Karin Smyth
MP for Bristol South · Labour · United Kingdom
“Absolutely, and I am committed to working with my hon. Friend and many other hon. Members across the House. I was pleased to meet my hon. Friend the Member for Manchester Withington (Jeff Smith) to discuss his amendments concerning medicines.”
“As the hon. and learned Gentleman knows—we have spent many long hours in this place discussing the arrangements with regard to our leaving the European Union—there are different regulations, as a result of Brexit, between Great Britain and Northern Ireland.”
“They provide a clearer legal framework for the Medicines and Healthcare products Regulatory Agency to share information with UK health systems, organisations and trusted international partners.”
“I thank my hon. Friend for her best wishes and commend the work that she and many other Members are doing directly with their trusts to understand the impact of the work that we are doing to bring down those waiting lists and improve access for patients.”
“Member for Gosport (Dame Caroline Dinenage), who spoke powerfully on behalf of the whole House; I commend the work that she has done. My hon. Friend the Member for Kingston upon Hull West and Haltemprice (Emma Hardy) has spoken to me in great detail about this issue, as has my hon.”
“I will carry on. As the hon. Member for Sleaford and North Hykeham knows well, provisions are already in place to appropriately control access to puberty-suppressing hormones for children and young people presenting with gender incongruence or dysphoria. Children and young people with gender incongruence deserve evidence-based care.”
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“We want to make sure that we take forward the learning on both those points into the new body. The new framework ensures that the essential characteristics of safety investigations are preserved. The commission will have a flexible power to investigate qualifying incidents that have or may have implications for patient safety, with a clear statutory purpose of identifying risks and improving systems and practices. We are maintaining the principle of safe space and introducing strong safeguards in the process, so that staff and the public can trust that they can speak of their experiences openly, without fear or favour, to provide learnings for the system.”
“Of course, patient safety is what we need to get right. I will come on to that point, but there is a lot to get through with this clause. We can see its importance from the number of organisations and channels that exist. I have said that before, and I am sure we have all struggled as constituency MPs to support our constituents—either patients or staff—through the system and to understand the best route forward on patient safety. We all have the same aim, and we should be clear that the issue is how best to achieve that aim. My hon. Friend is absolutely right. The test is about impact, learning and making the system and the culture change. My hon. Friend the Member for Lewisham East asked me about confidence, and the fear that staff sometimes have about speaking up, which is obviously an important part of that landscape.”
“Through the passage of the Bill, many people in the wider landscape have said to me, “Why are you bothering having a row about this?” I find that quite shocking as a riposte, because the answer is simple in the context. It is too important to not attempt to get this right and make changes to something that clearly is not working. I do not think I have heard anybody say that the current system is working. As the right hon. Member for Melton and Syston noted, I said during the passage of the Health and Care Act 2022 that the functions of HSSIB are really important and must be built to the highest standard. I absolutely stand by that. It is not working; that is why we are changing it, but also why we are preserving the function within a new system, which we will seek to improve.”
“We will continue to take note of all the points made and seek to address them. I fortunately had the lunch break to reflect and do that a bit more carefully. For people here and those reading our deliberations, what is difficult about the Bill—we understand this as legislators—is that we are abolishing an organisation and moving functions. That stands within a wider framework of changes to the safety and quality landscape that the Government are seeking. When one focuses on things that are being abolished, it is very binary. I will try and locate some of that without veering too far from the matter in front of us. Among all the discussions, there are a couple of key questions that I want to address, including why I do this.”
“It is a pleasure to serve under your chairship, Ms Lewell. This morning, we had really good and detailed exchanges about patient safety and learning the role of HSSIB. Often politics is confrontational and divisive, but I want to be clear that I take at face value that every single Member who has spoken and who I have met with, including people who do not want to see this change, have the best of intentions. They want to understand patient safety—in the long term we can talk about safety and quality of service, but let us focus on the safety aspects here—and they are trying to navigate something. They are seeing a change, which is always difficult, and we need to ensure we get that right. It is absolutely right that we do that in Committee, on Report and in the House of Lords.”
“This is not a party-political point, but because of what has happened in the last decade, we must move from a defensive culture into a culture of learning while keeping a safe space in which people can speak up. We have heard a lot about “perception” today. I accept that there is a perception of negativity that is damaging to patient safety and people speaking up, but that is what our wider reforms are seeking to address.”
