Briefing: Health Bill – House of Lords, committee stage

Despite pledging not to restructure the NHS, the government has embarked on a major top-down reorganisation of the health service. Evidence shows that NHS reorganisations cause widespread disruption and rarely deliver the benefits expected by ministers. While there is logic in bringing the workings of NHS England and the Department of Health and Social Care (DHSC) closer together, the government is yet to set out what the new operating structure for the NHS will look like and how it will work in practice. This is causing huge uncertainty for staff and is detracting from the focus needed on improving patient care.

The bill also transfers a long list of powers from NHS England to the Secretary of State – including on workforce planning, digital and data systems, oversight and regulation of local NHS bodies, and more. It also creates several entirely new powers for the Secretary of State, for example the broad power to direct NHS Integrated Care Boards (ICBs) in the exercise of their functions and new powers over foundation trusts (FTs).

Accountability for the health service will always rise upwards to ministers in a tax funded health system and it is right that they set strategy and direction for the NHS. But the bill hands ministers too much responsibility for its day-to-day management. Transferring functions from NHS England – an arm's length body with a defined statutory remit – to the DHSC – a government department with a far broader role – may also reduce clarity and transparency about how these functions are exercised in practice.

Two particular areas require additional safeguards to reduce the risk of excessive political interference and keep policy processes at arm's length from politicians:

1. Local appointments: appointments of chairs and non-executive directors of local NHS bodies (who appoint their chief executives) have been managed at arm’s length from politicians since 2001 via an appointments commission and then arm's length bodies. Under the bill, they will now fall to the Secretary of State, creating the risk of appointments being tainted by political bias.
2. Data and digital infrastructure: under proposals in the bill, the DHSC will be made responsible for digital and data functions like national data collection, publishing performance data, and the operation of national information systems. Stronger separation of these functions from politics may help ensure independent reporting of performance data and maintain trust in the infrastructure needed to run large national data systems over the long-term. Some of these functions have been held at arm’s length in the past and this could be considered again (for instance, through a special health authority, which measures in the bill would allow).

The bill also hands broad new powers to the Secretary of State and the DHSC to direct and intervene in ICB decision-making (with only limited exceptions, such as individual clinical decisions or interventions on drugs and treatments that would be inconsistent with National Institute for Health and Care Excellence (NICE) guidance). It also includes new powers to intervene in the decisions of FTs, including the ability to cap revenue spending (while NHS England has the power to limit capital spending, revenue spending is currently under FT control) and powers to deauthorise ‘failing’ FTs and convert them to NHS trusts.

The NHS in England is – by design – a highly centralised health system with a strong degree of political control and national oversight. Throughout its history, national policymakers have embraced rhetoric on devolution and localism, yet central grip appears to have strengthened over recent decades – not diminished. The bill appears to exacerbate the trend towards greater centralisation at the expense of local autonomy.

The bill also needs to be considered alongside the government’s wider devolution agenda. The English Devolution and Community Empowerment Act 2026 strengthens the role of Mayoral Strategic Authorities (MSAs) in improving health and reducing inequalities, including through a new health improvement duty, health and wellbeing being made a core competency of MSAs and greater powers to convene partners. 

The Cabinet statement ‘Rewiring the State’ sets out a major transfer of powers, resources and functions from central government to elected mayors and local authorities, and pledges more local democratic control over public services, including health. There is a tension between greater centralisation of NHS accountability in the bill and the government’s wider devolution agenda intended to give local and regional leaders greater responsibility and flexibility to improve health, reform public services and support inclusive growth. 

The bill goes too far in centralising power in the hands of ministers and risks undermining the government’s commitment to devolve power in the NHS. Ministers need to do more to articulate the benefits of handing such extensive powers to the Secretary of State and set out safeguards for how they will be used. More broadly, there is a tension between the extension of ministerial power in the bill and the government’s wider devolution agenda. 

The bill includes powers to establish a single patient record (SPR) – bringing together existing information on people’s health and social care use into one place. We support the aim of joining up data to improve patient care and it is positive to see some consensus among the political parties for the need to create a single patient record. Patients and staff are frustrated with the current system, while patients often have to report their story many times to different health and care professionals. 

Plans must avoid the fate of past national NHS IT programmes, which often failed to win public trust or be realistic about implementation challenges and timelines. Currently, detail on how the new record will look and work in practice is thin. Key questions government will need to answer to build trust in the proposals include:

1. How the SPR will work in practice – for instance, how it will tackle the existing fragmentation and poor data quality in local systems, what data standards will be set, who will enforce them and by when, and what funding and support will be on offer to support implementation. The challenge of implementing complex IT systems has often been underestimated, as has the scale of investment required.
2. How data will be accessed and governed – for instance, who will be responsible if things go wrong (will GPs continue to be liable for data they may no longer control?) and what safeguards will be in place to ensure data isn’t used in ways that could harm public confidence or go beyond the stated aims of the legislation.
3. How the public and NHS staff will be involved in the process. Ultimately, trust from patients, staff and the public will be essential for the plans to succeed: do people trust that the system is able to protect their data and use it to benefit the public, and do clinicians trust the systems and safeguards in place for appropriate use? Measures elsewhere in the bill  to bring digital and data responsibilities into the DHSC may undermine the trust needed to deliver. Our recent polling data suggest the public trusts the NHS more than the government with health data.

While the ambition to join up health and social care data to improve patient care is welcome, the government needs to provide greater clarity on how its proposed single patient record will work in practice – including how it will bring together fragmented local systems and how data will be accessed and governed. It will also be essential to build trust among patients and staff. Involving the public early to ensure their concerns have been heard and addressed will be critical.

