Health Bill (First sitting)
Karin Smyth Excerpts(1 month, 1 week ago)
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Helen Morgan (North Shropshire) (LD)
I am a vice-president of the Local Government Association.
The Minister for Secondary Care (Karin Smyth)
I am a member of the Managers in Partnership trade union, which is giving evidence this afternoon.
Liz Twist (Blaydon and Consett) (Lab)
I am co-chair of the Unison group of MPs, which is linked to Managers in Partnership.
Dr Johnson
Q
Dr Dash: I do not see a conflict. I think they are complementary and this is all about improving the regulatory landscape in the healthcare system.
Karin Smyth
Q
Dr Dash: One of the things that I observed when I was doing the review, and that I have observed even more so now that I am in post, is that we do not have effective mechanisms of really learning from patients and patient experience. If I compare how the NHS works with how other large organisations in our country work, we are not systematically collecting patient information, we are not looking at that in detail, we are not segmenting it into different groups of people, and we are not systematically bringing it into board meetings, which is where it should be in order to drive improvement. We are hoping, or expecting, that the new director of patient experience will take a real leadership role in this and will improve the way in which the centre works but, more importantly, will be working with organisations right across the NHS to build those skills and capabilities, and to put patient experience feedback and improvement in patient experience right at the centre of every discussion on improvement.
Helen Morgan
Q
Dr Dash: The CQC is an independent regulatory body as well. The hope and expectation is that we have a high-calibre, independent regulatory body that is the prime regulatory body for looking at how well health and care services are delivered and, as well as observing how well they are currently performing, is able to carry out specific, focused investigations when it spots systematic problems across the healthcare system, or indeed when particular problems are identified.
In terms of safe space, clearly, confidentiality is important. Confidentiality is important right across the board; staff need to feel able to report within NHS organisations and to the CQC where they have concerns. I have to say that I was concerned in that Health Committee session to hear an example given by Jeremy Hunt, who said that if a midwife is concerned about quality of care in their maternity unit, they need to be able to go somewhere and report that, and to know that HSSIB would not tell anyone else about it. I looked at Duncan, our chief nursing officer, who was there with me, and we were shocked to hear that. How can that possibly be right? We need to have a mechanism whereby if there are concerns about quality of care, they are properly investigated, and mechanisms to deal with those problems and improve services. Yes, we need confidentiality, but I was not convinced by what I heard then—that we needed a completely separate organisation that was duplicating the work of others.
Dr Johnson
Q
Jacob Lant: There are a few points on that. The narrative around the Bill is that Healthwatch is being abolished and its functions lifted and shifted across to local authorities and ICBs. That is not the case. We lose a number of important functions.
For example, the signposting support that Healthwatch provides will disappear so patients and care users will not have that to help them to understand how to navigate local services. I mentioned the unsolicited feedback that is gathered; that function will disappear. The outreach into communities, particularly marginalised communities, will disappear. The voice for patients and communities on health and wellbeing boards disappears, so there is no feed into those local decision-making bodies. There are several places where there is not a direct lift and shift across. That is a concern, and the Committee should probe it further.
On the resourcing point, at least local authorities will get part of the existing funding for Healthwatch to support their functions in that space. Under the Department’s impact assessment, ICBs will not get any funding from the current pot. That represents a 50% cut in the resourcing for listening to patients and communities, which is a concern.
Karin Smyth
Q
Sarah Woolnough: As an organisation, we have taken the view that we would not necessarily relitigate the decision. I think you can argue it both ways. I understand the desire to reduce duplication and to have clearer lines of accountability. Our concern has been the opportunity cost and everything that you are not doing at the time that you are spending so much energy and resource driving the abolition through.
Jacob Lant: I would echo everything Sarah says. From the work that we do, we see that decision making is taking longer, programmes are taking longer and it is taking longer to secure an impact on things. That is very frustrating, and underpinned by the massive change that is ongoing. Let us take as an example a programme exploring the experience of waiting for hospital care—of being stuck on waiting lists. Jim Mackey spoke about that at the NHS ConfedExpo last week. It is a major focus for the NHS and new guidance is expected by the end of the month. We have been waiting for that since 2021. The most recent effort towards it has been about 18 months. I can only think that drags on because we have so much other change going on in the system. I wish we focused more on doing things directly for patient care.
Karin Smyth
Q
Sarah Woolnough: It is a major opportunity. If they feel they have trust in the system, patients are generally supportive of a single patient record or joined-up records—they often assume one already exists. Of course, we have a patchwork across the country, and certain places are further ahead than others. The idea of having more national co-ordination and more infrastructure to drive progress in that area could be, and hopefully will be, transformative. I know from my previous work just how frustrating it is for so many people to experience fragmented care and to have to tell their story endlessly.
We must be a little careful, because telling your medical history is often part of a good consultation, but the idea of care being more streamlined and patients and staff having better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. Previous attempts to drive progress in this area have so often fallen down. Ensuring the right balance of progress, and building trust and sufficient safeguards, will hopefully lead to the most progress.
Jacob Lant: I have been working in patient and public engagement and involvement for about 15 years, and the most consistent theme in that time has been the frustration about constantly having to retell your story, and the fact that notes and information are not available for the care that people need in different settings.
There is a golden opportunity with the Bill to get the single patient record right and meet a long-standing patient need for that join-up of information. We are very supportive of the single patient record, and the debate needs to move on from whether we need one to what the safeguards are and how we build public trust. I have two things to say on that. First, you cannot legislate for everything on this, but it is important to have a commitment to an ongoing public conversation around the risks and benefits of data sharing. The Department has done some really good work in this space, on its public deliberative on use of data—that should continue—but we understand that cannot all be put into the Bill.
However, we know that the safeguards and red lines that we already have could be put into the Bill. For example, using patient data or non-consented data for insurance and marketing purposes is a red line that has been clearly talked about in policy for many year—we will not use data for that purpose. Why can’t we put that in the Bill to help build public trust? It would really help to be clear on red lines and what will not be included.
Karin Smyth
Q
Jacob Lant: There are three things there. First, we need transparency about what is being heard by the system. Wherever we put patient voice functions, it is really important that what they hear from communities is clear and made available publicly, in terms of themes and demographics, so that we understand who is being heard and who is not. That is really important for the transparency of what is being heard and how it is being interpreted by the system. What has it understood from the feedback it has received, and does that resonate with what people are actually trying to say?
The second thing is accountability. Can people see those voices leading to change—not just commitments to change, but following through? It is about evaluating where policy changes implemented as a result of patient feedback have improved patient experience, and drawing that golden thread through for people so they can understand how their feedback is making a difference. That is missing from the system at the moment.
The last point is around equity. My big concern is that we might design a system that hears from more people, but whether it hears from the right people and there is equity of voice is a real concern. The resourcing and support need to be put in, particularly at a local level, so that they can engage communities who are marginalised and make sure we are hearing from the people who are basically getting the worst experiences and outcomes at the moment.
If we can deliver on those three things—transparency, accountability and equity—we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it has had available. It works out that less than 0.01% of the health and care spend is on Healthwatch, and that generates about 1.4 million interactions every year, either by gathering people’s experiences or by supporting them to navigate the health and care system. That is a really good return on investment, and it will be hard to find something more efficient. The challenge is in the system being more culturally open to listening and changing as a result of what people say, regardless of the way the evidence comes through.
Helen Morgan
Q
Sarah Woolnough: There are probably two concerns in a couple of different areas: appointments and the power of direction, which is very broad. We think it would be helpful to probe the detail and understand the intention a little more to see whether the legislation could do with amendment.
There is more general point. If the narrative is that this is a straight transfer, of course, you cannot legislate for culture and how those powers will be used. Our concern is that, while the narrative is about a straight transfer, empowering local systems and earned autonomy, the legislation pulls a lot of power back to the Secretary of State, and you cannot legislate for how a future Secretary of State may enact those powers.
Dr Johnson
The question is, how do you find it within the way it is structured?
Karin Smyth
Q
Dr Dickson: Part of it has been touched on by the previous panel, regarding patient experience. Patients come in, they give the same story again and again to different healthcare professionals in different settings, and that frustrates them. Patients are human. I forget what I did last week; patients forget what they did last week, let alone what they did 10 or 20 years ago, although that is still relevant, increasingly. If you go on holiday to Whitby, fall over and break something, have tests done and come back to your house in central London, you cannot see information about that; you cannot share that information.
The opportunity to see everything on a patient across primary care, secondary care and social care is a huge benefit to them in terms of their view of seamless care, but also in terms of safety. I have a chronic health condition; part of my care is delivered by general practice and part by a hospital. At the start of the pandemic I was exceptionally clinically vulnerable; it took the NHS six weeks to tell me that. That is not safe.
Helen Morgan
Q
Dr Dickson: I am not a general practitioner. The key thing for data control and data sharing is the trust that patients have in us to share and to hold their data in a way that is beneficial for them as individuals, and potentially sometimes beneficial for the population, but not to share it for what you might call retail use.
One issue with data control is that most general practices are small businesses with a small number of staff working flat out. That legal obligation of a data controller looms large for them, whereas it does not loom as large for large NHS organisations—although, technically, the impact is as hard. I do not mind who controls the data; what we need to do is to find a way to enable that data to be shared safely and with a belief that it is done for patient benefit. I do not think it matters whether GPs maintain data control, with something else happening to support them, or whether it is taken away from them; it is about how we enable that to happen. But I do think that general practice struggles more with resilience.
Kay Keane: I think that is true, in that we are generalists, not experts in a lot of areas. Certainly, we can be very good data controllers of our own data—the stuff that we produce, and that we write and code about our patients. We have to code things to be able to respond to our contract, so we have to be good at that. Things fall down when information comes from other providers, which we have no control of. That would be an area of real concern—that such information would be part of our property and our jurisdiction.
I guess it is about the detail of how that record will be structured. If it is a brand-new thing and we all feed into it, that is very different from all the data coming to the current healthcare record that we hold. I think the detail is not there yet to enable us to describe who should be the data controller, but certainly I do not think that any practice manager would want to control data generated by someone other than themselves.
Dr Johnson
Q
Dr Benneyworth: There is no doubt that it helps to improve safety. That is something we have learned from 100 years of the air accidents investigation branch, which has had an immense impact on aviation safety, the rail accident investigation branch, and many others. Safe space, or protected disclosures, means that people can talk freely to us about things that have gone wrong without fear of sanctions, being told off by their line manager or losing their jobs.
We hear all the time about people who have ended up losing their jobs or getting into trouble because they have raised concerns. We see in our investigations that we are still working in a culture of fear. In an ideal world, that would not be the case and people would feel able to speak up openly about what has gone wrong, but we are working in a culture where people are not in that place.
This enables staff working in the service and patients to talk to us freely about what they see on a daily basis that they think needs to change. Patients sometimes worry that they will be treated differently and not get the same care after they raise things. This enables patients to talk to us in the knowledge that they will not be named. The patients we work with who have been harmed from healthcare tell us, “We don’t want this happening to other families. We’ve been through this awful, terrible time, and we want to change the system.” This enables them to talk to us.
We do not name individuals in our reports and do not name organisations. We are now in a stage where we are growing that trust. We are coming up to being three years old as an organisation, and we are growing that trust with the system. When we launch an investigation, organisations right across the country say, “Please come and see what’s happening here. Please come and talk to us.” I worry that that might be impacted by the changes ahead.
Karin Smyth
Q
Dr Benneyworth: The two key things have been touched on already. The first is the independence to choose what we investigate and make recommendations to any part of the system. The second area is around protected disclosure. The legislation needs to be much clearer around the protection of protected disclosure materials, to give the system confidence in our ability to hold and not share confidential information.
At the moment, the legislation talks about connected individuals having access to the protected materials. The clauses outlining connected individuals mean that anyone working in the CQC could potentially have access to protected materials. That is a very large number of people, and it will create risk. There needs to be a legal duty on the CQC to protect the safe space. There is also something about maintaining an identity that gives people confidence that when they are talking to us, their information will not automatically go into the CQC regulatory functions.
Some of that may be about perception rather than the reality of what is happening, but as we know, perception is very important. People will perceive that we are part of the regulatory system even if we have the same email address, for example.