“Friend the Member for Birmingham Edgbaston (Preet Kaur Gill), made it clear that the rationale for this change is not based on cost. It is not based on the recommendations being too expensive. Rather, as I am sure colleagues will agree, we have seen far too many recommendations regarding patient safety but too little action. Inaction is not helping to improve the patient landscape. Opposition Members referenced the view from the longest-serving Health Secretary, the right hon. Member for Godalming and Ash (Sir Jeremy Hunt), that the NHS will not change or adopt the recommendations. That is a profoundly depressing prospect. We cannot predicate our laws and the health landscape on the basis that the culture in the NHS cannot and will not change.”
“It looked really closely at what has not worked and why. I encourage hon. Members to go back to the work that Penny Dash was asked to do and the wider report. The hon. Member for Farnham and Bordon and the right hon. Member for Melton and Syston asked why the review covered only six organisations. The then Secretary of State authorised the Dash review to look at six organisations in this space that were directly overseen by the Department. Many other organisations in this space are not directly overseen by the Department, so they were not in scope of that review as they had their own regulatory landscape ecologies and so on. That is why those six organisations, which we oversee, were looked at. Last night at the Dispatch Box, the Under-Secretary of State for Health and Social Care, my hon.”
“I am going to try to go through these points because I have listened carefully to everybody’s contributions. If there is something outstanding, I will be happy to come back to it. To answer some of the direct questions that were put to me about the Dash review, I do not recall anybody particularly disagreeing with its findings when it was published or when we put it forward in our 10-year plan last year. I do not expect everyone to agree with every single recommendation or point made in that review. To an earlier point that was made by the Opposition, it was informed by a broad range of evidence and perspectives from across the health and social care system, including engagement with commissioners, providers, patients, families, and people harmed by poor-quality care, as well as charities, academics and national organisations.”
“I thank my hon. Friend for that. He and others on both sides of the House with clinical experience, including the hon. Member for Sleaford and North Hykeham, have shared live examples that can shock the layperson. It is important that those practices are changed clinically, and it is up to Government to make sure that the overarching legislative framework enables that.”
“Transferring investigation powers to the Care Quality Commission is an opportunity to strengthen the CQC. We have to move away from a defensive culture to a culture of shared learning if we are to improve patient care. The CQC can learn and improve from HSSIB best practice and take a more holistic approach to patient safety. Those executing the regulatory and investigatory functions can learn from each other and exchange skills, which would strengthen the links between learning, oversight and improvement, leading to real and sustained change across the system, driven by the CQC.”
“For example, if the CQC is going round the country and spotting a particular problem with the way in which anaesthesia is being given or with managing patients post-surgery, the CQC could then say to HSSIB—that team of people with specific expertise—‘Can you go in and take a look at this? Can you do a detailed focus review of this particular area of care that we are spotting through our visits and which seem to be a particular challenge?’ It is that bit about enabling the CQC to identify a problem and then asking HSSIB to review it in detail, and HSSIB bringing its expertise in investigations into the CQC to enable the CQC to go deeper and then come back to the NHS”. –– [ Official Report, Health Public Bill Committee, 16 June 2026; c. 7, Q8.] to enable best action. These organisations can learn better from each other.”
“I want to make some points first. I will pick up any outstanding points I do not cover. The abolition of HSSIB and the transfer of its functions to CQC is being done to strengthen the link between patient safety investigations and the action being taken on the frontline to simplify the patient safety landscape. We want to align the recommendations with action. Hon. Members quoted evidence that Dr Dash gave to the Committee. Let me remind the Committee of something else she told us, about how HSSIB’s functions can be better aligned as part of the CQC. She said: “by bringing HSSIB into the CQC, you can align the work of the two.”
“I now turn to the wider point about whether both an investigatory and a regulatory function can reside in the same body. Many organisations have different functions and responsibilities that they have to discharge simultaneously; we have also heard a lot about the safety body, which of course is part of the Department for Transport. It happens across a lot of bodies. I totally accept that it would be helpful for the debate if we were clearer on what some of those bodies are, and we will come forward with more information on that.”
“No. There will be no barrier to investigating whether CQC inspections are causing unintended harm. If they are, and the investigator feels that a recommendation for change should be made, they will make it. The insight gained from investigations will continue to inform recommendations concerning the CQC’s regulatory functions, and the Bill allows for the investigation function to make recommendations to the CQC in its report. The CQC would be legally required to respond to such recommendations. There will be no need for litigation through the courts. That is an important point. Again, I am addressing the points made by Opposition Members. We will continue to set this out more clearly for Members. I am happy to find different ways to do that.”
