seek.
14:36
Speaker 13
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Speaker 13
Well, it's it's quite interesting to think that it's been we've had 52 years of independent organisations representing the patient voice and that of the of the carer as well. And there was a step change that I think everyone here will be aware of after the Mid Staffs situation, when Healthwatch, both Healthwatch England and the local Healthwatch 153 local um health watches were set up and that was a step change in terms of the impact. I mean, we've produced over 20,000 reports, 20,000 reports, all of which I can say, if anyone is interested in having access to them, we can certainly provide that after this meeting for the end of the week.
And I think that, uh. Where Healthwatch, in my view, since I joined in 2023, has been very successful, is in reaching out to those communities that are often referred to as difficult to reach or diasporas, etc., where we all know that the health equalities are often the deepest. Now, I think Healthwatch has been very successful in making sure that we haven't just listened to the easy to reach groups. We've deliberately sought information, views from those other organisations, those parts of our society, an increasing part of our society.
And I have to say, I the quality of the research that has been done for those with those communities has. Recognised that it is quite often an investment of some six months of time of one of our people to go into that particular community, be that, you know, a cultural community or be it an ethnic community. And win the confidence of those people to actually talk to us about what the problems are. Now, I have to say, in the arrangements that are suggested in the bill, I would have to ask, how is that going to be replicated, that depth, that focus, etc..
That would be my, if you like, my extended first point about Healthwatch, I think we've had a lot of impact. And I use the word, you know, as a researcher myself, because impact is measured by the change that you make. And when we produce reports, be they national reports or be they local reports, we have recommendations. But the important thing is that we always follow up on those recommendations. Are they being implemented?Are they being listened to?And each year we produce a report that says, what is the change that has occurred as a result of the recommendations that we make?And I think that's extremely valuable because that is about independence and it's about holding organisations to account.
Now, clearly, those organisations report in line function to Department of Health, NHS E or to local authorities, etc. but we not only are the ears of the patient and the carer, but we're also the holding the feet to the flames at times about whether something sensible is being done. And we don't give up on this. We we pursue it, you know, down the rabbit hole.
And I think that, uh. Where Healthwatch, in my view, since I joined in 2023, has been very successful, is in reaching out to those communities that are often referred to as difficult to reach or diasporas, etc., where we all know that the health equalities are often the deepest. Now, I think Healthwatch has been very successful in making sure that we haven't just listened to the easy to reach groups. We've deliberately sought information, views from those other organisations, those parts of our society, an increasing part of our society.
And I have to say, I the quality of the research that has been done for those with those communities has. Recognised that it is quite often an investment of some six months of time of one of our people to go into that particular community, be that, you know, a cultural community or be it an ethnic community. And win the confidence of those people to actually talk to us about what the problems are. Now, I have to say, in the arrangements that are suggested in the bill, I would have to ask, how is that going to be replicated, that depth, that focus, etc..
That would be my, if you like, my extended first point about Healthwatch, I think we've had a lot of impact. And I use the word, you know, as a researcher myself, because impact is measured by the change that you make. And when we produce reports, be they national reports or be they local reports, we have recommendations. But the important thing is that we always follow up on those recommendations. Are they being implemented?Are they being listened to?And each year we produce a report that says, what is the change that has occurred as a result of the recommendations that we make?And I think that's extremely valuable because that is about independence and it's about holding organisations to account.
Now, clearly, those organisations report in line function to Department of Health, NHS E or to local authorities, etc. but we not only are the ears of the patient and the carer, but we're also the holding the feet to the flames at times about whether something sensible is being done. And we don't give up on this. We we pursue it, you know, down the rabbit hole.
14:39
14:39
Speaker 12
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Speaker 12
Well, I was going to say he's said absolutely everything. I was just about to say. So maybe I'll just say a few points just so that I don't go over absolutely everything. The main things that I was going to say is that we just need to make sure that this isn't diverting attention from the main priorities, which obviously is patients, and that's timely access to care, clear communication and involvement in decision about their treatment. And as you said, we really need a truly independent patient voice.
And I think by, um, abolishing Healthwatch is really creates the fragmentation of patient engagement responsibilities across icbs and local authorities and evidence that we see every day. You know, it consistently shows that patients are not feeling informed or involved or treated as equal partners in care. So I think we really need to ensure that the bill, any replacement model, is genuinely independent, as you've said, and is transparently accountable and equally resourced across the country to ensure we don't lose sight of the people it really is supposed to serve.
And I said I wouldn't go on too much, but I think trust is really, really important here, and independent organisations are who patients trust. And it really is around local communities, which I feel that this might be lost. And then lastly, again, sorry, it's exactly what you were saying. It's around reporting. I really think we need to consider the way that patient feedback data is reported and that that isn't getting lost. And I think themes and demographics still really need to be included to make sure we know who we are listening to and to ensure that services are provided for those that are feeding back or not feeding back.
And normally it's those who are not feeding back that we really need to consider.
And I think by, um, abolishing Healthwatch is really creates the fragmentation of patient engagement responsibilities across icbs and local authorities and evidence that we see every day. You know, it consistently shows that patients are not feeling informed or involved or treated as equal partners in care. So I think we really need to ensure that the bill, any replacement model, is genuinely independent, as you've said, and is transparently accountable and equally resourced across the country to ensure we don't lose sight of the people it really is supposed to serve.
And I said I wouldn't go on too much, but I think trust is really, really important here, and independent organisations are who patients trust. And it really is around local communities, which I feel that this might be lost. And then lastly, again, sorry, it's exactly what you were saying. It's around reporting. I really think we need to consider the way that patient feedback data is reported and that that isn't getting lost. And I think themes and demographics still really need to be included to make sure we know who we are listening to and to ensure that services are provided for those that are feeding back or not feeding back.
And normally it's those who are not feeding back that we really need to consider.
14:41
14:41
Speaker 6
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Speaker 6
Thank you, sir. Roger. Um, so as we've heard, 52 years, of independent, um voice. Uh, and I think you said 2000 reports. Um, um there are many others and many other hundreds recommendations and so on. Yet, um we have some of the worst patient satisfaction that we've ever had. We've also, ten years on from Francis. Um, and we know that recommendations are not being followed through either locally or nationally. So we have a landscape that doesn't work.
Um, and I think that that is pretty clear. So my question really is what do you think?And I represent like many others here, communities that are not in that space, um, and need a new way of being represented. Uh, what do you think the barriers really are?But for brevity, really, I guess, how can the single patient record and the information that we can create in different ways really help to reverse what is a shocking landscape for patient experience and patient voice?
Um, and I think that that is pretty clear. So my question really is what do you think?And I represent like many others here, communities that are not in that space, um, and need a new way of being represented. Uh, what do you think the barriers really are?But for brevity, really, I guess, how can the single patient record and the information that we can create in different ways really help to reverse what is a shocking landscape for patient experience and patient voice?
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14:43
Speaker 13
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Speaker 13
Fine. Um, I think the, the, the government's move to, uh, the integrated patient record is absolutely excellent. It's something I think most of us have wanted for a very long time and have also recognised some of the, uh. If you like the I t difficulties in doing this, as well as the whole question of security. However, as digital has advanced, I think we have nutcrackers to crack that particular nut that we haven't had before. So I think, uh, you know, I can only but support the move to that.
I think also from the point of view of the things that really matter, which is the ability to. For a person to feel that they can tell their story once and not tell it time and time again is something that comes up in the research that we do all the time. And eventually, in a great respect to everyone here, you know, we're very capable of standing up for ourselves and, you know, insisting that we get answers. The people that that I deal with, the people that I have the privilege of representing often are not in that sort of position at all and are overwhelmed when they're repeatedly asked the same question, often in a language in terms of, you know, medicalise if you like, that they don't really understand and they feel threatened by it.
Now, I think the single patient record is going to go a long way to help with that situation.
I think also from the point of view of the things that really matter, which is the ability to. For a person to feel that they can tell their story once and not tell it time and time again is something that comes up in the research that we do all the time. And eventually, in a great respect to everyone here, you know, we're very capable of standing up for ourselves and, you know, insisting that we get answers. The people that that I deal with, the people that I have the privilege of representing often are not in that sort of position at all and are overwhelmed when they're repeatedly asked the same question, often in a language in terms of, you know, medicalise if you like, that they don't really understand and they feel threatened by it.
Now, I think the single patient record is going to go a long way to help with that situation.
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14:44
Speaker 9
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Speaker 9
I think it's an excellent initiative. And as you've said, what we've been calling for for such a long time. But I think we really do need to consider the consent element, the data element. So a lot of pieces of work that we've done with patients is around how people are happy with their data being shared. And for, you know, these electronic records. But just as long as it's transparent and patients know what is being done with their data.
So I think that's a really, really important point. And there's the initiative of Care.data and GP. Dr., which were great initiatives, but because they didn't have genuine patient involvement right from the beginning, unfortunately, they failed. So we need to ensure that the Psbr also doesn't fail. And in terms of reaching underrepresented communities or those less heard, again, we need to really ensure that those are the people that we're hearing from straight away. How do they want this to work?How do they want to know how their data is being used?And also people that don't use the NHS app, how can we ensure that those people are involved and that their data is being shared?And for other people who are very, very hesitant, understandably, about digital technology and electronic records.
So I think that's a really, really important point. And there's the initiative of Care.data and GP. Dr., which were great initiatives, but because they didn't have genuine patient involvement right from the beginning, unfortunately, they failed. So we need to ensure that the Psbr also doesn't fail. And in terms of reaching underrepresented communities or those less heard, again, we need to really ensure that those are the people that we're hearing from straight away. How do they want this to work?How do they want to know how their data is being used?And also people that don't use the NHS app, how can we ensure that those people are involved and that their data is being shared?And for other people who are very, very hesitant, understandably, about digital technology and electronic records.
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Speaker 7
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Speaker 7
Thank you very much, Roger. Can I ask Sarah, the patient association has said that they're concerned about this reorganisation distracting from patient priorities. And I wondered if you could just elaborate a little bit on that for us. You know where those concerns come from and what you would hope to be done to mitigate that.
14:47
Speaker 9
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Speaker 9
Yeah. And I think I commented a lot on this earlier in the previous question. So I'm not sure how much more I have to add apart from the ensuring that I think my main thing, my main points are not to divert attention away from the urgent priorities that patients are facing at the moment, ensuring that there really is that truly independent patient voice. And trust. As I keep saying, there is, you know, there is a lack of trust amongst patients. And how are we going to ensure that the reporting system is there in terms of this?And, you know, ultimately, patients need reform to lead to better care and not simply just different structures, which I feel often is happening.
And Sir Robert Francis said, following the as you know, the mid staffs, that patients must come first. So I think throughout the passage of this bill, our question just remains simple. And we will as the patient association, just keep asking time and time again, will these changes actually help patients receive better care. And how will we know if they do?I think that is the first principle to come back to when everything is happening, when all of this restructure is happening, how are patients going to be affected?How are patients going to be involved in this?
And Sir Robert Francis said, following the as you know, the mid staffs, that patients must come first. So I think throughout the passage of this bill, our question just remains simple. And we will as the patient association, just keep asking time and time again, will these changes actually help patients receive better care. And how will we know if they do?I think that is the first principle to come back to when everything is happening, when all of this restructure is happening, how are patients going to be affected?How are patients going to be involved in this?
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Speaker 7
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Speaker 7
Thank you. And then have you got time for a second question?A second question really just on on Healthwatch. Um can I ask a. What we've talked a little bit in the, in the committee this morning about the variability of Healthwatch. Is effectiveness at a local level. What do you think could be done to ensure that it's that the best practice, the most effective health watches are rolled out across the whole of England.
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Speaker 8
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Speaker 8
Thank you for that question. Um, one of the reasons that there is a difference or a variation amongst the 153 is because the amount of funding is, is very different. Some of them, you know, get ten times the funding of, of others. So that does make a difference to the scope of what they can do, what it doesn't allow. And I think Healthwatch England has an important contributory role in this is to change the quality of the way in which the research is done.
One of the things that I. And it happened before I joined Healthwatch, but. But I have encouraged it very strongly is the use of qualitative data as well as quantitative data, because, you know, the system's kind of awash with quantitative data, but it doesn't necessarily cut through to the way that people are, the way that people think, the lexicon that people use, the concepts they use in communication, etc.. So I think one of the great strides that both Healthwatch England and and our 153 member network have made is the really intelligent use of qualitative data.
And that's an art in itself. I'd like to think it was a science, but it's certainly an art in itself. Now, it would be easy to remedy that in the sense that if the funding were more equitable across, then obviously that some of that variation would disappear. But the variation is not in the quality, it's not in the effectiveness of the listening. It's not in the ability to quite, uh, thoroughly look at what the impact is. And then it also doesn't affect the fact that they held responsible.
The organisation concerned for what happens to the recommendations in terms of implementation that is uniform across the system. Just the amount of it that will vary naturally because of the the differential funding.
One of the things that I. And it happened before I joined Healthwatch, but. But I have encouraged it very strongly is the use of qualitative data as well as quantitative data, because, you know, the system's kind of awash with quantitative data, but it doesn't necessarily cut through to the way that people are, the way that people think, the lexicon that people use, the concepts they use in communication, etc.. So I think one of the great strides that both Healthwatch England and and our 153 member network have made is the really intelligent use of qualitative data.
And that's an art in itself. I'd like to think it was a science, but it's certainly an art in itself. Now, it would be easy to remedy that in the sense that if the funding were more equitable across, then obviously that some of that variation would disappear. But the variation is not in the quality, it's not in the effectiveness of the listening. It's not in the ability to quite, uh, thoroughly look at what the impact is. And then it also doesn't affect the fact that they held responsible.
The organisation concerned for what happens to the recommendations in terms of implementation that is uniform across the system. Just the amount of it that will vary naturally because of the the differential funding.
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14:50
Speaker 4
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Speaker 4
Thank you chair. Going back to the single patient record, I see huge potential for it, at least in my constituency, where we have real challenges of the GPS and the hospitals not talking to each other and sharing information, but also the trust and the local authorities across Buckinghamshire and Bedfordshire and Hertfordshire not sharing that information. And Sarah touched on this a bit already, but I'd be interested to hear from our other witnesses as well, how you see that single patient record improving the patient experience and and also how we go about building that public understanding and trust in a new system.
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14:51
Speaker 10
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Speaker 10
I think there are some big opportunities in the single patient record, I think with the caveats that Sara mentioned around data governance and consent. I think for families of children who are seriously ill, this presents huge opportunities because of the complexity of their needs, which I set out earlier. Um, often there's a huge amount of information which they need to convey to any professional, whether that's across health, education, social care that they come into contact with. Now, there are many professionals who have a long standing relationship with these families.
That's NHS community, children's nurses or consultants with a speciality in the child's condition or children's hospice teams. But often these families will need to access emergency unplanned care, perhaps in the middle of the night, perhaps at weekends. In those instances when they're speaking to paramedics, when they're speaking to emergency doctors, it's imperative that they convey that as quickly as possible. Um, and in those instances, I could see huge benefits there also around issues such as advanced care planning. So reflecting the needs and wishes of those families and particularly as a child is coming towards the end of their life.
I think it's critical that that the whole range of professionals involved in the care of children have access to that. And I think I'd be welcome much more clarity from the government about when these families will benefit from from that particular initiative.
That's NHS community, children's nurses or consultants with a speciality in the child's condition or children's hospice teams. But often these families will need to access emergency unplanned care, perhaps in the middle of the night, perhaps at weekends. In those instances when they're speaking to paramedics, when they're speaking to emergency doctors, it's imperative that they convey that as quickly as possible. Um, and in those instances, I could see huge benefits there also around issues such as advanced care planning. So reflecting the needs and wishes of those families and particularly as a child is coming towards the end of their life.
I think it's critical that that the whole range of professionals involved in the care of children have access to that. And I think I'd be welcome much more clarity from the government about when these families will benefit from from that particular initiative.
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Speaker 8
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Speaker 8
Briefly, please. Um, I would just like to say that, you know, we have to recognise that a tremendous amount of work is done in the health and social care system with people with multiple co-morbidities, not just one thing one, but, you know, a number of things. And those often interact together. Now you can, without a single patient record, you can find that, you know, a consultant or a GP only has access to one part of that. If you like multiple co-morbidity and that can lead to all sorts of, you know, unforeseen errors occurring.
So I think that's an important point to make about the great advantage that you can get from a single patient record. Thank you sir.
So I think that's an important point to make about the great advantage that you can get from a single patient record. Thank you sir.
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14:53
Speaker 11
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Speaker 11
Professor, the local Healthwatch on the Isle of Wight has proved to be invaluable at amplifying patient voice gathering, patient experience and helping those who are democratically elected. So MPs and councillors hold health leaders to account. My concern is that if that function is folded into the ICB, it's the ICB that's very often been on the sharp end of critical analysis by Healthwatch, and the ICB will end up marking their own homework, and we will lose that critical voice that has, I'm sure, led to better decision making.
How can we possibly resolve that fundamental issue if Healthwatch is folded into Icbs?
How can we possibly resolve that fundamental issue if Healthwatch is folded into Icbs?
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Speaker 8
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Speaker 8
Well, I mean, you raise a very kind of pivotal and focused point on this because the independent is absolutely vital, not just because of the quality of what it produces, but the confidence that it gives to people. You know, they're speaking this is to an independent organisation because in the background, amongst some communities, there is a distrust about being critical, about the care that they're receiving in case it rebounds upon them. And that's, you know, that means that if you've got the same organisation responsible, as you've indicated, sir, for for marking its own homework, as you put it, I think that that problem will be much greater than it has been in the past.
So what you do about it, I think, is, you know, you stick to some basic principles. If we're moving forward positively, we've got to be locally driven. We must reach out to communities. They won't reach into us. We have to reach out to those communities and the individuals within them. I mentioned before valuing qualitative evidence, which is not always easy for big institutions to go through all the work of evaluating qualitative work. It's easy to look at quantitative statistics, but we must be also, the patient voice must be highly visible, and it must be central to policy making.
I mean, this was the, you know, the basic idea really behind the health and social care bill that we're discussing, that it would be about the patient, about the patient voice putting the patient right at the centre of the multiple discourses that take place. And as my colleagues have said, be totally transparent about priorities, impact, and holding people to account. If those principles are followed, all of them, five of them there, then it will work. But if they're not, it won't work.
So what you do about it, I think, is, you know, you stick to some basic principles. If we're moving forward positively, we've got to be locally driven. We must reach out to communities. They won't reach into us. We have to reach out to those communities and the individuals within them. I mentioned before valuing qualitative evidence, which is not always easy for big institutions to go through all the work of evaluating qualitative work. It's easy to look at quantitative statistics, but we must be also, the patient voice must be highly visible, and it must be central to policy making.
I mean, this was the, you know, the basic idea really behind the health and social care bill that we're discussing, that it would be about the patient, about the patient voice putting the patient right at the centre of the multiple discourses that take place. And as my colleagues have said, be totally transparent about priorities, impact, and holding people to account. If those principles are followed, all of them, five of them there, then it will work. But if they're not, it won't work.
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Speaker 13
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Speaker 13
Thank you. Chair. Um, just to Sarah, you mentioned the patient should be the centre of all this, and I don't think anybody disagree. Even any of the politicians making all these changes is the best interest for the patients. But we know in reality, so many changes happened over the decades. And we're looking at the data, um, for the last ten years, the patient safety incidents steadily going up, complaints going up. So what are the changes that happened hasn't made any impact on patient care or patient safety and patient experience.
So we need to do something here. So um each complaints or each incident come back with a recommendation or action plan. Which clinical staff or patients do not have much involvement and don't see any difference. And the Healthwatch for example, um, is very helpful finding the issues who may not actually go back and see what happening, what changes made following their recommendation. So is it right that the CQC who actually go physically into the clinical areas and see the difference, and who has got the power to make or take action against those people who are responsible, is it not a good change that more accountability, uh, will sit with the providers and the CQC or any other like local authorities or ICB who can take actions against them.
So we need to do something here. So um each complaints or each incident come back with a recommendation or action plan. Which clinical staff or patients do not have much involvement and don't see any difference. And the Healthwatch for example, um, is very helpful finding the issues who may not actually go back and see what happening, what changes made following their recommendation. So is it right that the CQC who actually go physically into the clinical areas and see the difference, and who has got the power to make or take action against those people who are responsible, is it not a good change that more accountability, uh, will sit with the providers and the CQC or any other like local authorities or ICB who can take actions against them.
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Speaker 8
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Speaker 8
I think there's always a danger, if I may say so, sir, in the use of the word streamline, because you have to think what's lost in the streamlining process. And I don't want to repeat what what I've said earlier and waste your time. But one of the things that is important is is there a golden thread running through from seeking out, listening to patients views?Putting those together in a coherent form, making recommendations for improvement. Because that's what we do all the time at Healthwatch, and then holding the people accountable for that.
It's been said, well, you know, I remember Penny saying, well, you know, one of the points of, uh, of the bill is to bring this closer to those that commission and those that deliver. Um, I'm not sure that it would take it necessarily closer to that simply by embedding it. As a colleague asked earlier, within the formal structure, because there is a danger in that, that it's the patient voice is often a spiky voice. It's not always as a former, you know, chair of.
Hospitals. ET cetera. You know, patients don't always say the things that are convenient to say. So that point about independence is vital. So I would just perhaps, if I may, sir, take slight issue with your term streamlining and just try and take that apart into the different parts, that different components that might comprise it.
It's been said, well, you know, I remember Penny saying, well, you know, one of the points of, uh, of the bill is to bring this closer to those that commission and those that deliver. Um, I'm not sure that it would take it necessarily closer to that simply by embedding it. As a colleague asked earlier, within the formal structure, because there is a danger in that, that it's the patient voice is often a spiky voice. It's not always as a former, you know, chair of.
Hospitals. ET cetera. You know, patients don't always say the things that are convenient to say. So that point about independence is vital. So I would just perhaps, if I may, sir, take slight issue with your term streamlining and just try and take that apart into the different parts, that different components that might comprise it.
15:00
Speaker 9
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Speaker 9
Yeah. I don't think I can comment too much around CQC, but I think in terms of there's a rise in complaints, but nothing seems to be happening. We're finding that patients don't want to complain anymore because they're finding that they're getting a worse service of care. So I think that might be a slightly separate issue, but I think considering that there are so many complaints and also patients are not wanting to complain because they're scared, I don't think, as you said, streamlining is the right way.
We do need that independent voice who will solely focus on the patient voice, which I think at the moment we are completely losing.
We do need that independent voice who will solely focus on the patient voice, which I think at the moment we are completely losing.
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15:01
Speaker 14
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Speaker 14
Thank you very much, chairman. Just so just on that streamlining point, um, you have articulated very clearly why you think it's inappropriate. Members of the committee have articulated what's not, why it's inappropriate. Most of the evidence we've received suggests it's not appropriate. What do you think is the reasoning behind the government's real push for this when the evidence against it is so, so clearly strong?Is it simply they want to save money in your opinion, or is there some other alternative motive?
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Speaker 8
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Speaker 8
Well, if we talk, if we talk, if we talk. About money. I will be quantitative here. Healthwatch England currently costs £3 million a year, and the network receives 25 million per year. So I know to people like me, 3,000,025 million is a lot of money. But in the greater scheme of things, this is not a significant amount of money, particularly when you think of what is being produced for it. I think I, I really can't speak appropriately in terms of my role as chair of Healthwatch about government policy.
You know, that's not my job to do that. That's the government's job. If you want to ask me a question on a purely personal basis, when I can step outside of that, I'm happy to answer that. But I would always have to draw a very distinct, line between anything that I say. Everything so far has been in my formal position as chair of Healthwatch, as opposed to any personal views, because I certainly don't want to comment on government policy.
You know, that's not my job to do that. That's the government's job. If you want to ask me a question on a purely personal basis, when I can step outside of that, I'm happy to answer that. But I would always have to draw a very distinct, line between anything that I say. Everything so far has been in my formal position as chair of Healthwatch, as opposed to any personal views, because I certainly don't want to comment on government policy.