Karin Smyth
Q
You talked about the culture of fear, which I think we have recognised over time. We are all constituency MPs, so we recognise that. Can you say something about the opportunities for learning that could arise from working with the CQC, which is in that regulatory space?
Dr Benneyworth: We already work very closely with the CQC. In fact, we meet with them on a very regular basis. They share their learning and concerns with us already. Some of our investigations have come from the learning that they have seen on inspection, so we have a very good relationship with the CQC.
There are significant opportunities for the whole patient safety landscape. We are a tiny part of the patient safety landscape. We need to all work much more collaboratively right across the regulatory space—ourselves, the investigatory bodies and the wider system. The National Quality Board will have a significant role to play in that to share learning and identify key patient safety risks. That is already happening in our work with the CQC. This legislation will not significantly change that.
Helen Morgan
Q
Dr Benneyworth: First, we do not replace local investigations. If something goes wrong, the local teams are very much responsible for investigating their work. Dr Dash talked about the new processes around PSIRF and the new investigation processes, which we fully support. In fact, our education team have had 40,000 people enrolled over the last three years, free of charge in the NHS, to support them in developing those investigation skills, really supporting that excellence in local investigation. We have a long way to go there, because they are variable in quality.
We do not replace that immediate, “There has been an incident and it needs investigation.” We know that, quite often, the things that need to change are not sitting within one provider. We know that the same things are happening in Cornwall and Cumbria and everywhere in between, and that they often need national solutions to change.
As a recent example, we published a report a few weeks ago looking at the care of people in mental health crisis in emergency departments. That showed that the legislation around the care of mental health patients is not supporting people in emergency departments to look after these people properly. That is not something that can be changed by a regulator. The CQC going to look at that emergency department will not impact that. It is not something that the individual provider can change, but we can make national recommendations about it to change the national system to enable people on the ground working in health and care to do their job properly. We can make sure that the systems and processes really consider how things work, and really change them so that providers and systems locally can do their job.
Karin Smyth
Q
Sir Jeremy Hunt: I would just like this to have teeth, because I think people are fed up, as I say, with Governments of all colours receiving recommendations and then nothing happening. I would like the Bill to place a legal obligation on the Government, for a certain category of recommendation, that within a period of time a proper decision will be made with a timescale. If the decision is no, because the money is not available, that is fine, and the Government should say so, but people would prefer to have a decision than for Governments to continually say, “We are reviewing this.” Frankly, I am worried that inertia in the system, and the fact that it is always easier for Ministers to kick things into the long grass rather than give a yes or a no, means that a vague commitment that the NQB will do this job will not be enough. If it is the NQB, I would like there to be a legal obligation that, within six months of recommendations being made by public inquiries, Select Committees and HSSIB, the Government will give a proper yes or no, with a timescale if it is yes.
Karin Smyth
Q
Sir Jeremy Hunt: I set up NHS England, following the Lansley reforms, and it may surprise you that I have not opposed the Government’s decision to abolish it, for this reason. When it was set up, it did have a very valuable function, which is that it depoliticised a lot of very contentious issues. Typically, those were things such as the closure or downgrading of an A&E that was clinically advised as important, but very difficult politically, or, for example, which drugs are made available through the NHS and which are not. I felt that putting those decisions at arm’s length from Ministers was helpful. However, I think it became too big.
My real problem is that I think the NHS has become the world’s largest health bureaucracy, in which it is very hard to get anything done because 1.5 million people are accountable to one person. The way the DHSC does this, as you know just as well as me, is through the ruthless imposition of targets, so every hospital has 18 monthly operational targets. That makes it very difficult to have any kind of local innovation or local autonomy, because everyone is performance-managed with incredible strictness—their whole career depends on it—by these targets. I felt NHS England was beginning to embody that targets system, so when the former Heath Secretary said he was planning to scrap it, I said, “That’s absolutely fine, as long as this is a decentralising move, and you don’t simply transfer that ruthless central control from NHS England to DHSC.” I have to say I am concerned that that is, in fact, happening—or that we are just getting all those targets recreated by DHSC, rather than NHS England, as I think former Health Secretary Patricia Hewitt has also gone on record as saying.
Helen Morgan
Q
Sir Jeremy Hunt: Ideally, when something goes wrong, what you want is for there to be an investigation and for lessons to be learned, so that grieving families can say, “Well, at least we are confident that this wouldn’t happen again.” What happens in the health world is that families still think the only way they can get real change is through a public inquiry, so there is endless demand for more inquiries, rather than for things to actually change. If HSSIB was allowed to flourish, and there was confidence that its recommendations really would be acted on quickly, I think that would reduce the demand for public inquiries. They are very expensive, and the fact that they often take five, six or even seven years also means that there is enormous delay before anything changes.
Health Bill (Second sitting)
Karin Smyth ExcerptsTuesday 16th June 2026
(1 month, 1 week ago)
Public Bill CommitteesRead Full debate Health Bill 2026-27 View all Health Bill 2026-27 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 16 June 2026 - (16 Jun 2026)
Dr Johnson
Q
James Blythe: Councils of governors across the NHS have added significant value since they were instituted and brought into foundation trusts. The foundation trust councils of governors play two roles. The first relates to the appointment and holding to account of the non-executive directors on the board. The second relates to securing public and patient involvement and voice in the organisation and the management of our services.
Since councils of governors were instituted, we have developed increasingly sophisticated ways of getting public and patient voice into services. If you look at innovations such as maternity and neonatal voices partnerships, which really involve service users in how services are developed on the ground and are very close to the teams that are running them, that gives us different ways of involving patients and the public in services where possibly councils of governors have not been able to do in the past. Councils of governors have played a really important role in foundation trusts, but certainly in terms of that patient and public voice function, we have moved on as a system and developed more sophisticated ways of doing that.
The Minister for Secondary Care (Karin Smyth)
Q
Sir Ciarán Devane: The biggest difference should be that the local providers and ICBs are incentivised to get together to make collective commissioning decisions. That means that, whether you call it a neighbourhood, footprint or local authority area, they make those decisions based on population evidence, which is why the single patient record is important, and they have the autonomy to do that with a lighter-touch centre that is set in guidance saying, “Look, this is broadly what we’d like you to do.” That guidance should be developed in conjunction with the people who have to do the job on the ground. That is what it should be; if the Bill allows that, that is fantastic.
The second bit is that the mechanism—it is not necessarily a legislative thing—by which the NHS is managed day-to-day will still need to exist. Who is going to be keeping an eye on things 24/7, 365 days a year? What happens if there is a fire—maybe even a literal fire—in a hospital? How is the NHS going to be corralled and brought in to help out a trust where something like that happens? That management function—the day-to-day operational management—needs to remain strong enough in the target operating model, as it is called, in the Department. If it is not, that could prove very difficult. Not necessarily day to day or in the short term, but in the long term, that bit has to be got right. One of the big risks of the legislation—there is not a legislative solution to this risk—is how day-to-day management works. We all have views on the relative strengths of the regions, of NHS England and so on, but how is that going to work in the new world? If one loses “grip”—that word is used a lot—then the risk to service delivery is quite high, and the risk to financial control is even higher.
James Blythe: Put simply, as an NHS organisational leader I think there are always a lot of things from which you can take your guidance on what you should be prioritising and focusing on as an organisation. If the result of this legislation is that we as organisational leaders have a really tightly defined set of priorities to deliver, articulated as far as possible as outcomes for local people and our population as a whole in terms of waiting times, quality and improving population health, I think that will allow us locally to get on with the partnerships that we already have as a day-to-day part of running local public services. We can focus on that very small set of things and do them really well.
Over the last year, there has been a sense of increasing clarity about those priorities as NHS England and the Department of Health and Social Care have worked more closely together. The NHS has delivered on those priorities to a large degree, but it all comes down, as my colleague says, to how senior officials and Ministers operate the system, because there is to be significantly more freedom to set priorities, and to design and run the system that essentially delivers them for the NHS. How that is done, retaining clarity about the things that we want to have delivered through the system and empowering local systems to do them will be really important.
Karin Smyth
Q
Sir Ciarán Devane: No, we are not.
Karin Smyth
Q
Sir Ciarán Devane: Yes, completely.
Karin Smyth
Q
James Blythe: I think the single patient record offers enormous opportunities to improve patient care. We know that we see patients every day whose quality of care and patient experience would be improved through having access to a continuous record that ran through primary and secondary care, mental health care and other services. To my mind, having had experience of working with systems that have introduced to some degree the single record or a single care plan, it will be extremely important 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, at best it will be inconsistently used and sometimes it will just be missed altogether. If we are going to invest, which I think is right, in a single patient record, we also have to invest in those systems and human factors around it, and make sure that we train people to use it well.
Helen Morgan (North Shropshire) (LD)
Q
Can I ask about Healthwatch? We heard this morning that ICBs will be taking on a chunk of the current operations of local healthwatches, but that they will not have any additional budget to enable them to do that. In fact, we know that their budgets have been significantly reduced. Could you elaborate on how you think that will work, and will it be as effective as the current system?
Sir Ciarán Devane: The ICBs have a capitation fee of £19.40, which they have to do everything out of. This is an additional duty placed on them. They will have to work out how to do it if there is no extra money coming, but it will be pressured.
I hear the argument that local healthwatches were variable. This function has been slightly outside and independent, playing back into decisions; we have to ensure that the level of independence remains somehow in how this is constructed, but that the variability is not just transferred from local healthwatches to how it is done within or across ICBs. Again, the implementation will need to be done well. That leads into the question about local authorities and the connection with them, making sure the democratic voice is brought in and equally the local voice. The legislation does not stop an ICB doing this well. Therefore, without the legislation, part of what we can be doing collectively is trying to make sure that what was good about healthwatches is preserved and is understood by ICBs. There are only 25 of them, so it should be a manageable task for the rest of us.
The effectiveness comes back to whether you believe this is a good thing. One of the things we have to do is secure that the benefits of having the patient voice in there, along with the clinical voice and the voice of the manager, at the same time, so that it is not a case of saying, “Oh, now we’ll go and consult the patients on the font size of the report,” but is authentic. That puts a lot of work on to the ICBs and on to those of us who believe passionately in engaging with the patient voice, but there is a risk because of that pressure. Done well, it will enable strategic commissioning and ensure the quality remains, but they are starting, if maybe not from scratch, from a new place.
The Chair
Thank you. Those opening comments were extremely helpful, but I now ask for brevity in your answers, as several Members wish to put questions to you.
Karin Smyth
Q
Professor Croisdale-Appleby: Sorry, I had some difficulty in hearing the question, but I hope I heard it correctly. Was it about the patient record?
Karin Smyth
Yes.
Professor Croisdale-Appleby: Fine. The Government’s move to the integrated patient record is absolutely excellent. Most of us have wanted that for a very long time, but we also recognised the IT difficulties in doing it, as well as the question of security. However, as digital has advanced, we have nutcrackers that we did not have before to crack that particular nut. I can but support that move.
From the point of view of the things that really matter, the ability of a person to feel that they can tell their story once—not time and again—comes up all the time in our research. With great respect to everyone here, we are very capable of standing up for ourselves and insisting that we get answers, but the people I deal with and have the privilege of representing are often not in that position at all. They are overwhelmed when they are repeatedly asked the same question, often in a language—medicalese, if you like—that they do not really understand and feel threatened by. The single patient record is going to go a long way towards helping with that situation. It is not the complete answer but at least it does the hygiene part, as opposed to the motivator part, very well.
Sarah Tilsed: It is an excellent initiative—1as the professor said, we have been calling for it for such a long time—but we really need to consider the consent and data elements. A lot of pieces of work that we have done with patients shows that people are happy with their data being shared for these electronic records, as long as they are transparent and patients know what is being done with their data—that is a really important point.
The care.data initiative and general practice data for planning and research—GPDPR—were great, but unfortunately, because they did not have genuine patient involvement right from the beginning, they failed. We need to ensure that the SPR does not fail. In terms of reaching underrepresented or less-heard communities, we need to ensure that we hear from those people straightaway. How do they want this to work? Do they want to know how their data is being used? How can we ensure that people who do not use the NHS app are involved and that their data is being shared? How do we approach people who are understandably very hesitant about digital technology and electronic records?