“Amendment 56 would allow the Care Quality Commission to recover charges that are higher than the actual costs it incurs when providing assistance to anyone other than an NHS body or the Secretary of State. I understand the intention behind the amendment—to give the commission greater financial flexibility—but the Government do not think that it is necessary. The charging framework in the Bill is based on the clear principle of cost recovery. Removing subsection (9) of proposed new section 51R of the Health and Social Care Act 2008 would mean that the commission could charge more than it actually costs to provide a service, shifting away from recovering costs and towards allowing the commission to make a surplus through its charging powers.”
“The Bill already amends section 96 of the Health and Social Care Act 2008 so that it applies to the new CQC investigatory function. Section 96 makes provision for the application of CQC legislation to the Crown, which means that the mechanism that the amendment is seeking to introduce is already in place within the existing legislative framework. Additionally, the Bill already provides for a power which enables the Secretary of State to disapply these investigatory powers in relation to Crown premises when it is in the interest of national security. The amendment would therefore duplicate an existing provision and would add unnecessary complexity to the legislation without delivering any additional benefit.”
“I am going to persist on some of these arguments. I think I have addressed all the points made by the Opposition. It is the job of effective leadership to manage those interests and responsibilities, and that is what we expect of the CQC’s leadership. I will now turn to the amendments on this topic, which I thank the hon. Members for Sleaford and North Hykeham and for North Shropshire for tabling. Amendment 55 would make provision for the Secretary of State to disapply investigation powers in certain circumstances. I recognise the importance of ensuring that investigatory powers are not exercised in relation to sensitive Crown or Government premises where there is a national security interest. I want to be clear: the Bill already provides for that.”
“Under the amendment, governance arrangements would be fixed in statute, rather than having the capability to evolve as the organisation learns and develops. Those additional administrative and governance requirements would increase bureaucracy and complexity, which the Government are looking to reduce. I re-emphasise that, in addition, a statutory committee would weaken the important links between learning and the action that the transfer of this organisation is intended to support. One of the key benefits of bringing these functions into the CQC is the opportunity to strengthen strategic oversight and ensure that learning from investigations can more readily inform improvement activity across the system.”
“The Bill already provides a clear legislative framework for the transfer of those functions and enables the CQC to discharge them appropriately, within its broader statutory responsibilities. Furthermore, the CQC already operates within a robust statutory framework and is capable of establishing governance arrangements that support the effective delivery of its functions, including appropriate safeguards to protect investigative independence and the handling of safe-space material. The amendment would reduce organisational flexibility by mandating a specific committee structure, and would constrain the CQC’s ability to adapt its governance arrangements over time in response to operational experience, changes in circumstances or future improvements in best practice.”
“The Government have protected safe spaces in legislation, and we agree that operational independence of the investigation function is required, but our plans support and enable that. For that reason, we cannot support the amendment, which would impose a highly prescriptive governance structure on the CQC by requiring the creation of a separate statutory committee and setting out in primary legislation detailed requirements for its purpose, membership appointments and operational arrangements. While the Government fully agree that effective safety investigations must be conducted independently and objectively, we do not consider it necessary to put such detailed organisational arrangements in the Bill.”
“A non-legislative approach ensures flexibility, scale and adaptive function while maintaining robust oversight. I agree with the intention behind amendment 5, tabled by the hon. Member for North Shropshire, which is, as I understand it, to ensure that the Health Services Safety Investigations Body functions that are transferred to the CQC retain a high level of operational independence and continue to command the confidence—the Committee heard that word a lot this morning; I completely agree on its importance—of patients and their families, healthcare professionals and the wider public. Similarly, I understand that the objective of the amendment is to maximise the perception—again, that is a word I am coming back to; I tried to address the issue earlier—of independence in the CQC.”
“Robust financial oversight will require the CQC to demonstrate that grant in aid is used appropriately, and solely to support the investigation function, without the need to prescribe funding arrangements in legislation. As there is already an operational mechanism for the Secretary of State to provide adequate funding and resources for investigations, the new clause is not needed. It would also be inappropriate to prescribe the form or level of funding in legislation. The new clause would reduce the Department’s ability to manage funding through the established spending review and estimates process; introduce unnecessary rigidity as the merged function evolves; and risk creating binding funding expectations that may not align with future fiscal constraints.”