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Speaker 10
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Speaker 10
The key here is about making sure that the independent patient voice is well resourced and is held accountable for doing its job and works, particularly for those who the system finds it hardest to reach. Um, and I think families of seriously ill children definitely fall into that bracket. So I think certainly interest have short lives in the children's palliative care sector is making sure that those structures do that.
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15:04
Speaker 6
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Speaker 6
Views that we've heard, not just this session, but previous sessions as well. There's one mindset that, um, with. With, um, with bringing in patient voice into Icbs. Icbs are literally going to be marking their own homework, but equally, when I think about Wolverhampton, places like Wolverhampton, we've got such baked in inequalities that we just simply have not shifted the dial for far too long. And you can see that in the in the difference with life expectancy. So I've also heard that if you want to bring real change, it's best to bring change from within the system.
So just open.
So just open.
15:04
Speaker 9
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Speaker 9
Um, I would, I would. Disagree with that. Um, I think it's fine for ICB to be involved, but I think it's all around local partnership working. So bringing in the voluntary sector and really going into the community and doing it in partnership. And I think that's the only way of doing it. I think if you're bringing it into the ICB, if you're considering how much funding there is, when it was Healthwatch doing it, um, and I don't want to repeat it, but I'm going to.
It is um, marking their own homework. So for me it is around partnership working and it's going from the community. So not from in the system and not within the NHS. It's going out to the community and feeding inwards.
It is um, marking their own homework. So for me it is around partnership working and it's going from the community. So not from in the system and not within the NHS. It's going out to the community and feeding inwards.
15:05
Speaker 15
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Speaker 15
Thank you. Um sir Roger and I know that in this conversation some have highlighted that patients have stated their experience has worsened or not improved. But I'd argue that's not a Healthwatch failure, but is actually failures down to the NHS or Icbs not acting on Healthwatch recommendations. So it seems to me perverse to give that voice to the organisations that are actually part of the problem through not acting now, whether right or wrong. And I, as a minister, was on the receiving end of some quite sharp recommendations in the past from Healthwatch, but they were always constructive.
Um, my fear is it risks a perception among patients that it will actually be down to NHS managers and the ICB, essentially to make recommendations that reflect their priorities rather than patients priorities and not be patients voices. So even if the principles that you've enunciated, professor that were this to go ahead might mitigate that risk. Um and were applied to the new model, are you really confident that that can mitigate the risk to patient confidence that their voice is genuinely independently, however, however perceived to be unhelpful by bits of the NHS is genuinely heard, loud and clear.
Um, my fear is it risks a perception among patients that it will actually be down to NHS managers and the ICB, essentially to make recommendations that reflect their priorities rather than patients priorities and not be patients voices. So even if the principles that you've enunciated, professor that were this to go ahead might mitigate that risk. Um and were applied to the new model, are you really confident that that can mitigate the risk to patient confidence that their voice is genuinely independently, however, however perceived to be unhelpful by bits of the NHS is genuinely heard, loud and clear.
15:06
Speaker 8
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Speaker 8
Well, I can't be confident of that because of course we we're in the foothills, not not up the slope at the moment, and the details haven't been given, but Icbs have received, you know, something approaching 50% cut in their running costs. Uh, I'm not going to comment on the appropriateness or otherwise of that, but I think one has to be realistic and think how far a really informed patient voice, you know, seeking out the views, where the hell of those both communities and individuals, where the health inequalities are the greatest is going to be very high on the priority list.
And I, you know, I would question that. You know, just leave it there, if I may.
And I, you know, I would question that. You know, just leave it there, if I may.
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15:07
Speaker 16
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Speaker 16
Thank you. Uh. You're all representing patient organisations in different ways. So I'd like to kind of put this in the context of the, the ten year plan and shifting and the shift to involving patients and communities in actually shaping services. And I wonder if you can say from your patient perspective, how can we best support icbs, local authorities and other people to actually drive that change for patients?
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15:07
Speaker 10
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Speaker 10
Thank you. I think it's really key that Icbs are given of that support, and certainly the conversations that have short lives has with Icbs, and certainly the services we represent have with Icbs. The sense that we get is they do want support. They want to know how much they should be funding certain services. They want to know how to plan. Um, and there is, you know, a lot of guidance that's already out there, particularly in children's palliative care.
We have service specifications and nice guidance, quality standards. There's even a legal duty to make sure Icbs commissioned palliative care for children and adults. Um, so I think that accountability and that support from the centre and making sure that resource is there is, is absolutely key. Thank you.
We have service specifications and nice guidance, quality standards. There's even a legal duty to make sure Icbs commissioned palliative care for children and adults. Um, so I think that accountability and that support from the centre and making sure that resource is there is, is absolutely key. Thank you.
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15:08
Speaker 8
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Speaker 8
Might I make a final comment, sir?Forgive me. May I just wanted to reassure the um colleagues who are here that Healthwatch England and the Healthwatch Network are still fully functional. Uh, that's important, I think, for you to know. Um, although we are sensibly on a reducing trajectory. In line with the government's plans of abolishment, we will maintain that full functionality and the ability to meet our formal mandate right through until the bill itself is enacted. And indeed, until the guidance that will probably follow the bill is in place.
So I'd just like to reassure, uh, the committee about this.
So I'd just like to reassure, uh, the committee about this.
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Speaker 1
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Speaker 1
Good afternoon. We shall now hear oral evidence from Local Government Association. The Association of Directors of Adult Social Services and South East London Icss. And we have until 350 for this panel. So from camera left to right, could you identify yourselves for the benefit of the record, please?
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Speaker 12
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Speaker 12
Um thank you. I presume that will be directed at me because representing local government, um, we feel it's going to weaken it. Um, we feel uh that. The current having someone on the ICB is really useful for helping shape health strategy, helping to, um, uh, ensure that the wider determinants of health are taken into consideration when planning health. Um, so, uh, we would like to see some kind of, um, structure where we, where local authorities and other other partners that are involved in that wider determining how wider perspective have a voice within, within, um, the NHS delivering health locally.
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Speaker 18
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Speaker 18
I think whenever we. We, um, we introduce these changes into the system. We have to remember that we're talking about a group of professionals who are trying to deliver for the NHS, for citizens and patients. Um, this bill obviously was first announced back in March 25th. I think it would be fair to say that for an awful lot of people since then there has been, um organisational, um, unknowns, but also personal unknowns. And so, um, I think that the best intentions to deliver against the agenda and against the three shifts, um, can be hindered in that uncertainty and implementation, as with everything is absolutely critical in this.
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15:14
Speaker 19
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Speaker 19
You. So the the Better Care Fund is a really important source of funding for statutory core services. Um, it funds about 80% of social care. Um, 80% is statutory in terms of the use of the better care fund by social care. So whilst the ability to use it differently could be really valuable, um, we would be worried about um, diverting it away from those core services into other functions. Um and we I think have also benefited from the fact that the better care fund is uplifted at the same rate as the NHS funding.
Um, if we lost that, um that would be significant because social care is systematically less well funded. Um, over time, um compared to some other services.
Um, if we lost that, um that would be significant because social care is systematically less well funded. Um, over time, um compared to some other services.
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Speaker 20
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Speaker 20
Thank you sir Roger. I wonder if um if um particularly to um Councillor Wright in terms of the current, obviously this legislation essentially abolishes NHS England. Um I don't know if you've got any comments about how that works at the moment in terms of local government. Um but particularly, um how do you think we can unlock some of the potential in this legislation and with the changes to NHS England with regards to local government, particularly on health and wellbeing boards, um and the entire place agenda.
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Speaker 12
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Speaker 12
Um thank you. Thanks. Um with regards to the abolition of NHS England, um the main problem it's caused is um upheaval and uncertainty with our health partners. So many of the health partners that we're meeting at our health, health and wellbeing board meetings at our place committee meetings, they're almost saying to us, I don't know if I'll be here at the next meeting. So you have that. You have that, um, instability of being able, lack of being able to plan what's going to happen next when, when there's such turmoil in this, this changeover.
So that's, that's one of the, um, that's one of the challenges that we feel. Um, and, you know, we are working with our health partners and we're, we are getting those assurances that there will be continuity. But it's quite hard when the person we're working with will be change is changing. Um, with regards to health and wellbeing boards, um, we're really excited about um, neighbourhood health sitting under health and wellbeing boards. We love, we love the idea of um, uh, neighbourhood health being, um, looking at the wider determinants of health, having a very localised health response to what are the issues that that community needs to help it, um, one of our anxieties is that, um, icbs a lot of icbs have become bigger, so they have less connection with the place.
So therefore, um. Uh, and they're also, they're also, um, shrinking, I think the NHS England's larger geography. And larger geography, less people. So, um there's, there um we've had a letter from our ICB, for example, saying that um they are kind of giving us the heads up that they might not be able to guarantee that they can send the right person to our health and wellbeing committees, which is obviously going to make it difficult for planning neighborhood health. Um, the other challenge we find for neighbourhood health is um.
Local authority boundaries might not necessarily match neighbourhood boundaries. Um, and I'll give an example of where I live. Um I'm in Bracknell Forest Council. Bracknell is very clearly a neighbourhood, but then the south of the borough, which is still within the council is probably sits within Bracknell and Wokingham. And a little bit of reading. So it's almost like. It's going to be hard to bring in true neighbourhoods. Um with the current structure, but that's um.
That's something that we're working around and we're hopeful that we'll be able to, to, to sort that out. But that's, but, and I think we all really like the idea of health and wellbeing boards being the, the place that.
So that's, that's one of the, um, that's one of the challenges that we feel. Um, and, you know, we are working with our health partners and we're, we are getting those assurances that there will be continuity. But it's quite hard when the person we're working with will be change is changing. Um, with regards to health and wellbeing boards, um, we're really excited about um, neighbourhood health sitting under health and wellbeing boards. We love, we love the idea of um, uh, neighbourhood health being, um, looking at the wider determinants of health, having a very localised health response to what are the issues that that community needs to help it, um, one of our anxieties is that, um, icbs a lot of icbs have become bigger, so they have less connection with the place.
So therefore, um. Uh, and they're also, they're also, um, shrinking, I think the NHS England's larger geography. And larger geography, less people. So, um there's, there um we've had a letter from our ICB, for example, saying that um they are kind of giving us the heads up that they might not be able to guarantee that they can send the right person to our health and wellbeing committees, which is obviously going to make it difficult for planning neighborhood health. Um, the other challenge we find for neighbourhood health is um.
Local authority boundaries might not necessarily match neighbourhood boundaries. Um, and I'll give an example of where I live. Um I'm in Bracknell Forest Council. Bracknell is very clearly a neighbourhood, but then the south of the borough, which is still within the council is probably sits within Bracknell and Wokingham. And a little bit of reading. So it's almost like. It's going to be hard to bring in true neighbourhoods. Um with the current structure, but that's um.
That's something that we're working around and we're hopeful that we'll be able to, to, to sort that out. But that's, but, and I think we all really like the idea of health and wellbeing boards being the, the place that.
15:18
15:18
Speaker 19
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Speaker 19
Thank you so much. Um, so health and wellbeing boards will probably become even more important following the removal of the local government representation from the ICB. It will be the only place where we have NHS partners and local government partners, and specifically the statutory responsibilities of social care required to work together, and as others have noted, they are at place level and therefore are going to be crucial for connecting to the neighborhood. I guess the other factor that it's helpful to note is that there's a huge amount of pressure on systems at the moment, and the cuts to Icbs are having a really profound effect on the relationships they have with local government partners.
Um, and we are hearing from our members that continuing health care is a real point of concern with reviews leading to the withdrawal of that care and that placing, um, challenges on, on local authorities. So in that context, um, making sure that we're supporting health and wellbeing boards to be as effective as possible for neighbourhood health. Um, and in that strategic joining up role becomes even more important.
Um, and we are hearing from our members that continuing health care is a real point of concern with reviews leading to the withdrawal of that care and that placing, um, challenges on, on local authorities. So in that context, um, making sure that we're supporting health and wellbeing boards to be as effective as possible for neighbourhood health. Um, and in that strategic joining up role becomes even more important.
15:19
15:19
Speaker 19
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Speaker 19
Neighbourhood health is a really important vision that we support very strongly. Um, it's in a way, obviously the right thing to do to, to move services more closer to the people that they serve and to work very closely with communities. Health and wellbeing boards have an opportunity to drive that neighbourhood health agenda because they are responsible for neighbourhood health planning and because they have the connection to local government and the voluntary sector in many cases, and the NHS. So it feels like that is a real space of opportunity to drive neighbourhood health and to really realise the benefits that it could offer.
Thank you.
Thank you.
15:19
15:20
Speaker 18
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Speaker 18
I think, um, a couple of things. One is I wouldn't want to I don't think it's possible to overstate the importance of the partnership working between the NHS and local authorities. Um, if we want neighbourhood health and if we want the shift to prevention more broadly to be successful, working closely with local authorities, including, by the way, the public health teams, which weren't in your question, but I think should deserve a mention, is absolutely imperative. And I'm sure we'll come on to the question about the relationship with the Mayoralties.
And I think there's something about that geography question and the insight and the experience that that local authorities bring is really important. Um. Sorry, that was the one thing I think I think ought to be mentioned.
And I think there's something about that geography question and the insight and the experience that that local authorities bring is really important. Um. Sorry, that was the one thing I think I think ought to be mentioned.
15:20
15:20
Speaker 7
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Speaker 7
Thank you very much. Roger. I'm a vice president of the LGA and I'm also on the Patient safety all party group. Uh, just to declare that interest up front. Um, I just want to use the example of my own local authority, Shropshire, which is a unitary authority. It's extremely financially challenged and it operates with an ICB in a similar situation. And the handoff that you described, Sally, between continuing healthcare and provision of social care is really problematic because neither organisation really wants to pay for the care for the people that need it because they don't have the funds.
So, uh, it's a, it's a really tense relationship between the two. AM concerned that given that we're not a combined mayoral authority and we won't have a mayor sitting on our ICB and our ICB merged footprint doesn't fit with our local authority. Uh, geography, I'm really concerned that that's going to become even more problematic because they, uh, can't work together. So can you give me some pointers as to how you would like to see the health and wellbeing boards work between the two organisations to deliver good social care?Um, yeah, I think that's it to start off with.
So, uh, it's a, it's a really tense relationship between the two. AM concerned that given that we're not a combined mayoral authority and we won't have a mayor sitting on our ICB and our ICB merged footprint doesn't fit with our local authority. Uh, geography, I'm really concerned that that's going to become even more problematic because they, uh, can't work together. So can you give me some pointers as to how you would like to see the health and wellbeing boards work between the two organisations to deliver good social care?Um, yeah, I think that's it to start off with.
15:22
15:22
15:22
15:22
15:22
Speaker 12
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Speaker 12
It's a challenge. I completely hear that. And um. Care is you know, it's. It's it's. A really difficult one. And you're right. And patient residents are kind of seen. As a financial burden which which shouldn't happen. Um, I think. There's a lot to I think this is why we need strong health and wellbeing boards and we need strong, honest conversations between local authorities and the NHS for ensuring that good continuity of care.
Well, I mean, obviously what I think the aim overall of the ten year health plan is that, you know, we're moving much more to a prevention treatment in the community kind of model where you'd hope that we that these that we'd be able to intervene earlier and set up good standards of care for these people before it gets to a stage where it becomes so adversarial. Um, so, I mean, so that's a kind of. You know, what we're aiming for, but I think when it comes to actually, um, those kind of adversarial, what would you say, Sally?I mean, I know, I know that we have, we have challenges in our local authority and we've had to push back on a few, a few cases where we felt that the NHS should be, should be helping these people.
Yeah.
Well, I mean, obviously what I think the aim overall of the ten year health plan is that, you know, we're moving much more to a prevention treatment in the community kind of model where you'd hope that we that these that we'd be able to intervene earlier and set up good standards of care for these people before it gets to a stage where it becomes so adversarial. Um, so, I mean, so that's a kind of. You know, what we're aiming for, but I think when it comes to actually, um, those kind of adversarial, what would you say, Sally?I mean, I know, I know that we have, we have challenges in our local authority and we've had to push back on a few, a few cases where we felt that the NHS should be, should be helping these people.
Yeah.
15:23
15:24
15:24
15:24
Speaker 19
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Speaker 19
Thank you. So, so um the problem is getting bigger over time. Um, and we did some joint work last year with the NHS Confederation to try and look at those difficult issues on the boundaries between health and social care, including continuing health care and mental health aftercare. And that identified some good models. So we do see arrangements for joint commissioning of continuing health care, which can work well. Um, we've seen a little bit of withdrawal of from that by some icbs.
Um, and I, I think part of the issue has got to be that, um, we're, we're seeing a real intention to cut costs and that leads to lots of reviews taking place, which does withdraw continuing health care. And we've seen that trend at the same time as the demographics are pointing to potentially more demand, not less. Um, so I don't think there's a substitute for better relationships. The legal framework is pretty clear. Um, but if we can find a way to, um, have a set of conversations at national level, which is what's the right solution for people and start there and then think about whether the, the reviews in the ways they're taking place are right.
That would be a helpful way into the, into the problem.
Um, and I, I think part of the issue has got to be that, um, we're, we're seeing a real intention to cut costs and that leads to lots of reviews taking place, which does withdraw continuing health care. And we've seen that trend at the same time as the demographics are pointing to potentially more demand, not less. Um, so I don't think there's a substitute for better relationships. The legal framework is pretty clear. Um, but if we can find a way to, um, have a set of conversations at national level, which is what's the right solution for people and start there and then think about whether the, the reviews in the ways they're taking place are right.
That would be a helpful way into the, into the problem.
15:25
15:25
Speaker 18
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Speaker 18
I think the one thing I would add is that it is tricky when we apply sort of a broad brush kind of, well, it's going to be about the mayoralty, etc. in reality, um, you know, certainly within London we often describe ourselves as a system of systems. We work with six local authorities across one ICB now partnering with South Shetland as well. It's not as easy as a one one um, one approach fits all. And I think as this bill goes through implementation, being very conscious of that will be very important to get the best out of those relationships.
15:26
15:26
Speaker 12
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Speaker 12
Um. I think I think health and wellbeing boards, I mean, I chair our health and wellbeing board. We've got, we've got everyone comes to those. There's a, there's a really good conversation. It's really good. Um, uh, reviews of what's what's happening. I think, I think they're in a really good position. What I, what I worry is how much influence they're going to have over NHS wider strategy. And I suppose I was at a fun day and someone said something which I thought was so true.
And the NHS Bill and the NHS ten year plan is the NHS ten year plan. The NHS will be judged on how it. How it achieves, what it's meant to achieve. So although we've got all these wide, all we've got all these. As local authorities, we want to help with prevention. We want to help with, you know, those wider determinants of health. But ultimately it's the responsibility sits with the NHS. And so it's trying to work out how do we have how do we have those better conversations with the NHS saying we've done neighborhood health for years.
You know, this is what we do as local authorities. We, we, we, we look at all these things. We use public health. We use our adult social care system to create healthy environments. We need you to be on board with that. So I think there's something about the power dynamics in health and wellbeing boards and how do we how do we address those power dynamics?But overall, I feel they are the best way of, um, of ensuring community health.
Um, the other slight thing is that thing about geographies, um health and wellbeing boards might not actually um match neighborhood health geographies. So it's kind of working out how that's going to work. So there are some challenges there as well. All right.
And the NHS Bill and the NHS ten year plan is the NHS ten year plan. The NHS will be judged on how it. How it achieves, what it's meant to achieve. So although we've got all these wide, all we've got all these. As local authorities, we want to help with prevention. We want to help with, you know, those wider determinants of health. But ultimately it's the responsibility sits with the NHS. And so it's trying to work out how do we have how do we have those better conversations with the NHS saying we've done neighborhood health for years.
You know, this is what we do as local authorities. We, we, we, we look at all these things. We use public health. We use our adult social care system to create healthy environments. We need you to be on board with that. So I think there's something about the power dynamics in health and wellbeing boards and how do we how do we address those power dynamics?But overall, I feel they are the best way of, um, of ensuring community health.
Um, the other slight thing is that thing about geographies, um health and wellbeing boards might not actually um match neighborhood health geographies. So it's kind of working out how that's going to work. So there are some challenges there as well. All right.
15:29
Speaker 15
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Speaker 15
Thank you. Um sir Roger. And I'm very conscious that any, having been a local councillor, having been a health minister, any joint working arrangements between different bodies, uh, the real test comes when budgets start getting a little bit tighter and we see with the cuts made to icbs budgets, that tension growing a little bit. Now, I was the minister that created Icbs. I sat on that bill committee with the minister. I'm getting a sense of déja vu. We're on different sides of the chamber, but we sat through the 2022 Health Act, Health and Social Care Act committee stage.
Now, we deliberately or deliberately created those icbs to match the geography of upper tier authorities because of the fact that health and social care is essentially one system if one bit doesn't work, the other bit doesn't work. Since then, we've seen significant mergers and larger areas actually further removing them from that direct relationship and read across, um, and I NHS icbs I fear the good ones do, but a lot don't fully reflect the intention behind their creation, which was to see it as a genuinely collaborative exercise with equal voices in the room.
Um, so my, my question in a sense is if. We see ever larger areas or fragmented areas, be it with neighbourhood health plans or be it with mergers and acquisitions among. ICI B's, how do we maintain that genuine local accountability and the relationships which underpin any structure written in law or on a piece of paper or in guidelines, um and. Notwithstanding what's being done about the health and wellbeing boards increasing involvement, do they actually have the teeth they need?Because in my experience, actually, however good the collaboration, it's actually in the ICB boardroom where the decisions are actually made, however well they've been discussed beforehand.
And the Icbs will make its own decisions based on its own priorities. So does the removal of that voice from the ICB strengthen or weaken the ability to see this as one local system and deliver a genuinely holistic local solution?
Now, we deliberately or deliberately created those icbs to match the geography of upper tier authorities because of the fact that health and social care is essentially one system if one bit doesn't work, the other bit doesn't work. Since then, we've seen significant mergers and larger areas actually further removing them from that direct relationship and read across, um, and I NHS icbs I fear the good ones do, but a lot don't fully reflect the intention behind their creation, which was to see it as a genuinely collaborative exercise with equal voices in the room.
Um, so my, my question in a sense is if. We see ever larger areas or fragmented areas, be it with neighbourhood health plans or be it with mergers and acquisitions among. ICI B's, how do we maintain that genuine local accountability and the relationships which underpin any structure written in law or on a piece of paper or in guidelines, um and. Notwithstanding what's being done about the health and wellbeing boards increasing involvement, do they actually have the teeth they need?Because in my experience, actually, however good the collaboration, it's actually in the ICB boardroom where the decisions are actually made, however well they've been discussed beforehand.
And the Icbs will make its own decisions based on its own priorities. So does the removal of that voice from the ICB strengthen or weaken the ability to see this as one local system and deliver a genuinely holistic local solution?
15:30
15:30
Speaker 12
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Speaker 12
Thank you. I think I think it probably is going to weaken it unless, unless we make sure that we, um, you know, that we're, that we're allowed, we're given more. More say in our local health and wellbeing boards. I mean, so our, we've got Thames Valley, ICB, we have one director of public health, Thames Valley, ICB, I think covers nine local authorities. And we have one chief executive who sits on that and one director of public health. So already the voice on that board is quite small.
And and if we're going to lose that voice. You know, where are we going to have those conversations?I mean, and it brings me back to that whole thing about the health and wellbeing boards need to be stronger. Definitely.
And and if we're going to lose that voice. You know, where are we going to have those conversations?I mean, and it brings me back to that whole thing about the health and wellbeing boards need to be stronger. Definitely.
15:31
15:31
15:31
Speaker 19
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Speaker 19
We would we would agree with that. If if you take away the voice which is able to speak on behalf of social care and public health and wider public services, it is going to be harder and an additional job to bring in that consideration. Um, and. It's, it's even harder to expect there to be notional teeth in that relationship. So we, we have concerns about that.