Helen Morgan
Q
Sarah Tilsed: I said a lot about that earlier, in response to a previous question, so I am not sure how much more I have to add. I think my main point is that we must not divert attention away from the urgent priorities that patients are facing at the moment, ensuring there is a truly independent patient voice and trust—there is a lack of trust among patients, as I keep saying. How are we going to ensure that the reporting system is there for this?
Ultimately, patients need reform to lead to better care, not simply to different structures, which I fear is what often happens. Sir Robert Francis said, following the Mid Staffs situation, that patients must come first. Throughout the passage of the Bill, the Patients Association question will remain simple, and we will ask it time and again: will these changes actually help patients to receive better care, and how will we know if they do? That is the first principle to come back to. When everything is happening—all this restructure—how are patients going to be affected and involved in it?
Dr Johnson
So you are losing a protection with the Bill.
Sally Burlington: Exactly.
Karin Smyth
Q
Councillor Wright: The main problem the abolition of NHS England has caused is upheaval and uncertainty with our health partners. Many of the health partners at our health and wellbeing board meetings or our place committee meetings are almost saying to us, “I don’t know if I will be here at the next meeting.” Such turmoil in the changeover creates instability from a lack of being able to plan what will happen next. That is one of the challenges that we feel. We are working with our health partners and getting assurances that there will be continuity, but it is quite hard when the person we are working with is changing.
We are really excited about neighbourhood health sitting under health and wellbeing boards. We love the idea of neighbourhood health looking at the wider determinants of health and having a very localised health response to the issues that that community needs to help it. One of our anxieties is that a lot of ICBs have become bigger and have less connection with the place. They are also shrinking; I think NHS England is losing 30%—
Maria Higson: Larger geography, fewer people!
Councillor Wright: Exactly. We have had a letter from our ICB 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 will obviously make it difficult to plan neighbourhood health.
The other challenge we find in neighbourhood health is that local authority boundaries might not necessarily match neighbourhood boundaries. I will give an example from Bracknell, where I live. Bracknell is very clearly a neighbourhood, but the south of the borough, which is within the Bracknell Forest council area, probably sits within Bracknell and Wokingham and a little bit within Reading. It will be hard to bring in true neighbourhoods with the current structure, but that is something we are working around, and we are hopeful that we will be able to sort it out.
Karin Smyth
Q
Sally Burlington: Health and wellbeing boards will probably become even more important following the removal of local government representation from the ICB. It will be the only place we have NHS and local government partners with the specific statutory responsibility to work together on social care. As others have noted, they are at place level and will therefore be crucial for connecting with the neighbourhood.
The other factor that is helpful to note is that there is a huge amount of pressure on systems at the moment, and the cuts to ICBs are having a profound effect on the relationships they have with local government partners. We are hearing from our members that continuing healthcare is a real point of concern, with reviews leading to the withdrawal of that care, placing challenges on local authorities. In that context, making sure that we are supporting health and wellbeing boards to be as effective as possible for neighbourhood health, and in that strategic joining-up role, becomes even more important.
Karin Smyth
Q
Sally Burlington: Neighbourhood health is a really important vision that we strongly support. In a way, it is obviously the right thing to do to move services closer to the people 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 have the connection to local government, to the voluntary sector in many cases, and to the NHS. It feels like that is a real space of opportunity to drive neighbourhood health and realise the benefits that it could offer.
The Chair
Q
Maria Higson: A couple of things. One is that it is not possible to overstate the importance of the partnership working between the NHS and local authorities. If we want neighbourhood health and the shift to prevention more broadly to be successful, working closely with local authorities, including the public health teams—which were not in the question but deserve a mention—is imperative. I am sure we will come to the question about the relationship with the mayoralties. There is something about that geography question. The insight and experience that local authorities bring is really important. That is the one thing that I think ought to be mentioned.
Dr Johnson
Q
Kath Abrahams: On digital exclusion, the same risks apply, although there is a different age demographic. If you have somebody who has a particular disability, has English as a second language, or has difficulty reading, we need to ensure that alongside the single patient record we are not excluding people without meaning to. Having said that, there are real opportunities to reduce inequities as a result of this change, such as by ensuring that everyone’s information is there, and that people do not have to retell their story if they find it difficult to speak to their clinician.
What the single patient record will not do is solve all the problems found in the national maternity and neonatal investigation. An action plan will come out of that investigation, and it must be looked at really seriously. A single patient record does not replace compassionate care or somebody really being looked after well, but it can potentially provide a safer environment—I am very happy to go into detail on that.
The national maternity ambitions have expired, but we are pushing very hard for them to be restated. There is potentially an opportunity to use the data at a broader level to measure progress. If it was possible to use the single patient record to understand how things were going towards improvement, that could be very helpful.
Karin Smyth
Q
Kath Abrahams: Right now, the situation is really tricky and people are being failed in their pregnancy and maternity care. Women report constantly having to retell their story—highly sensitive or traumatic experiences of loss—and that repetition can happen across the early pregnancy unit and maternity services. There is a common misconception that the NHS is one system, so when they find that people in another bit of the system do not know something, that can be really frustrating and annoying, because they assume that it exists.
There is also a lack of continuity. A clinician can be completely unaware of a sensitive or traumatic experience that somebody has had, and there can also be genuine dangers in outcomes. We know from the reports into Morecambe Bay, Shrewsbury and Telford that the lack of joined-up sharing of information and good communication between different parts of the system has led to some really difficult outcomes, particularly if somebody also has gestational diabetes, for example, or another condition and they are taking a particular medication that could cause harm to an unborn baby.
There are lots of situations in which not having the complete history is preventing people from getting not only really good, compassionate care, but the safe care they need. If someone is in an emergency situation and they are bleeding out, or their baby is not moving as much as they should, there is not time to start from scratch; they might not be in a position to explain what is happening to them and what their history is. They might not even know all the relevant bits of their history. Having that complete record, if it was done really well, would give clinicians the information that would allow them to make really timely decisions. Maternity can often be high risk—I do not need to say that to you; you know that—but these are often fast-moving situations where time is absolutely of the essence.
Emily Holzhausen: To build on what I said earlier about the amount of co-ordination and admin that people do, I will just refer to some carers’ words. One said that if they had to phone, they would end up in a long waiting queue or having to travel to the GP in person. There are people juggling work and care, so this has real, everyday impacts on their lives and their time.
When I refer to errors, I mean things such as medication errors or diagnosis errors. When you care for someone with very complex conditions, you can have health appointments every week—sometimes twice a week—and it is so hard to stay on top of it. When I say it is so hard, and talk about unpaid carers, we know that caring is a social determinant of health: in itself it is a single factor for poorer health outcomes. We know that 600 people a day give up work to care.
We have done a report on the tipping point: what tips carers out of work? One such thing is social care; another 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 to manage care, we improve outcomes for everybody: the health and wellbeing of the carer and the safety of the person that they care for. People are trying to do their best in quite a difficult situation.
One of our members, Norman Phillips, has talked about that a lot. He was in contact with more than 24 professionals, knitting up care around his wife who had advanced multiple sclerosis and dementia. That is an incredible amount of co-ordination of care. You can see how a single patient record, as it is envisaged in the future, could really help to support people who provide care. It is critical, given that we have an ageing population, that we recognise and support families in what they do.
Paul Farmer: I would start by talking about people with long-term conditions. Let us bear in mind that by the time we are 65, 82% of us will have one long-term condition, and half of people aged 70-plus have more than one long-term condition. Most of those long-term conditions are diagnosed within primary care, but of course they have a huge impact on access to secondary care services. For a clinician not to be able to see that whole picture and for the individual to have to explain again and again their physical health issues, and potentially their comorbid mental health issues, creates a huge challenge for people in getting access to the right help and support in a timely manner.
I would build on that to think about two areas that particularly affect older people: frailty and dementia. In this context, we know that assessment for frailty can make a big difference to ensuring people receive the right kind of help and support. That should be done in primary care, but often, sadly, people with frailty will present in hospital with a range of conditions. Understanding the frailty assessment score and what help and support is needed is key. For people with dementia and their family carers, having access to the right information for the clinician and for the individual concerned can make a huge difference. A disjointed experience just exacerbates what can often be a very challenging time.
Dr Johnson
Q
We keep hearing that it is difficult for people to have to repeat their story. I understand that stories can be traumatic and repeating them can be unpleasant, particularly if it must be done many times, but is there sometimes a clinical value in asking people to go through their story? If so, what is it?
Dr Imam: My specialty is frailty, which is a medical condition characterised by a loss of independence. Although it is associated with ageing, it is not an inevitable part of ageing. The treatment that I deliver as a clinician is called a comprehensive geriatric assessment. It is evidence-based and we know that it improves patient outcomes and maintains independence. What it describes is a multidisciplinary team approach to a holistic assessment that focuses on what matters most to the patient.
One of the issues that we have right now, however, is that the NHS does not consistently identify people who are living with frailty right across the system from community to hospital. If we are identifying people and diagnosing them with a condition, you would expect treatment options to be offered, yet we do not consistently do that across the country. That is essentially driving ineffective and inefficient care. Sometimes, therefore, when a crisis sets in—we have seen this in other reports around corridor care—that can ensue in older people living with frailty.
In my day job, where I look after people in a busy A&E department, I see people who have may have had a fall or become confused, or where there has been a breakdown in their social situation. My practitioners and I are spending hours trying to piece together information from multiple different sources. Those could be paper-based, digital or telephone—we could be trying to phone people to get up-to-date information. As you can imagine, sometimes they do not pick up the phone, so we are sometimes working from incomplete information and things that are not up to date.
Once we have done that, we try to create a care plan for a patient that allows them to be looked after in the community. However, that care plan may not follow the patient, because everyone uses different electronic patient record systems. Some important partners in that care, like social care or ambulance services, cannot actually see the care plan that I have developed for my patient.
Unfortunately, if a patient with frailty then succumbs to a crisis of some kind, the default setting is, in many cases, to trigger an admission to hospital. If a patient does not need to be in a hospital environment and they are frail, they can end up becoming more frail and weak, and lose their independence. That means that they will need even more social care than would otherwise have been required.
Where the solution comes in is that a nationally rolled-out single patient record system could fundamentally reshape this form of care, because we would be moving it from the fragmented, reactive model that I just described to one that is proactive, co-ordinated and truly centred around a patient. Another thing about frailty is that there are so many different people involved in that person’s care, so we need to try to restore the continuity of care for that type of patient, which has become eroded over time. The SPR addresses that with a single up-to-date view of a patient. It enables earlier risk identification, faster clinical decision making and that whole-system integrated response I have been describing, which is lacking at the moment.
There is often duplication; one of the other issues is that assessing patients in this manner can take a long period of time—up to two and a half hours is often quoted by the British Geriatrics Society. You can imagine that if you had an electronic record that could be auto-populated or could rely on the most recent, up-to-date plan done by someone else, that would avoid reassessment as we would be working from contemporaneous information.
Over time, you can see how, for frailty and many other conditions, that could lead to a more preventive approach that is more community based, that reduces the need for admissions, and that provides a better overall experience for staff and patients. Importantly, there needs to be a shift towards neighbourhood working on frailty, and this allows the multidisciplinary team to work towards one plan. You have also heard today about patient voice and carer voice, and this type of care plan also gives them the opportunity to become partners in looking after themselves.
Dr Cocker: The brief answer to the original question would be that communicating and getting a history from a patient are the cornerstone of the patient-doctor relationship. I do not think that the SPR is ever intended to replace that. Where I see its value within maternity, although I am sure that this is the same across all specialties, is that it would form a reliable means of cross-referencing information and being able to get information that—as we have alluded to previously—is often held on many separate systems. As a clinician, you will often not have the ability or the credentials to access that.
For example, in maternity care at my trust we use a certain piece of software. If you do not work in maternity, although you might be able to get generic access to it, you might not be able to navigate that system. The idea of the SPR is that it would pull out those key bits regarding current concerns about the pregnancy or what follow up has been arranged—all those kinds of things. That would not rely on the ability to use lots of different systems; instead, the information would be available. If there is information that requires cross-referencing or checking, it would also give you the ability to do that rather than replacing the process of taking a history and working out what is wrong with someone.