“New clause 42 relates to funding provisions for the CQC’s new investigation function. The Department already provides grant in aid to the CQC to provide adequate funding for investigations and special reviews; similarly, HSSIB’s budget is provided through grant in aid and is set each year. When the CQC takes on HSSIB’s functions, the funding streams will remain distinct, and the CQC will have to assure the Department that the amount allocated to the new investigation function is being used for that purpose. Funding decisions for the investigation function will continue to be captured in wider departmental budget-planning processes and considered centrally. That provides assurance that business and strategic priorities for the investigation functions can be met.”
“I am happy to get back to the hon. Lady on that specific point, if that is the case. The charging framework is about recovering costs, not making a surplus, which is what the amendment would result in. If that is not the case, I will make sure that she receives a proper correction. The Government do not think that there is a good case for the amendment, because, as I have said, the aim of the provision is to provide for fair and transparent cost recovery, not to raise extra income beyond cost. I am not sure whether the hon. Lady is suggesting that it might be good for the commission to create additional funding, but if that is not clear, I am happy to get back to her on it. The provision makes the recovery of costs more predictable and consistent for those who have to pay them. That is usual for public bodies.”
“We will of course work closely with both the CQC and HSSIB on their transition arrangements through a transition board, whether on the issues of ensuring operation independence of the investigation function and the ways in which that learning is shared, or, further to the Opposition spokesperson’s point, how we make sure that learning is shared and creates an impact, and where that is felt most clearly. For those reasons, I ask hon. Members not to press their amendments, and I commend clauses 59, 60 and 61 to the Committee. Question put, That the clause stand part of the Bill.”
“We believe the integration of investigatory functions can be secured through clear statutory functions and appropriate safeguards, rather than through organisational structures set out in primary legislation that are too rigid. Establishing detailed governance requirements in statute may also make future improvements more difficult to implement without legislative change. I understand and respect the concerns that underpin the amendment, but the Government believe that the Bill already provides the necessary framework for the safe and effective delivery of health services’ safety investigations following their transfer to the CQC.”
“We are probably not going to agree on this point. I have made the point several times—and we made it in the Dash review—about bringing these organisations together. As I said again in my opening comments, it is about the opportunity to get this right and share that learning and experience. It is not about the cost but about aligning the recommendations and the actions that follow through from them. That learning, and the opportunity to push that through, is something we should grasp. Coming back to amendment 5, creating a separate statutory committee risks introducing additional layers of separation that could slow the flow of intelligence and impede timely action in response to emerging patient safety concerns.”
“This approach will also provide important flexibility: as commissioning arrangements change, the right function can be brought into scope without unnecessary delays. Taken together, this clause will protect the CQC’s independence, maintain accountability and provide a sensible framework for scrutiny where it adds real value for patient safety and care quality. I commend the clause to the Committee.”
“The scope of the special reviews and investigations will continue to apply only to commissioning functions under the National Health Service Act 2006 or section 117 of the Mental Health Act 1983, which is the CQC’s existing remit. This approach will ensure that the CQC’s investigatory powers will not be automatically extended to departmental functions, which would fundamentally change the relationship between an arm’s length body and a Government Department and would not align with the original intention of section 48 reviews. For that reason, the Bill will provide for scrutiny through secondary legislation. That will set out a transparent and accountable way to specify which commissioning functions are in scope, enabling parliamentary scrutiny and CQC oversight where it is genuinely relevant to patient safety and care quality.”
“With NHS England being abolished and its functions being transferred to the Department and across the wider system, this clause will remove NHSE from the scope of section 48 and allow Ministers to set out, through regulations, the future scope of section 48. NHS England’s commissioning functions will mostly transfer to the integrated care boards but, as we discussed previously, NHSE’s most specialised commissioning functions will transfer to the Secretary of State. In future, regulations will set out the specific commissioning functions that the Secretary of State will be responsible for and that the CQC may review or investigate.”
“Clause 62 underscores the importance that we place on special reviews and investigations, and it will maintain the Care Quality Commission’s ability to conduct them by ensuring that the CQC’s investigatory role remains properly aligned with its original statutory purpose. The CQC is the independent regulator of health and care providers, and in the case of commissioners, it has the powers to undertake a special review or investigation when requested to by the Secretary of State. On 30 January 2024, the then Secretary of State, the right hon. Member for Louth and Horncastle (Victoria Atkins), commissioned a section 48 review into mental health services in Nottinghamshire following the tragic events of June 2023. As we know, that revealed serious and systemic failings and led to strengthened oversight and a clear improvement plan.”