The bill proposes removing the requirement for NHS foundation trusts to have councils of governors – a policy originally intended to boost accountability to communities, rather than central government. The government also currently plans to abolish Healthwatch – the independent organisation that operates nationally and locally to gather patient and public views.  

The experience of Healthwatch has been varied and its impact hampered by budget cuts and a power imbalance with the NHS. But scrapping it entirely and bringing its functions ‘in house’ means patients are losing an important institutionally independent voice and risks further organisational disruption. 

The NHS has a mixed record of listening to patients, as repeated inquiries into patient safety failings show. And it is not clear that the DHSC or ICBs will have the information, skills, capacity or legitimacy – or funding – to play this role effectively, particularly following such deep cuts to headcount and ICB budgets. Moving the NHS functions of local Healthwatch organisations into newly enlarged ICB footprints could also result in the loss of a more nuanced local understanding of the public’s priorities and needs, with particular implications for seldom heard or more vulnerable communities. 

Boosting the ‘in house’ skills and capabilities of the DHSC and NHS England to hear and respond to patients’ voices is welcome. But this can and should be done without removing the independent infrastructure that exists to gather patient and public views. 

The government should think again about these changes. Ministers could choose to do more to listen to patient and public views without reorganising anything. Three elements are needed if they go ahead with replacing or reforming the current Healthwatch setup: 

1. Some degree of independence from the NHS and government – as 50 years of policy has tried to do. 
2. Sufficient infrastructure to gather local data in a meaningful and equitable way and influence national decisions. 
3. Sufficient resources to carry out both those roles effectively.  

The government’s proposals currently fall short on several counts.

Turning the rising tide of ill health requires a new approach that establishes rebuilding the UK’s health as a key driver of government policy. This means taking a cross-government approach to addressing the wider factors that shape people’s health such as poverty, inadequate housing and poor-quality work, a shift to prevention and a new strategy to address health inequalities. Successive governments have understood this but failed to take the necessary action. This includes the Labour government under Keir Starmer which largely abandoned its health mission, including the pledge to improve healthy life expectancy and halve inequalities between different regions in England.

Addressing this goes beyond the scope of legislation alone. However, the bill provides an opportunity to strengthen the current statutory framework for improving health and reducing health inequalities. The bill replicates the existing duties on the Secretary of State and NHS England, created by the 2012 Act, to have regard to the need to improve health and reduce health inequalities, but only in the provision of health care. The existing statutory framework for prevention and health inequalities beyond health care is relatively weak. 

As the Health and Social Care Committee recommended in their report on the bill the duties on the Secretary of State – and other ministers - should be strengthened to improve health and reduce inequalities through cross-government action. These changes could ensure consistent duties from central to local government and create parity of esteem between prevention and healthcare provision, supporting the strategic shift proposed by the 10-Year Health Plan and the devolution agenda. Building on this, a revised statutory framework could include requirements on the government to produce a strategy for improving health and reducing inequalities, supported by targets to drive action and independent monitoring and reporting on progress. 

With the UK’s health under severe strain and health inequalities wider than ever, the government should take the opportunity provided by the bill  to strengthen the statutory framework for improving health and reducing health inequalities. Health Equals, the campaign coalition to reduce health inequalities funded by the Health Foundation, has worked with Lord Patel, Baroness Walmsley, Baroness Tyler and Baroness Cass to table amendments to this effect.

The 10-Year Health Plan marked a return to market-style mechanisms with a sharper split between NHS commissioners and providers, greater freedoms for hospitals over finances, and measures encouraging competition between them (such as league tables). 

The bill legislates for some of these changes – for instance, revising ICB membership (to focus them more squarely on the job of commissioning), and scrapping requirements for local NHS organisations to collectively manage their finances. The bill also abolishes integrated care partnerships (ICPs) and the requirement for them to produce integrated care strategies. Hierarchy, competition, and collaboration coexist in the NHS. But the government’s reforms mean the dial is shifting away from collaboration as the organising principle for managing the health service. 

Standing back, the big challenges facing health require a coordinated response. For example, the number of people living with multiple long-term conditions is rising substantially. ICBs were originally designed to encourage cross-sector collaboration on these and other issues. Changes in the bill might help simplify the system but risk running against the partnership working needed to improve health and care. Given this, we are pleased the government has reversed plans to remove mandatory local authority representatives from ICBs, but the shift in their focus away from collaboration remains a concern.

Closer links between the NHS and MSAs on health is a positive step. But the new role for strategic authorities on ICBs should not be framed too narrowly around NHS operations and governance. The distinctive contribution of MSAs lies in their influence over the wider building blocks of health – such as housing and employment - and their ability to convene partners across systems. The government needs to be clearer about the purpose of mayoral involvement in ICBs and support mayors to connect NHS decision making with wider work (for example, in relation to public services, economic development and the building blocks of health). 

Evidence indicates that previous reforms of NHS commissioning have struggled to improve patient care and outcomes. Substantial cuts to ICB budgets and another lengthy round of organisational disruption risk weakening the starting position for commissioners even further. For strategic commissioning to have any chance of success, policymakers will need to play an active role in supporting it. ICB leaders in our research pointed to a mix of skills and capabilities that they wanted support on – including analytical, economic and actuarial skills, and capabilities seen as core to strengthening commissioning and contracting within their organisations.

Policy changes enacted by the bill risk undermining the collaboration needed to address the challenges facing the health and care system. We welcome recent changes that could help rebalance this including the government amendment to restore mandatory local authority members on ICBs. But ministers need to do more to set out how ‘strategic commissioning’ is intended to drive improvements in population health, reduce health inequalities and ensure equitable access to high-quality care, and ensure the skills and capabilities are in place to support these aims.