Dr Byrne: It is a terrific question. Healthcare is a relationship; it is not simply a transaction of facts. At its best, it is a working relationship between a clinician and a patient, but that is also why it is so hard sometimes. Our stories are a combination of two things: the facts and the interpretation of those facts. We heard a moving example earlier of someone saying that they had had five miscarriages and those facts were then not known and how distressing it was that they were not. That is a good example of why getting the facts from conversation to conversation could be really helpful.
Our life story changes over time, however, as does the interpretation that comes up in a conversation. As a doctor in the moment with a patient, I am sometimes as interested in what they are choosing not to tell me at a particular time as what they are choosing to tell me. For all of us, the story changes and is fluid. I think that is a potentially helpful distinction to make.
Karin Smyth
Q
Dr Cocker: Having seen the maternity-focused prototype that NHS England developed in the north-west, we learned that it is technically difficult because there are lots of systems. There needs to be a level of interoperability that allows you to pull the data or it is not going to be much use as a reliable system.
The other thing was about trying to ensure that we design those systems for the patients most in need. That might be social or medical need, and there are many different facets to that. That was one of the other challenges. A lot of the focus went into trying to determine a set of theoretical patients who were very high need, and ensuring that you have encompassed all those possible needs, so that if you design the systems for those in most need, they will cater for as many people as possible.
Dr Imam: To expand on Dr Cocker’s point about the identification of problems, people living with frailty often have multiple under-identified issues. In the prototype we have been shown, the SPR has the potential to analyse the wealth of data on a person and summarise it in a manner that makes sense to the clinician logged into the record. It can also piece together a timeline of what has been happening with a person.
As I said earlier, we often follow a manual process to try to understand what has been going on recently for a person. The SPR will not only enable the automation of that process, but give us the ability to know who the key individuals involved in that person’s care are, so when that person is in a crisis or emergency situation, we know exactly who to call and who the last person to touch the patient was.
There are other important functions. It is not only about sharing information across an entire pathway and having the whole-system approach that I described—from community to hospital, and vice versa. Importantly, many people living with frailty require multiple different referrals and the involvement of multiple different people in their care. The SPR will be able to streamline some of those processes and make recommendations for certain referrals that a clinician, who, under an earlier version, would have logged into the record, may not have otherwise thought about, so it may even improve outcomes for patients by providing solutions to improve their care that we would not have come up with otherwise.
Karin Smyth
Q
Dr Byrne: You have to show that you take the risks and people’s concerns seriously, and give a credible analysis of the risks. The key thing is to engage with the risks meaningfully. You should then think about what safeguards you could put into the Bill and future regulations that would actually be effective and be seen as credible, depending on what risks you are trying to address.
I know it is difficult to get into the detail on the primary legislation at this stage, not least because you are trying to sequence things when we do not yet know what the SPR will be, which I appreciate is a further constraint. I would suggest that you consider putting in the Bill one particular safeguard relating to secondary purposes. People have concerns around two main things: confidentiality and their privacy, and secondary uses—who might access their data in future, and why and for what purpose, other than for their direct care. Focusing on that second factor, there are lots of things that might come up that you could do in regulations, but right now, I would suggest that you could build in the safeguard of an independent oversight mechanism for how decisions are made on who gets to access the data and why. In that, you can involve public and layperson representation to bring in that consideration of the risks that matter to the public, alongside the potential benefits.
That could be helpful for two reasons. First, it would be a safeguard against having any unchecked decision-making power on access, whether now or in future. Secondly, it recognises the reality of human systems and organisations. No one expert or small group of experts, however wise or whatever their integrity, can see the whole picture and have a 360° view of what matters to the public. It would be a meaningful way to give the public agency and representation in that decision making—a meaningful exercise of citizen control, if you like. As humans, we are at our best and our decision making is at its safest and strongest when we get a diversity of perspectives involved—as, indeed, the Committee is doing right now. In this context, that should involve patients and the public.
My second point, which is perhaps germane to your wider discussions around the Bill, is that no one organisation can effectively and consistently scrutinise and challenge itself. That goes for questions around data use and access—and wider, as well—in your considerations.
Helen Morgan
Q
Do you have any advice for us on the development of that single patient record and how we make sure that the data is clean and consistent between trusts and different systems, so that the single patient record is actually meaningful? I will ask Dr Cocker first, if he is the technical expert.
Dr Cocker: I would not go that far—my involvement in this whole project is clinical, rather than having any sort of particular technical expertise. I think that is a pertinent issue, however, because, as has been discussed previously, if an error enters the SPR—say, a code is incorrectly followed through into the system—that error can then perpetuate. That is the risk of a single record: a documentation error can ripple out, rather than being contained within the system it originated in.
Does safeguarding that involve putting requirements on the providers of systems to mean that data can be exported in, maybe not a standardised format, but a set of formats that the SPR recognises? It is a technical question that I do not know the answer to, or the possible solutions to, but that would be one of my suggestions. Rather than having hundreds of different systems that all require slightly different solutions in order to be fed into the SPR accurately, there could be some sort of framework setting out requirements on the providers of the software products used by all the different organisations that will feed into the SPR.
Dr Imam: Like Dr Cocker, I am not technical but, from previous pieces of work that I have been involved with, some of it is to do with the data architecture and making sure that you can agree on the fields being used across the various systems. On frailty specifically, we have had the question of, “If we have multiple source systems that have the same field, which one should we be showing within the single patient record?” Our thinking at the moment is that we would show various entries, with who they have been done by and at what time, so that the clinician could decide how to interpret that data.
Dr Johnson
Q
Jon Restell: Obviously, we have the 10-year health plan, which most people broadly see as a good vision for the service, but there are too many key design questions around the new department, the role of the department’s regions, what ICBs will be doing and what trusts will take on as part of this reorganisation. Behind it, there is a lot of capacity and resource organisational memory being taken out of the system.
We do not talk nearly enough about the work of the commissioning support units staff, who are providing internal consultancy and a huge range of business services to the health service, including overseeing child immunisation programmes in some cases. It is really unclear what the future of those functions is. We are taking out a lot of staff who have skills, expertise, organisational memory and commitment, but we do not quite know yet what the precise form of those organisations will be. It is a very difficult change to manage.
Karin Smyth
Q
We had a lot of change with the Health and Social Care Act 2012, and the Bill seeks to reverse that in terms of the architecture of the NHS. We absolutely appreciate as a Government that that is very difficult for staff working in it. I appreciate that the operating model and so on is coming forward, but could you say a bit about people’s feelings about the Bill? There will be more clarity to the centre and the role of providers is not changing, while the real change is around commissioning functions and, as you said, commissioning support organisations. We heard earlier that everything is being reorganised. That is not true, but there is a big change in the geography and the functions of ICBs and commissioners, and the Secretary of State’s role will clearly be different. What might people’s approach to that be?
Jon Restell: Clarity, definitely. No one wants to start with the system that came in in 2011 and 2012. Successive Governments started to correct it almost as soon as it was put in place. I think most people would welcome sorting out the clarity around commissioning there, but I do not think that is the same thing as cutting 50% of those organisations’ staff and running costs. You are clarifying the relationship between the centre and ICBs, commissioning and providers. You still need enough managers with enough skills working in the right system to deliver. That is the nub of what we are doing.
For us it is not really about how the Bill will eventually pan out; it is about the cut and how that is being administered by NHS England, the Department and ICBs. The whole system of management is under strain across the health service. You say that providers are not changing but they are also being asked to take out quite significant amounts of management resource. They are merging to form bigger, potentially more centralised units that may be less responsive and less innovative. I think that organisational form is really important, even if the headline of the Bill might tidy up and clarify those relationships, which would be welcome.
A point made by a lot of members, particularly those in ICBs, is that they do not think that the model design—where we started with ICBs, then went to regions and we are eventually going to get to the 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. When the system is up and running, how well will it work together to share information, share risk and so on? It feels like the Bill is very high level and the detailed design of the organisations is being undertaken in a completely fragmented way. People see that as potentially requiring the next round of reorganisation. You are a former NHS manager, Minister; you know how often reorganisation is reached for as the solution. I genuinely feel that people have got to the point where enough is enough. That kind of continual change will create more and more problems for doing the things that the public actually want to see: innovation, improvement in the quality of service and happier staff—all the things that managers should be focused on, not the merry-go-round of organisational change.
Helen Morgan
Q
Jon Restell: It certainly needs to be clarified. Whether it needs to be clarified in legislation, I do not know. Leaving aside the fact it took a very long time to get permission to move forward with their consultations, ICBs were thinking about what they needed to do around May or June last year. They will have made a lot of decisions and a lot of staff will have gone already based on the then understanding of what an ICB was supposed to be doing, based on the ICB blueprint that was published by NHS England, so I think that resource has gone. The people who may be connected with the functions that you are talking to have also gone in many cases. The question for me is: if the ICBs are to get more things to do, what is the implication for their running costs? As you know, they are currently capped at about £19 per head. If they get more functions, will they get more resources to do that? Will there need to be other ways of delivering those functions? I do not think that 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 and the discretionary stuff, much of which is already on hold—will probably be the stuff that goes while they deliver their statutory obligations.
On the providers side, we need urgent clarity about what is going to go to the providers’ responsibility because they are taking out a lot of costs. I do not think that all, or many, providers know that these plans are afoot for them. That will create quite a shock. Again, they are choosing people to go now based on their current understanding of what is needed.
Dr Johnson
Q
Sir Andrew Dilnot: I would not claim to be expert here, but I have read the Bill and the briefings. The role of local authorities in social care is a very interesting one. If we were to stand way back and honestly answer the question, “Why is social care managed by local authorities at the moment?”, we would say, “Because it was forgotten in 1948, when the rest of 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 has happened since then is that it has grown and grown, and it is now putting enormous strain on at least many local authorities.
I think we should draw a clear distinction in something that is definitely appropriate—that is, care being provided within a local context. The kind of care that is appropriate in Camden will be different to the type of care that is appropriate in the highlands of Scotland. Local delivery seems relevant, but whether local financing makes sense in 2026 is a very big question. That is the context.
On its own, it is hard to see the potential reduction in the role of local authorities in ICBs making things better. It will not necessarily make things significantly worse, but I do not think it will help local authorities and the NHS in trying to integrate these two essentially non-integrated functions.
Karin Smyth
Q
Sir Andrew Dilnot: The question of the fine details of how legislation should be passed is certainly outside my skillset, so I have to be agnostic about whether the Bill should have addressed the wider questions of social care. On the question of whether we could address social care or not, the answer is definitely yes. After all, several Governments over the last few years have promised to do so. The former Secretary of State for Health and Social Care, when he was the shadow Secretary of State during the election two years ago, promised that he would do it. Such measures have received Royal Assent twice, but they have still not taken place, even though they were promised by the then shadow Secretary of State for Health and Social Care, before he became the Secretary of State.
Yes, we definitely could do it. The amounts of money involved, while of course significant, are small relative to the aggregate costs of the NHS or the uplift in spending on the NHS that, with my full support, we have seen in the last couple of years. I think it is a genuine puzzle and a black mark for all of us, including me, that all these years have gone by and we have done nothing. We have a social care system that is supported by millions of wonderful informal carers and about 1.5 million formal carers, benefiting hundreds of thousands of people, but it is creaking under intolerable strain. It really makes no sense to me, and I really do not know why or how we have managed to go for so long without addressing it. We should do so, not only because it is the right thing to do, but because it is now so bad that it is doing direct, instrumental damage to the NHS.
Helen Morgan
Q
Sir Andrew Dilnot: I think there are two main ways. The first, and perhaps the one that has received most attention, is that there are people who have been hospitalised, perhaps following a fall or infection, who have some mobility challenges and need some care, but who cannot leave hospital because a social care package is not available for them in the community. That is extremely damaging for the NHS, because if we have somebody in a bed that they do not need to be in because they have nowhere else to go, not only are we spending money having them there but we are then not able to use the bed for other activities.
If you have somebody with a delayed transfer of care that means they are stuck in hospital, when they do not need to be, for 20 days, which is not uncommon, very large numbers of elective procedures cannot take place because that bed is being used. That is a dead-weight loss from the system.
There is another thing that I think is at least as important, which is that, because of the lack of good social care, we have people falling, injuring themselves and needing to be hospitalised. We have people sustaining more urinary tract infections than they perhaps would if they had good social care. That is adding an additional burden, which the NHS deals with as well as it can, but all of this just seems unnecessary.