15:32
Speaker 18
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Speaker 18
Um, I also think it's worth recognising that this, that delivery of any strategy or any plan will require that partnership working with local authorities. So if they're not in the room, whether or not they're in the room, they will be needed for delivery. And the proof is always in the pudding. So that partnership is for me, somewhat non-negotiable. In order to achieve a delivery.
15:32
15:33
Speaker 6
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Speaker 6
Thank you. I've had constituents raise issues with me when it. Particularly elderly patients or patients with dementia. When it comes to discharge and the transfer of care. Because of lack of effective data and information sharing. So to what extent do the provisions in this bill relating to the single patient record allow data to be shared with social care providers?And I'll ask Councillor Wright to start off with.
15:33
15:33
Speaker 12
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Speaker 12
Well, the LGA we're we're trying to um bring the. The argument for a single a single person record that we have a single patient record that actually brings in social care providers or at least the local authorities, social care statutory provision. Um, and that we, so that, um as someone is discharged into the community that they've still got access to records, they still know what's going on, what's happened to that person, um, what they need. So, um, yes, we, we agree, um, we'd hope that a single patient record would make things as smooth as possible from discharge to hospital to home, and also, um, uh, help with when someone comes into hospital that they, um, have a better, the clinicians have a better idea of what their quality of life was like, what treatments they're on, etc..
So I mean, we're definitely in support of the single patient record for that and would like to see it become a single person record.
So I mean, we're definitely in support of the single patient record for that and would like to see it become a single person record.
15:34
15:34
Speaker 19
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Speaker 19
Thank you. Yes. Supportive as well, um, that the bill itself is unlikely to solve all the problems in this space, isn't it. So that there are a huge number of practical cultural systems problems in data sharing. Um, so the regulations that follow the bill will be really important to enable this to work for social care providers and commissioners. Um, and it's. Worth noting that there are thousands of social care providers. So the implementation of the bill and subsequent regulations will be really important.
And we'd be really keen to ensure that the approaches are co-produced with the social care sector, as well as the NHS. It's going to be a lot of thinking, a lot of planning, a lot of hard work to get it right. And, um, social care providers will need lots of notice to upgrade their systems in the right consistent way to enable them to speak to each other. If we're to see the vision of the single person record, um, delivered. Um, and I guess it would also be helpful to think about the role of carers as we move into that space, because we know from Covid that that was data sharing around carers was one of the issues that came up.
Thank you.
And we'd be really keen to ensure that the approaches are co-produced with the social care sector, as well as the NHS. It's going to be a lot of thinking, a lot of planning, a lot of hard work to get it right. And, um, social care providers will need lots of notice to upgrade their systems in the right consistent way to enable them to speak to each other. If we're to see the vision of the single person record, um, delivered. Um, and I guess it would also be helpful to think about the role of carers as we move into that space, because we know from Covid that that was data sharing around carers was one of the issues that came up.
Thank you.
15:35
15:35
15:35
15:36
Speaker 14
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Speaker 14
Well, this question is for Miss Hixon. So um, given that you're a director of transformation and this is, I suppose, a transformation of the NHS in its wider sense, if you had the money, the resources, the political capital that the the current government has, would you be doing this?Would you be doing something else?
15:36
Speaker 18
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Speaker 18
I think any time that we go through an NHS reorganisation, it is very distracting. I think that is a fair reality of these kind of um, situations. And I think that it is unfortunate that over the past 15 months this has been a large distraction, uh, amongst people who are genuinely trying to deliver the three shifts that I think is broadly agreed. So prevention, digital neighborhoods. Um, I think that is true. It has been a distraction. I think that there are, um.
Perhaps other opportunities, and I'm not sure if this is the space to kind of go into those, as I'm aware that this is to discuss a bill, but there are probably opportunities to go further in some elements that may help us in the future. Um, so.
Perhaps other opportunities, and I'm not sure if this is the space to kind of go into those, as I'm aware that this is to discuss a bill, but there are probably opportunities to go further in some elements that may help us in the future. Um, so.
15:37
15:37
Speaker 18
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Speaker 18
So to take one example, um, I would love to see an NHS where we step away from some of the short term activity metrics and, and further towards outcomes. Um, and that is mentioned in the bill, but I think this constant firefight of activity is, is quite challenging. And how can we move that dialogue so that we can make genuinely genuine transformation?I think that is an example of something where we could potentially go further than this bill, for me suggests. Um, but I again, I'm conscious I'm supposed to be commenting on a bill, not, um, not giving my own, uh, random thoughts.
Thank you.
Thank you.
15:38
15:38
Speaker 21
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Speaker 21
Thank you sir. Sir. Roger. Um, so one of the concerns by my local healthcare trust is the release of elderly patients into the community. And they find that that the relationship with the ECB is sometimes quite difficult. How do you believe that neighborhood health plans can be at work cohesively with healthcare trusts?In order to release patients into community care.
15:39
15:39
15:39
15:39
15:39
Speaker 12
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Speaker 12
Yes. Um, I think we can answer this together. I think one of the things obviously, is that the whole point of neighbourhood health is bringing in everyone the voluntary sector, you know, your patient transport, you know, all those things so that there's so that there's a, you know, your joint strategic needs assessment has a really good understanding of what's available for someone in the community for when they come home. I think as we were talking before about having a strong single patient record. So there's that good communication there.
Um, I think, um, so I think neighbourhood health has, has the ability to strengthen this. There's also that thing that, um. Uh, neighbourhood health shouldn't just be seen about shifting the, the, the need from hospital, from community to, from hospital to community. It should also be about reducing that need in the first place that less people need to go to hospital. But at the same time, we are seeing some some good developments in the NHS like frailty teams, hospital at home teams, which.
All of which help that um, continuity, uh, you know, help stop people being admitted to hospital in the first place. And then when they come home, there's a team to visit them. But you're right. Um, that communication thing, um, is I. Mean, where I, where I am, this hasn't been an issue. We've got very good communication system with our local ICB about, about people being discharged and making sure that they're, um, uh, that there's someone there to meet them.
They've got the, um, what's it called?Uh, the, the, when you come home and you get the nurses coming out, see, I can't remember, but you know, we've got the right systems in place and they're working. Um, the other thing is that, um, I mean, I don't quite know how neighbourhood health will work everywhere, but we've also got our sort of step down unit within our borough so that people, when they come out of hospital quite often go to it's called heathlands, and it's where there's a lot of rehabilitation.
So already you're starting that plan of getting them home from hospital to this sort of step down place and then to home. So having those good systems in place, hopefully, all of which should be supported by neighbourhood health, because they should have a good knowledge of what's available locally.
Um, I think, um, so I think neighbourhood health has, has the ability to strengthen this. There's also that thing that, um. Uh, neighbourhood health shouldn't just be seen about shifting the, the, the need from hospital, from community to, from hospital to community. It should also be about reducing that need in the first place that less people need to go to hospital. But at the same time, we are seeing some some good developments in the NHS like frailty teams, hospital at home teams, which.
All of which help that um, continuity, uh, you know, help stop people being admitted to hospital in the first place. And then when they come home, there's a team to visit them. But you're right. Um, that communication thing, um, is I. Mean, where I, where I am, this hasn't been an issue. We've got very good communication system with our local ICB about, about people being discharged and making sure that they're, um, uh, that there's someone there to meet them.
They've got the, um, what's it called?Uh, the, the, when you come home and you get the nurses coming out, see, I can't remember, but you know, we've got the right systems in place and they're working. Um, the other thing is that, um, I mean, I don't quite know how neighbourhood health will work everywhere, but we've also got our sort of step down unit within our borough so that people, when they come out of hospital quite often go to it's called heathlands, and it's where there's a lot of rehabilitation.
So already you're starting that plan of getting them home from hospital to this sort of step down place and then to home. So having those good systems in place, hopefully, all of which should be supported by neighbourhood health, because they should have a good knowledge of what's available locally.
15:41
Speaker 19
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Speaker 19
I can't add much to that, but yes, it should definitely help. If it works well. We should see more capability and capacity in the community closer to where people live, which is available to help them when they come out of hospital. There's lots of good practice understanding already about good discharge and how you plan from the point somebody admitted to, um, to when they come out of hospital. Um, the, the emphasis on integrated neighbourhood teams will be important. And I guess it would be helpful if we could all remember that that must include social care and those wider local government services and connections into those, not just integration within NHS teams.
Um, but it's definitely a positive step forward. And if we can try and make sure that the relationships between um, health, social care, public health and wider services is really brought to life in neighbourhood health, it will kind of help us in this way and lots of other ways.
Um, but it's definitely a positive step forward. And if we can try and make sure that the relationships between um, health, social care, public health and wider services is really brought to life in neighbourhood health, it will kind of help us in this way and lots of other ways.
15:42
15:42
Speaker 17
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Speaker 17
Thank you sir. Um, um, my question is directed towards um Sally if that's all right. And you said a bit on this already, but I was just wondering if you could just say a bit more about how the single patient record could change and improve day to day experience of health and social care system, but also say a bit about the safeguards as well that you may be concerned about.
15:43
Speaker 19
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Speaker 19
So as I understand it, the the safeguards around data sharing remain in place under the bill so they don't change. Um, the. The, the part of the single patient record, which is really attractive to our world, I think, is that people won't have to repeat themselves to every professional they meet, so they won't have to tell their story again and again. They won't have to be retraumatized by explaining the detail of what they've been through. So the kind of potential advantages are there, um, obviously there are concerns about data protection and how data is used.
Um, and it's incumbent on us all to take those really seriously and think, think them through and make sure the safeguards are appropriately implemented locally and in all the institutions that have access. Um, but that probably is less a matter for the bill and more a matter for the implementation and the supporting regulations. But we and other partners will be really keen to be a part of that process to make sure that the safeguards are appropriate.
Um, and it's incumbent on us all to take those really seriously and think, think them through and make sure the safeguards are appropriately implemented locally and in all the institutions that have access. Um, but that probably is less a matter for the bill and more a matter for the implementation and the supporting regulations. But we and other partners will be really keen to be a part of that process to make sure that the safeguards are appropriate.
15:43
15:43
15:43
Speaker 4
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Speaker 4
Thanks, chair. Um, I, I come from a county that's got really significant health inequalities. So if you live in the wealthy parts of the county, you live 10 or 12 years longer than some of the more deprived parts of Aylesbury that I represent. I'd love to hear your thoughts on how we ensure that local authorities and icbs continue and voluntary sector continue working well together through this, but specifically how we do that in a way that drives this reduction that we need to see in those health inequalities.
And I'd be interested in all of your thoughts on that.
And I'd be interested in all of your thoughts on that.
15:44
Speaker 18
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Speaker 18
I think the neighbourhood plan is the I think we're all agreed that working at that neighbourhood level is absolutely the right way to go about that. I think that is where your health inequalities can be best addressed, because it can be most nuanced, it can be most tailored. So working on that smaller footprint, I think is really important. I would just because you mentioned VCs, I think that is a hugely important part, which actually has been broadly missed out. I'd argue from the conversation around around these changes, we work very closely with VCs partners.
We know they deliver huge amounts for the communities, and frankly, they understand the communities in which they're embedded incredibly well. So I think making sure that that VCs voice is a part of those neighbourhood teams will be really important again, for that nuance, that tailoring, that kind of local element.
We know they deliver huge amounts for the communities, and frankly, they understand the communities in which they're embedded incredibly well. So I think making sure that that VCs voice is a part of those neighbourhood teams will be really important again, for that nuance, that tailoring, that kind of local element.
15:45
Speaker 12
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Speaker 12
Yeah, I mean, I agree with that entirely. I think, um, I think there's something about, um. Local authorities in a very good position to engage voluntary and community sector. Um, and, uh, but again, you know, we're fighting for a voice with the NHS. They're fighting for a voice with us, you know?So, so it's a, so I think, I think there needs to be some really, um, honest. Discussions with Icbs and that real strategy and looking at those health inequalities and what is driving those health inequalities, because it won't purely be access to hospitals.
It will be access to, um, meaningful employment, housing, transport, um, mental health, social isolation. There'll be so much around that, around what's, you know, driving those wider determinants of health and affecting healthy life expectancy. So, I mean, local authorities are in a prime position to, to do that. And, and they need to be listened to. And I think that's I think that's going to be the challenge is how, how do we how do we collectively say, right, what, what needs to be done other than implementing the bill?How do we actually look at those that whole health inequality picture and address it?
It will be access to, um, meaningful employment, housing, transport, um, mental health, social isolation. There'll be so much around that, around what's, you know, driving those wider determinants of health and affecting healthy life expectancy. So, I mean, local authorities are in a prime position to, to do that. And, and they need to be listened to. And I think that's I think that's going to be the challenge is how, how do we how do we collectively say, right, what, what needs to be done other than implementing the bill?How do we actually look at those that whole health inequality picture and address it?
15:46
Speaker 19
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Speaker 19
Thanks. And I'd agree with the others as well. Um, tackling health inequalities is really difficult. Um, and doing it the same in every area wouldn't work. And particularly in a world where there isn't enough resource to do everything we'd all like to do, you've got to tailor how you approach local service delivery and what's needed locally according to local needs. The local community capability, how people work and what their preferences are locally. So, um, the neighborhood health agenda is our best shot at tailoring in that way.
I think, um, I think you're going to come on to Healthwatch, but we'd have concerns that in separating out the Healthwatch duties from to look at NHS and social care separately, we risk missing some of the people that are most likely to um, need both. And that could exacerbate health inequalities rather than make them better.
I think, um, I think you're going to come on to Healthwatch, but we'd have concerns that in separating out the Healthwatch duties from to look at NHS and social care separately, we risk missing some of the people that are most likely to um, need both. And that could exacerbate health inequalities rather than make them better.
15:47
15:47
Speaker 5
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Speaker 5
Thank you very much. Who do you envisage will be the organisations or the people that will run the neighborhood health centres. Will they be run out of general practice organisations, or will the local authorities themselves be best placed to run these neighborhood health centres so as to join up hospital care with community services?
15:47
Speaker 12
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Speaker 12
It's quite interesting because, um, I've just been a different, uh, session this morning looking at communities and um, there was a, there was a comment that for the NHS communities are about buildings and for, for the local authority, it's about people and um, um, you. See, I, I kind of see that I think it would be the icbs and whoever the icbs commissioned to provide those health and those neighborhood health centres. But what I would hope is that there would be enough, um, input from the voluntary sector, from local authority, from adult social care, public health, everyone.
But I see I do see the icbs being the, the sort of, um, the commissioners, the people who organise the health and then yeah.
But I see I do see the icbs being the, the sort of, um, the commissioners, the people who organise the health and then yeah.
15:48
15:48
Speaker 10
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Speaker 10
I think if we want to be, as you know, as open to change as possible. My argument would be that that should be that is something that a local that should be decided locally. Wouldn't it be fantastic, for example, if some of these were actually led by VCs who worked in really close partnerships and had clinics where GPS came in?And you can you can envisage a whole number of different scenarios led by local communities, by local organisations. And I think this plays back to the health inequalities point.
I think that's the way you do it, but it relies on you being very open to different models and not trying to do a one size fits all, which I think is is really tricky when you're trying to implement a.
I think that's the way you do it, but it relies on you being very open to different models and not trying to do a one size fits all, which I think is is really tricky when you're trying to implement a.
15:48
15:48
Speaker 11
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Speaker 11
I would strongly agree with that. And I think if you were asking the question, who is best placed to, to run them, the answer would be it probably looks different everywhere because the different. It will rely on local leadership, local capability and capacity, which which does vary across all our sectors. So making the most of the, the, the leadership ambition and the kind of skills and capacity locally is a really good opportunity.
15:49
Speaker 1
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Speaker 1
Thank you. Ladies. Thank you very much. Committee is most grateful to you. If I could just explain now, while we're changing over. We will introduce the. Well, it depends what happens, but we will introduce the next panel. There are then likely in fairly short order, because the Minister's on his feet to be four divisions in the House. I shall suspend the committee as soon as the Division is called until ten.
Minutes after the start of the last Division. I hope that's clear. Ten minutes after the start of the last division, we start again. It does mean, I'm afraid to our panel that we're going to have to ask you to be very patient. It's extremely tedious and very discourteous. But that's the way this place operates, I'm afraid. Um, so we now come to the next panel and we take evidence from carers UK, age, UK and Tommy's and from camera left to camera.
Right. Uh, could you introduce yourselves for the sake of the record, please?
Minutes after the start of the last Division. I hope that's clear. Ten minutes after the start of the last division, we start again. It does mean, I'm afraid to our panel that we're going to have to ask you to be very patient. It's extremely tedious and very discourteous. But that's the way this place operates, I'm afraid. Um, so we now come to the next panel and we take evidence from carers UK, age, UK and Tommy's and from camera left to camera.
Right. Uh, could you introduce yourselves for the sake of the record, please?
15:51
15:51
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15:51
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15:52
Speaker 20
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Speaker 20
Thank you. Um, from the perspective of older people and people with long term conditions, the single patient record will be, broadly speaking, welcomed. And I want to explain very briefly why. Um, if you are an older person and you find yourself in hospital with and you have a multiple long term condition, you often find yourself having to explain your experience, explain your health needs time and time again. And that's often because of a lack of join up of the current data systems.
Um, this allows the individual patient to be able to have need. They don't need to repeat their, um, their stories, their, their, their lived experience, but more importantly, it allows clinicians to be able to have a really clear overview of, um, of, of an individual patient's health records. And of course, there are issues that need to be considered. I'm sure we will get into these, particularly around making sure that people are not digitally excluded, but at a high level, we would welcome the introduction of a single patient record.
Um, this allows the individual patient to be able to have need. They don't need to repeat their, um, their stories, their, their, their lived experience, but more importantly, it allows clinicians to be able to have a really clear overview of, um, of, of an individual patient's health records. And of course, there are issues that need to be considered. I'm sure we will get into these, particularly around making sure that people are not digitally excluded, but at a high level, we would welcome the introduction of a single patient record.
15:53
15:53
Speaker 22
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Speaker 22
Thank you. Some very similar themes. I mean, a lack of shared patient record is a particular issue in pregnancy and maternity. You're being seen by your GP, your early pregnancy unit, your maternity unit. You might have other conditions which affect pregnancy or could affect the outcome of your baby being born. And at the moment, those systems are very, very unjoined up. And I think the other particular piece in maternity, which won't come as a surprise to you, is that if you've lost a baby, you end up having to retell your story over and over again.
And that can be very traumatic. That can sometimes lead to people disengaging with care, but also being retraumatized in, in many cases. So broadly, we welcome it. Lots of caveats around people feeling able to trust the data and trust that their data is safe, but overall, very supportive.
And that can be very traumatic. That can sometimes lead to people disengaging with care, but also being retraumatized in, in many cases. So broadly, we welcome it. Lots of caveats around people feeling able to trust the data and trust that their data is safe, but overall, very supportive.
15:54
15:54
Speaker 23
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Speaker 23
Um, so again, very similar to my colleagues supportive because when we ask unpaid carers what matters to them, sharing of information is really critical. So I just there's a slightly different perspective here. And obviously the first is that carers would like to have access to the record with the right permissions. That's not on the face of the bill, but is suggested that this may be covered in regulations. And we'd like to see some assurances of that. And the ways it changes is, again, not having to retell information.
Carers call it triggering, exhausting. Um they will they are more able to spot errors or things that aren't quite right, which is important for the person that they're caring for. And when you're responsible as an unpaid carer for caring for someone, that is a huge weight on your shoulders, you really want to make sure it's being done right. And the final thing is that most of us care remotely. We don't all live with the person that we care for, and this could really transform, um, help to transform carers, carers lives and the pressure and the weight that they feel.
Just one statistic for you. Um, we have one in just under 1 in 8 carers spending over 40 hours a month on NHS admin. If the NHS app and the single patient record can reduce that, that would change things. Um the, the only other point I would like to say is where this tips over into social care. This is something we need to build with social care. And all those people who go across all these different services.
Carers call it triggering, exhausting. Um they will they are more able to spot errors or things that aren't quite right, which is important for the person that they're caring for. And when you're responsible as an unpaid carer for caring for someone, that is a huge weight on your shoulders, you really want to make sure it's being done right. And the final thing is that most of us care remotely. We don't all live with the person that we care for, and this could really transform, um, help to transform carers, carers lives and the pressure and the weight that they feel.
Just one statistic for you. Um, we have one in just under 1 in 8 carers spending over 40 hours a month on NHS admin. If the NHS app and the single patient record can reduce that, that would change things. Um the, the only other point I would like to say is where this tips over into social care. This is something we need to build with social care. And all those people who go across all these different services.
15:56
Speaker 16
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Speaker 16
Thank you. Um, question for Emily about the, the digital exclusion and the app. Um, what can be done to help people not be digitally excluded?How do you see this working in areas of the country with poorer, um, broadband connections for example, and people have not got so many resources to get the broadband. And also, what about the record sharing your medical records is not an all or nothing thing, is it?It may be that someone is happy to share their current illness or current medical circumstance with their carer, but perhaps aspects of their history, they may want to remain a secret.
So do you have any have you had any indications from government on how that might work?
So do you have any have you had any indications from government on how that might work?
15:56
Speaker 23
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Speaker 23
Yes, lots of different questions. So it has to be with the right permissions, doesn't it?With the patient being in control of their data. And that's a that's a that's really a very strongly held principle, isn't it, within the NHS. And there'll be situations where people don't have capacity and their primary care, it might be their partner, their son or daughter who, who might need access. And there are, you know, we have lasting power of attorney in England that could be used as a mechanism and other assurance mechanisms.
As for digital access, that that is an issue. I'm sure that Paul will want to come on to this as well. Um, what, what we've, what we've called for, especially when, when digital access costs money and we've got people in poverty that that could be supported by government to make sure that everybody has digital access. People have to feel confident about it. Um, whilst we've seen a doubling in the number of carers who are using the NHS app themselves, um, to manage their own health and care in the last two years, there are key groups that are being excluded, older carers, people on lower incomes, people that feel less confident with technology as well for a whole range of different reasons.
Um, and that's, that's often delivered. Some of this stuff is delivered very well through voluntary and community service. Um, and I know that age UK have helped my family, for example, locally, but I'll stop there because I'm sure that Paul will want to come in on that.
As for digital access, that that is an issue. I'm sure that Paul will want to come on to this as well. Um, what, what we've, what we've called for, especially when, when digital access costs money and we've got people in poverty that that could be supported by government to make sure that everybody has digital access. People have to feel confident about it. Um, whilst we've seen a doubling in the number of carers who are using the NHS app themselves, um, to manage their own health and care in the last two years, there are key groups that are being excluded, older carers, people on lower incomes, people that feel less confident with technology as well for a whole range of different reasons.
Um, and that's, that's often delivered. Some of this stuff is delivered very well through voluntary and community service. Um, and I know that age UK have helped my family, for example, locally, but I'll stop there because I'm sure that Paul will want to come in on that.
15:58
15:58
Speaker 20
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Speaker 20
Thank you very much. I would very much like to come in on this subject, if I may. Um, so, so I think probably it's the greatest risk and the greatest opportunity here in the context of, of digital exclusion and digital inclusion. So the risk around digital exclusion is that older, older people in particular, or this isn't exclusively an older people's issue will lack the access to their own care record as it's electronically based. So we need to really pay that. Bear that in mind when we're thinking about the rollout of that and the availability of the content of that, of that patient record to people who are digitally excluded.
However, I do think this is a very significant opportunity, and this is part of a course of a much broader question around digital inclusion more generally, and inclusion into accessing public services more generally is a key theme of the work we're doing at age UK, and we had money funds from Dorset to support the work of our local age UK's, where we run a number of Digital Champions programmes. Members are very welcome to come and visit those programmes at any time. Um which where we worked with 8000 older people in, in a two month period.
