Helen Morgan
MP for North Shropshire · Liberal Democrat · United Kingdom
“In 2022, we welcomed the first women’s health strategy, which promised to “listen more carefully to women, close gaps in care, improve research and tackle inequalities.” Those were all vital goals, but three years on, the problems remain stubbornly in place: long waits for gynaecology treatment, patchy access to services, women reporting…”
“I thank the Minister for outlining the existing statutory framework. I agree that it ought to be sufficient, but there are high-profile instances where it has not been, so I look forward to hearing more from her on Report about how the cultural change will be implemented so that further legislation is not necessary.”
“There is significant vaccine hesitancy across some ethnic minority communities and in hard-to-reach places across the country. We must do more to support doctors, nurses and the NHS to fight fiction with facts, or the long-term health of the country will suffer. That is what new clause 77 seeks to do.”
“May I associate myself with the Minister’s comments and thanks to everybody who has been involved in working on the Bill? I have also enjoyed my time on the Committee, despite the heat.”
“Some pockets of the population have been left unable to get an NHS dental appointment. The action taken so far by the Labour Government has not been good enough, but the fault for this dire situation lies solely at the door of the Conservatives. Their years of neglect have left our dentistry in a shocking condition.”
“New clause 36 would introduce a mandatory individual duty for members of NHS trust and NHS foundation trust boards to escalate evidence of systemic medical malpractice to the Care Quality Commission, the Department of Health and Social Care and the Health Services Safety Investigations Body.”
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“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.”
“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.”
“Q I re-declare that I am a member of the all-party parliamentary group on patient safety. We have heard this morning about a tension between needing to be able to report when something has gone wrong that HSSIB has become aware of to ensure that it is dealt with—the example given by Dr Dash earlier was a maternity failing—and the importance of a safe space, so that people can report to HSSIB when something has gone wrong and then HSSIB can make the appropriate recommendations to change the problem within the system that has led to that issue. Can you talk a bit more about that tension? What is the best way to manage that? Dr Benneyworth: First, we do not replace local investigations. If something goes wrong, the local teams are very much responsible for investigating their work.”
“Q What could be changed in this legislation to ensure that HSSIB can retain trust and independence from the regulatory body? Dr Benneyworth: There needs to be much more clarity about governance and how that will work in the legislation to protect independence. There are potential compromises that could happen, such as a Healthwatch-style model that has its own independent leadership within the CQC, its own governance arrangements and, importantly, its own identity. That would enable it to keep its independence, while being part of a larger organisation. In the legislation, it is vital that there is a legal duty for the CQC to protect safe space.”
“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.”
“Q I am a member of the all-party parliamentary group on patient safety, and one of the things we have heard is that the idea behind HSSIB and the air accidents investigation branch is, in the long run, to reduce the need for public inquiries to save money. Can you elaborate on that a little bit? 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.”
“Q As a former Secretary of State for Health, what are your reflections on the abolition of Healthwatch and the absorption of its functions into the Department of Health, ICBs and local authorities? Sir Jeremy Hunt: It is not dissimilar to my earlier reflections. It is really important that patients have a voice, but it is even more important that their voice is heard not just through a bureaucratic process that listens to them, and gives them a sense of being listened to, but then nothing happens. The problem with the Healthwatch structure we have is that it is very good at the listening bit, but I do not think people have confidence that things actually change.”
“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.”
“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.”
“Q I am a member of the all-party parliamentary group on patient safety and I am also a vice-president of the Local Government Association. 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.”
“That will mainly be about relationships on the ground between an acute hospital team, a community services team, a mental health team and a social work team. The role of ICBs is very much to give the contractual tools and mechanisms to local NHS organisations to work effectively with their local authorities so that there are really good neighbourhood health plans. Most importantly, they should not just write them but actually see them through.”
“From my experience of delivering meaningful collaboration and joint working between health and local government, I think it tends to happen at a more local level than that. The neighbourhood health plan in the Bill becomes extremely important. As a system, we should be very ambitious for those neighbourhood health plans. They should go a lot further than just describing what should happen in terms of improving health outcomes at a local level. We should set an aspiration as a system that there should be a responsibility on health bodies and local government bodies to describe how changes will be made. The role of ICBs is to enable groups of providers and other organisations in local areas—most ICBs will have several places—to come together and not just work out what a local population needs, but actually do it.”