Social care appears to be so invisible to us all. It is easy to blame politicians, and of course it is politicians like you who ultimately have to vote for these things, but the electorate—the whole of our society—have to look at ourselves and ask, “Why can’t we make this challenge, which is so significant, better?” Any of you who have experienced it in your own family know how brutal and difficult it can be.
If I can 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 is 73. In this country, average life expectancy at birth in 1900 was 46, and now it is 81. We have added 35 years to the expectation of life from birth, which is an astonishing transformation. Some consequences come with that, one of which is that there is much more social care to be done, but we should be celebrating this, delighting in it and doing it well, instead of hiding it away and ignoring it for so long that it is doing real damage to the NHS, let alone to the lives of people who need social care.
Compassionate Use Medicine Schemes: VAT
Karin Smyth Excerpts(1 month, 2 weeks ago)
Commons ChamberRead Full debate Read Hansard Text Watch Debate Read Debate Ministerial Extracts
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
(Urgent Question): To ask the Secretary of State for Health and Social Care if he will make a statement on the effect of VAT on the availability of medicines through compassionate use schemes.
The Minister for Secondary Care (Karin Smyth)
It is very important for patients to have access to innovative medicines as quickly as possible, especially where there is unmet clinical need or no alternative treatment. We are working to streamline the decisions of the National Institute for Health and Care Excellence and the Medicines and Healthcare products Regulatory Agency so that NHS patients benefit from the latest medicines as soon as they are proven to be safe and effective.
Early access and compassionate use programmes can play an important role in enabling patient access to medicines ahead of routine commissioning decisions. However, we should be clear that these programmes are commercial decisions taken by pharmaceutical companies: companies choose whether and how to provide medicines free of charge to patients and the NHS before the medicines go through licensing, post-trial access or a funding decision.
The tax system is, as Members know, a matter for the Chancellor, so I will not get into details about that at the Dispatch Box, but under long-standing VAT rules, supplies of goods free of charge can still be treated as taxable “deemed supplies” where input tax has been recovered. That means that VAT can apply even where no payment is made, reflecting established principles of the tax system. We recognise the concerns raised by industry and others about the potential impact of this treatment on the provision of free-of-charge medicines. We are working closely with the Treasury and His Majesty’s Revenue and Customs to explore options to address these issues, as witnessed by my hon. Friend the Exchequer Secretary to the Treasury, who is here with me on the Front Bench. We will carefully consider the legal, fiscal and operational implications of any potential changes. Until then, we will continue to engage constructively with industry, the NHS and all our partners to make sure that British patients, who we have in our thoughts at all times, have access to innovative medicines.
Dr Johnson
I declare an interest as a consultant paediatrician. One of the worst moments as a paediatrician is when all treatments have failed and there is no suitable clinical trial. At that point, in those dark moments, compassionate use schemes can be a glimmer of hope, and new unlicensed medicines with clinical potential have been provided free to the patient, and free to the NHS. Last year, however, the Government started charging VAT on the deemed value of those drugs, meaning that companies had to pay tax to give the drugs away. When hearing that “every meeting” with Labour MPs was about
“who can we tax in order to pay benefits to others?”
few would have imagined that that would include potentially lifesaving, charitably given drugs for sick adults and dying children.
Following lobbying by my hon. Friend the Member for Hornchurch and Upminster (Julia Lopez), the Government have paused enforcement while they review the situation, but they have said that liabilities remain, and they are taking too long. Bayer has now withdrawn from the scheme, and others could follow. Patients are at risk. Does the Minister recognise that that makes trials in the UK less attractive, and that HMRC’s pause is not enough? How much money do the Government expect to raise with this VAT? How did the Government find time to reduce VAT on fairground rides at Alton Towers, but not to sort out this problem? How many patients have missed out so far? Does the Minister recognise that this delay could cost lives, and who was the Minister who signed this off? Was it the Health Secretary when he was a Minister in the Treasury?
I understand that the Government say this situation is not new, and that it may apply to a law dating back over 30 years. I gently point out, however, that the application is new, and that the levers to change it—and change it quickly—lie in this Government’s hands. Patients need them to act swiftly.
Karin Smyth
I pay tribute to the hon. Lady’s service as a clinician, and she is right to say that, at times, for patients facing such situations, compassionate use schemes are a glimmer of hope, but I think the rest of her comments were ill deserved. I understand the desire of the Opposition to attack a new Secretary of State because he was in the Treasury, but I will move on to the actual issues, because patients care about this. The rules had been in place for a long time when this Government took office, and we have not changed them. We have inherited this system, and we are looking at how we can improve it.
The previous Government could have abolished VAT on such medicines, but they chose not to do so. What is more, since we have been in office, we have struck a deal with the USA that not only guarantees 0% on pharmaceutical tariffs, but changes the old formula that we use for medicines. For the first time in 20 years, the Government are spending more to ensure that our patients are first in the queue for innovative medicines. The previous Government could also have raised the threshold, but they chose not to do so. Now, for example, patients facing Duchenne muscular dystrophy, children as young as 12 who need a brain cancer drug, or those who have a type of rare and aggressive stomach cancer, are being treated.
We recognise the importance of the UK remaining a leading location for life sciences, investment and innovation. That is precisely why we are engaging with industry and partners across the Government to understand and address concerns, including the issue of VAT payable on donated medicines. In considering a way forward, it is important to safeguard the robust and fair system by which routine access to medicines commissioned by the NHS is determined. A range of options are being considered. No decisions have been made at this stage, and I will not pre-empt any.
Dr Scott Arthur (Edinburgh South West) (Lab)
I thank the Minister for her response—I am sure she is working hard to resolve this issue. As the hon. Member for Sleaford and North Hykeham (Dr Johnson) explained, a pause was introduced. That was welcomed by charities such as Sarcoma UK, which asked for that pause to be made permanent. If the Minister is working hard to get the Treasury to understand the impact that the VAT charge is having on patients, will she invite a Treasury Minister to meet charities such as Sarcoma UK to hear first hand about the impact of charging VAT?
Karin Smyth
I commend my hon. Friend’s work in this area on behalf of patients. As I said, no decisions have been made and we are continuing to work on this issue. The Exchequer Secretary to the Treasury is with me on the Front Bench and will be happy to keep engaging with all interested parties.
Helen Maguire (Epsom and Ewell) (LD)
I was deeply shocked to hear about the change in HMRC’s policy. It is extremely worrying that pharmaceutical companies must now pay VAT on drugs available through compassionate use and early-access schemes. In April, HMRC told the pharma industry that it would pause enforcing VAT bills while the Government considered measures to support the industry in supplying patients who desperately need these drugs. The changes have been mired in uncertainty and misunderstanding, and there has been poor communication from HMRC from the start.
The Government must ensure that they create a workable long-term solution for the pharmaceutical industry to support these patients who are in desperate need. Patients must not lose access to medicines as a result and HMRC must communicate with pharma and patients effectively. For patients of all ages with rare cancer types, schemes such as these are the only way to access potentially life-extending treatment. Has the Minister spoken to cancer charities about the real-life effects that the changes will have? We should be making it easier for patients to access life-extending drugs, not harder. Will the Minister confirm that patients will not be denied lifesaving drugs as a result of these changes?
Karin Smyth
I thank the Liberal Democrat spokesperson for her comments. She knows that we engage with the sector all the time and, as I said in my earlier response, we will continue to work with bodies across the life sciences sector and with patients, the NHS, HMRC and the Treasury. A range of options are being considered and no decisions have been made.
Jerome Mayhew (Broadland and Fakenham) (Con)
The Minister is responding to this urgent question because the Government have decided to charge VAT on donated medicines used for compassionate EAM schemes. The Minister says, “Well, that is not our fault—the scheme has been around for 30 years”. That may be true, but they have decided to apply the rules for the first time. Why have the Government decided to impose VAT now?
Karin Smyth
It is important for hon. Members to recognise the deep concern caused to patients with unmet clinical need, who rely on the glimmer of hope provided by these medicines, when they hear these sorts of exchanges. These are long-standing rules and we continue to engage on the issue.
Sir Ashley Fox (Bridgwater) (Con)
It is utterly shameful that this Government are presiding over the imposition of VAT on drugs donated for compassionate use. The Minister referred to the previous Government. VAT was not put on those drugs under the previous Government, but it is being put on them under this Government. Was it the Health Secretary who signed this off when he was in the Treasury?
Karin Smyth
The hon. Gentleman’s last comment reveals exactly why he is raising this issue.
Jim Shannon (Strangford) (DUP)
Hon. Members have raised concerns for compassionate reasons and on behalf of their constituents who feel the pain. Compassionate access schemes are a critical lifeline for terminally ill patients, often stepping in when the NHS has exhausted all standard funding avenues. Any move by HMRC to levy, to barter or to impose deemed supply VAT on free clinical treatment places an unacceptable risk on voluntary patient provision. I say this kindly, but will the Minister ensure that the Treasury works collaboratively with the devolved health Executive to create a permanent and water-tight VAT exemption, so that no patient, regardless of their postcode, is left behind and compassion is a UK-wide attribute, not a postcode lottery?
Karin Smyth
The hon. Gentleman works very hard in this area. He is right to use the word “compassion”, because that is exactly how we must approach the issue for patients who have an unmet clinical need and are desperate for innovation. That is why we are putting our collaboration and work with the life sciences sector front and centre and working closely with HMRC. My hon. Friend the Exchequer Secretary to the Treasury is on the Treasury Bench listening attentively to the issues and we will continue to work together. They are long-standing rules. As the hon. Gentleman would acknowledge, we have made huge progress in this area for patients in this category, particularly with our revision of the National Institute for Health and Care Excellence threshold, and we will continue to do so, on behalf of the patients we all want to help.
Oral Answers to Questions
Karin Smyth Excerpts(1 month, 2 weeks ago)
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The Minister for Secondary Care (Karin Smyth)
We inherited a decades-old system whereby patient voice was divorced from decision makers, with more than 20 organisations offering a place for patients and users to share feedback. The Health Bill will put the views of patients and users at the heart of decision making, ensuring that that directly informs those responsible for commissioning locally, and we will create a new patient experience directorate in the Department to ensure that patient and user insight directly shapes national policymaking.
Steve Darling
The abolition of Healthwatch will see the NHS and the Government effectively marking their own homework. Can the Minister please give some assurances about how the Government will ensure that the voice of those with learning disabilities, complex needs and dementia is heard?
Karin Smyth
The hon. Gentleman makes an important point about the variety of needs that local commissioners need to take account of. That is exactly what the Health Bill will try to do, not by outsourcing that role to an outside body but by putting those views at the heart of what all commissioners do, which includes making sure that under-represented or often unheard voices do have a voice.
Munira Wilson
When Boots decided to close two pharmacies in Hampton, leaving a large number of elderly and vulnerable residents without local pharmacy provision, Healthwatch Richmond played a crucial role in ensuring that we got a new community pharmacy in the area. That locally led patient voice cannot be replaced by officials in Whitehall or our local ICB, which is about to suffer cuts of over 50% in its operating budget. If the Minister is really serious about championing patients, will she think again?
Karin Smyth
The hon. Lady raises an interesting example of somewhere where local commissioners have failed to provide a service or recognise when a service disappears. They can do that by using very different voices, rather than outsourcing that responsibility. Through the Health Bill, we have to make sure that commissioners do their job properly, which includes taking account of patient voice at a very local level.
Rachael Maskell (York Central) (Lab/Co-op)
Replacing Healthwatch will mean that, ultimately, patients will not have confidence in the commissioners. We have just heard one example, and I can offer many examples from York. Healthwatch York, which is phenomenal and is led by Siân Balsom, has produced reports that have brought about change. I plead with the Government to review clauses 64 and 65 of the Health Bill to maintain Healthwatch. It should not be an either/or. We need commissioners to engage with the patient voice, but we also need Healthwatch to have the independence to advocate for patients.
Karin Smyth
I thank my hon. Friend for her comments about her local healthwatch. There are certainly examples of where this approach works well in local communities, and we need to understand those. However, it does not work well everywhere, and it means that local commissioners are not empowered and are not held accountable for their job of making sure that the patient voice and experience is held locally. There is also nothing to stop ICBs undertaking that role as they see fit in their local communities in the future, rather than our dictating how they should do it through one particular body.