Um we engaged over a thousand of that group into our digital champions programme and two thirds of people took up the offer of engaging in a training module around accessing the NHS app. And it was something that we were aware we were unable to able to enable people who are particularly partially digitally excluded. And we have a report being published on this later, which we will share with the committee in time, um, about the, about the, the opportunities for people who are not fully excluded but are partially excluded where we think people are able to go on that journey.
However, it does need support and we would encourage the government to think about putting alongside the implementation of the single patient record, a really thorough programme of inclusion, digital inclusion to support older people, people with long term conditions, people perhaps with learning disabilities and other conditions who might need extra help and support in being able to access the NHS app. So there is a risk here of people being excluded, but an opportunity for inclusion. Mrs. B in Lincolnshire, who was helped by age UK Lincolnshire, tells us that she would never have been able to provide the support.
She is a carer for her husband who has has had a stroke. She had a home visit from the local age UK and they were able to set up the NHS app for her, so she said she wouldn't have been able to do that without that extra help and support.
However, I do think this is a very significant opportunity, and this is part of a course of a much broader question around digital inclusion more generally, and inclusion into accessing public services more generally is a key theme of the work we're doing at age UK, and we had money funds from Dorset to support the work of our local age UK's, where we run a number of Digital Champions programmes. Members are very welcome to come and visit those programmes at any time. Um which where we worked with 8000 older people in, in a two month period.
Um we engaged over a thousand of that group into our digital champions programme and two thirds of people took up the offer of engaging in a training module around accessing the NHS app. And it was something that we were aware we were unable to able to enable people who are particularly partially digitally excluded. And we have a report being published on this later, which we will share with the committee in time, um, about the, about the, the opportunities for people who are not fully excluded but are partially excluded where we think people are able to go on that journey.
However, it does need support and we would encourage the government to think about putting alongside the implementation of the single patient record, a really thorough programme of inclusion, digital inclusion to support older people, people with long term conditions, people perhaps with learning disabilities and other conditions who might need extra help and support in being able to access the NHS app. So there is a risk here of people being excluded, but an opportunity for inclusion. Mrs. B in Lincolnshire, who was helped by age UK Lincolnshire, tells us that she would never have been able to provide the support.
She is a carer for her husband who has has had a stroke. She had a home visit from the local age UK and they were able to set up the NHS app for her, so she said she wouldn't have been able to do that without that extra help and support.
15:59
Speaker 16
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Speaker 16
Well, as a Lincolnshire MP, I'm delighted to know that that's operating. Um, if not necessarily in my constituency, certainly in the county. Um and the question for Kath, how does that apply to maternity. How does a single patient record apply in terms of safeguarding and access to that sort of information. And as an aside, this bill allows the minister, the Secretary of State, to set targets. How would you see that working in maternity care?
16:00
Speaker 22
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Speaker 22
Thank you. So I think in terms of digital exclusion, I think the same risks apply, although obviously there is a different age demographic. But if you have somebody who has a particular disability who has English as a second language, for example, or has difficulty reading, um, actually, you know, we need to make sure that alongside the single patient record, we are making sure we're not excluding people without meaning to, um, having said that, there are real opportunities to reduce inequities as a result of this. So, you know, making sure that everybody's information is there, people not having to retell their story if they find it difficult to speak to their clinician, for example.
And what the single patient record won't do is solve the problems in maternity at all. The national maternity and neonatal investigation. There's an action plan that will come out of that that has to be looked at really seriously and, and doesn't replace a single patient record. It doesn't replace compassionate care. It doesn't replace, you know, somebody really being looked after well, but it can provide a safer environment potentially. And I'm very happy to go into detail on that.
In terms of ambitions, the national maternity ambitions have expired. Um, we're pushing very, very hard for those ambitions to be restated. And actually there's an opportunity potentially to use the data at a broader level, to measure progress. So if it was possible to create, to use the single patient record as a way of then understanding how things were going towards improvement, that could be very helpful.
And what the single patient record won't do is solve the problems in maternity at all. The national maternity and neonatal investigation. There's an action plan that will come out of that that has to be looked at really seriously and, and doesn't replace a single patient record. It doesn't replace compassionate care. It doesn't replace, you know, somebody really being looked after well, but it can provide a safer environment potentially. And I'm very happy to go into detail on that.
In terms of ambitions, the national maternity ambitions have expired. Um, we're pushing very, very hard for those ambitions to be restated. And actually there's an opportunity potentially to use the data at a broader level, to measure progress. So if it was possible to create, to use the single patient record as a way of then understanding how things were going towards improvement, that could be very helpful.
16:01
16:01
Speaker 13
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Speaker 13
Well, to follow on from Doctor Johnson's questions, really, because you have all expressed support for the single patient record. Um that's great. Um, but that's not universal. And obviously the bill has to enact the legislation in order for that to go forward. Um, so I think, um, it would be helpful to hear from you about your experience now in your, in your different areas of older people, maternity and for carers, the examples, you've got a bit more detail. Miss Abrahams of why not having this.
Let's not assume because that's, that's the process of the bill to make it happen. And we've heard today some concerns about that. There are people that don't want this to happen. What is happening in your world that this will help with?Yes.
Let's not assume because that's, that's the process of the bill to make it happen. And we've heard today some concerns about that. There are people that don't want this to happen. What is happening in your world that this will help with?Yes.
16:02
Speaker 22
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Speaker 22
So right now, the situation is really tricky and people are being failed in their pregnancy and maternity care. There are lots of women report constantly having to retell their story. Highly sensitive, traumatic experiences of loss. That repetition can happen across maternity services. There is a common misconception that NHS is one system. So when people then find that people in another bit of the system don't know, um, that is that can be really frustrating and annoying because people assume it exists.
There's also a lack of continuity. So a clinician can be completely unaware of a sensitive or traumatic experience that somebody has had. And there can also be, you know, genuine dangers in terms of outcomes. So we know from the reports into Morecambe Bay, Morecambe Bay and Shrewsbury and Telford that that kind of lack of joined up sharing of information, um, good communication between different parts of the system has led to some really difficult outcomes, you know, particularly, for example, if somebody also has gestational diabetes or also has another condition is taking a particular sort of medication that could cause harm to an unborn baby.
Um, there are lots of situations in which not having the complete history is both preventing people from getting that kind of really good, compassionate care, but also preventing people from getting the safe care that they need. If someone's in an emergency situation and you know, they're bleeding out or their or their baby's not moving as much as they should do, there isn't time to start from scratch. The woman might not be in a position to explain what's happening to them and what their history is. They might not know the relevant bit, all the relevant bits of their history.
So having that kind of complete record, if it was done really well, would give clinicians the information that would allow them to make really timely decisions, because often maternity can be high risk. I don't need to say that to you. You know that. But you know, this is fast moving situations, often where time is absolutely of the essence.
There's also a lack of continuity. So a clinician can be completely unaware of a sensitive or traumatic experience that somebody has had. And there can also be, you know, genuine dangers in terms of outcomes. So we know from the reports into Morecambe Bay, Morecambe Bay and Shrewsbury and Telford that that kind of lack of joined up sharing of information, um, good communication between different parts of the system has led to some really difficult outcomes, you know, particularly, for example, if somebody also has gestational diabetes or also has another condition is taking a particular sort of medication that could cause harm to an unborn baby.
Um, there are lots of situations in which not having the complete history is both preventing people from getting that kind of really good, compassionate care, but also preventing people from getting the safe care that they need. If someone's in an emergency situation and you know, they're bleeding out or their or their baby's not moving as much as they should do, there isn't time to start from scratch. The woman might not be in a position to explain what's happening to them and what their history is. They might not know the relevant bit, all the relevant bits of their history.
So having that kind of complete record, if it was done really well, would give clinicians the information that would allow them to make really timely decisions, because often maternity can be high risk. I don't need to say that to you. You know that. But you know, this is fast moving situations, often where time is absolutely of the essence.
16:04
16:04
Speaker 23
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Speaker 23
Yeah. Um, yes. To build on what I said earlier, the amount of sort of coordination and admin that people do, if I just read some carers words, um, it's, uh, if I had a phone, I'd be ending up in a long waiting queue or to go. To the GP in person, which I, you know, would have to do and travel to get there. There are people juggling work and care. This has a real everyday impacts on on people's lives in terms of their time and um, and when I say errors, it's things like medication errors or diagnosis errors.
When you're caring for someone with very complex conditions, you can have health appointments every week, sometimes twice a week. And it's so hard trying to stay on top of it. When I say so hard when I talk about unpaid carers, we know that caring is a social determinant of health. So that in itself is a single factor for poorer health outcomes. We know that 600 people a day give up work to care, and we've done a report on tipping point. What tips carers out of work.
One of those things is is social care and one is how they are treated in the health system. If we reduce the pressure on carers and put information at their fingertips to help them manage care, we improve outcomes for everybody, health and wellbeing for them, safety of the person that they're caring for as well. You know, people trying to do their best in quite a difficult situation. One of our members, um Norman Phillips, has talked about this a lot. He he was in contact with 24 plus professionals knitting up care around his wife who had more advanced M.S.
and dementia. I mean, incredible amount of coordination of care. So you can see how a single patient record as it is envisaged in the future, could really help to support people, provide care. And it's critical when we've got an ageing population as well, that we recognise and support families in what they do.
When you're caring for someone with very complex conditions, you can have health appointments every week, sometimes twice a week. And it's so hard trying to stay on top of it. When I say so hard when I talk about unpaid carers, we know that caring is a social determinant of health. So that in itself is a single factor for poorer health outcomes. We know that 600 people a day give up work to care, and we've done a report on tipping point. What tips carers out of work.
One of those things is is social care and one is how they are treated in the health system. If we reduce the pressure on carers and put information at their fingertips to help them manage care, we improve outcomes for everybody, health and wellbeing for them, safety of the person that they're caring for as well. You know, people trying to do their best in quite a difficult situation. One of our members, um Norman Phillips, has talked about this a lot. He he was in contact with 24 plus professionals knitting up care around his wife who had more advanced M.S.
and dementia. I mean, incredible amount of coordination of care. So you can see how a single patient record as it is envisaged in the future, could really help to support people, provide care. And it's critical when we've got an ageing population as well, that we recognise and support families in what they do.
16:06
Speaker 20
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Speaker 20
So I'd start with talking about people with long term conditions. And let's bear in mind that by the time we're 65, 82% of us will have one long term condition by the time we're 70, half of half of that group of 70 plus have more than one long term condition. So when you're thinking about having to undo most of those long term conditions, of course are diagnosed within primary care. But of course, it has a huge impact on access to secondary care services. So being able to not for a clinician, not to be able to see that whole picture for the individual having to explain again and again and again about their physical health issues and indeed potentially their co-morbid mental health issues, um, creates a huge challenge for people being able to get access to the right help and support in a timely manner.
And then I would build on that to think particularly about two areas that particularly affect older people. So that is frailty and dementia. So in this particular context, we know that assessment for frailty can really make such a big difference to the way that people receive the right kind of help and support. Again, that should be done in primary care, but often, sadly, with people with frailty, we'll find themselves presenting in hospital with a range of conditions. So understanding what that frailty assessment score looks like, what the help and support is needed is key.
And then, of course, for people with dementia and their family carers having access to that right information, both for the clinician and for the individual concerned, can make a huge difference. And that disjointed experience just exacerbates what can often be a very challenging and very challenging time.
And then I would build on that to think particularly about two areas that particularly affect older people. So that is frailty and dementia. So in this particular context, we know that assessment for frailty can really make such a big difference to the way that people receive the right kind of help and support. Again, that should be done in primary care, but often, sadly, with people with frailty, we'll find themselves presenting in hospital with a range of conditions. So understanding what that frailty assessment score looks like, what the help and support is needed is key.
And then, of course, for people with dementia and their family carers having access to that right information, both for the clinician and for the individual concerned, can make a huge difference. And that disjointed experience just exacerbates what can often be a very challenging and very challenging time.
16:07
16:47
Speaker 11
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Speaker 11
Thank you very much, sir. Roger. So we've talked a lot about the single patient record, but I just wanted to touch on whether you thought the bill did enough for people who have historically not been listened to enough. I think we've heard that about people who are carers and people, and obviously we've heard it for women who have suffered in the maternity system. And so I just wondered if you could give us an overview of whether you thought that the bill dealt with that, not listening to problem and what opportunities there are to improve the bill to improve that situation.
And that's a question to everybody.
And that's a question to everybody.
16:47
Speaker 13
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Speaker 13
I'll start, if that's okay. I mean, I think I think listening to patients is an incredibly important part of any health system. And it's really necessary to make sure that there are the right mechanisms in place, both at an individual and at a system level. Um, and, and I think in that context, uh, the, the aspects of the bill that cover patient experience do need careful consideration. Um, there are many people who are fans of what Healthwatch delivered and others who aren't.
However, there was clearly a very clearly established system and mechanism in place for, for that to, to, to ensure that patient voices were heard. So I think it is really important that a really clear, uh, clear. Items are established to ensure that that patient experience is, um, is really heard and having, having been operated around the health system for a number of years and seen a number of incarnations of patient voice organisations and representation, um, it really. Have to think about it from the individual and the whole system level from top to bottom.
I think it will be really important that the committee looks at the, the provisions in that in that context to make sure that where there have been good, good, good support that that that's preserved, but also that we can build on it. So, for example, how do you make sure that patient voice is heard at ICB level?How do you make sure it's heard in in providers and in the, in the new world of neighborhood health in particular?
However, there was clearly a very clearly established system and mechanism in place for, for that to, to, to ensure that patient voices were heard. So I think it is really important that a really clear, uh, clear. Items are established to ensure that that patient experience is, um, is really heard and having, having been operated around the health system for a number of years and seen a number of incarnations of patient voice organisations and representation, um, it really. Have to think about it from the individual and the whole system level from top to bottom.
I think it will be really important that the committee looks at the, the provisions in that in that context to make sure that where there have been good, good, good support that that that's preserved, but also that we can build on it. So, for example, how do you make sure that patient voice is heard at ICB level?How do you make sure it's heard in in providers and in the, in the new world of neighborhood health in particular?
16:49
Speaker 15
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Speaker 15
Thank you. Um, it's a, it's a great question. Thank you. And, you know, clearly. The, the bill in itself, certainly the single patient record in itself is, is never going to replace wonderful, kind, compassionate care where people feel they're listened to. And, you know, I've. Already said, but we'll say again, a combination of people either not being listened to at all and knowing their own health better than anyone else. Sometimes, you know, but not being listened to, um, or having to retell their stories.
They're both kind of, they, they both have a. Very challenging consequences and they both leave somebody feeling like nobody really cares about them and they don't really understand. I spoke to somebody this morning who is a supporter of Tommy's and has had five miscarriages. And she was saying just the what appears to be quite a small thing of every time she went to see her, a clinician, they said, oh, you've had four losses or you've had three not understanding and having to correct her records or getting letters through.
So, so I think that sense of not being listened to, uh. As, as we develop the bill. Women and birthing people from maternity perspective, having the opportunity to, uh, contribute. To the, to the way something like the single patient record is shaped, for example, because you could have a. Digitally accurate system that did nothing to reassure women or help them feel, uh, looked after or listened to. Or you could have a beautiful system where the information was recorded in such a way that it really helped.
But alongside that, clinicians need to continue to receive the right sort of training. They need to have enough time. Um, and you do need those patient voices, as Paul said, overseeing and, and being able to look at how things are going and contribute and help. So the bill in itself. As a mechanism will not do enough, but it's about designing it really carefully with patients in mind, involving women in, in Maternities case, right from the start.
They're both kind of, they, they both have a. Very challenging consequences and they both leave somebody feeling like nobody really cares about them and they don't really understand. I spoke to somebody this morning who is a supporter of Tommy's and has had five miscarriages. And she was saying just the what appears to be quite a small thing of every time she went to see her, a clinician, they said, oh, you've had four losses or you've had three not understanding and having to correct her records or getting letters through.
So, so I think that sense of not being listened to, uh. As, as we develop the bill. Women and birthing people from maternity perspective, having the opportunity to, uh, contribute. To the, to the way something like the single patient record is shaped, for example, because you could have a. Digitally accurate system that did nothing to reassure women or help them feel, uh, looked after or listened to. Or you could have a beautiful system where the information was recorded in such a way that it really helped.
But alongside that, clinicians need to continue to receive the right sort of training. They need to have enough time. Um, and you do need those patient voices, as Paul said, overseeing and, and being able to look at how things are going and contribute and help. So the bill in itself. As a mechanism will not do enough, but it's about designing it really carefully with patients in mind, involving women in, in Maternities case, right from the start.
16:51
Speaker 16
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Speaker 16
Thank you. Um, just there are provisions in the bill that, um, that transfer responsibilities from NHS England to the Secretary of State in terms of involving patients. And it's very explicit that it also involves carers. And that's very important that where there have been Healthwatch duties to involve carers that were explicit have been transferred into this bill in relation to integrated care boards. And that matters because, of course, their portfolio of commissioning different services is increasing, and to local authorities. Um, and it's, you know, there's are strategic duties and why that's important, of course, to be very specific about carers is because they, they provide £152 billion worth of care.
They outnumber staff 3 to 1. They are experts in care over time. And they they do want to be involved. Of course, what colleagues have said about good practice is critically important to have a look at what the changes to Healthwatch um does though, and I know others have raised this is that um, it doesn't see the person and their journey across different services, across health and care. And of course, there's an independent voice that we don't have and won't have in quite the, the same, the same way.
Um, a very small proportion of carers really felt that if they raised a complaint it would be acted on. So that kind of independent voice is actually very important. Now as you say, as Kath said, it doesn't. Those duties are really important. But we need top to toe listening to patients and being explicit about listening to carers, not just on behalf of the patient, but what is your experience as a carer of managing this care?Because it is very different.
I don't think we have the right data flows to be honest behind that, to collect and to understand people's journeys and to improve things. So that's something which which I hope will also be looked at. Thank you.
They outnumber staff 3 to 1. They are experts in care over time. And they they do want to be involved. Of course, what colleagues have said about good practice is critically important to have a look at what the changes to Healthwatch um does though, and I know others have raised this is that um, it doesn't see the person and their journey across different services, across health and care. And of course, there's an independent voice that we don't have and won't have in quite the, the same, the same way.
Um, a very small proportion of carers really felt that if they raised a complaint it would be acted on. So that kind of independent voice is actually very important. Now as you say, as Kath said, it doesn't. Those duties are really important. But we need top to toe listening to patients and being explicit about listening to carers, not just on behalf of the patient, but what is your experience as a carer of managing this care?Because it is very different.
I don't think we have the right data flows to be honest behind that, to collect and to understand people's journeys and to improve things. So that's something which which I hope will also be looked at. Thank you.
16:54
Speaker 1
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Speaker 1
Any other questions?If not, and I'm sorry to have kept you waiting so long for such a relatively short period of time, but it's important that all the front benches had the chance to question you and any other members that wish to. But can I thank you all very much indeed for being so patient and for giving us the benefit of your thoughts and wisdom. Thank you very much indeed.
16:54
16:55
Speaker 1
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Speaker 1
Is on the screen. Everybody is ready and settled. Back and one of our three guests you will note is on the screen. So we have. Doctor Michael Cocker from the East Lancashire Hospitals Trust. Doctor Imam from Croydon Health Services and Doctor Nicola Byrne, National Data guardian for health and social care. Um, we'll get through this as reasonably swiftly as we possibly can without cutting corners, if that's all right. Um, I shall try and bring this to a logical conclusion within.
16:56
16:56
Speaker 1
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Speaker 1
I'm terribly sorry. Nearly. Division in the house. Those who are going to vote, please vote. The committee will sit again at in 15 minutes. For oral evidence from Doctor Michael Cocker. East Lancashire Hospitals NHS trust doctor Imam from the Croydon Health Services NHS trust and doctor Nicola Byrne, National Data Guardian for health and social care. We have until 550 for this panel and. oh three I beg your pardon. Six do we?
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Speaker 8
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Speaker 8
Thank you chair. Um, and I should say I also work as an NHS consultant paediatrician. Um, the single patient record offers great opportunity for um for doctors and clinicians and patients to all be much more joined up. Um, but there was a quote from the Secretary of State in the second reading where he said, rather than the data being transferred from where it is at the moment to a new system, it will stay where it is in the surgeries, hospitals and so on. But we're linked up to one person, including the patient can see all that data.
So is. That how how easy will that work in practice?I know within the trust that I work in, we have a different system for blood results, a different system for results, a different system for tracking patients appointments, a different system for maternity, different system for A&E. Um, is it realistic to expect someone to be able to log on from one part of the country and understand all the different systems and all the other parts of the country, or do you think it needs to work in a different way?
So is. That how how easy will that work in practice?I know within the trust that I work in, we have a different system for blood results, a different system for results, a different system for tracking patients appointments, a different system for maternity, different system for A&E. Um, is it realistic to expect someone to be able to log on from one part of the country and understand all the different systems and all the other parts of the country, or do you think it needs to work in a different way?
17:12
17:12
Speaker 26
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Speaker 26
Um, so. We actually about a month ago published, um, some NHS England guidance around best practice for frailty. And included in it are some examples of some shared care records where people who are living with frailty have been assessed by health services can actually view one record. And the way those work is they take information from multiple different records and then place it into one shared care record. In order for clinicians from various different backgrounds and multidisciplinary teams to to work together.
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17:14
Speaker 27
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Speaker 27
Yeah. Similarly, I believe that the the technical solution to how it would be delivered hasn't been finalised. When we did the pilot based on maternity in the northwest, the the kind of the wireframe prototype that was developed pulled information from all the separate systems. So maternity system, a hospital central electronic patient record system, a GP system. So the the pilot based was based on pulling it from all each individual system into one place where it could be viewed. Um, but obviously that was a, that's a, a few.
Archer sort of aim and I know that obviously there's a focus on a phased implementation, so it wouldn't all be immediately available like that. But that's the, the vision.
Archer sort of aim and I know that obviously there's a focus on a phased implementation, so it wouldn't all be immediately available like that. But that's the, the vision.
17:14
Speaker 8
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Speaker 8
Thank you. And it's of course something that needs to be viewable across the whole of the country for people that travel around. So what about the security of this data?There's been lots of people have expressed concerns about the security of the data, both from people who are a bit nosy and want to have a look, and from other people who would wish to do the country harm, hacking large volumes of data. Um, how do we keep it safe.
17:15
17:15
Speaker 27
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Speaker 27
So yes, I think it's a very pertinent question. I know that's been a focus of a lot of um concern, um since the bill's been publicized. Um, I believe that um the, the structure of the SPR would be recognized as a critical national infrastructure type of project. So it would have access to more resource to protect it. Um, but I think there's always going to be an inherent risk when you've got something centralized that that is a single target rather than multiple targets that could be, say, attacked with a cyber attack.
Excuse me. Um, and I think role based access would be important. So having an understanding of that information only being accessed for the provision of clinical care. Um, and that's something that again would have to be, um, it would have to be finalized in terms of how that was actually delivered on a technical level. Um, which wasn't part of the prototyping work we did because that was more of a sort of proof of concept rather than sort of those more minute sort of technical challenges.
Excuse me. Um, and I think role based access would be important. So having an understanding of that information only being accessed for the provision of clinical care. Um, and that's something that again would have to be, um, it would have to be finalized in terms of how that was actually delivered on a technical level. Um, which wasn't part of the prototyping work we did because that was more of a sort of proof of concept rather than sort of those more minute sort of technical challenges.
17:16
17:16
Speaker 3
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Speaker 3
I'm glad Doctor Cocker took that first, because I think he's given you a very helpful technical answer to that question, I suppose as National Data Guardian, my mission and concern is primarily around public and professional trust. And I think the trust in whether this is a system that can be, um, relied upon in. People's confidentiality is something that concerns me very much. And also, uh, people's trust and confidence in, um, secondary purposes and how it will be used and what safeguards would be around it.
So I'd be happy to sort of answer from that perspective when it comes to people's confidence. Um, and I think you've heard a lot about the potential benefits of this system, but I think it's very important to bear in mind that if people don't trust it, this program will fail. And however great the potential benefits are. And as a clinician, I would share that excitement and I'm very supportive of that ambition. People won't trust it if they perceive the risks to be greater to the security of their data, to confidentiality.