“As a representative organisation, we have to say to people, “We hear you saying that you really believe in this. Therefore, you need to demonstrate, not least to the Secretary of State, that you are following it through.” I have a small additional point about mayors in unitary authorities being able to appoint somebody who is both the chair of the ICB and the local health commissioner. That should help. Those individuals will have to work out how to serve two masters, but that is okay—other people learn how to do that, too. James Blythe: I would focus on a slightly different part of the Bill in terms of how this needs to work. There are 25 ICBs; that is quite a large footprint.”
“Q My second question is similar. In reality and in practice, how do you envisage ICBs will be locally accountable once these legislative changes have taken place? Sir Ciarán Devane: According to the ICBs we are talking to, which is all of them, they are saying that they believe in local authority engagement. We will be saying, “You may not be told you have to, but we would encourage you to do it.” I am sure that should be coming from the Department as well. The witness to my right is an example of that; we know that when the NHS has really good local connections, you can get things done in the interests of your patients much more easily. The belief is there, but we need to make sure that the legislation is not seen as a signal that this is unimportant. That is a risk.”
“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?”
“Q Sarah, the Patients Association has said that it is concerned about this reorganisation distracting from patient priorities. Could you elaborate on where those concerns come from and what should be done to mitigate that? 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.”
“It would be easy to remedy that, in the sense that if the funding were more equitable, some of that variation would disappear, but the variation is not in the quality, the effectiveness of the listening or the ability to look thoroughly at the impact, and it does not affect the fact that the organisations concerned are held responsible for what happens to the recommendations in terms of implementation. That is uniform across the system—it is just the amount of it that will vary naturally, because of the differential funding.”
“One of the things that I have encouraged very strongly—although it happened before I joined Healthwatch—is the use of qualitative as well as quantitative data. The system is awash with quantitative data, but that does not necessarily cut through to the way that people are, the way they think, the lexicon they use, the concepts they use in communication etc. One of the great strides that Healthwatch England and our 153-member network have made is the intelligent use of qualitative data. That is an art in itself—I would like to think that is a science, but it is certainly an art.”
“Q My second question is about Healthwatch. The Committee heard this morning about the variability of Healthwatch’s effectiveness at a local level. What could be done to ensure that the best and most effective Healthwatch practice is rolled out across the whole of England? Professor Croisdale-Appleby: Thank you for that question. One of the reasons there is a difference or variation among the 153 is that the amount of funding is very different. Some of them get 10 times the funding of others, which makes a difference to the scope of what they can do. What it does not allow—and I think Healthwatch England has an important contributory role in this—is a change in the quality of the way in which the research is done.”
“I am really concerned that that will become even more problematic because they cannot work together, given that we are not a combined mayoral authority, that we will not have a mayor sitting on our ICB and that our ICB merged footprint does not fit with our local authority geography. How can the health and wellbeing boards work between the two organisations to deliver good social care?”
“Q I am a vice-president of the LGA, and I am also on the all-party parliamentary patient safety group, just to declare that interest up front. I will use the example of my own local authority, Shropshire, which is a unitary authority. It is extremely financially challenged and operates with an ICB in a similar situation. The hand-off that Sally described between continuing healthcare and provision of social care is really problematic because neither organisation really wants to pay for the care for the people who need it because they do not have the funds. It is a really tense relationship between the two.”
“Health and wellbeing boards might not match neighbourhood health geographies, so there are also some challenges in working out how that will work.”
“Although, as local authorities, we want to help with prevention and those wider determinants of health, ultimately the responsibility sits with the NHS. It is about trying to work out how we have better conversations with the NHS, to say, “We have done neighbourhood health for years; this is what we do as local authorities. We look at all these things and we use public health and our adult social care system to create healthy environments. We need you to be on board with us.” I therefore think there is something about the power dynamics regarding health and wellbeing boards and how we address them. But overall, I feel that they are the best way of ensuring community health. The other thing is about geographies.”