Mr Jonathan Brash (Hartlepool) (Lab)
While I support the Government’s desire to drive out bureaucracy from the NHS and simplify systems for patients, Healthwatch Hartlepool has done an outstanding job in ensuring that patients’ voices are heard as systems and services are improved. What can the Minister do to ensure that local expertise is retained in any new system?
Karin Smyth
I thank my hon. Friend for his comments. If that works well for his local system, there is nothing to stop it. How the ICB undertakes its role has to be determined locally to make it most effective for local circumstances, and it can undertake that role as it sees fit.
Graham Stuart (Beverley and Holderness) (Con)
The Minister for Secondary Care (Karin Smyth)
Over 85% of waiting list removals are made as a result of patient care, and since the end of the pandemic, unreported removals have been below pre-pandemic levels. Record levels of elective activity are being delivered by NHS staff, enabling us to cut waiting lists and meet our interim target of 65% of patients being seen within 18 weeks—the highest performance in over four years.
Graham Stuart
People in Beverley and Holderness want high-quality and speedy care, not massaged waiting list numbers that suit Labour narratives. Of course, Mr Speaker, you will remember that the last Labour Government had form on this as well, because the National Audit Office repeatedly found that the numbers were manipulated when waiting lists were similarly put on a pedestal. The Minister has the new Secretary of State by her side. Can she reassure people in Beverley and Holderness that we will have genuinely improved healthcare, rather than widespread manipulation and the cleansing of waiting lists to suit political purposes?
Karin Smyth
If anyone has forgotten, the last Labour Government left the NHS in a better state than it was in under successive Governments. That is not in dispute in terms of waiting list targets or, indeed, patient satisfaction. The right hon. Gentleman might want to look again at the record.
The point that the Conservatives seem to be intent on following up forever is an important one. Some 85% of the activity is a result of direct patient care. Validation, both clinical and clerical, is a long-standing routine practice of waiting list management. At roughly 15%—it was slightly higher before the pandemic—the rate is no different now from what it has been before, so it is not the case that something different is going on here. What we are doing is making sure that the right hon. Gentleman’s constituents—I appreciate that there are many other local problems in his system at the moment—can be clear that we have the right people on the right list for the right care in the right place by the right clinicians. That is what we are determined to do.
Lewis Atkinson (Sunderland Central) (Lab)
I commend the Minister for her work in reducing waiting lists for GP referral to first treatment, and they are genuinely coming down. She will be aware, however, that that statistic does not capture the entire picture, particularly for people who require subsequent follow-up care—for example, women with endometriosis or women waiting for breast reconstruction following mastectomies. Could she say a little about any plans she has to capture those waiting lists?
Karin Smyth
My hon. Friend is someone who does understand the way waiting lists are managed and so on. We do not have any plans to add any new targets to those to which we have already committed to give confidence to the British public that we can fix the NHS and get waiting lists down. However, he raises an important point about how we support patients to understand where they are in the system and where their care will be provided. Part of our commitment in the elective reform plan, which we outlined last year, is that patients are kept up to date about where they are being treated and why they are being referred to perhaps a more local service, and we will continue to try to do that.
Dr Luke Evans (Hinckley and Bosworth) (Con)
Last month, the Health Service Journal reported that the elective waiting list target was met largely—largely—because a record number of patients were removed from waiting lists in March without receiving treatment. Can the Minister tell the House how many patients were removed in March and what happened to them, and whether she is satisfied that they definitely did not need treatment?
Karin Smyth
As I have said, I am still a bit perplexed about why the Conservatives are perpetually highlighting their inadequate management of the health service, and the idea that patients are simply referred to a waiting list and then left there for a couple of years, which is what happened on their watch. It is important that patients know why they are on a waiting list, and obviously that they get the best clinical care as quickly as possible.
I do not have to hand the exact figure for March, which will be published as part of the normal process of publishing the waiting list figures. However, I can tell the hon. Gentleman that completed pathways were 5.9% higher in the 21 months from July 2024, when we took office, to March 2025 than in the previous 21 months. Patients, as they deserve, are getting the right care in the right place under this Government.
Dr Evans
It is not just the Conservatives who are raising this issue; it is patients and the Health Service Journal. The answer is that 350,000 people—a city the size of Coventry—were wiped off the waiting list with no treatment, and that is 100,000 more than the month before. If there is genuinely nothing to hide, the Government should not worry about putting out the figures. Will the Minister commit to a review to find out what has happened to those 350,000 patients, or does she believe that waiting list targets should be met by removing patients from the figures rather than actually treating them?
Karin Smyth
This is an established way of managing waiting lists and waiting times. We are making sure that there is adequate clerical and clinical validation of the lists, and that patients are treated where they need to be, which may often be closer to home and in more local circumstances. Of course, we have committed to greater transparency than there was under the previous Government, and we will continue to provide that. I did not quite follow the hon. Gentleman’s question, but I am obviously very happy to look at anything arising from it. We are confident in the data that is coming out—as I have said, this is standard practice—and the figure is roughly 15%, as it has been over many years.
Mr Luke Charters (York Outer) (Lab)
Lewis Cocking (Broxbourne) (Con)
The Minister for Secondary Care (Karin Smyth)
The NHS modernisation Bill will clarify and strengthen accountability in the NHS. It ends the fragmented accountability that we inherited on coming into government, and the reforms will restore clear democratic accountability, with the Secretary of State directly accountable to Parliament and the public. We will enhance local autonomy, ensuring NHS organisations are good partners and deliver for their local populations.
Lewis Cocking
We need more local accountability in the NHS. In Broxbourne we have seen thousands of new houses built, but when I and local Conservative councillors have pushed for new healthcare facilities to cope with the new demand, we have been refused. Can the Minister explain who will be accountable for that under the Government’s new system?
Karin Smyth
The hon. Gentleman highlights a situation familiar to many of us. One of the many problems that we inherited from the last Government was the fragmented landscape, so I thank him for his question. A key part of the responsibility of integrated care boards is commissioning for their populations to improve access to healthcare and reduce inequalities. For the first time, ICBs will be held accountable through the outcomes framework.
Helena Dollimore (Hastings and Rye) (Lab/Co-op)
Jules Fielder from Hastings was diagnosed with stage 4 terminal lung cancer after doctors missed her symptoms, mistaking them for tennis elbow. As a non-smoking young woman, she did not meet the stereotype of what lung cancer patients often present with, but she was determined to channel her own tragedy into change. She campaigned for better, earlier awareness of symptoms among clinicians and members of the public, and she took that message to everyone she could. Together, we convinced Boots to roll out on-shelf awareness labels in the cold and flu medicine section to raise better awareness. Sadly, Jules passed away last month. Will the Minister join me in paying tribute to all of Jules’s campaigning, and commit to continuing her vision in the Department of Health and Social Care by ensuring we use every possible avenue to raise better awareness and catch cancer earlier?
Karin Smyth
I thank my hon. Friend for raising that example of tremendous public service in the face of adversity. We are sorry to hear of Jules’s passing, and our thoughts are with her friends and family. My hon. Friend highlights the way in which people can access and determine outcomes and the fact that it is the responsibility of those working in local health services—in this case, the ICB in particular—to involve people and use their experience to drive the change that we want to see as part of the Health Bill.
Peter Swallow (Bracknell) (Lab)
The Minister for Secondary Care (Karin Smyth)
The single patient record will give clinicians timely access to a single trusted record so that decisions can be made more efficiently, avoiding duplication, allowing them to spend more time with patients. The system makes all information on a patient accessible in a single place and will allow the sharing of patient data among different settings, as my hon. Friend outlines, and provide more flexibility in where services are made available.
Debbie Abrahams (Oldham East and Saddleworth) (Lab)
Karin Smyth
I commend my hon. Friend for her experience in this area. She tempts me to look at amendments in that space, but we do not have plans for that at the moment. The changes we made to NHS England placed the responsibility regarding health inequalities in all our policies firmly at the Secretary of State’s door. I am happy to talk to my hon. Friend about her other ideas on that. The Bill transfers that responsibility to the Secretary of State and we have no plans to make any changes in that area.
Alison Griffiths (Bognor Regis and Littlehampton) (Con)
Maternity Nurses, Nannies and the Infant Sleep Industry
Karin Smyth Excerpts(1 month, 3 weeks ago)
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The Minister for Secondary Care (Karin Smyth)
I thank my hon. Friend the Member for Altrincham and Sale West (Mr Rand) for securing this debate and acknowledging the concern that has been raised recently in the field and by the media. We are all deeply saddened to see the impact of those giving poor advice on infant sleeping. Public safety is and has to remain the top priority.
As my hon. Friend said, being a new parent is a difficult time; I certainly recognise that helping an infant settle into a regular sleep pattern can be difficult for new parents and carers. It is a worrying and stressful time, as he said. Rogue advice from so-called experts can have a devastating effect on those who seek reputable advice and guidance.
Before I talk about regulation of the infant sleep industry, I want to clarify that the Department for Education is responsible for the regulation of nannies and childcare services, which my hon. Friend mentioned. The early years foundation stage statutory framework sets the standards and requirements that early years providers must meet to ensure that children have the best start in life and are kept healthy and safe. All early years providers are already required to meet the safer sleep requirements set out in the statutory framework, which currently links to the NHS safer sleep guidance. The Department for Education plans to update the wording in the early years foundation stage statutory framework so that the requirements are set out directly in the framework itself. That is due to come into effect from September 2026, subject to the usual parliamentary and legislative processes. The Department for Education has already written to providers informing them of the proposed new wording and to remind them that they must meet the current requirements.
The “Best Start in Life” campaign provides parents and carers with NHS safer sleep advice through a range of communication channels, including social media, the website and an email programme. Recently, we have collaborated with experts such as Rosey Davidson, a paediatric sleep consultant, to support the promotion of safer-sleep guidance, reaching approximately 40,000 parents through one post alone. The healthy babies programme supports new parents and families by offering integrated, preventive and universal support, including for perinatal mental health, parent-infant relationships and infant feeding, in the 1,001 days from pregnancy to age two. By delivering those services through a physical and digital Best Start family hubs network, we are ensuring that parents and carers have access to joined-up, family-centred advice and support that is delivered in communities where there are high levels of need.
In January, NHS England published a post-natal toolkit to improve the post-natal care experience for women and their families. The toolkit supports integrated care boards, their place-based partners, and health and care providers to work together with service users and professionals to improve the post-natal care experience and both short-term and long-term maternal and infant health outcomes. Additionally, NHS England has published guidance for GPs on the post-natal appointment that women should be offered six weeks to eight weeks after giving birth. That provides an important opportunity for GPs to listen to women in a discreet, supportive environment.
Qualified health visitors and their teams also have an important role, as my hon. Friend said, in supporting infant health, wellbeing and parenting confidence. They promote safe sleeping for babies and provide safe advice to parents. Services such as health visiting are being strengthened by providing over £13.4 billion of public health funding for local government over the three years from 2026/27 through a consolidated ringfenced public health grant.
“Maternity nurse”, “night nurse”, “baby sleep consultant” or other terms for these roles are not regulated professions. Often, those working in a sleep industry role will refer to themselves as a “nurse” to indicate that they are suitably qualified to advise. That can mislead the public by providing an impression that such individuals are qualified and professionally registered to provide a particular level of care, advice or care intervention that they do not hold, which puts the public and babies at risk.
In May 2025, the Government announced our intention to protect the professional title “nurse” within this Parliament. Protecting the title “nurse” will make it a criminal offence for someone to call themselves a nurse unless they are registered as a nurse with the Nursing and Midwifery Council, or part of one of a number of exempt professions, such as dental nurses and veterinary nurses. These new protections will also apply to longer professional titles that include the word “nurse”, such as “maternity nurse” and “night nurse”. To ensure that we get these changes right, we will shortly be publishing a call for evidence on the protection of the title of “nurse”.