And so with that in mind, the two things I'd want to draw attention to, um, that concern trust. Because I think what I want to do is emphasize that trust isn't simply important here. And I know the word trust has come up repeatedly today. I'd say it was absolutely foundational to the success of this. And so the question about how is this system demonstrably trustworthy should be the primary foundational question. And all other questions, including technical flow from that one question.
So the confidentiality aspect at the moment, I think there's a provision under clause 47, which is potentially very significant in terms of having unintended consequences as far as I'm concerned. And I know that, as I've understood not the intention of the drafting, but I do have concerns about it. And I also have a potential solution to suggest, um, the clauses, the provision itself is um clause 47, subsection three, section two, five, zero E, and it creates the power for the Secretary of State to remove the duty of confidentiality for any processing in the SPR, in line with regulations.
And I guess I need to register my concern about that wholesale lifting of the duty of confidentiality from the entire system, a system level. I think there are two risks. One is to patient and professional confidence in the confidentiality of the data. Once it's accessed by or in a system. Um, confidentiality is absolutely the cornerstone of all clinician patient relationships. It means people are comfortable to share the most sensitive information about themselves and often loved ones. It's not just information about ourselves and our records.
It's often about our loved ones too. So if people don't trust that, that confidentiality is a constant ethical constraint for anyone accessing the record further on, they may be less able to share information about themselves or their loved ones, and clinicians may be less likely to document it if they have ethical concerns about who may access that information. If it's particularly sensitive further on. So that will negatively impact on care and also negatively impact on the quality of the data for any secondary purposes in future.
The second point I'd make about this confidentiality provision is that I understand, uh, the drafting intent is to remove any ambiguity about people's concerns about duty of confidence in terms of allowing access to their data at an organizational level. But as it's currently drafted, I would read it that it could be interpreted to remove the duty of confidentiality for not just direct care, but for secondary purposes. And indeed any way secondary purposes in future could be, um, dealt with by, by regulation. So that lack of clarity, I think poses a risk.
And the proposed solution I'd want to suggest is to redraft that provision, uh, drawing on the precedent set already in the Health and Social Care Act 2012, where section 259 prevents disclosure of data from an organisation being a breach. So people could allow that access organizationally with confidence. And you remove that ambiguity, but it doesn't remove wholesale that duty of confidence, that ethical safeguard for the data in the system itself. And I think that's important both for people's own direct care. And, as I say, particularly important if there are any questions around secondary uses in future.
So I'd be happy to sort of answer from that perspective when it comes to people's confidence. Um, and I think you've heard a lot about the potential benefits of this system, but I think it's very important to bear in mind that if people don't trust it, this program will fail. And however great the potential benefits are. And as a clinician, I would share that excitement and I'm very supportive of that ambition. People won't trust it if they perceive the risks to be greater to the security of their data, to confidentiality.
And so with that in mind, the two things I'd want to draw attention to, um, that concern trust. Because I think what I want to do is emphasize that trust isn't simply important here. And I know the word trust has come up repeatedly today. I'd say it was absolutely foundational to the success of this. And so the question about how is this system demonstrably trustworthy should be the primary foundational question. And all other questions, including technical flow from that one question.
So the confidentiality aspect at the moment, I think there's a provision under clause 47, which is potentially very significant in terms of having unintended consequences as far as I'm concerned. And I know that, as I've understood not the intention of the drafting, but I do have concerns about it. And I also have a potential solution to suggest, um, the clauses, the provision itself is um clause 47, subsection three, section two, five, zero E, and it creates the power for the Secretary of State to remove the duty of confidentiality for any processing in the SPR, in line with regulations.
And I guess I need to register my concern about that wholesale lifting of the duty of confidentiality from the entire system, a system level. I think there are two risks. One is to patient and professional confidence in the confidentiality of the data. Once it's accessed by or in a system. Um, confidentiality is absolutely the cornerstone of all clinician patient relationships. It means people are comfortable to share the most sensitive information about themselves and often loved ones. It's not just information about ourselves and our records.
It's often about our loved ones too. So if people don't trust that, that confidentiality is a constant ethical constraint for anyone accessing the record further on, they may be less able to share information about themselves or their loved ones, and clinicians may be less likely to document it if they have ethical concerns about who may access that information. If it's particularly sensitive further on. So that will negatively impact on care and also negatively impact on the quality of the data for any secondary purposes in future.
The second point I'd make about this confidentiality provision is that I understand, uh, the drafting intent is to remove any ambiguity about people's concerns about duty of confidence in terms of allowing access to their data at an organizational level. But as it's currently drafted, I would read it that it could be interpreted to remove the duty of confidentiality for not just direct care, but for secondary purposes. And indeed any way secondary purposes in future could be, um, dealt with by, by regulation. So that lack of clarity, I think poses a risk.
And the proposed solution I'd want to suggest is to redraft that provision, uh, drawing on the precedent set already in the Health and Social Care Act 2012, where section 259 prevents disclosure of data from an organisation being a breach. So people could allow that access organizationally with confidence. And you remove that ambiguity, but it doesn't remove wholesale that duty of confidence, that ethical safeguard for the data in the system itself. And I think that's important both for people's own direct care. And, as I say, particularly important if there are any questions around secondary uses in future.
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17:20
Speaker 8
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Speaker 8
Thank you. Chair. Does it surprise you that the bill is being brought forward before it's been designed properly, properly and completely yet?Um, we have tabled some amendments on 47, but I appreciate you won't have had a chance to look at those yet, but we'll be interested in your thoughts if you could provide them after committee. Um, and also, um, the repeat we keep hearing it's difficult if people have to repeat their story. And I understand that stories can be very traumatic and they're repeating them can be unpleasant, particularly if it's got to be done many times.
But is there clinical value in sometimes asking people to go through their story?And if so, what is it.
But is there clinical value in sometimes asking people to go through their story?And if so, what is it.
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17:21
Speaker 26
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Speaker 26
Thank you. Um, so my specialty is, is frailty and frailty. It's a medical condition that is characterized by a loss of independence that although it's associated with aging, it's not an inevitable part of aging. Um, and the treatment that I deliver as a clinician is something called CGA or comprehensive geriatric assessment, which is evidence based. We know that it improves patient outcomes and maintains independence. Um, so what this describes is a multidisciplinary team approach to a holistic assessment and focuses on what matters most to a patient.
Um, however, one of the issues we have right now is the NHS doesn't consistently identify people who are living with frailty right across the system, right from community to hospital. And so if we're, if we're identifying people and you're diagnosing people with a condition, you would expect treatment options to be offered. And yet we don't consistently do that across this country. And so that is essentially driving ineffective care and inefficient care. And sometimes, therefore, when a crisis does set in, uh, you know, and we've seen this in, in other reports around corridor care, um, that can ensue in older people living with frailty.
So in my day job where I look after people in a busy A&E department, um, I'm seeing people who may have had a fall or they've become confused or there's been a breakdown in their social situation. Um, and myself and my practitioners, what we're doing is we're spending hours trying to piece together information from multiple different sources. So this could be paper based digital telephone, trying to phone people to, to get up to date information. And you can imagine sometimes they don't pick up the phone.
And so we're sometimes working on incomplete information, things that are not up to date. Um, once we have done that, um, we then try to create a care plan for a patient that then allows them to be looked after in community. Um, however that care plan may not follow the patient because everyone uses different electronic patient record systems and some important partners in that care, like social care, ambulance services can't actually see the care plan that I've developed for my patient. And unfortunately, if, um, you know, the patient with frailty then succumbs to a crisis of some kind, the default setting, unfortunately, many times for these patients is to trigger an admission to hospital.
Um, and if a patient doesn't need to be in a hospital environment and they are frail, they can end up becoming more frail, weak and lose their independence and meaning that they're going to need an even more social care than would have been otherwise required. So where this solution then comes in, so a nationally rolled out single patient record system could fundamentally reshape this form of care, because we'd be moving it from this fragmented, reactive model that I've just described to one that is proactive and coordinated and centred truly around a patient.
So one of the things around frailty as well is there are so many different people involved in that person's care. And so what we need to try and do is restore continuity of care for those types of patients, which has also become eroded over time. And so the SPR addresses this with one single up to date view of a of a patient. It enables earlier risk identification, faster clinical decision making. And that whole system integrated response that I've been describing that's lacking at the moment.
There's often duplication. So one of the other issues is that um patients to assess them in this manner, it can take a long period of time up to 2.5 hours, is often quoted by the British Geriatrics Society. So you can imagine if you have an electronic record which can be auto populated or can rely on the most up to date recent plan that's been done by someone else, it avoids reassessment. We're working off contemporaneous information. And so over time, you can see how this could, for at least frailty and many other conditions, lead to a more preventative approach that's more community based, reducing need for admissions and overall better experience for staff and for patients, and importantly, you know, there needs to be a shift towards neighbourhood working when it when it comes to to frailty.
And it therefore allows that multidisciplinary team to work towards one plan. But importantly, you've also heard today about patient voice and you've also heard about carer voice in this as well. It gives the opportunity for them to actually become partners in looking after themselves as well through this type of care plan.
Um, however, one of the issues we have right now is the NHS doesn't consistently identify people who are living with frailty right across the system, right from community to hospital. And so if we're, if we're identifying people and you're diagnosing people with a condition, you would expect treatment options to be offered. And yet we don't consistently do that across this country. And so that is essentially driving ineffective care and inefficient care. And sometimes, therefore, when a crisis does set in, uh, you know, and we've seen this in, in other reports around corridor care, um, that can ensue in older people living with frailty.
So in my day job where I look after people in a busy A&E department, um, I'm seeing people who may have had a fall or they've become confused or there's been a breakdown in their social situation. Um, and myself and my practitioners, what we're doing is we're spending hours trying to piece together information from multiple different sources. So this could be paper based digital telephone, trying to phone people to, to get up to date information. And you can imagine sometimes they don't pick up the phone.
And so we're sometimes working on incomplete information, things that are not up to date. Um, once we have done that, um, we then try to create a care plan for a patient that then allows them to be looked after in community. Um, however that care plan may not follow the patient because everyone uses different electronic patient record systems and some important partners in that care, like social care, ambulance services can't actually see the care plan that I've developed for my patient. And unfortunately, if, um, you know, the patient with frailty then succumbs to a crisis of some kind, the default setting, unfortunately, many times for these patients is to trigger an admission to hospital.
Um, and if a patient doesn't need to be in a hospital environment and they are frail, they can end up becoming more frail, weak and lose their independence and meaning that they're going to need an even more social care than would have been otherwise required. So where this solution then comes in, so a nationally rolled out single patient record system could fundamentally reshape this form of care, because we'd be moving it from this fragmented, reactive model that I've just described to one that is proactive and coordinated and centred truly around a patient.
So one of the things around frailty as well is there are so many different people involved in that person's care. And so what we need to try and do is restore continuity of care for those types of patients, which has also become eroded over time. And so the SPR addresses this with one single up to date view of a of a patient. It enables earlier risk identification, faster clinical decision making. And that whole system integrated response that I've been describing that's lacking at the moment.
There's often duplication. So one of the other issues is that um patients to assess them in this manner, it can take a long period of time up to 2.5 hours, is often quoted by the British Geriatrics Society. So you can imagine if you have an electronic record which can be auto populated or can rely on the most up to date recent plan that's been done by someone else, it avoids reassessment. We're working off contemporaneous information. And so over time, you can see how this could, for at least frailty and many other conditions, lead to a more preventative approach that's more community based, reducing need for admissions and overall better experience for staff and for patients, and importantly, you know, there needs to be a shift towards neighbourhood working when it when it comes to to frailty.
And it therefore allows that multidisciplinary team to work towards one plan. But importantly, you've also heard today about patient voice and you've also heard about carer voice in this as well. It gives the opportunity for them to actually become partners in looking after themselves as well through this type of care plan.
17:25
Speaker 27
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Speaker 27
Um, I think the most sort of brief answer to the original question would be that that communicating and getting a history from a patient is cornerstones for patient doctor relationship. And I don't think the SPR is ever intended to replace that. Um, where I see its value and especially in within maternity, but I'm sure this is the same across all specialties is that it's a, it would form a reliable means of cross-referencing information and also of being able to get information that, as we've alluded to previously, is often held on many separate systems that often as a clinician, you won't have the ability or the credentials to, to access.
So for example, in maternity care, at my trust, we use a certain piece of software that if you don't work in maternity, although you might be able to get generic access to it, you might not be able to navigate that system. And the idea with the SPR is it would pull out those key bits about what are the concerns about the pregnancy at the moment. What's the follow up that's been arranged?All those kind of things. That means it doesn't rely on ability to use lots of different systems.
That information is available. And if there is information that requires cross-referencing or checking, it gives you that ability to do that rather than it kind of replacing the kind of process of taking a history and actually working out what's wrong with someone.
So for example, in maternity care, at my trust, we use a certain piece of software that if you don't work in maternity, although you might be able to get generic access to it, you might not be able to navigate that system. And the idea with the SPR is it would pull out those key bits about what are the concerns about the pregnancy at the moment. What's the follow up that's been arranged?All those kind of things. That means it doesn't rely on ability to use lots of different systems.
That information is available. And if there is information that requires cross-referencing or checking, it gives you that ability to do that rather than it kind of replacing the kind of process of taking a history and actually working out what's wrong with someone.
17:26
Speaker 3
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Speaker 3
Well, I think it's a terrific question because healthcare is a relationship. It's not simply a transaction of facts between a clinician and a patient. At its best, it's a working relationship. But it's also why it's so hard sometimes. And our stories are a combination of two things. I suggest they're a combination of facts, and they're a combination of the interpretation of those facts. So I think we heard a really moving example earlier of someone saying, you know, they'd had five miscarriages, those facts not being known and how distressing it was that that wasn't known.
Um, so that's a good example of why getting the facts from conversation to conversation there could be really, really helpful. But the actual interpretation that comes up in a conversation, the story changes are all our life story changes over time. And as a doctor, live in the moment with the patient. For me, I'm as interested in what someone's not choosing to tell me at a particular point in time, sometimes as what they are choosing to tell me. Because for all of us, the story changes and it's fluid.
And so I think it's making those distinct that I think that's a potentially a helpful distinction to make.
Um, so that's a good example of why getting the facts from conversation to conversation there could be really, really helpful. But the actual interpretation that comes up in a conversation, the story changes are all our life story changes over time. And as a doctor, live in the moment with the patient. For me, I'm as interested in what someone's not choosing to tell me at a particular point in time, sometimes as what they are choosing to tell me. Because for all of us, the story changes and it's fluid.
And so I think it's making those distinct that I think that's a potentially a helpful distinction to make.
17:27
17:28
Speaker 5
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Speaker 5
Thank you. And I think my questions around the benefits that you see have been really well answered. So, um, I won't go back to that. But if, um, Doctor Cocker and Doctor Iman could say in your work so far, just just to be clear for the for the committee on both maternity and Frailty, um work as to how this might work. What do you think the early lessons that you've picked up from how this potentially might work for you?Doctor Cocker?
17:28
Speaker 27
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Speaker 27
Um, so I think I'd say having seen the, the kind of prototype that NHS England developed with maternity to focus up in the North west, I think the the lessons we learned was that technically it's it is difficult because there are lots of systems and there needs to be a level of interoperability in those systems that allows you to pull the data or it's, it's not going to be much use as a as a reliable system. Um, and I think the, the other thing is trying to ensure that we design those systems for the patients most at need.
So that might be social need. It could be medical needs. There are many different facets to that. And I think that was one of the, um, challenges, but a lot of the, the focus went into that of trying to determine a set of theoretical patients that were very high need and ensuring that you've encompassed all of those possible needs so that if you design it for those in most need, it will cater for, for as many people as possible.
So that might be social need. It could be medical needs. There are many different facets to that. And I think that was one of the, um, challenges, but a lot of the, the focus went into that of trying to determine a set of theoretical patients that were very high need and ensuring that you've encompassed all of those possible needs so that if you design it for those in most need, it will cater for, for as many people as possible.
17:29
17:29
Speaker 26
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Speaker 26
Um, so. To, to um, expand on Doctor Cocker's point there around identification of problems. The people living with frailty often have multiple different issues which are under identified. So in the prototype that we've been shown, um there is the potential for the SPR to, to analyse a lot of the wealth of data on this person and then try to summarise it in a manner that actually makes sense to the clinician who's logged in to the record. Um, it can piece together a timeline for what's been happening with, with a person.
So as I said earlier, that often what we're doing is a manual process to try and understand what's been going on recently for that person. Um, there will be an ability for that to be automated, but also for us to know who are the key individuals that are involved in that person's care. So when they are in a crisis or there is an emergency situation, we know exactly who to call or who the last person was to, to touch this patient. The other important function is not only the bit around the sharing of information across an entire pathway.
And that whole system approach I was describing, right from community to hospital and vice versa, but also importantly that, um, many people living with frailty, they require multiple different referrals, multiple different people to be involved in their care. And so it will have the ability to be able to streamline some of those processes, make recommendations to for certain referrals that perhaps a clinician who would have logged into the record in a, in an earlier version may not have otherwise thought about, and so may actually even improve the outcomes for patients by, um, providing us with solutions to, um, to improving their care that we wouldn't have come up with otherwise.
So as I said earlier, that often what we're doing is a manual process to try and understand what's been going on recently for that person. Um, there will be an ability for that to be automated, but also for us to know who are the key individuals that are involved in that person's care. So when they are in a crisis or there is an emergency situation, we know exactly who to call or who the last person was to, to touch this patient. The other important function is not only the bit around the sharing of information across an entire pathway.
And that whole system approach I was describing, right from community to hospital and vice versa, but also importantly that, um, many people living with frailty, they require multiple different referrals, multiple different people to be involved in their care. And so it will have the ability to be able to streamline some of those processes, make recommendations to for certain referrals that perhaps a clinician who would have logged into the record in a, in an earlier version may not have otherwise thought about, and so may actually even improve the outcomes for patients by, um, providing us with solutions to, um, to improving their care that we wouldn't have come up with otherwise.
17:30
Speaker 5
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Speaker 5
Thank you. And if I can ask Doctor Byrne, I mean, you talked about trust. We recognised recognise that. Absolutely. So how and given we're hearing quite a lot of the work that's going on to try and get this right technically. But um, further to what you've said and suggested, I mean, how would you advise the government to communicate clearly about the benefits, but understanding the concerns that people have now about should this legislation pass the next stages of getting a single patient record?
17:31
17:31
Speaker 3
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Speaker 3
Yeah. I think you've got to show that you take people's risks and concerns seriously and show a sort of credible analysis of those risks. So to get into engage with them meaningfully, I guess is the key thing. And then to think about what safeguards you could put in now and in future regulations that will actually be effective and people will see them as credible, depending on what risks you know, you're trying to address. Um, I would suggest I know at this stage in the primary legislation, it's, it's difficult to get into detail.
Not, not, not least because you're trying to sequence things when you don't actually know what we don't know what the SPR is going to be. So, uh, I. Appreciate that's a further constraint, but I think there is one particular safeguard that I would suggest considering putting on the face of the bill. Um, and that relates to secondary purposes because we know that people are concerned, really have concerns around two main things a confidentiality and the privacy. But people are also very concerned about.
Secondary uses.
Not, not, not least because you're trying to sequence things when you don't actually know what we don't know what the SPR is going to be. So, uh, I. Appreciate that's a further constraint, but I think there is one particular safeguard that I would suggest considering putting on the face of the bill. Um, and that relates to secondary purposes because we know that people are concerned, really have concerns around two main things a confidentiality and the privacy. But people are also very concerned about.
Secondary uses.
17:32
17:32
Speaker 3
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Speaker 3
So I continue um who might access their data and why and for what purpose in future other than from the direct care. So those are the two main concerns. So to focus on that second one, whilst there'll be lots of um things that might come up that you could potentially do in the secondary in the, in the regulations, I would suggest right now you could build in a safeguard for an independent oversight mechanism for how decisions are made about who gets to access the data and why.
And that involves public and lay representation to bring in that consideration of the risks that matter to the to the public, alongside potential benefits. And I'd say, Jess, there are two reasons why I think that could be very helpful. One is that it would be a safeguard against any unchecked power, whether now or in future, when it comes to decision making about access. But secondly, I think it recognises the reality of human systems and organisations. Um, no one person, no one expert or small group of experts, however wise or um.
However, their integrity can see the whole picture can have a 360 view on what matters to people in the public. And this, this would be a really meaningful way of giving the public agency and some representation in those decision making that would actually be, you a meaningful exercise of citizen control if you like. Um, and we are best as humans, our decision making is, is a safest and strongest when we get a diversity of perspectives involved, as indeed you're, you're doing right now. But in this context, that should involve patients in the public.
And the second point I'd make about that, and this is perhaps germane to your wider discussions you've been having around the bill, is that one no one organisation can effectively and consistently scrutinise and challenge itself and that. That goes for questions around data use and access and wider as well in your considerations.
And that involves public and lay representation to bring in that consideration of the risks that matter to the to the public, alongside potential benefits. And I'd say, Jess, there are two reasons why I think that could be very helpful. One is that it would be a safeguard against any unchecked power, whether now or in future, when it comes to decision making about access. But secondly, I think it recognises the reality of human systems and organisations. Um, no one person, no one expert or small group of experts, however wise or um.
However, their integrity can see the whole picture can have a 360 view on what matters to people in the public. And this, this would be a really meaningful way of giving the public agency and some representation in those decision making that would actually be, you a meaningful exercise of citizen control if you like. Um, and we are best as humans, our decision making is, is a safest and strongest when we get a diversity of perspectives involved, as indeed you're, you're doing right now. But in this context, that should involve patients in the public.
And the second point I'd make about that, and this is perhaps germane to your wider discussions you've been having around the bill, is that one no one organisation can effectively and consistently scrutinise and challenge itself and that. That goes for questions around data use and access and wider as well in your considerations.
17:34
17:34
17:34
Speaker 11
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Speaker 11
Thank you very much. Um, I think everyone's agreed about the sort of transformative potential of the single patient record. Heard sort of various concerns around privacy and other types of use. I'm, I'm just interested into how all these different systems can speak to each other. Because my experience as an accountant is that you can have interoperability. But if the data that you are interoperating with isn't consistently curated, then you have a problem because you have something that looks the same for everybody, but is actually means something very different to each of the people that input that data.
And I wonder if you have any advice for the, the development of that single patient record for us on how we get data clean and consistent between trusts and between different systems, so that we're looking at a single patient record that's actually meaningful. And I probably ask Doctor Cocker that first if he's a technical doctor.
And I wonder if you have any advice for the, the development of that single patient record for us on how we get data clean and consistent between trusts and between different systems, so that we're looking at a single patient record that's actually meaningful. And I probably ask Doctor Cocker that first if he's a technical doctor.
17:35
Speaker 27
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Speaker 27
I wouldn't go that far. Say I was the technical solution. Um, my, my, I say my involvement in this whole project is, is clinical. Rather than having any sort of technical expertise, particularly, I mean, I think, I think that that is a pertinent issue because as has been, um, discussed previously, if you do have an error that enters the SPR, so say a code that is incorrectly. Followed through into the system, then that error can perpetuate, which is the risk of a single record.
Is that a documentation error can can ripple out rather than being contained within the system it originates in. Um, whether safeguarding that involves, uh, requirements on providers of systems to mean that data can be exported in a, in a not, maybe not standardised, but a set of formats that the SPR can recognise. Um, I think, I think it, it's, it is a technical question. I don't know the answer to all the possible solutions to. But that would be sort of. One of my suggestions is that rather than having hundreds of different systems all require slightly different solutions in order to be able to feed into the SPR accurately, whether there is some sort of framework that is, um, set out, that is a requirement on the provider, these software products that all the different organisations that will feed into SPR use.