“Q Do you think that the health and wellbeing boards, as envisaged by the Bill, will be the right structure to deliver those relationships, and how do you ensure that they have the right skills? Councillor Wright: I chair a health and wellbeing board, and everyone comes to those; there are really good conversations and really good reviews of what is happening. I think they are in a really good position. What I worry about is how much influence they will have over NHS wider strategy. I was at a King’s Fund day, and someone said something that I thought was so true: the Health Bill and the NHS 10-year plan is the NHS 10-year plan. The NHS will be judged on how it achieves what it is meant to achieve.”
“We also need to be explicit about listening to carers, not just on behalf of the patient, but by asking, “What is your experience as a carer of managing this care?” because that is very different. To be honest, I do not think we have the right data flows behind that to collect and understand people’s journeys and improve things. I hope that that is also something that will be looked at.”
“Those are strategic duties. The reason why that is important, to be very specific about carers, is that they provide £152 billion-worth of care. They outnumber staff three to one. They are experts in care over time and they want to be involved. Of course, what colleagues have said about good practice is critical to look at. The changes to Healthwatch—others have raised this—do not consider the person’s journey across different services, health and care. There is an independent voice that we do not have, and will not have, in quite the same way. A very small proportion of carers felt that, if they raised a complaint, it would be acted on. That kind of independent voice is actually very important. As Kath said, those duties are really important, but we need top-to-toe listening to patients.”
“They need to have enough time. As Paul said, you need those patient voices involved in overseeing how things are going, and able to contribute and help. The Bill itself, as a mechanism, will not do enough. This is about designing it carefully with patients in mind and, in the case of maternity services, involving women right from the start. Emily Holzhausen: There are provisions in the Bill that transfer responsibilities from NHS England to the Secretary of State in relation to involving patients, and it is very explicit that this also involves carers. It is very important that explicit Healthwatch duties to involve carers have been transferred into the Bill in relation to integrated care boards. That matters because their portfolio of commissioning different services is increasing, as is that of local authorities.”
“She was saying it appears to be quite a small thing, but every time she went to see a clinician, they said, “Oh, you’ve had four losses” or “You’ve had three losses.” It was about them not understanding, and her having to correct her records and getting letters through. It is about that sense of not being listened to. As we develop the Bill, women and birthing people, from a maternity perspective, should have the opportunity to contribute to the way something like the single patient record is shaped. You could have a digitally accurate system that did nothing to reassure women or help them feel looked after or listened to, or you could have a beautiful system where the information was recorded in such a way that it really helped. Alongside that, clinicians need to continue to receive the right sort of training.”
“For example, how do you make sure that patient voice is heard at ICB level, in providers and, in particular, in the new world of neighbourhood health? Kath Abrahams: Helen, it is a great question. Clearly, the Bill itself, and certainly the single patient record, are never going to replace wonderful, kind and compassionate care where people feel they are listened to. As I have already said, but I will say again, a combination of people not being listened to at all, despite knowing their own health better than anyone else, or having to retell their stories has very challenging consequences. Both leave somebody feeling that nobody really cares or understands them. I spoke to a supporter of Tommy’s this morning who has had five miscarriages.”
“Many people were fans of what Healthwatch delivered, and others were not, but it had a clearly established system and mechanism in place to ensure that patient voices were heard. It is important that clear systems are established to ensure that that patient experience is heard. I have operated around the health system for a number of years, seeing a number of incarnations of patient voice organisations and representation; you really have to think about it from the individual and the whole-system level—from top to bottom. It is important that the Committee looks at the provisions in the Bill in that context to make sure that where there are good supports, they not only are preserved but can be built on.”
“Q We have talked a lot about the single patient record, but I want to touch on whether the Bill does enough for people who have historically not been listened to, as we have heard has been the case for carers and women who have suffered in the maternity system. Does the Bill deal with the problem of people not being listened to? What opportunities are there to improve the Bill in a way that improves the situation? Paul Farmer: Listening to patients is an incredibly important part of any health system. It is necessary to make sure that the right mechanisms are in place at both the individual and the systems level. The aspects of the Bill that cover patient experience need careful consideration.”
“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.”
“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.”