I invite everyone present and those interested in this debate to share their views, which will inform the future legislation underpinning the Nursing and Midwifery Council that will implement this change. We want to hear from those working in healthcare, but also those in other fields such as childcare and care for animals as well as the general public, to understand what exemptions should apply and to ensure that those who may be affected by this change can feed in their concerns. We are also seeking views on protecting other titles such as “nursing” and “health visitor”.
However, ultimately this is about patient and public safety. When someone seeks treatment, support or advice from a “nurse”, there is a legitimate expectation that the individual is suitably qualified and professionally registered. Our proposed changes will make it a criminal offence for someone who does not hold such qualifications and professional registration to claim to be a nurse.
This is an important subject and I am grateful to my hon. Friend for raising it, and I know there is further interest across the House. I hope people will respond to the call for evidence, and we will of course continue to work with colleagues to make sure this is a safe place for parents.
Question put and agreed to.
General Medical Council
Karin Smyth Excerpts(1 month, 3 weeks ago)
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The Minister for Secondary Care (Karin Smyth)
I thank the right hon. Member for North East Cambridgeshire (Steve Barclay) for raising this extremely serious matter very powerfully on behalf of his constituent Elizabeth, following the tragic loss of her son Jack. Our thoughts are with her and the rest of the family. We Members of Parliament find ourselves dealing with tragedies, but we are able to give our constituents a voice, and that is a great honour—a sad one, but one we take very seriously. I commit to working with the right hon. Gentleman as we move forward.
As the right hon. Gentleman said, the General Medical Council is there first and foremost to protect patients and maintain public confidence in the medical profession. It is the regulator of all medical doctors, anaesthesia associates and physician associates practising in the United Kingdom. It defines standards for ethics, competence and patient safety, and it has a duty to investigate concerns about doctors’ performance or conduct.
The right hon. Gentleman mentioned the Verita review, so let me start there. In January last year, Cambridge University hospitals trust commissioned Verita, an objective investigations company, to undertake a review of the hospital’s governance. Meanwhile, the Kennedy report into the missed opportunities surrounding Dr Stohr’s case is still ongoing. Verita’s report was published in October 2025 and made 23 recommendations. The broad themes that emerged from that investigation were: first, that doctors needed more oversight, clinical supervision and performance management; secondly, improving safety governance through better board-level visibility and escalation pathways; thirdly, proper oversight of clinical reviews, and ensuring that they are acted on promptly, and that changes are made; and finally, a change in medical culture and behaviour, so that staff feel empowered to hold their hands up when things go wrong. The trust has accepted the findings, published an action plan and apologised to affected families, as I understand it. We expect the hospital to implement the findings of the review in full, because Jack Moate’s family deserve absolute transparency from the authorities, and they have the right to know that lessons will be learned when things go wrong.
The right hon. Gentleman wrote to the Department on 15 May, and his letter makes it very clear that this is one of the worst and most distressing cases that he, in his long experience, has ever encountered. Having read that letter, I agree with him, and I know he does not use those words lightly. I can confirm that the GMC has now done the right thing and launched an investigation into the conduct of Kuldeep Stohr.
The GMC is an independent body, and I cannot go into all the specifics of an individual case, as the right hon. Gentleman will know from his time as Health Secretary. It would be wrong for me to give any further commentary on a live investigation, not least because that could prejudice the outcome and be a barrier to Jack’s family getting justice. Suffice it to say that I am just as appalled as the right hon. Gentleman is that this has gone on for so long.
It has taken almost a decade of missed opportunities for the families to start getting the answers they deserve. I understand that the former Minister for patient safety, my hon. Friend the Member for Glasgow South West (Dr Ahmed), met some of the families in November. He also intended to go to Cambridge to meet families and representatives of the trust. Today I can confirm that the new Minister for patient safety, my hon. Friend the Member for Birmingham Edgbaston (Preet Kaur Gill), is willing to meet the right hon. Gentleman and the Moate family to discuss the shocking circumstances of their case. I hope that they can take some comfort from knowing that although my hon. Friend is new in post, she takes these issues very seriously, she has been a champion for her own constituents who faced patient safety failures in her local trust, and she will be following this case very closely indeed.
It may be helpful for me to outline the broader principles that govern the GMC and its regulatory framework. When an allegation is made about a doctor, the GMC has a duty to investigate and, where necessary, take action to safeguard the health and wellbeing of the public. In serious cases, it can refer a doctor to the Medical Practitioners Tribunal Service. These procedures can result in doctors being removed from the medical register. That strips away their right to legally practice medicine in this country. The MPTS is a statutory committee of the GMC. It operates separately and independently, which is crucial to maintaining public confidence in its findings. The tribunals have a legal duty to protect the public, and we have clear expectations of them.
This year, we are taking action to modernise the regulation of all healthcare professionals in the UK. In March, we published a consultation on reforming the General Medical Council legislative framework. The reforms would make the process for assessing a doctor’s fitness to practice swifter and fairer, and, as we have heard, the consultation runs until 23 June. The right hon. Gentleman tempts me to consider making amendments to the Health Bill. Given his experience, he will understand that I will not commit to doing that, but I can commit to discussing the matter further, and I encourage him and others, including my hon. Friend the Member for Lichfield (Dave Robertson), who raised the shocking al-Fayed case, to engage with that consultation. We will consider the outcomes of that consultation before we bring legislation to the House, but we expect to lay the General Medical Council order before Parliament later this year, subject to those conversations. I am happy to ensure that the right hon. Member for North East Cambridgeshire and my hon. Friend the Member for Lichfield have any further meetings that are necessary with me or with officials, given the tight deadlines that will have to be met under that timetable.
I will touch on the Mann review, which the right hon. Gentleman also highlighted. As we all know, the NHS was founded on the principle of treating everyone equally and with respect. We have been crystal clear that racism and discrimination betray everything the NHS stands for and its ability to provide safe, world-class care. That is why the former Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), asked the noble Lord Mann to conduct a review into antisemitism and other forms of racism in the NHS. As the right hon. Member for North East Cambridgeshire said, this morning Lord Mann published a series of robust and practical recommendations, and we support every one of them.
The right hon. Gentleman read out some shocking stories from his time as Health Secretary. I cannot comment on them now, but I assure him and other hon. Members that in the weeks and months ahead, we will work with all organisations that have been named in the review, including the GMC, to ensure partners across the system are supported in delivering meaningful change based on the recommendations. I know that the GMC is as committed to rooting out racism from its ranks as we are, and we will leave no stone unturned to get this done.
Trust is the glue that holds our institutions together. The public have an absolute right to know that they can trust their doctor, and when things do go wrong, they have a right to swift and transparent justice. I cannot begin to imagine what Jack’s family, and especially his poor mum, are going through. I thank them for their consideration in discussing this with us, and I know that there are many other families involved. The system that we build has to do right by families like theirs. I commit to working further with the right hon. Gentleman and others in this place to do just that.
Question put and agreed to.
Health Bill
Karin Smyth ExcerptsMonday 1st June 2026
(1 month, 4 weeks ago)
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The Minister for Secondary Care (Karin Smyth)
I was going to say that sometimes it is the hope that kills you, but instead I will say that it is a pleasure to close the debate on behalf of this Government.
Let me begin by commending the many fantastic speeches that we have heard this evening. My hon. Friend the Member for Middlesbrough and Thornaby East (Andy McDonald) made some excellent points about spinal cord injury and specialised commissioning. His comments apply to many people, and I take them on board. My hon. Friend the Member for Beckenham and Penge (Liam Conlon) talked about the experience of Alex Savage and his work with the Tessa Jowell Foundation; we thank Mr Savage for that, and mourn his passing. The Chair of the Health and Social Care Committee, the hon. Member for Oxford West and Abingdon (Layla Moran), made a number of valuable points, and I will continue to engage with her and her Committee. I also note the points made by my hon. Friend the Member for Calder Valley (Josh Fenton-Glynn). My hon. Friends the Members for Thurrock (Jen Craft) and for Bexleyheath and Crayford (Daniel Francis) talked about the experience that they bring to this place in relation to SEND, supporting disabled people—particularly children—and joining up services. My hon. Friend the Member for Dudley (Sonia Kumar) drew on her experience of designing services for the future around people and patients.
As ever, I thank my hon. Friend the Member for Sunderland Central (Lewis Atkinson)—another excellent manager from the service—for the expertise that he brought to the debate. My hon. Friend the Member for Cannock Chase (Josh Newbury) made some excellent points about professionals in NHS England, and about communications professionals as well. We know that it is difficult, and we want to use their expertise as we go forward. My hon. Friends the Members for Gloucester (Alex McIntyre), for Rossendale and Darwen (Andy MacNae) and for Stockport (Navendu Mishra) talked about mental health, obesity prevention and their local services. I thank the former Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), for his support for my work in presenting the Bill, and I am relieved that he is still here in support this evening. That is good to know. A week is a long time in politics.
As I often tell people—you have heard it before, Madam Deputy Speaker—I have Lord Lansley to thank —or blame—for my being at this Dispatch Box. I left the NHS and stood for the Bristol South constituency because I could see the coming catastrophe of those coalition reforms. In 2010, patient satisfaction was an all-time high; in 2024, it is at an all-time low. In 2010, the last Government inherited the shortest waiting lists in history; in 2024, they left the waiting lists at record highs. In 2010, the NHS was efficient and delivered value for money; by 2024, we had dropped down international rankings despite a massive increase in headcount at the centre. That is the scorecard that the last Government left for the 2012 reorganisation.
In preparing for this debate, I have looked through my past comments since becoming an MP. In 2016, I said that despite being a non-executive director and manager in the NHS, I could not easily navigate the plethora of bodies in the health and care field. From 2016, it got worse. Each crisis or scandal brought more so-called independent bodies, but no more efficiency, effectiveness or, crucially, safety. We on the Public Accounts Committee were desperately trying to get clarity on accountability for spending, but we did not get it. In 2019—this is on the record—I did an interview with the Health Service Journal in which I highlighted how the role of Parliament in nodding through the estimates bore no relation to financial accountability or spending in my local NHS, and how it was impossible to follow through on funding allocations for facilities for my constituents, or even to understand the decision making of local commissioners, trust boards, regions, NHS England, the Department or the Treasury. When I sat on the Opposition Benches, I watched Tory MP after Tory MP chastise their own Government about what was happening in their constituencies, which was met with a shrug of the shoulders to say, “It’s all down to NHS England.”
The Opposition spokesperson, the hon. Member for Sleaford and North Hykeham (Dr Johnson), talked about ICB accountability, but there is none. Many MPs come to me and say that they cannot get a response from their ICBs. At the moment, some people cannot even get a response to their emails. It is shocking, as my hon. Friend the Member for Lichfield (Dave Robertson) outlined so clearly. The Conservatives’ approach was to hand £200 billion of taxpayers’ money to one body, and more taxpayers’ money to a host of others that were charged with delivering, monitoring and checking a health system in which there is a lot of monitoring, a lot of checking and no end of tick boxes but, crucially, too little delivery of the high-quality services that the British public deserve and the staff want to give.
That cavalier approach changed with this Labour Government, why is why we are bringing forward this Bill. We are abolishing NHS England, devolving commissioning budgets to ICBs, putting patient voice at the heart of the new directorate, and making local commissioners in councils and ICBs embed patient voice and experience in their commissioning, rather than outsourcing their responsibility and then ignoring it. The system does not work, and Members know it. Patients deserve better.
This is the biggest transfer of power to local systems that we have seen. Most significantly, this Government are delivering on giving power to patients, who are frankly astonished to find in 2026 that their records are not joined up in the NHS. My hon. Friend the Member for Portsmouth North (Amanda Martin) made an excellent point about the impact that that has on veterans. Although we have a patchwork of local workarounds that benefit a few people—in Manchester, Bristol or the north-east, for example—patients across England have the right to their own record, and for their clinicians to have access in order to deliver the care they need. That point was well made by my hon. Friends the Members for Glasgow South West (Dr Ahmed), for Ashford (Sojan Joseph), and for Bury St Edmunds and Stowmarket (Peter Prinsley), all of whom gave us real examples of patient experience. As my hon. Friend the Member for Stroud (Dr Opher) says, it is about time that we had single patient records. We heard about the impact on patients from my hon. Friend the Member for Basingstoke (Luke Murphy), who spoke about the sad passing of his father.