Is that a documentation error can can ripple out rather than being contained within the system it originates in. Um, whether safeguarding that involves, uh, requirements on providers of systems to mean that data can be exported in a, in a not, maybe not standardised, but a set of formats that the SPR can recognise. Um, I think, I think it, it's, it is a technical question. I don't know the answer to all the possible solutions to. But that would be sort of. One of my suggestions is that rather than having hundreds of different systems all require slightly different solutions in order to be able to feed into the SPR accurately, whether there is some sort of framework that is, um, set out, that is a requirement on the provider, these software products that all the different organisations that will feed into SPR use.
17:36
17:37
Speaker 26
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Speaker 26
Um, so, uh, like Doctor Cocker, I'm not technical either, but um, from previous pieces of work that I've been involved with, um, some of it is to do with the data architecture and making sure that the, the fields that are being used across the various different systems, um, you can agree on, on the same fields when it comes to frailty, specifically. Um, we have had the question of if we've got multiple source systems that have the same field, which one, you know, should we be, um, showing within the single patient record and um, our thinking at the moment is that we would, we would show various different entries who they've been done by and at what time points so that the clinician themselves could then decide in terms of the interpretation of that data.
17:37
Speaker 11
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Speaker 11
Thank you. Can I ask a second question?Um, so my other question was really going to be about digital exclusions, particularly to Doctor Imam because, uh, we associate older people with being digitally excluded. I know it's not exclusively older people that are digitally excluded, but how would you envisage the, the. The digital record interacting with something more analog for those people that can't use the NHS app for whatever reason?
17:38
Speaker 26
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Speaker 26
Yeah, it's a really important question actually. And, um, I think this is something that needs to be thought about very carefully when it comes to the implementation. Um, I think from my, again, my previous kind of NHS England experience where we have had digital innovations implemented in the older age group or those that maybe are traditionally digitally excluded. This has included, um, partnerships that enable that people to have the option of someone coming and, you know, there being, um, a thought process behind those people that perhaps aren't able to engage with technology as easily.
And so this could involve people from the vxi sector. You know, in the previous panel, we had age UK, for example, and there are lots of good examples of that, that type of work taking place to ensure that, um, people are not disadvantaged.
And so this could involve people from the vxi sector. You know, in the previous panel, we had age UK, for example, and there are lots of good examples of that, that type of work taking place to ensure that, um, people are not disadvantaged.
17:39
17:39
Speaker 3
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Speaker 3
I might just add a comment because I think there's an opportunity here as well. When we're thinking about digital exclusion in the context of a digital first NHS, I think it's really helpful to think, to be continually thinking about what the analog version of the system is in terms of in the event of further, you know, cyber incidents and outages of the system, we need to continually build and maintain a resilient system for when the times when digital first is not going to be available. So I think it's an important opportunity as well to do so.
If we think about that question of exclusion.
If we think about that question of exclusion.
17:40
17:40
17:40
Speaker 19
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Speaker 19
Um, thank you chair. Um, my question is to Doctor Byrne, and I was listening to your concerns about um the. Confidentiality and trust. I just want to declare that I have worked in the NHS for many years in the mental health sector. And I worked in one of the biggest mental health trusts, Kent and Medway NHS trust. And we use a an electronic. Patient record called Rio. So so before. Okay, doctor Coker said anyone given access.
The individual will have to have a training or information governance and data protection and the access is given based on their roles. And this system do leave or give an opportunity for audit trail. So the patient can request any time to ask how many people access my information in the last one month or two months. So there are facilities on the system to check on that. So is it that the staff training and um are. Awareness among patients is important to create that trust and confidentiality.
The individual will have to have a training or information governance and data protection and the access is given based on their roles. And this system do leave or give an opportunity for audit trail. So the patient can request any time to ask how many people access my information in the last one month or two months. So there are facilities on the system to check on that. So is it that the staff training and um are. Awareness among patients is important to create that trust and confidentiality.
17:41
Speaker 3
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Speaker 3
Those things are very important. Yes. And there are some technical solutions. Uh, in the SPR. Again an opportunity to look at that across the system because systems vary greatly in their sophistication in terms of their audit function, for example. But even when you have an audit function, it's not necessarily if someone has legitimate access through their role as a doctor or a nurse, it can be difficult to know whether their access is nevertheless legitimate in any particular case.
And these these these are not common occurrences, but they are extremely distressing for patients. If their confidentiality is breached for any reason. Um, so it's not simply a matter of technical controls. I think what we need to look at, and I'm keen to look at, and I'm delighted that I think the Department of Health and NHS England are very interested in this, having this conversation with me is how do we build stronger, more effective deterrents across the system in terms of effective sanctions for when incidents do occur, because at the moment, certainly, it would seem that there is a very rare variable response across the system to inappropriate access.
And I think certainly looking ahead to the SPR, we need to look at that and improve that so the public can can have faith in the fact that if anyone does access their records inappropriately, that that will be taken very seriously, given the harm that can cause them. So I think there are both technical and cultural, but also system things to think about here. And the SPR is definitely an opportunity to to do that. And I'm very keen to, to, to, to, to work with other stakeholders on that.
And these these these are not common occurrences, but they are extremely distressing for patients. If their confidentiality is breached for any reason. Um, so it's not simply a matter of technical controls. I think what we need to look at, and I'm keen to look at, and I'm delighted that I think the Department of Health and NHS England are very interested in this, having this conversation with me is how do we build stronger, more effective deterrents across the system in terms of effective sanctions for when incidents do occur, because at the moment, certainly, it would seem that there is a very rare variable response across the system to inappropriate access.
And I think certainly looking ahead to the SPR, we need to look at that and improve that so the public can can have faith in the fact that if anyone does access their records inappropriately, that that will be taken very seriously, given the harm that can cause them. So I think there are both technical and cultural, but also system things to think about here. And the SPR is definitely an opportunity to to do that. And I'm very keen to, to, to, to, to work with other stakeholders on that.
17:43
17:43
17:43
Speaker 3
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Speaker 3
I think it's an interesting idea, but I'm not sure. And I heard your question earlier about data controllership specifically in this regard. And I think my answer won't necessarily be one you might like, but I think there are two ways of answering this question, perhaps straightforwardly, legally, but also clinically. If we start from the the legal answer, which in some ways is, is easier, uh, data controllership and data protection law is a very technical term, and it's determined by who it is that's making the decisions about the processing and means of the data.
So an organization running and controlling an electronic patient record would be the data controller. And obviously this is ultimately a question for the regulator and the ICO to determine. But but but nevertheless that would be the the legal position. I think clinically we have to come back to thinking about what is a patient record for. And primarily it is to provide good care within the context of that clinician patient relationship. Now, if you prioritise the needs of either side of that relationship, I think it's problematic.
The needs of one mustn't outweigh the needs of the other. And and the clinical record is there for clinicians to be able to record what someone's presenting with, the difficulties they're having, what investigations are appropriate, the findings, what the plan is, and that needs to be there for that tool to work. And I suppose it's to take you on a slight thought experiment there that if it was entirely held within a patient's control, however loosely we use that term legally or otherwise, what that would mean if people could if we could all amend, correct, change, add our diagnoses, findings, treatments, if that was all up to us entirely to control, I think that might be clinically problematic.
So I think that may not be the answer. You might want, but I think it's a sort of the straight answer, if I'm honest, from both the clinical and legal perspective.
So an organization running and controlling an electronic patient record would be the data controller. And obviously this is ultimately a question for the regulator and the ICO to determine. But but but nevertheless that would be the the legal position. I think clinically we have to come back to thinking about what is a patient record for. And primarily it is to provide good care within the context of that clinician patient relationship. Now, if you prioritise the needs of either side of that relationship, I think it's problematic.
The needs of one mustn't outweigh the needs of the other. And and the clinical record is there for clinicians to be able to record what someone's presenting with, the difficulties they're having, what investigations are appropriate, the findings, what the plan is, and that needs to be there for that tool to work. And I suppose it's to take you on a slight thought experiment there that if it was entirely held within a patient's control, however loosely we use that term legally or otherwise, what that would mean if people could if we could all amend, correct, change, add our diagnoses, findings, treatments, if that was all up to us entirely to control, I think that might be clinically problematic.
So I think that may not be the answer. You might want, but I think it's a sort of the straight answer, if I'm honest, from both the clinical and legal perspective.
17:45
17:45
Speaker 3
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Speaker 3
Well, I totally support that ambition. Absolutely, absolutely. Yes. Patients in the public being having more agency in their care, strengthening that relationship, being able to access your information through the NHS app. What a great thing. You know, that's hugely, hugely helpful. And again, a real potential with the SPR as well to strengthen that. We've landed on agreement.
17:46
17:46
Speaker 8
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Speaker 8
Thank you chair. Um, I just wondered if you had any thoughts about the separation of aspects of the record. So safeguarding records sexual health records. Um there may be carers. We've heard about carers being able to see parts of the record. Um surely there are circumstances when people, we may want people to see parts of the record and other parts, or people may wish to share parts and other parts. What provision is being made or arranged for that, that you're aware of?
17:47
17:47
Speaker 3
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Speaker 3
At the moment, I think it's too early to say. I'm not aware of. I think those are absolutely important questions that will have to be addressed in the design. At the moment, I'm not sure how the programme intends to to look at those questions, but absolutely clinically that needs to be thought about it. You know, there are. Yeah, complications here that need to be thought about very carefully in terms of, of the record and the access. And sometimes that is clinically complicated, but I'm not aware to answer your question about what the plans are for that.
17:48
17:48
Speaker 27
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Speaker 27
Going to say that we did do some exploratory work, um in relation to safeguarding because that's quite a key part of safe maternity care. Um but because of the, the issues that would have with confidentiality for other involved parties to say, um, a mother's partner or someone else in a family. Um, and the risk of that information being pulled through to someone else's single patient records, it was felt that any information would contain information about anyone else we couldn't include. So that aspect has been considered.
But as Doctor Byrne said, that would need careful consideration. Um, as to all those different sources and, and if and if there'd be any. Option to change what, what feeds in or not. Um, but the, the only one I'm aware of have actually looked at specifically was safeguarding. And it was primarily due to confidentiality issues with other involved parties.
But as Doctor Byrne said, that would need careful consideration. Um, as to all those different sources and, and if and if there'd be any. Option to change what, what feeds in or not. Um, but the, the only one I'm aware of have actually looked at specifically was safeguarding. And it was primarily due to confidentiality issues with other involved parties.
17:49
17:49
17:49
17:49
17:49
17:50
17:50
17:50
17:51
17:51
17:51
17:52
Speaker 29
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Speaker 29
Um. I think there's lots of different ways you can answer that. Obviously some functions um in terms of say NHS England moving into the department with powers to the Secretary of State, that feels like a centralising measure. Um, I know the ambition of government is to give local, uh, NHS bodies more freedom and autonomy, but the bill is very careful to leave powers with the Secretary of State to intervene in a lot of detail in the running of those local bodies. So on the whole, it would probably be more of a centralising measure.
There's another way in which I think some changes outside of the bill process is centralised, and that's the the merger of Icbs and arguably quite a lot of providers. So whereas before, you might have 2 or 3 icbs covering an area, you now have got half the staff covering much bigger geographies. I would argue that centralising decision making to a higher level than, than where it used to exist.
There's another way in which I think some changes outside of the bill process is centralised, and that's the the merger of Icbs and arguably quite a lot of providers. So whereas before, you might have 2 or 3 icbs covering an area, you now have got half the staff covering much bigger geographies. I would argue that centralising decision making to a higher level than, than where it used to exist.
17:52
Speaker 26
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Speaker 26
Thank you. And what effect does that having on managers and on their ability to do the day job and deliver care?We've got a lot of presumably time, effort and energy going in. A lot of worry, perhaps going into the process of reorganisation. What effect does that have on delivery of services and development of new ones?
17:53
Speaker 29
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Speaker 29
I think, I mean, this for us is the crux of what's going on. So the bill's the bill, but there is a management resource within the health service that's finite. Internationally, it's considered quite low. And I think certainly people like Lord Darcy Institute for government IFS have all pointed to a shortage of management as potentially being one of the weaknesses of the NHS. So what's going on right now is knocking another big hole in an already limited resource of managers within within the health service.
And I think that is creating very large workloads and potentially for people in the new system. And those will inevitably mean certain things won't get done or won't get done well enough. I think it certainly feels that we've gone into a, an environment where we're cutting a management costs without thinking about the management capability. The health service needs to innovate to deliver reform and to do basic safety and resource management.
And I think that is creating very large workloads and potentially for people in the new system. And those will inevitably mean certain things won't get done or won't get done well enough. I think it certainly feels that we've gone into a, an environment where we're cutting a management costs without thinking about the management capability. The health service needs to innovate to deliver reform and to do basic safety and resource management.
17:54
17:54
Speaker 29
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Speaker 29
Um I think our members interest had been a bit of a journey on this one. And I think we're broadly support the regulatory proposals that the government will bring forward after the consultation. In terms of real impact, I think they're going to be very limited. They cover a relatively small number of people. They'd be very exceptional circumstances in which they are. They are used. So I don't think they will transform management culture, deal with this management capability issue that we have.
They are a very personal form of professional regulation that, as I say, will have very limited impact.
They are a very personal form of professional regulation that, as I say, will have very limited impact.
17:55
Speaker 26
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Speaker 26
Thank you. And finally, um, we've heard a lot today about things not being quite finalised yet, not being quite sure yet. We're not quite sure where the destination is. Is it difficult for managers to be asked to transform from a current service to a new service, if there isn't a really well explained vision and understanding of what the new looks like?
17:55
Speaker 29
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Speaker 29
I think this is probably driving most of the anxiety uncertainty that people are experiencing and why, for some, for some members, this has become very psychologically difficult. So you've got a change programme that started in March last year with the announcement by the Prime Minister, abolition of NHS England, halving the staff of NHS England, halving the staff of Icbs and for 18 months that process has dragged on with still lots of design decisions still to be taken about how the organisation will look, what functions it will have, what will be going to the department, what might be going elsewhere, what will go to trust potentially from icbs, Icbs to regions and all of that uncertainty still exists, and yet people are being told to make decisions about voluntary redundancy.
They're being asked to make decisions about the future, and they don't understand where that future potentially sits for them. And I think that is undoubtedly driving a lot of people to feel psychologically unwell and distressed. And they're leaving. You know, people are beginning to leave because they need to protect themselves. I think there is another part to this, which obviously that's a very personal, um, issue. For, for our members. But the other thing is they are really worried about the service to the public, the safety of the changes, what happens to various functions that they are responsible for if teams get halved, if responsibilities are taken to a higher level and that sort of more centralised model.
And for example, we have a lot of members working in Icbs who have really hands on roles around individual, the care of individual children, particularly where providers fail. And I think those kinds of concerns, I don't think are being properly addressed in terms of risk. Um, you know, the continuity of service to those to those people. And we're going to survey our members. We'll share it with the committee in the next week or so. Just about what specifically is worrying them about the way change is being managed.
So I think, you know, due respect to the minister, this was all announced without a plan, and we are now waiting for a plan to emerge. Uh, 18 months into into the process.
They're being asked to make decisions about the future, and they don't understand where that future potentially sits for them. And I think that is undoubtedly driving a lot of people to feel psychologically unwell and distressed. And they're leaving. You know, people are beginning to leave because they need to protect themselves. I think there is another part to this, which obviously that's a very personal, um, issue. For, for our members. But the other thing is they are really worried about the service to the public, the safety of the changes, what happens to various functions that they are responsible for if teams get halved, if responsibilities are taken to a higher level and that sort of more centralised model.
And for example, we have a lot of members working in Icbs who have really hands on roles around individual, the care of individual children, particularly where providers fail. And I think those kinds of concerns, I don't think are being properly addressed in terms of risk. Um, you know, the continuity of service to those to those people. And we're going to survey our members. We'll share it with the committee in the next week or so. Just about what specifically is worrying them about the way change is being managed.
So I think, you know, due respect to the minister, this was all announced without a plan, and we are now waiting for a plan to emerge. Uh, 18 months into into the process.
17:57
17:57
Speaker 29
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Speaker 29
I think we've got obviously, we've got the, the ten year health plan, which, you know, most people would would probably see us as a good is a good vision for, for the service. But there are too many key design questions around the new department. The role of the departments, regions, what Icbs will be doing, what um, trusts will take on as part of this reorganisation. And behind it there's a lot of capacity and resource, organisational memory being taken out of the system. I mean, we don't talk nearly enough about the work of the commissioning support units, staff who are providing internal consultancy, a huge range of business services to the health service, including including overseeing immunisation, child immunisation programmes.
In some cases, it's really unclear what the future of those functions is. So I think we're taking out a lot of staff. Have skills, expertise, organisation and commitment. But we don't quite know yet what the precise form of those organisations will look like. So it's a very difficult change to, to, to manage.
In some cases, it's really unclear what the future of those functions is. So I think we're taking out a lot of staff. Have skills, expertise, organisation and commitment. But we don't quite know yet what the precise form of those organisations will look like. So it's a very difficult change to, to, to manage.
17:58
17:58
Speaker 23
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Speaker 23
Thank you chair. And it's always good to have a doctor from the NHS supporting managers in the NHS. Um having been one and I declared my interest earlier that I am a member of managers in Partnership. Um so we have a situation where we um had a lot of change with the 2012 act and that is this bill seeks to reverse that in terms of the architecture of the NHS. And we absolutely appreciate as a government that that is very difficult for staff working, working in it.
I wonder if you could say and appreciate that the operating model and so on is is coming forward. But in terms of the bill, um, if you could say a bit about people's feelings in terms of, uh, more clarity to the centre, the role of providers doesn't change. That's not changing. But the real change is around commissioning functions. And as you said, commissioning support organisations. So we heard earlier that everything is being reorganised and um. That is not true.
Um, but there's big change around the geography and the functions of icbs and commissioners. Clearly Secretary of State's role is something different. I wonder if you can say what people's approach to that might be.
I wonder if you could say and appreciate that the operating model and so on is is coming forward. But in terms of the bill, um, if you could say a bit about people's feelings in terms of, uh, more clarity to the centre, the role of providers doesn't change. That's not changing. But the real change is around commissioning functions. And as you said, commissioning support organisations. So we heard earlier that everything is being reorganised and um. That is not true.
Um, but there's big change around the geography and the functions of icbs and commissioners. Clearly Secretary of State's role is something different. I wonder if you can say what people's approach to that might be.
17:59
18:00
Speaker 29
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Speaker 29
Um, I mean, clarity, definitely. I mean, no one wants to start with, um, the system that came in in 2011, 2012. I think most people realise the successive governments started to correct it almost as soon as it was put in place. So I think sort of sorting out the the clarity around commissioning there, uh, I think most people would welcome, but I don't think that's the same thing as cutting 50% of those organisations staff. And running costs. Uh, that isn't because you're clarifying the relationship between the centre.
Um, and, and icbs commissioning and then providers. You still need enough managers with enough skills working in the right system to deliver. And I think that's the nub of what we're doing. This isn't really for us about how the bill will, will eventually pan out. It's about the cuts and how it is being administered. NHS England, by the Department, by Icbs. And I think the whole system of management across the health service is under strain.
So you say providers aren't changing but they're also being asked to take out quite significant amounts of of management resource. Um they're merging to form bigger, potentially more centralised units, which may be less responsive, less innovative. So I think this organisational form thing is really, really important. Even if the headline of the bill might tidy up and clarify those relationships, which would be welcome, a point that's made by a lot of members, particularly in Icbs, is they don't think the way this is being designed.
So we've started with Icbs. Then we went to regions, then we were eventually going to get to the targeting target operating model for the department is being done at a time where you can see the proper connections that need to be made between those organisations, so that when the system is up and running, how well will it be working together, sharing information, sharing risk and so on. So I think it feels like the bill's very high level, but these detailed design of the organisations is being undertaken now, but in a completely fragmented, fragmented way.
And I think people see that as potentially going to require the next round of reorganisation. You're a former NHS manager. You know how often that is reached for as the solution?Uh, and I think I, I genuinely feel that people have got to the point where enough is enough. And that kind of continual change, um, is, is, is going to create more and more problems for, for doing the things that the public actually want to see, which is innovation, improvement in quality of service, happier staff, all of those things which managers should be focusing on, not this merry go round of organisational change.
Thank you.
Um, and, and icbs commissioning and then providers. You still need enough managers with enough skills working in the right system to deliver. And I think that's the nub of what we're doing. This isn't really for us about how the bill will, will eventually pan out. It's about the cuts and how it is being administered. NHS England, by the Department, by Icbs. And I think the whole system of management across the health service is under strain.
So you say providers aren't changing but they're also being asked to take out quite significant amounts of of management resource. Um they're merging to form bigger, potentially more centralised units, which may be less responsive, less innovative. So I think this organisational form thing is really, really important. Even if the headline of the bill might tidy up and clarify those relationships, which would be welcome, a point that's made by a lot of members, particularly in Icbs, is they don't think the way this is being designed.
So we've started with Icbs. Then we went to regions, then we were eventually going to get to the targeting target operating model for the department is being done at a time where you can see the proper connections that need to be made between those organisations, so that when the system is up and running, how well will it be working together, sharing information, sharing risk and so on. So I think it feels like the bill's very high level, but these detailed design of the organisations is being undertaken now, but in a completely fragmented, fragmented way.
And I think people see that as potentially going to require the next round of reorganisation. You're a former NHS manager. You know how often that is reached for as the solution?Uh, and I think I, I genuinely feel that people have got to the point where enough is enough. And that kind of continual change, um, is, is, is going to create more and more problems for, for doing the things that the public actually want to see, which is innovation, improvement in quality of service, happier staff, all of those things which managers should be focusing on, not this merry go round of organisational change.
Thank you.
18:02
18:02
18:02
Speaker 3
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Speaker 3
Thank you very much. Um, I was going to ask about the additional responsibilities that the bill confers on ICB. So there are additional commissioning responsibilities. There's additional, uh, requirement to look after what was Healthwatch and that patient voice element. But as you have described, you've lost a large number of staff. You've got a bigger geographic footprint, and you've also lost quite a lot of budget. So what do you stop doing?Or what is being transferred out to other provider organisations?And does their role if it's changing?Regarding some of the things that the ICB was doing, does that need to be clarified in the legislation?
18:03
Speaker 29
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Speaker 29
It certainly needs to be clarified whether it needs to be clarified in legislation, I don't know, but I think what I would say is that, um, Icbs have been, you know, leave. Aside the fact that it took a very long time to get permission to start moving forward with their consultations, they were thinking about what they needed to do, uh, around about the May, June time of last year. So they will have made a lot of decisions. A lot of staff will already have gone based on the then understanding of what an ICB was supposed to be doing.
Um, through the ICB blueprint that was published by, by NHS England. So I think that resource has gone. And the people who may be connected with the functions you're talking to have also gone in many cases. So I think the question for me is if the icbs are to get more things to do, then what is the implication for their running costs, which, as you know, are capped at the moment, 19 odd pounds ahead if they get more functions, will they get more resources to do that?Will they need to be other ways of delivering that function?I don't think a lot of them can stop doing statutory functions, but that means all the good stuff that we want to see done in health systems, the innovation, the discretionary stuff, much of which is already on hold, will probably be the stuff that goes whilst they, you know, deliver their statutory obligations.
I think on the providers side, I think there's really needs urgent clarity about what's going to go to providers responsibility. Um, because as I say, they are taking out a lot of costs and I don't think all or many providers know that these plans are afoot for them. And I think that will, you know, that's going to create quite a shock because again, they're choosing people to go now based on their current understanding of what's needed.
Um, through the ICB blueprint that was published by, by NHS England. So I think that resource has gone. And the people who may be connected with the functions you're talking to have also gone in many cases. So I think the question for me is if the icbs are to get more things to do, then what is the implication for their running costs, which, as you know, are capped at the moment, 19 odd pounds ahead if they get more functions, will they get more resources to do that?Will they need to be other ways of delivering that function?I don't think a lot of them can stop doing statutory functions, but that means all the good stuff that we want to see done in health systems, the innovation, the discretionary stuff, much of which is already on hold, will probably be the stuff that goes whilst they, you know, deliver their statutory obligations.