“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?”
“Q I think everyone is agreed about the transformative potential of the single patient record, and we have heard various concerns around privacy and the types of use. I am interested in how all these different systems can speak to each other, because, in my experience as an accountant, you can have interoperability, but if the data that you are interoperating with is not consistently curated, you have a problem, because you have something that looks the same for everybody, but that actually means something very different to each person who inputs that data. 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?”
“In a digital-first NHS, it is really helpful to think continually about what the analogue version of the system is in the event of further cyber incidents and outages of the system. We need to continually build and maintain a resilient system for the times when digital-first is not available. It is an important opportunity to do so if we think about that question of exclusion.”
“From my previous NHS England experience, where we have had digital innovations implemented in the older age group, or among those who are perhaps traditionally digitally excluded, that has included partnerships to enable people to have the option of someone coming around, and there has been a thought process regarding people who perhaps cannot engage with technology as easily. That could involve people from the voluntary, community and social enterprise sector—for example, we had Age UK in the previous panel. There are lots of good examples of that type of work to ensure that people are not disadvantaged. Dr Byrne: There is an opportunity here in the context of digital exclusion.”
“Q My other question is about digital exclusion. This is particularly for Dr Imam, because we associate older people with being digitally excluded, although I know it is not exclusively older people who are digitally excluded: how would you envisage the digital record interacting with something more analogue for people who cannot use the NHS app for whatever reason? Dr Imam: That is a really important question; it is something that needs to be thought about very carefully when it comes to the implementation.”
“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.”
“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?”
“Q I will ask about the additional responsibilities that the Bill confers on ICBs. There are additional commissioning responsibilities and an additional requirement to look after what was Healthwatch—the patient voice element. As you have described, you have lost a large number of staff, you have a bigger geographic footprint and you have also lost quite a lot of budget. What do you stop doing, and what is being transferred out to other provider organisations? If the role of such organisations is changing to include some things that the ICB was doing, does that need to be clarified in the legislation? Jon Restell: It certainly needs to be clarified. Whether it needs to be clarified in legislation, I do not know.”
“That really needs to be thrashed out: is that the new democratic accountability for health services, or does it remain, as now, with the Secretary of State, accountable to Parliament, making provision for healthcare? It feels a little unclear how much decision-making power those new local government voices will have on ICBs. Have people raised that as a concern? Of course they have; it is uncharted.”
“Q If I may ask a related question, one element of the Bill is the reorganisation of who sits on the ICB. We have seen the removal of local authority representatives and their replacement by a mayor or his or her appointee. What concern does that cause to your members—or do they think that is the right way to go? Jon Restell: A lot of the concern is to do with the political make-up of mayoralties in the future and what that might mean; if mayors have an ever-growing responsibility and say in the who, what and where of health services, that is probably different from the more representative, advisory function that they have had.”
“It is some of the system stuff, where I think a lot of our members would say the innovation will come in the way different organisations try to solve problems around patients and populations, that they feel is at risk, by the way—not just from the Bill putting things together, but from the stripping out of resource to do anything different.”
“Q I am a vice-president of the Local Government Association. With changes to the better care fund pooling and the link-up with local authorities, are there concerns at ICB level that the partnership with social care will start to become more difficult? Jon Restell: I cannot comment specifically on the BCF, but a general theme coming out of what our members are telling us in surveys, and in the regular surgeries and meetings that we have with them, is the sense that policy at the moment is trying to get you thinking in terms of your own organisation again, and thinking less about system-wide transformation, innovation or co-ordination. ICBs are getting bigger and providers are getting bigger.”
“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.”
“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.”
“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.”
“Q You just used the phrase, “instrumental damage to the NHS”. Can you elaborate a bit on that, and perhaps explain how the NHS might be able to function better if there were a mechanism within the Bill to sort out social care? 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.”
“The fact that it is dementia and severe arthritis means we have drawn an arbitrary line, and while that line still exists and there is still inadequate funding, even in a means-tested system, we are hamstringing the NHS. Now, that is not the most important problem, which is that we are failing to give people flourishing lives and allow them to live to the full, but it is now so bad that it is actually making it hard for the NHS to work.”