“My understanding is that the clause will not change that particular power, but I will get back to the hon. Lady if I am wrong. Question put and agreed to. Clause 62 accordingly ordered to stand part of the Bill. Clause 63 Time limit for bringing proceedings Question proposed , That the clause stand part of the Bill.”
“For example, the CQC may only receive information about an offence two and half years after it was committed, leaving little time in the remaining six-month period to investigate. Extending the period to five years would help mitigate such circumstances, and that is why we are extending the statutory limitation period. This will ensure that the CQC has the ability in far more cases to address the serious regulatory failings that it should and must address, without risking falling foul of a time limitation. I therefore commend the clause to the Committee.”
“The coronial process serves a different purpose. A coroner’s role is to establish facts surrounding an unnatural death rather than to find fault. In a complex case, a police investigation or a coroner’s inquest—sometimes both—can take time to conclude. Those independent processes are a useful source of information for the CQC to form a full picture of a breach of regulation. A culture of learning from investigations, inquiries, errors and poor care should be the norm in the NHS. It is therefore expected that a service provider may also commission its own internal investigation to learn from an unnatural death. Furthermore, there are cases where the CQC is approached late with information after an offence may have been committed.”
“Let me be clear: extending the three-year limitation from the time of the offence will not alter the first requirement that the CQC should act within 12 months of sufficient evidence of a serious breach of regulations becoming available. That 12-month window for action once the regulator is aware of the offence will remain unchanged. Extending the limitation period to five years from the date of the offence will mean that fewer events that should be considered by the regulator will effectively time out and go beyond the reach of the regulator’s action. The CQC is not the only body with an interest in investigating serious breaches of regulations that result in unnatural death; there are other investigatory bodies, such as the police, with equal interest and powers to investigate deaths for the purpose of pursuing criminal prosecution.”
“The 10-year health plan reaffirms the Government’s commitment to families affected by bereavement or serious harm, ensuring that lessons are learned from their experience and that more cases are fully reviewed and acted on. Families seek closure following serious harm to or the death of a loved one by wanting to understand what went wrong and what could be done to stop other families experiencing similar trauma, and by wanting to hold someone to account. Families often turn to the Care Quality Commission for help. Clause 63 will extend the CQC’s power to bring proceedings against a health and social care provider for a serious breach of regulations from the existing limitation of three years from the date of the offence to five years.”
“Put simply, the answer to the hon. Lady’s questions is that we are not seeking to change other aspects. The CQC wants to get to points as soon as possible, so the 12-month period has not been changed. The function of clause 63 is merely to recognise the issues around the three years and to change that to five years. We are not seeking to alter anything else in that regard. On her point about the commencement date, that is merely recognising what is considered to be parliamentary convention. Question put and agreed to. Clause 63 accordingly ordered to stand part of the Bill. Clause 64 Abolition of Healthwatch England Question proposed, That the clause stand part of the Bill.”
“This is a popular clause, Ms Lewell—and rightly so. I recognise that this provision has elicited a lot of interest among our constituents and the wider public. I look forward to hearing Members’ contributions.”
“It has to focus on the voices that are too often overlooked. The central priority of the directorate will be to reach under-represented and seldom heard groups and to ensure that engagement is accessible, inclusive and proactive, so that the experiences of vulnerable people help inform and shape the decisions that affect their lives.”
“By coming inside the organisation, it has done exactly some of the things we want to do: drive cultural difference and change inside the organisation, rather than being outside of it. As I said before, this is a slightly philosophical argument and political argument. I appreciate that there are views on either side, but that is absolutely our intention. On the patient experience directorate, we recognise that public trust will be crucial. We need to ensure that there is system learning across the piece. The patient experience directorate has to earn the trust of the public and parliamentarians, so we will design it to operate transparently and sit at the centre of decision making rather than at its margins. Ministers will be accountable for and answerable to Parliament on the work of the patient experience directorate.”