I think on the providers side, I think there's really needs urgent clarity about what's going to go to providers responsibility. Um, because as I say, they are taking out a lot of costs and I don't think all or many providers know that these plans are afoot for them. And I think that will, you know, that's going to create quite a shock because again, they're choosing people to go now based on their current understanding of what's needed.
18:04
Speaker 3
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Speaker 3
And can I ask, um, a related question, I suppose one of the. Elements of the bill is the reorganisation of who sits on the ICB board. And we're going to see the removal of local authority, uh, representatives, the replacement of a mayor or his, his or her appointee. Does that what concern does that cause to your members?Um, or are they or do they think that's the right way to go?
18:05
Speaker 29
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Speaker 29
I think it, I mean, a lot of it will concern in terms of the political makeup of Mayoralties in the future and what that might mean. You know, if if mayors have an ever growing responsibility and say in, you know, who, what and where of health services, then I think that is probably different from the more sort of representative advisory kind of function that they have had. Um, and I think, you know, that that really needs to be, is that the new democratic accountability for health services or does it remain as now the Secretary of State accountable to Parliament?Um, making provision for, for healthcare?It feels a little unclear how much power and decision making power those, those new local government sort of voices will have on Icbs.
But have people raised it as a concern?Of course they have, because it's it's uncharted.
But have people raised it as a concern?Of course they have, because it's it's uncharted.
18:06
18:06
18:06
18:06
18:06
Speaker 29
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Speaker 29
Really comment specifically on the BCF, but I think a general theme coming out of um. What our members are telling us in surveys and we have regular regular surgeries and meetings with them. Is this the sense that what policy at the moment is trying to do is get you thinking in terms of your own organisation again, and thinking less about system wide, um, transformation, innovation, coordination. So I think, you know, we're seeing obviously icbs are getting bigger, providers are getting bigger. Some of the system stuff where I think a lot of our members would say the innovation will come, you know, the way different organisations try and solve problems around patients and populations, I think they feel that that is clearly at risk by, by the way, not just the bills, um, putting things together, but the, the stripping out of resource to do anything different.
18:07
18:07
18:07
18:07
18:08
18:08
18:08
18:08
18:09
Speaker 30
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Speaker 30
It is largely absent from the bill. Indeed, when I was asked to come and give evidence to this committee, I was initially somewhat puzzled, since it is so largely absent. The question that you ask is absolutely to the point. Certainly we can improve the efficiency of the NHS without doing anything about social care, but we can't really address many of the fundamental problems facing the NHS if we don't sort out social care. And that's partly because not having a good social care system means that we're not achieving the levels of human flourishing that are the objective of the health service and the social care system.
It's also the case that the social care system is now under such pressure that it is leading to direct challenges for the NHS. So we hear a lot about delayed transfers of care, and that's an important part of this. But it's not just delayed transfers of care, it's people who end up needing health care because they haven't had appropriate social care support. So the short answer to your question is we can make the NHS a bit more efficient without reforming the social care system.
But until we address social care, we have at least two hands and probably one foot tied behind our back. It seems to me pretty astonishing that we have a ten year NHS plan, but no real plan for social care.
It's also the case that the social care system is now under such pressure that it is leading to direct challenges for the NHS. So we hear a lot about delayed transfers of care, and that's an important part of this. But it's not just delayed transfers of care, it's people who end up needing health care because they haven't had appropriate social care support. So the short answer to your question is we can make the NHS a bit more efficient without reforming the social care system.
But until we address social care, we have at least two hands and probably one foot tied behind our back. It seems to me pretty astonishing that we have a ten year NHS plan, but no real plan for social care.
18:10
18:10
Speaker 30
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Speaker 30
Uh, so I wouldn't claim to be expert here. I have I've read the bill, I've read the briefings. The role of local authorities in social care is a very interesting one. I think if we were to stand way back and say, why is social care managed by local authorities at the moment, if we were honest, we'd say because it was forgotten in 1948 when the rest of the welfare state, the modern welfare state, was created. At that stage, social care was a pretty small activity, and it was just left with local authorities.
What's happened since then is that it's grown and grown, and it's now putting enormous strain on at least many local authorities. And I think we should draw a clear distinction between something that is definitely appropriate, which is that care should be provided with a within a local context, the kind of care that's appropriate in Camden will be different to the type of care that's appropriate in the highlands of Scotland. So. So local delivery seems relevant. But whether local financing makes sense in 2026, I think is a very big question.
Context. Potential reduction in the role of local authorities in Icbs. Um, just on its own. It's hard to see that making things better won't necessarily make things significantly worse, but I don't think it will help local authorities. Uh, and the NHS in trying to integrate between these two essentially non-integrated functions.
What's happened since then is that it's grown and grown, and it's now putting enormous strain on at least many local authorities. And I think we should draw a clear distinction between something that is definitely appropriate, which is that care should be provided with a within a local context, the kind of care that's appropriate in Camden will be different to the type of care that's appropriate in the highlands of Scotland. So. So local delivery seems relevant. But whether local financing makes sense in 2026, I think is a very big question.
Context. Potential reduction in the role of local authorities in Icbs. Um, just on its own. It's hard to see that making things better won't necessarily make things significantly worse, but I don't think it will help local authorities. Uh, and the NHS in trying to integrate between these two essentially non-integrated functions.
18:11
18:12
18:12
18:12
Speaker 30
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Speaker 30
The question of the um, fine details of how legislation should be passed is certainly outside my skill set. Uh, so whether this bill should have addressed the wider questions of social care, I have to be agnostic about whether we could address social care or not. The answer to that is definitely yes, after all, several governments in the last few years have promised to do this, and the. The then Shadow Secretary of State for Health and Social Care when he was the shadow Secretary of State in the election last two years ago, promised that he would do it.
Um measures here have had the Royal assent twice, but still not taken place, and were promised by the then Shadow Secretary of State for Health and Social Care before he became the health. So yes, we definitely could do it. The amounts of money involved. While. Of course significant, are small relative to the aggregate cost of the NHS or the uplift in spending on the NHS, which, with my full support we've seen in the last couple of years, it is a genuine puzzle, I think, and a.
A black mark for all of us, including me, that all these years have gone by and we've done nothing. We have a social care system that is supported by millions of wonderful informal carers by 1.5 million wonderful formal carers. That is, that benefits hundreds of thousands of people, but is creaking under intolerable strain. And it really makes no sense to me. And I don't know why or how we've managed to go for so long without addressing this. And we should both, because it will be the right thing to do, and because now it's so bad that it's doing direct instrumental damage to the NHS.
Um measures here have had the Royal assent twice, but still not taken place, and were promised by the then Shadow Secretary of State for Health and Social Care before he became the health. So yes, we definitely could do it. The amounts of money involved. While. Of course significant, are small relative to the aggregate cost of the NHS or the uplift in spending on the NHS, which, with my full support we've seen in the last couple of years, it is a genuine puzzle, I think, and a.
A black mark for all of us, including me, that all these years have gone by and we've done nothing. We have a social care system that is supported by millions of wonderful informal carers by 1.5 million wonderful formal carers. That is, that benefits hundreds of thousands of people, but is creaking under intolerable strain. And it really makes no sense to me. And I don't know why or how we've managed to go for so long without addressing this. And we should both, because it will be the right thing to do, and because now it's so bad that it's doing direct instrumental damage to the NHS.
18:14
18:14
Speaker 30
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Speaker 30
I think there are two main ways. The first, and perhaps the one that's received most attention, is that there are people who have been hospitalised, perhaps with a fall in infection, uh, have some mobility challenges, need some care and can't. Leave hospital because a social care package is not available for them in the community. Uh, that's extremely damaging for the NHS because if we have somebody in a bed that they don't need to be in, but where they have nowhere else to go, not only are we spending money, uh, having that person there, but we're not then able to use that bed for other activities.
So if you have, which is not uncommon, somebody with a delayed transfer of care, so stuck in hospital doesn't need to be for 20 days, very, very large numbers of elective procedures can't take place because that bed is being used for that. So that's, that's a sort of a kind of deadweight loss from the system. But there's another thing which I think is, is at least as important. And that is that because of the lack of good social care, we have people falling and injuring themselves and needing to be hospitalised.
We have people getting and sustaining more UTIs than they perhaps could if they were being if they had good social care. So that's adding an additional burden, which the NHS deals with as well as it can. But all of this just seems unnecessary. Why?Social care appears to be so invisible to us all, and it's easy to. And for any of you who've who've experienced but all of this just seems unnecessary. Um, and why social care appears to be so invisible to us all.
And it's easy to blame politicians. And of course, it's politicians like you who ultimately have to vote for these things. But I think we all, you know, the electorate as well, a whole of our society. We have to look at us and say, why is this challenge, which is so significant?And for any of you who've who've experienced it in your own families, you know how brutal and difficult, why can't we make this better?And if I if I could be allowed one more general point, we should reflect that this is the result of the great triumph of the last 150 years at the beginning of the last century, across the world, average life expectancy at birth was 32, and now it's 73.
In this country, average life expectancy in 1900, life expectancy at birth was 46, and now it's 81. We've added 35 years to the expectation of life from birth. That is an astonishing transformation. And with it comes some consequences, one of which is that there's much more social care to be done. But we should be celebrating this and delighting in it and doing it well. Instead of hiding it away and ignoring it, and now ignoring it for so long that it's doing real damage to the NHS, let alone to the lives of the people who need social care.
So if you have, which is not uncommon, somebody with a delayed transfer of care, so stuck in hospital doesn't need to be for 20 days, very, very large numbers of elective procedures can't take place because that bed is being used for that. So that's, that's a sort of a kind of deadweight loss from the system. But there's another thing which I think is, is at least as important. And that is that because of the lack of good social care, we have people falling and injuring themselves and needing to be hospitalised.
We have people getting and sustaining more UTIs than they perhaps could if they were being if they had good social care. So that's adding an additional burden, which the NHS deals with as well as it can. But all of this just seems unnecessary. Why?Social care appears to be so invisible to us all, and it's easy to. And for any of you who've who've experienced but all of this just seems unnecessary. Um, and why social care appears to be so invisible to us all.
And it's easy to blame politicians. And of course, it's politicians like you who ultimately have to vote for these things. But I think we all, you know, the electorate as well, a whole of our society. We have to look at us and say, why is this challenge, which is so significant?And for any of you who've who've experienced it in your own families, you know how brutal and difficult, why can't we make this better?And if I if I could be allowed one more general point, we should reflect that this is the result of the great triumph of the last 150 years at the beginning of the last century, across the world, average life expectancy at birth was 32, and now it's 73.
In this country, average life expectancy in 1900, life expectancy at birth was 46, and now it's 81. We've added 35 years to the expectation of life from birth. That is an astonishing transformation. And with it comes some consequences, one of which is that there's much more social care to be done. But we should be celebrating this and delighting in it and doing it well. Instead of hiding it away and ignoring it, and now ignoring it for so long that it's doing real damage to the NHS, let alone to the lives of the people who need social care.
18:17
Speaker 3
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Speaker 3
And if I can ask one more question, um. I suppose I'm going to put words into your mouth and you can, you can disagree with me. Um, do you think the bill should tackle this point about having a properly funded care service so that the transition from, from hospital to the community can actually take place?Because as you have just said, if people aren't cared for properly, they end up back in hospital. And that is, I think, what everybody here agrees that we are trying to avoid.
18:17
Speaker 30
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Speaker 30
Yes. I mean, it's it's very odd and it's worth doing the odd thought experiment. Imagine that the bit of health care that was underfunded, only available, subject to a means test and not free were heart disease. Well, we can't imagine that. I mean, that would clearly the fact that it's dementia or severe arthritis or. We've drawn an arbitrary line and. While that line still exists and while there's inadequate funding even of the means tested system.
We are hamstringing the NHS. Now, that's not. I think the most important problem, the most important problem is that we're failing to give people flourishing lives and allow them to live the full. But actually not so bad. It's actually making it hard for the NHS to work.
We are hamstringing the NHS. Now, that's not. I think the most important problem, the most important problem is that we're failing to give people flourishing lives and allow them to live the full. But actually not so bad. It's actually making it hard for the NHS to work.
18:18
18:19
18:19
Speaker 9
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Speaker 9
Thank you. Um. Hospital pressures on the Isle of Wight are particularly, severe, and part of the way in dealing with so-called corridor care is for the hospital and local authority to look at discharging some frail patients to the mainland, including those living with dementia, which is plainly not a solution in anyone's normal interpretation. Is there anything in this bill notwithstanding, it doesn't deal with the fundamental problems of social care. Is there anything in this bill not only that can help resolve those sorts of situations, but could help resolve those situations if they went a little bit further.
So I'm looking for opportunities here where we can actually use this bill to try and do a little bit more in and around discharge and social care.
So I'm looking for opportunities here where we can actually use this bill to try and do a little bit more in and around discharge and social care.
18:19
Speaker 30
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Speaker 30
It's a very good question, to which I don't have a very immediate answer or I mean, I do have an immediate answer, which as far as I can see, nothing very substantial. I mean, I do think that the single patient record offer some prospects here and something that is terribly important for people receiving social care, which again, reflects how much longer there's much, much more multiple morbidity. Now, so many of the people who are benefiting from and can benefit from social care will have quite complicated medical experiences and medical histories.
And so we really, really do want, uh, that's the kind of group that could particularly benefit from a single patient record so that we're not having inappropriate prescription or just that's going to help, but I don't that's going to be a, it's going to be a second order issue. I think the fundamental issue, if I can let me be very blunt, there are two fundamental challenges facing the social care system. The first is that the means tested bit of it, where we say, if you don't have any resource of your own, the state will look after you.
That must be a minimum for any humane society, essentially. Any year for at least the last decade, the Treasury has announced emergency funding for that in year. That money then doesn't get spent well. And honestly, if you're announcing an emergency package every year for ten years, it's not an emergency package. You should wake up, pay attention, have a mature response, and fund that system properly. That's the minimum. The second is that the the only big risk that we all face that isn't pooled is social care.
So our risk of health care is pulled by the state. Our risk of having a car accident or a our house burning down is pulled by private insurance. This is the one risk that is not pooled. And the reason it's not pooled is the state doesn't. And the private sector can't. The reason the private sector can't is it's too far ahead for a private insurance market to deal with it. So only the state can pull the risk.
If there's any area where the case for social insurance is absolutely clear, it's social care. It's even more powerful in social care than it is in health. So we have at the moment a situation where often people will feel that the best thing that can happen to them, if they think they might have a social care need, is that they die before too long. It's a bit like standing in the middle of the road with a lorry driving towards you, and you're hoping that the best thing that might happen is that you die before it hits you.
Well, that's not a good way to be running any kind of society or country, and it those those challenges, the lack of adequate funding of the means tested system and the lack of any risk pooling for the population as a whole lead directly to the kind of experience that you're describing in the Isle of Wight, where there's simply excess demand for. And so we're then trying to ship people across to the mainland. It's it's a it's a reflection of the fundamental challenges that we've ignored for 35 years.
And so we really, really do want, uh, that's the kind of group that could particularly benefit from a single patient record so that we're not having inappropriate prescription or just that's going to help, but I don't that's going to be a, it's going to be a second order issue. I think the fundamental issue, if I can let me be very blunt, there are two fundamental challenges facing the social care system. The first is that the means tested bit of it, where we say, if you don't have any resource of your own, the state will look after you.
That must be a minimum for any humane society, essentially. Any year for at least the last decade, the Treasury has announced emergency funding for that in year. That money then doesn't get spent well. And honestly, if you're announcing an emergency package every year for ten years, it's not an emergency package. You should wake up, pay attention, have a mature response, and fund that system properly. That's the minimum. The second is that the the only big risk that we all face that isn't pooled is social care.
So our risk of health care is pulled by the state. Our risk of having a car accident or a our house burning down is pulled by private insurance. This is the one risk that is not pooled. And the reason it's not pooled is the state doesn't. And the private sector can't. The reason the private sector can't is it's too far ahead for a private insurance market to deal with it. So only the state can pull the risk.
If there's any area where the case for social insurance is absolutely clear, it's social care. It's even more powerful in social care than it is in health. So we have at the moment a situation where often people will feel that the best thing that can happen to them, if they think they might have a social care need, is that they die before too long. It's a bit like standing in the middle of the road with a lorry driving towards you, and you're hoping that the best thing that might happen is that you die before it hits you.
Well, that's not a good way to be running any kind of society or country, and it those those challenges, the lack of adequate funding of the means tested system and the lack of any risk pooling for the population as a whole lead directly to the kind of experience that you're describing in the Isle of Wight, where there's simply excess demand for. And so we're then trying to ship people across to the mainland. It's it's a it's a reflection of the fundamental challenges that we've ignored for 35 years.
18:22
18:22
Speaker 26
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Speaker 26
Thank you. Chair. Um, you've talked a lot about adult social care in terms of the very elderly and frail and people with dementia, but it also affects younger people as well. And I know at the moment, for example, Swallow Lodge, which is a adult working age adult facility in my constituency, is under threat of closure. Um, and I think, you know, I've made the arguments and the people have made the arguments about how it's a lifeline for them. It allows the families to have a break.
It allows the individuals using the service to flourish and enjoy life. But there's an economic argument too. And how well do you think that's understood the economic arguments to the NHS of, um, closing such a place could lead actually to higher costs for NHS, for mental health, support, for physical health, support for further social care admissions and the like.
It allows the individuals using the service to flourish and enjoy life. But there's an economic argument too. And how well do you think that's understood the economic arguments to the NHS of, um, closing such a place could lead actually to higher costs for NHS, for mental health, support, for physical health, support for further social care admissions and the like.
18:23
Speaker 30
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Speaker 30
You're absolutely right to emphasize the importance of of non-elderly adult social care, which is roughly half of of all of the expenditure and growing. And actually, one of the reasons that we see particular pressures in the elderly care sphere is that the less elderly that that need has grown very dramatically, again, because of the scope for increased human flourishing. Um, on the whole, as far as I can see, there's very little understanding of the integrated nature of these costs between social care and the NHS. So I think very little thinking in budgetary terms about the consequences of the squeeze on social care, leading to increased expenditures, increased needs elsewhere in the NHS.
And that's not and that's not easy to resolve. Uh, moving to a system that. Properly integrated those trade offs will be difficult. And it requires a different sort of funding regime. But while we don't, uh. Those costs exist. Again, my sense is their second order at the national level, but where they're certainly not second order is for the individuals concerned and their families for whom this kind of thing is a kind of an eruption of, of anxiety and grief in the context that families are already under pressures that most of us would find hard to imagine.
And that's not and that's not easy to resolve. Uh, moving to a system that. Properly integrated those trade offs will be difficult. And it requires a different sort of funding regime. But while we don't, uh. Those costs exist. Again, my sense is their second order at the national level, but where they're certainly not second order is for the individuals concerned and their families for whom this kind of thing is a kind of an eruption of, of anxiety and grief in the context that families are already under pressures that most of us would find hard to imagine.
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Speaker 26
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Speaker 26
Thank you. Chair Minister. Thank you. Um, previously you said that the reorganisation of health services always distracts from people's jobs, destroys morale and wastes money. In response to a written question this week, though, which asked what assessment you've made of the disruption of development of new services caused by the abolition of NHS England, you said the abolition of NHS England is causing no disruption to the development of new services. Um, I wonder which of those statements you agree with the most and whether you wanted, in light of any of the evidence you've heard today, to change your mind.
18:27
Speaker 23
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Speaker 23
Um, I don't know exactly what year you're quoting from. Um, but, um, I'm happy to take, take that full on. Of course. Uh, change reorganisations, changes in legislation. Um, has, uh. You know, has consequences, um, at different times depending on what it is. Um, that will determine changes to, to some services at local level. I think that quote is probably in relation to the 2012. Changes, which as I've often said, brought me into Parliament where the entire infrastructure of the health service was destroyed and changed in order to bring forward that legislation.
And I can never find anybody. And I know I think I've heard Lord Lansley say this, um, anybody who thinks that that was a good thing. Um, and again, very happy to, to say part of the rationale was about the fact that I don't think, um, despite lots of warnings. About, um, the damage to that infrastructure that that wasn't learned. And then we did obviously have the, we won't go through the history of that passage of that bill. Um, for even having to pause it midway through to, to enact other sorts of ways of making things work.
I think for this one. And I'm sure you'll come back in your second question as to, um, decisions around some of the provisions in this bill. Um, it is of course true in a matter of record that as an incoming government, we did not intend to make the change to NHS England and abolish that as an organisation. In the passage of our first few months in government, um in determination to change the outcomes of the health service, that decision was then made, um, some eight months into us being in government.
And I don't think and I think today, again, we have not heard a single person suggest that that is a wrong decision. And obviously, um, Doctor Johnson is the opposition. It was not opposed. Second reading in principle. So I think there's overwhelming consensus for the major provision in this bill around the abolition of NHS England and for the single patient record. I am very mindful on a personal level, the consequences of individual people's jobs and trying to get that right.
I accept much of the criticism from Mr. Bristol in terms of, um, the. This would be much better done much more quickly and making sure that that, that that was done in a, in a different way. But the consequences of, of abolishing NHS England are some of the things that we are seeing.
And I can never find anybody. And I know I think I've heard Lord Lansley say this, um, anybody who thinks that that was a good thing. Um, and again, very happy to, to say part of the rationale was about the fact that I don't think, um, despite lots of warnings. About, um, the damage to that infrastructure that that wasn't learned. And then we did obviously have the, we won't go through the history of that passage of that bill. Um, for even having to pause it midway through to, to enact other sorts of ways of making things work.
I think for this one. And I'm sure you'll come back in your second question as to, um, decisions around some of the provisions in this bill. Um, it is of course true in a matter of record that as an incoming government, we did not intend to make the change to NHS England and abolish that as an organisation. In the passage of our first few months in government, um in determination to change the outcomes of the health service, that decision was then made, um, some eight months into us being in government.
And I don't think and I think today, again, we have not heard a single person suggest that that is a wrong decision. And obviously, um, Doctor Johnson is the opposition. It was not opposed. Second reading in principle. So I think there's overwhelming consensus for the major provision in this bill around the abolition of NHS England and for the single patient record. I am very mindful on a personal level, the consequences of individual people's jobs and trying to get that right.
I accept much of the criticism from Mr. Bristol in terms of, um, the. This would be much better done much more quickly and making sure that that, that that was done in a, in a different way. But the consequences of, of abolishing NHS England are some of the things that we are seeing.
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Speaker 26
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Speaker 26
Okay. All right. Um, the other question I had for you was about the, the vision when we heard my right hon. Friend, um, from Milton talk earlier on about his reforms of the past, there was a sort of a coherent vision to it. And one of the things we've heard today is there wasn't really a plan, whether it's a single patient record or other aspects of, of the, of the, um, this bill. There were lots of decisions still left to be made.
You're asking people to move from here to there without specifying really where there is. Do you think this is really ready?Are you are you trying to get to a landing place that you understand as a coherent vision, or are you just trying to unpick things that somebody did before that you didn't like?
You're asking people to move from here to there without specifying really where there is. Do you think this is really ready?Are you are you trying to get to a landing place that you understand as a coherent vision, or are you just trying to unpick things that somebody did before that you didn't like?
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Speaker 26
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Speaker 26
Mean the, the, the, the system as a whole?I mean, if you look at what my right hon. Friend was talking about earlier on the Icbs, the designed to tier with upper tier local authorities. And he gave a reason why that is. Whereas the. What's happened with these reforms is we've now got ice beds. Like I look at Lincolnshire, Lincolnshire. ICB was part of a mayoral authority. It's now linked in with Derbyshire and Nottinghamshire, which are part of another moral authority, but not a complete other moral authority.
And so you've got things all jumbled up. And I wonder if that's because instead of having a vision of where you want it to be, you've started to unpick somebody else's work because you didn't like it. And the same way with the single patient record, we heard that there were lots of decisions that needed to be made that have not been made before. The bill has been brought. So people are being asked to deliver things that haven't been properly considered. Do you think that's fair?