A lot of questions have rightly been asked about the single patient record and data, including by the hon. Member for South Northamptonshire (Sarah Bool), my hon. Friend the Member for Morecambe and Lunesdale (Lizzi Collinge), the hon. Member for Newton Abbot (Martin Wrigley), and my hon. Friends the Members for City of Durham (Mary Kelly Foy), for Worthing West (Dr Cooper), for Bournemouth West (Jessica Toale) and for Wolverhampton North East (Sureena Brackenridge). We want to make sure that we get this right. They should know that although the Bill establishes the legal framework for the SPR, much of the detail will be in secondary legislation. I can assure the House that all Members will have a chance to scrutinise the regulations in due course. However, we firmly believe that pursuing a single patient record is the right thing to do. We have found that patients and staff support it, as long as it is built with the strongest safeguards for security and privacy. We hear their concerns, and we will make sure that those safeguards are built in.
The single patient record will protect personal data by default. It will be considered critical national infrastructure, with the highest standards of cyber-security and information governance, so that only the right people can access the right information at the right time and for the right reasons. There will be audit trails of who has accessed a patient’s data, and UK GDPR and the Data Protection Act 2018 will apply. The Bill does not create new legal gateways for purposes other than direct care. It does allow data to be used for research, population analysis and service improvement, but only where there is a separate legal basis for doing so.
Let me pick up on the issue of accountability, which is very important to me personally. I agree that it is important to get this right, and we need to work both nationally and locally. I am old enough to remember the world before 2012. For 60 years, the Secretary of State had overall responsibility and accountability for this service. I think the comments about local accountability were well made by the hon. Member for Runnymede and Weybridge (Dr Spencer) and my hon. Friends the Members for Birmingham Erdington (Paulette Hamilton) and for York Central (Rachael Maskell). Let me be clear: the Bill puts more power, not less, in the hands of local organisations. ICBs will be responsible for commissioning a wider range of services, including primary care, and they will hold a large proportion of the NHS budget—over £179 billion, as before—but at the same time the public expect Ministers to be accountable for the NHS they pay for.
Therefore, Ministers should have the tools to hold ICBs to account and direct the system where necessary. That is why the Bill provides the Secretary of State with a power of direction, but with important safeguards on appointing specific individuals and directions to intervene in decisions about services provided to a particular person. If a NICE recommendation on a drug or treatment exists, this takes precedence over a direction. The powers in the Bill will ensure the Secretary of State is able to create the conditions for ICBs to succeed with effective and proportionate forms of intervention, where necessary.
Another major point made this evening was about Healthwatch. I think there is an important philosophical point about independence, the perception of independence and effective decision making, which we will discuss in Committee and it will be important to do so. However, as the Liberal Democrat spokesperson, the hon. Member for North Shropshire (Helen Morgan), outlined very well, we have had these bodies for 50 years. Patients are saying that the system does not work and are not reporting to it, so the system does not work. I listened carefully to the hon. Member for St Neots and Mid Cambridgeshire (Ian Sollom) and my hon. Friends the Members for Blaydon and Consett (Liz Twist) and for Dartford (Jim Dickson) about getting the balance right, and we will discuss those really valuable points.
Currently, the patient voice sits isolated in separate organisations, which criticise the status quo but are not able to change it. That is why we want a new director of patient experience in the Department to ensure that voices are heard as part of every decision. Locally, it is the job of the commissioner—and I have been a commissioner—and of a good commission organisation to include the patient voice and experience in all its decision making. That is where the difference is made, and such organisations should not be outsourcing those decisions. That is the difference, but a debate is to be had, and we have to assure people on the perception issue. We want to ensure local ICBs incorporate the patient voice and experience appropriately—including digitally excluded people, as the hon. Member for Meriden and Solihull East (Saqib Bhatti) said— into their decision making. How that happens is not set in stone. It is our job to set the destination, not exactly how we get there. If an organisation can provide a good service locally for the patient voice and experience, the ICB could continue to contract with it.
Briefly on HSSIB, I hear the points from the hon. Member for Harwich and North Essex (Sir Bernard Jenkin), whom I have met, and my hon. Friend the Member for Shipley (Anna Dixon) and other Members have raised these issues. The Dash review is very clear—I recommend Members to read it—and it is why the new CQC will combine its regulatory functions with the depth of HSSIB’s investigatory capability to the benefit of both. As was rightly raised by the hon. Member for St Ives (Andrew George), the safe space is important to enable people to share concerns in confidence, and that is safeguarded in the Bill. I understand that there is a perception issue, but we must ensure that that is real. The CQC has also raised some operational issues with implementing the integration of HSSIB, and we are working with it to ensure that, when passed, the measures concerned will be implemented effectively.
To conclude, the Bill is only one part of our modernisation agenda, but it is a crucial one, because for decades Governments have failed to grapple with this fragmentation. Like capital and the workforce, the problem was put in the “too difficult” box and left to this Government to solve, but solve it we will. The single patient record will finally mean patients get the joined-up, proactive care they deserve. By voting for this Bill, we can have a fresh start in NHS history. I commend it to the House.
Question put and agreed to.
Bill accordingly read a Second time.
Health Bill: Programme
Motion made, and Question put forthwith (Standing Order No. 83A(7)),
That the following provisions shall apply to the Health Bill:
Committal
(1) That the Bill shall be committed to a Public Bill Committee.
Proceedings in Public Bill Committee
(2) Proceedings in the Public Bill Committee shall (so far as not previously concluded) be brought to a conclusion on Thursday 16 July 2026.
(3) The Public Bill Committee shall have leave to sit twice on the first day on which it meets.
Consideration and Third Reading
(4) Proceedings on Consideration shall (so far as not previously concluded) be brought to a conclusion one hour before the moment of interruption on the day on which those proceedings are commenced.
(5) Proceedings on Third Reading shall (so far as not previously concluded) be brought to a conclusion at the moment of interruption on that day.
(6) Standing Order No. 83B (Programming committees) shall not apply to proceedings on Consideration and Third Reading.
Other proceedings
(7) Any other proceedings on the Bill may be programmed.—(Jade Botterill.)
Question agreed to.
Senior NHS Workforce Pay
Karin Smyth Excerpts(2 months, 1 week ago)
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The Minister for Secondary Care (Karin Smyth)
I am pleased to announce that we are publishing our response to the recommendations made by the independent Senior Salaries Review Body for the 2026-27 financial year.
I hugely appreciate the incredible work of talented staff across our NHS, and that is why I am formally accepting the headline pay recommendation of 3.0% for senior leaders across the NHS in England, to give them a well-deserved pay rise. This award relates to:
Over 3,200 very senior managers (VSMs)
Over 400 executive senior managers (ESMs)
These awards mean that the Government are delivering a well-deserved pay rise, on top of those in preceding years, underlining the extent to which we value our senior leaders. Eligibility for pay awards for VSMs is linked to their organisation’s performance as determined by the NHS oversight framework segment to which they are assigned: https://www.england.nhs.uk/publication/nhs-oversight-framework/
I am grateful to the Chair and members of the SSRB for their thoughtful consideration of the evidence presented to them. Their report recognises the vital contribution that NHS leaders make to our country. The SSRB has examined the economic picture and evidence on recruitment, retention, motivation and morale to reach their recommendations.
The SSRB made a further two recommendations, which are not directly related to headline pay. I recognise the challenge of recruiting those at the top of the Agenda for Change pay scale into VSM roles. To help address this, I am therefore pleased to accept the recommendation to deliver training and support knowledge-sharing for remuneration committees and chief people officers. However, we will do this over a longer timeframe than envisaged by the SSRB, to allow sufficient engagement with relevant stakeholders in the design and delivery of the training. Following engagement with stakeholders, we will deliver this training within this financial year.
I can also confirm that I am accepting, in principle, the recommendation to withdraw the very out-of-date executive senior managers pay framework. It is not feasible to withdraw and replace the framework ahead of April 2027. Any changes to ESM pay setting and reward will need to be carefully sequenced and considered alongside the ongoing DHSC/NHSE transformation.
We will continue to implement commitments to improve the support NHS staff receive and their experience at work. Ensuring the NHS is a great place to work is fundamental to improving patient experience: from reducing the backlog in elective care to ensuring timely access to GP appointments.
Next steps
We have listened to the workforce and understand the difficulties they face when pay awards are not delivered on time. I am pleased to be announcing the pay awards earlier than the previous year. We will continue work across Government to keep bringing forward the pay round for all public sector staff.
The SSRB report will be presented to Parliament and published on gov.uk.
[HCWS66]
NHS Pension Scheme: McCloud Implementation
Karin Smyth Excerpts(2 months, 1 week ago)
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The Minister for Secondary Care (Karin Smyth)
On 11 December 2025, I issued a written statement on the implementation of the McCloud remedy for affected NHS pension scheme members. I updated on progress in planning for the delivery of the remedy and reaffirmed my commitment to deliver the remedy to the coalition Government’s discrimination. I also committed to keeping the House informed of progress.
The NHS Business Services Authority has now developed and aligned its plans for the delivery of the McCloud remedy. An independent review, led by Lisa Tennant, has considered those plans and the NHSBSA’s capacity, capability and functions to deliver the remedy. Lisa Tennant is now preparing a final report, which I intend to publish in due course.
The independent review has found that significant progress has been made in the NHSBSA’s planning for the remedy, including the comprehensive analysis of steps that will need to be taken to provide each individual member with their remedy choice and to enact it. Given the level of complexities in the membership of the NHS pension scheme, this has been a substantial undertaking. The review also highlights a number of dependencies that are critical to delivering the remedy. These include:
Procuring external suppliers to bolster NHSBSA’s capacity to manually calculate remediable service statements for some members;
The release of software to automate statements as far as possible, enabling future retirees to make their remedy choice at the point of retirement, and to further automate calculations for members who are already retired.
I remain committed to setting deadlines that prioritise the delivery of the remedy to members who are likely to be facing financial detriment as a consequence of the discrimination identified by the McCloud judgment. The deadlines must be realistic and achievable. They must also ensure that the scheme’s ongoing performance is maintained and protected alongside the delivery of the remedy. I expect these dependencies will have advanced sufficiently, or been appropriately mitigated, to enable me to issue new statutory deadlines with confidence before summer recess.
Subject to the dependencies outlined above, the NHSBSA’s plans currently forecast that:
Retired members whose remedy period 1 April 2015 to 31 March 2022 benefits are still affected by the discrimination identified by the McCloud judgment—in that some or all of the accrual for that period is 2015 scheme accrual—should receive their remedy choice by the end of December 2027;
Retired members whose remedy period benefits are no longer affected by this discrimination—in that all of their accrual for the period is 1995 to 2008 scheme accrual—should receive their remedy choice by the end of June 2030;
All active and deferred members who are due a remedial pension saving statement should have received this by the end of March 2027.
I have asked the NHSBSA to take steps to communicate to members when they can expect to receive their remedy choice, and which deadlines, when issued, will apply to them.
The NHSBSA continues to issue remediable service statements and remedial pension saving statements in line with its delivery plans. To date, 10,462 remediable service statements have been issued to retired members who are most likely to be facing financial detriment. Of those, 5,804 have been returned and 5,368 decisions have been enacted. A further 11,457 have been calculated and are scheduled to be issued in alignment with the NHSBSA’s delivery plan. In addition, a remediable pension savings statement has been issued to 121,824 members, and 19,952 are outstanding.
[HCWS55]
Health and Social Care
Karin Smyth Excerpts(3 months ago)
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Karin Smyth
The waiting list for gynae care was north of 600,000 when we took office. Today that figure is finally moving in the right direction, but we cannot make as much progress as we would like because the system simply was not designed with women in mind…
Women’s health pathways are being prioritised in NHS Online, and menopause and menstrual health services will be among the first to go live when it becomes operational this year.
[Official Report, 16 April 2026; Vol. 783, c. 1049.]
Written correction submitted by the Minister for Secondary Care, the hon. Member for Bristol South (Karin Smyth):
Karin Smyth
The waiting list for gynae care was nearly 600,000 when we took office. Today that figure is finally moving in the right direction, but we cannot make as much progress as we would like because the system simply was not designed with women in mind…
Women’s health pathways are being prioritised in NHS Online, and menopause and menstrual health services will be among the first to go live when it becomes operational next year.