“Again, I commend work on that and the individuals involved in it. Hon. Members mentioned Jacob Lant of National Voices and the King’s Fund, which have worked with us very well to challenge us and try to make this legislation better. I really appreciate their work, and we will continue to talk with them. The hon. Member for Farnham and Bordon mentioned GIRFT. I cannot help but respond to his point, because he suggested that being inside NHS England has somehow made it less effective, and I could not disagree with him more. It is not because he has left and is here; his presence is obviously missed at GIRFT and welcomed here. To be serious, every meeting I have with NHS England and everything we are attempting to do in reforming outcomes for patients on the ground involves GIRFT. It is now at the very heart of what NHS England does.”
“That is also true of other areas that have experienced shocking scandals, as we call them. I take that very seriously. I will pick up on the question of independence that we veered into before, which was mentioned by the hon. Member for Sleaford and North Hykeham. She highlighted her concerns and the issues raised by my right hon. Friend the Member for Makerfield, and I heard what she said. Independence was also raised by the hon. Member for Winchester and my hon. Friend the Member for Lichfield. We therefore return to that point about independence and, as my hon. Friend said, about being in the room, making those decisions and changing the entire culture of the organisation to do something different. The question is then whether bringing the functions of Healthwatch to the national level is the right method.”
“I think that the record will show that I have taken several interventions in recent days, and I will continue to do so. I have been very clear that we have some fundamental disagreements on philosophy and approach. I will desperately try not to veer into the next groups, but it may be tricky. I am sure that you will steer me through, Ms Lewell. I want to pick up on some good, helpful points that have been made. I pay particular tribute to my hon. Friend the Member for Lichfield for the comments he made. I appreciate that certain areas, particularly Mid Staffs, have elicited a lot of debate and concern. I commend him for following that through on behalf of his constituency. I know that other Members in Staffordshire want to understand how the Government’s future plans will address their very real concerns.”
“That is an important way of ensuring that the Department and the new experience directorate will be accountable. I recognise the important contribution that Healthwatch has made in capturing patient insight and informing the design and delivery of services, but we do not believe that new clause 78 is necessary. It is inconsistent with the purpose of the Bill. I am aware of the views of the hon. Member for North Shropshire, but the Government’s policy is to abolish Healthwatch and ensure that patient and public voice is more directly connected to decision making. It would therefore not be appropriate or consistent to legislate for a specific funding level for organisations that would no longer exist, or to constrain how funding is deployed to support the new arrangements.”
“I thank my hon. Friend for making the intention of her comments clear to the Committee. It is right that we need to build trust in patient voice and experience. We will pick up on that in our debate on local healthwatch branches, because that is perhaps where Members of Parliament are particularly important. At a national level, there are many voices and organisations continuing to review the issue and challenge the Government, including through reports, meetings with Ministers and in Parliament, highlighting the good work that they do and numerous Committees. Health Ministers appear before the Public Accounts Committee, the Health and Social Care Committee and Lords Committees; I have appeared before the Science, Innovation and Technology Committee.”
“I understand. I am grateful to the hon. Member for that clarification, but her new clause represents an incomplete picture of Government funding for Healthwatch. A £14.15 million grant has been provided to local authorities for local healthwatches, and that is only part of the overall funding; a larger proportion is rolled into the wider local government financial settlement, and because that is not visible as a distinct line, headline figures often understate the total funding available. All of this funding is not ringfenced.”
“Bringing the patient and community voice closer to the organisations responsible for improvement—it is actually their job as commissioners—will help to make feedback more actionable, reduce confusion and support better services. I commend the clause to the Committee.”
“We know exactly where they live, who they are, how old they are and what sex they are. We know largely what diseases they have. We know their level of income. We know their levels of education and attainment, and how they impact their health outcomes. They are not hard to reach; the system is not set up to listen to them. That is what we are determined to change. Dr Penny Dash’s review of patient safety described a cluttered landscape, with overlaps in how user experience and advocacy are organised. It described the burden that that can place on the frontline, producing multiple, poorly co-ordinated asks with limited impact.”
“Friend the Member for Lichfield said, the people are in the room. It makes it easier to connect lived experience to priorities, quality improvement and the tackling of inequalities, rather than leaving intelligence at arm’s length from decision makers. This is about strengthening impact, not silencing criticism. Integrated care boards and local authorities will have a statutory duty to demonstrate how they have engaged with all people in their area, including seldom heard groups, and will be expected to have clear routes for people to raise concerns. We expect transparency about what people have told the system, what the system has done in response and how learning is shared across partners. As I said in my evidence, many constituents in my Bristol South constituency are said to be hard to reach. They are not hard to reach, in my view.”