And so you've got things all jumbled up. And I wonder if that's because instead of having a vision of where you want it to be, you've started to unpick somebody else's work because you didn't like it. And the same way with the single patient record, we heard that there were lots of decisions that needed to be made that have not been made before. The bill has been brought. So people are being asked to deliver things that haven't been properly considered. Do you think that's fair?
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Speaker 23
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Speaker 23
Um, I think they're two separate things. So I think in terms of the provision of the bill, obviously abolishing NHS England brings with it a lot of technical detail, making sure that the the legal responsibilities and duties are placed rightly on the Secretary of State, um and into Icbs and clarifies that landscape in a very technical and licenses for foundation trusts, etc.. So, um, large chunk of that on the detail of the consequences of abolishing NHS England. Alongside that, um, is the move then to make icbs on a larger footprint and in parallel, obviously with the government's agenda on devolution.
And I accept that that is a lot of change. And in in all our constituencies and for all our areas and making sure that we do make the most of those mayoral authorities to allow mayors to be on Icbs as they are largely determiners of a lot of economic development, transport, and indeed the wider determinants of health. And we are still going through some some of that change. And you recently been written to about your views about that as local members of Parliament and local government, and we do need to make sure that that is embedded as quickly as possible so that we can stabilise that side of the system in terms of the single patient record.
Um, the bill gives the enabling powers to, in order to bring forward the single patient record. And then in regulations and in further consultation and detail consultation, as we've heard both from clinicians and from the patients and the public, because building trust for this is absolutely critical. Um, that that comes next, which is usually in parliamentary terms, isn't it?For us as legislators, we understand that providing the provisions and then secondary legislation on the regulations, I accept that that is that that is something we need to.
And I thought, um, Doctor Byrne was very helpful earlier in terms of bringing the public with us on that trust to explain the sort of two stages to how this comes forward.
And I accept that that is a lot of change. And in in all our constituencies and for all our areas and making sure that we do make the most of those mayoral authorities to allow mayors to be on Icbs as they are largely determiners of a lot of economic development, transport, and indeed the wider determinants of health. And we are still going through some some of that change. And you recently been written to about your views about that as local members of Parliament and local government, and we do need to make sure that that is embedded as quickly as possible so that we can stabilise that side of the system in terms of the single patient record.
Um, the bill gives the enabling powers to, in order to bring forward the single patient record. And then in regulations and in further consultation and detail consultation, as we've heard both from clinicians and from the patients and the public, because building trust for this is absolutely critical. Um, that that comes next, which is usually in parliamentary terms, isn't it?For us as legislators, we understand that providing the provisions and then secondary legislation on the regulations, I accept that that is that that is something we need to.
And I thought, um, Doctor Byrne was very helpful earlier in terms of bringing the public with us on that trust to explain the sort of two stages to how this comes forward.
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Speaker 26
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Speaker 26
Thank you. And finally, we've heard a lot about independence, the independence of H. SIB, its ability to independently investigate and to independently recommend. And we've heard about Healthwatch ability to independently, um, describe patient voice without interference from those whose homework it's marking. Do you have any reflections on the bill and what it contains in light of what you've heard?
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Speaker 23
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Speaker 23
I mean, I do think there's a fundamental, um. Maybe a political difference in approach that this government is taking to what has gone before in terms of this notion of, um, responsibility, accountability, uh. For both commissioning and delivering services and this position of independence. And we've talked earlier today about perception and reality. So, um. You know, the system has not worked. And to my earlier question, um, and I think I said this in second reading, we've had what's called an independent voice in some of these bodies for over 50 years.
We've had numerous recommendations, uh, under and, you know, I do disagree with Jeremy Hunt on this and his provision earlier that under his stewardship of the new NHS England, what we've had is a plethora of recommendations, new organisations layer upon layer of bureaucracy, totally remote from any kind of democratic accountability or oversight. And it has not it is not working. And I don't think anybody is really defending that. It is the job of NHS, both providers and commissioners, to include patient voice and patient experience in their work.
And I think it was um. Kieran de from Alliance, I think he, he said um getting boards right in terms of their managerial, their clinical and their patient experience work that is their responsibility. And I do think that outsourcing lots of that work to other bodies. One, it hasn't worked, but two, I think it is outsourcing that responsibility. We have to make boards work at a local level. Um, they have to, they have to step up to that plate and I think they want to, and they certainly equipped to be able to do that, taking into account that people will need some skilling in some of this area.
So I think there is a debate to be had, and I think we'll have a good debate in committee about, um, independence or independent organizations. And I just just a final comment before you come back, I thought, you know, this this is a bit of a bugbear of mine. And perhaps as I'm speaking behalf of the department, I shouldn't say it, but I will. Um, none of my constituents are hard to reach. Not a single one of them. We know exactly where they are.
We know what?We largely know what's wrong with them. We largely know what their health outcomes are going to be. We know what they are in terms of ethnicity, demographics, etc. what's hard to reach is remote. Organisations that haven't served them well, and that is what we're determined to put right. And putting that right in this bill is the start of doing that.
We've had numerous recommendations, uh, under and, you know, I do disagree with Jeremy Hunt on this and his provision earlier that under his stewardship of the new NHS England, what we've had is a plethora of recommendations, new organisations layer upon layer of bureaucracy, totally remote from any kind of democratic accountability or oversight. And it has not it is not working. And I don't think anybody is really defending that. It is the job of NHS, both providers and commissioners, to include patient voice and patient experience in their work.
And I think it was um. Kieran de from Alliance, I think he, he said um getting boards right in terms of their managerial, their clinical and their patient experience work that is their responsibility. And I do think that outsourcing lots of that work to other bodies. One, it hasn't worked, but two, I think it is outsourcing that responsibility. We have to make boards work at a local level. Um, they have to, they have to step up to that plate and I think they want to, and they certainly equipped to be able to do that, taking into account that people will need some skilling in some of this area.
So I think there is a debate to be had, and I think we'll have a good debate in committee about, um, independence or independent organizations. And I just just a final comment before you come back, I thought, you know, this this is a bit of a bugbear of mine. And perhaps as I'm speaking behalf of the department, I shouldn't say it, but I will. Um, none of my constituents are hard to reach. Not a single one of them. We know exactly where they are.
We know what?We largely know what's wrong with them. We largely know what their health outcomes are going to be. We know what they are in terms of ethnicity, demographics, etc. what's hard to reach is remote. Organisations that haven't served them well, and that is what we're determined to put right. And putting that right in this bill is the start of doing that.
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Speaker 26
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Speaker 26
About was about trust and how people can be trusting of figures. So, um, for example, with Healthwatch, if you internalize patient experience into an organisation, do people then trust you when you say it's got better because they will only have their own experience and experience of their own family to work on. And that will be the lens that they look at things. So we know that the waiting list numbers have come down and that there is not widespread trust for those numbers for all sorts of reasons.
If the numbers for patient experience are governed by the Department of Health or the Icbs themselves marking their own homework, will the public trust them?Whether they should trust them is one question. But will they trust them?
If the numbers for patient experience are governed by the Department of Health or the Icbs themselves marking their own homework, will the public trust them?Whether they should trust them is one question. But will they trust them?
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Speaker 23
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Speaker 23
The waiting list. But I mean, I think you're absolutely right about trust, and I certainly by saying that I expect this to be the board's job. I think it is their job to get this right, and we need to support them to do that. And that is also about we heard a bit about from Penny Dash about the National Quality Board. Um, and the patient experience director inside the Department of Health reporting directly to the Chief executive. That has to be part of the wider architecture, of course, which is outside the bill.
So we do need to be able to tell that story to the wider public. And, and this issue of of trust. Of course, we know from all the recommendations and the reviews and where we all are and the support we give as members of Parliament to our constituents, that that is really important, getting that right and bringing people on that journey with us will be really important. And independence does help with that. So that's why I think it's good to debate it in the bill.
I think it's good to be able to air some of that, but I think people would accept that it is not working and it has not worked. Um, I think your question about waiting lists is about data and information about saying where it where it is. I mean, what I say on that is a really complex following NHS England's data, of which there is a lot. Um and I commend the amount of data um that is available, but you do need to be quite clever at spreadsheets and finding things and articulating it in order to bring it back to your own constituency, your own local place to be able to, to, to do that and to be able to show that.
And these things are complex. It is complex to record and keep and track and recognise how people move through a waiting list, for example. And I think it's good that we're transparent about that. One of the things I was very keen to push out is about data on performance in trusts. That's controversial. Um, so-called league tables. But I think the more that we have out there of the information, the more we have honest debates about how complex it is, how difficult it is.
Very happy to have your questions around how the, how that moves in order for us to explain that, that helps to build the trust.
So we do need to be able to tell that story to the wider public. And, and this issue of of trust. Of course, we know from all the recommendations and the reviews and where we all are and the support we give as members of Parliament to our constituents, that that is really important, getting that right and bringing people on that journey with us will be really important. And independence does help with that. So that's why I think it's good to debate it in the bill.
I think it's good to be able to air some of that, but I think people would accept that it is not working and it has not worked. Um, I think your question about waiting lists is about data and information about saying where it where it is. I mean, what I say on that is a really complex following NHS England's data, of which there is a lot. Um and I commend the amount of data um that is available, but you do need to be quite clever at spreadsheets and finding things and articulating it in order to bring it back to your own constituency, your own local place to be able to, to, to do that and to be able to show that.
And these things are complex. It is complex to record and keep and track and recognise how people move through a waiting list, for example. And I think it's good that we're transparent about that. One of the things I was very keen to push out is about data on performance in trusts. That's controversial. Um, so-called league tables. But I think the more that we have out there of the information, the more we have honest debates about how complex it is, how difficult it is.
Very happy to have your questions around how the, how that moves in order for us to explain that, that helps to build the trust.
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Speaker 23
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Speaker 23
NHS England and the single patient record. I'll come to the single patient record because I think this is, um I mean people use the word game changer. And we've we've heard today from some fantastic experts about the work they're doing to, um, to identify how it might work, um, and how we might bring patients with us more and the public. But again, and I don't think we should just bank this, um, we haven't heard anybody object to it. Now we did have some evidence, um highlighting how this has gone wrong in the past.
Um care.data, I worked at the PCT and CCG at the, at the time of that being brought forward. Um we can all point to where it's gone wrong. Um, but nobody has said this is not the right thing to do. Um so that's good. Um, but there's still a lot of detail to go through that. And I think we do need to, um, keep highlighting the benefits which are. Yes, as we heard from um, Peter Prinsley as well about whether the patients have more control, we do think this is about empowering patients.
That is, that is what we said in the ten year plan. The ten year plan is about empowering patients in this very large system, for which they are now paying £200 billion worth of their taxes. But again, I think we heard excellently from the clinical panel near the end about the need for clinicians, and I defer to clinicians on this about what they need, both if they're dealing with chronic long term conditions. And as we heard, 2.5 hours for an assessment sometime, or someone working in a busy Ed that that it works for them, but the fact that it's needed and it will be controversial.
There'll be a lot of questions about this, a lot of concern about privacy data. Um, cyber, etc.. So we need to hold on to, to those benefits, which are huge, which are huge, I think in clinical terms. And both for the patients. And another point we heard, which is also true, people already think this happens. People do not understand why when they turn up at an A&E, as we heard in Whitby or somewhere else, and go back to central London.
These systems can't talk to each other. And that, for me again, is about people's trust and belief in a public service which this what this is. I think it's a really important part of doing that. Um, and the abolishing NHS England again, I don't think, you know, I don't think anyone's, you know, come to one of my constituency surgeries or come along and said, oh, please, please do this or talk about it in great detail. Um, but I think people do understand and I think, um, my experience in opposition and, and so far in government, um, I think MPs are perplexed when they try and intervene on behalf of patients or the public or get an answer locally.
Why on earth in some cases, I'm afraid a chief executives of icbs or trusts do not respond even to members of parliaments requests for meetings. I find that shocking. But it does happen. So how on earth is a patient or somebody struggling through the system expected to get a response?So I do think this this issue of getting it right, and it's not a black and white, it's not easy to get the balance between the secretary of state's Democratic oversight and autonomy at a local level.
It isn't it isn't easy to get it right. Um, but the bill starts that starts that process, um, to do that. And I think that is fundamentally really important. And the other provisions, I do accept the great work that's been done by many people around Healthwatch and predecessor organizations, um, and people working in patient safety landscape. But again, it isn't working. I do think these bodies have been allowed to abdicate responsibility for that core role of having patient experience and patient voice.
It's not, it's not their homework, it's their actual job. It's their actual job to do it. It's not something that should be outside. So that's why I think it's a really important bill.
Um care.data, I worked at the PCT and CCG at the, at the time of that being brought forward. Um we can all point to where it's gone wrong. Um, but nobody has said this is not the right thing to do. Um so that's good. Um, but there's still a lot of detail to go through that. And I think we do need to, um, keep highlighting the benefits which are. Yes, as we heard from um, Peter Prinsley as well about whether the patients have more control, we do think this is about empowering patients.
That is, that is what we said in the ten year plan. The ten year plan is about empowering patients in this very large system, for which they are now paying £200 billion worth of their taxes. But again, I think we heard excellently from the clinical panel near the end about the need for clinicians, and I defer to clinicians on this about what they need, both if they're dealing with chronic long term conditions. And as we heard, 2.5 hours for an assessment sometime, or someone working in a busy Ed that that it works for them, but the fact that it's needed and it will be controversial.
There'll be a lot of questions about this, a lot of concern about privacy data. Um, cyber, etc.. So we need to hold on to, to those benefits, which are huge, which are huge, I think in clinical terms. And both for the patients. And another point we heard, which is also true, people already think this happens. People do not understand why when they turn up at an A&E, as we heard in Whitby or somewhere else, and go back to central London.
These systems can't talk to each other. And that, for me again, is about people's trust and belief in a public service which this what this is. I think it's a really important part of doing that. Um, and the abolishing NHS England again, I don't think, you know, I don't think anyone's, you know, come to one of my constituency surgeries or come along and said, oh, please, please do this or talk about it in great detail. Um, but I think people do understand and I think, um, my experience in opposition and, and so far in government, um, I think MPs are perplexed when they try and intervene on behalf of patients or the public or get an answer locally.
Why on earth in some cases, I'm afraid a chief executives of icbs or trusts do not respond even to members of parliaments requests for meetings. I find that shocking. But it does happen. So how on earth is a patient or somebody struggling through the system expected to get a response?So I do think this this issue of getting it right, and it's not a black and white, it's not easy to get the balance between the secretary of state's Democratic oversight and autonomy at a local level.
It isn't it isn't easy to get it right. Um, but the bill starts that starts that process, um, to do that. And I think that is fundamentally really important. And the other provisions, I do accept the great work that's been done by many people around Healthwatch and predecessor organizations, um, and people working in patient safety landscape. But again, it isn't working. I do think these bodies have been allowed to abdicate responsibility for that core role of having patient experience and patient voice.
It's not, it's not their homework, it's their actual job. It's their actual job to do it. It's not something that should be outside. So that's why I think it's a really important bill.
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Speaker 3
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Speaker 3
Thank you very much, Mr.. I think I would agree with you, Minister, that no one thinks that abolishing NHS England is in itself a bad idea. Um, because of the duplication and the cost. I don't think people think that a single patient record is a bad idea. I think they assume that it already exists and it could be transformative. So I think there's some really good points of agreement on the bill. But I think I think it would be helpful to reflect on where there isn't agreement.
And that's around, um, abolishing Healthwatch and Adhesive.
And that's around, um, abolishing Healthwatch and Adhesive.
18:46
Speaker 23
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Speaker 23
Abolishing house watch and adhesive. And you've made the very good point that they haven't been successful in their current incarnation. But I think it's important to consider whether that's because they don't have teeth, and because the organizations that they are trying to change are defensive. And we heard from a witness earlier about the culture of fear. And I think we've probably all had people in our surgeries who can describe that, being frightened to speak up about their own personal care because they feel that they might be victimised for it, and in my case, um, clinicians frightened to speak up about their own experience in the organisation in which they work because they feel that they'll be, you know, punished for.
That. So in the light of that defensive culture, which we know exists in the NHS and which has been highlighted time and again, mid Staffs, Shrewsbury and Telford, maternity scandal is the is the answer not to not to put those organisations in those or in not to put the patient voice in the organisations that have a culture problem, but to give those organisations the teeth they need or to confer a duty on those on the icbs or the providers to actually act on the recommendations that are given to them, because I think that might be a more helpful way of dealing with this problem.
That. So in the light of that defensive culture, which we know exists in the NHS and which has been highlighted time and again, mid Staffs, Shrewsbury and Telford, maternity scandal is the is the answer not to not to put those organisations in those or in not to put the patient voice in the organisations that have a culture problem, but to give those organisations the teeth they need or to confer a duty on those on the icbs or the providers to actually act on the recommendations that are given to them, because I think that might be a more helpful way of dealing with this problem.
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18:47
Speaker 15
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Speaker 15
Thank you. I mean, I do think this gets to the crux of of some of this. And I think we will discuss this a lot in committee. And I'm very open to obviously to, um, keep, keep discussing it. Um, thank you for um support on the main provisions. Um, don't take that for granted because that again, is still controversial. Um, but the, I mean, as I think I said earlier, I mean, you're right, these and.
It's not true everywhere and I'm not blaming individuals because I think people have to do a difficult job. And particularly in the through the pandemic, getting us through to the pandemic and, and beyond. Um, but they are defensive. That's why members of Parliament and other people don't get responses to their phone calls or their emails. Um, that is a culture we have to change and we have to support people to change. And one of the things that I'm, again, out with the bill, we will, we will bring in regulations.
That's a manifesto, that's a commitment from this government. But also we're developing a leadership college, um, which is also a commitment we've made with this to support particularly managers in a very difficult job, both clinical and non-clinical managers with the right skills to be able to be in the new world, which patients, the public rightly expect to be more open, more transparent. And we have to change this defensive culture. But the adding even since Frances, the adding of bodies and the adding of recommendations in your very good experience was bad experience that you've.
You've done so much for. Um and Morgan, um, is, is that something different has to happen?So again, what we heard from Jeremy Hunt was we needed to put more, more prescription into the system, yet more requirements to do something without actually making it their central function and job. Now it is a source of disagreement. As I said, I think that is a philosophical disagreement about the best way forward. Um, and it's not an antagonistic disagreement. It is a, is a fairly fundamental different view about doing it.
We, we will have continued discussions because I think ultimately we all want the same thing, which is to have a more open, transparent, supportive culture. Nobody wants to work in a defensive culture either. By the way. I think people want that. But that is that is up to us as politicians, again, to support some difficult conversations and trade offs that happen locally. Um, my view has always been that politicians will support difficult conversations and trade offs. We had a little bit about reconfigurations earlier.
If the system provides good clinical rationale, good data and good evidence, and that those those those bits of it don't always line up. That's what I'd like to get to. Um, I. Understand and hear and we'll hear more of it and we'll discuss it more. And I can see all the amendments about the best way. I think we all want to get to the same place. But what is the best way to do that, given we all know that this is really not working and it can't continue?
It's not true everywhere and I'm not blaming individuals because I think people have to do a difficult job. And particularly in the through the pandemic, getting us through to the pandemic and, and beyond. Um, but they are defensive. That's why members of Parliament and other people don't get responses to their phone calls or their emails. Um, that is a culture we have to change and we have to support people to change. And one of the things that I'm, again, out with the bill, we will, we will bring in regulations.
That's a manifesto, that's a commitment from this government. But also we're developing a leadership college, um, which is also a commitment we've made with this to support particularly managers in a very difficult job, both clinical and non-clinical managers with the right skills to be able to be in the new world, which patients, the public rightly expect to be more open, more transparent. And we have to change this defensive culture. But the adding even since Frances, the adding of bodies and the adding of recommendations in your very good experience was bad experience that you've.
You've done so much for. Um and Morgan, um, is, is that something different has to happen?So again, what we heard from Jeremy Hunt was we needed to put more, more prescription into the system, yet more requirements to do something without actually making it their central function and job. Now it is a source of disagreement. As I said, I think that is a philosophical disagreement about the best way forward. Um, and it's not an antagonistic disagreement. It is a, is a fairly fundamental different view about doing it.
We, we will have continued discussions because I think ultimately we all want the same thing, which is to have a more open, transparent, supportive culture. Nobody wants to work in a defensive culture either. By the way. I think people want that. But that is that is up to us as politicians, again, to support some difficult conversations and trade offs that happen locally. Um, my view has always been that politicians will support difficult conversations and trade offs. We had a little bit about reconfigurations earlier.
If the system provides good clinical rationale, good data and good evidence, and that those those those bits of it don't always line up. That's what I'd like to get to. Um, I. Understand and hear and we'll hear more of it and we'll discuss it more. And I can see all the amendments about the best way. I think we all want to get to the same place. But what is the best way to do that, given we all know that this is really not working and it can't continue?
18:50
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18:51
Speaker 23
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Speaker 23
Could I have a second question?It's very quick. It's a technical question. Is that okay?It's a it's a technical question about foundation trust. So in the ten year plan, um, it says that foundation trust could be given population responsibility for commissioning and budgets. And I don't understand how that fits in with the bill that we've got in front of us. And so I wondered if you could just clarify whether that isn't envisaged for now or whether, um, whether it's lurking somewhere else in the bill that I haven't spotted.
18:51
Speaker 15
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Speaker 15
Okay. Um, I might need to come back to you on, on the detail of that because a lot, a lot of what is in the bill is we are trying not to over, over prescribe, um, on certain things, but we need to get the right, the foundation trusts licensing and some things you need to have in the bill, which is what we've put in as possible. And some things you don't. But can I come back to you on that specific point if that doesn't answer your question?
18:52
Speaker 16
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Speaker 16
Okay. Thank you. Um, so you are speaking with this with tremendous passion. And I see that you see this as an opportunity to, to make the NHS function far better than it was. You mentioned at the very beginning that it took eight months to make the announcement that you're going to abolish the NHS, NHS England. How quickly did you realize that NHS England was malfunctioning, was far too bureaucratic and was not delivering on the priorities for people in this country?
18:52
Speaker 15
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Speaker 15
Um. That is a good long question. I think. I mean, I think I was I was aware, I mean, I'm someone in opposition who spoke frequently and about accountability and democracy as, as, um, Doctor Johnson was trying to highlight, I'm sure we'll have some more quotes. Um. But I, I think and I can't speak for the former secretary of state, not here, I'm sure he will speak, but I think it did surprise us really up close. Um, I think probably going into the financial year when we were faced with still, despite very clear direction and expectation, etc., about, um, the financial situation that the government inherited and what needed to happen, um, that we were still faced with what was coming in as a very large, um.
Projected deficit that actually the duplication may, there's a lot of people in the room. Um, clearly things were being handed off. Um, that, that didn't, that weren't working. Um and that ultimately, I guess this is a question that always lurked and I, and I see, I know Mr. Agar is here and the last bill we did say to, you know, that might have been the opportunity to do this. I think previous secretaries of state, as was alluded to earlier, thought that they might do that.
But ultimately, um, the benefits of doing it now do outweigh the risks. And that the, the only way to be able to make the system change. Um, and I think we heard from the King's fund that, I mean, about opportunity costs and that the benefits don't outweigh the risks. Um, and we don't think that's true.
Projected deficit that actually the duplication may, there's a lot of people in the room. Um, clearly things were being handed off. Um, that, that didn't, that weren't working. Um and that ultimately, I guess this is a question that always lurked and I, and I see, I know Mr. Agar is here and the last bill we did say to, you know, that might have been the opportunity to do this. I think previous secretaries of state, as was alluded to earlier, thought that they might do that.
But ultimately, um, the benefits of doing it now do outweigh the risks. And that the, the only way to be able to make the system change. Um, and I think we heard from the King's fund that, I mean, about opportunity costs and that the benefits don't outweigh the risks. Um, and we don't think that's true.
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