Written evidence: Health Bill, 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 some logic in bringing the workings of NHS England and the Department of Health and Social Care (DHSC) closer together, the communication and planning of the government’s decision to abolish NHS England left much to be desired and the decision caused disruption to the service at a time when patients need it most. Given the changes are already underway, the question now is how to make the new structure work.

The bill 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) (see Clauses 11, 29, 33, 35–36).

Accountability for the health service will always rise upwards to politicians in a tax-funded health system and it is right that ministers 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 arms-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.

The bill risks enabling excessive political interference that could cause harm in the future. For instance, through political bias in appointing local leaders who may push a particular view on the health service or political pressure linked to publication of NHS performance data. Simply merging NHS management back into the DHSC (without some demarcation), alongside cuts to the number of staff working in these bodies, also runs the risk of the NHS dominating health policy even more than it does today.

We identify at least three areas that require additional safeguards to keep policy processes at arms-length from politicians:

1. Local appointments: the appointment of chairs and non-executive directors of local NHS bodies (who appoint their chief executives) has been managed at arm’s length of 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.
2. Data and digital infrastructure: under proposals in the bill, 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 or 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.
3. Patient voice: see Clauses 64–65.

The bill goes too far in centralising power in the hands of ministers. The government needs to do more to articulate the benefits of handing such extensive powers to the Secretary of State and set out safeguards for how these powers are used. For instance, to keep some processes such as appointments at arm’s length. Ultimately, some split between policy and management should remain at the top of the NHS.

The 10-Year Health Plan emphasises the government’s commitment to 'meaningful devolution' in the NHS to drive improvements in care. This includes a promise to 'reinvigorate and reinvent' the foundation trust model, with plans for 'earned autonomy' and additional freedoms for NHS organisations deemed high performers, accompanied by a 'reduction in the burden that central bodies place on systems and providers'.

However, alongside the transfer of powers over local appointments, the bill hands broad new powers to the Secretary of State and 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. Policies to encourage decentralisation of decision making have been limited and local leaders have often struggled to make use of them (partly because the NHS and government’s centralising tendencies contribute to an unwillingness to exercise autonomy locally). The bill appears to exacerbate the trend towards greater centralisation at the expense of local autonomy.

Increased ministerial oversight of local NHS bodies risk undermining the government’s commitment to devolve power in the NHS. Ministers should set out much more clearly how they intend to use these broad powers and how they will be transparently reported. 

The 10-Year Health Plan marked a return to market-style mechanisms that were a prominent feature of the last Labour government’s approach to managing the health service in the 2000s, 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. There is also a tension between the measures set out in the bill to increase central control in the NHS and the devolution of responsibilities for improving health and reducing inequalities contained in the English Devolution and Community Empowerment Act.

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 work needed to improve heath and care. Closer links between the NHS and strategic authorities on health is a positive step, but, as the Health and Social Care Committee pointed out in their recent report on the bill, the decision to remove mandatory local authority representatives from ICBs could weaken the links between the NHS, social care and public health at a more local level.

Evidence indicates that previous reforms of NHS commissioning have struggled to improve patient care and outcomes. The same is true in other countries with hospitals consistently having more power and resources than commissioning organisations. Substantial cuts to ICB budgets and another 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.

The bill risks undermining the collaboration needed to address the challenges facing the health and care system. Changes should be made to rebalance this, for instance by reversing the decision to remove mandatory local authority members from ICBs. The government also needs to do more to set out how 'strategic commissioning' is intended to drive improvement in the NHS and ensure the skills and capabilities are in place to support it.

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. The aim of joining up data to improve patient care is good. Patients and staff are frustrated with the current system, with clinicians navigating multiple and incomplete information systems, while patients often have to report their story many times to different health and care professionals. 

Whether the plans can avoid the fate of past national NHS IT programmes, which have often failed to win public trust or be realistic about implementation challenges and timelines, is unclear. 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 (see Clauses 1–11). 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.

Building on recommendations of the patient safety review carried out by the current Chair of NHS England, Dr Penny Dash, in July 2025, the bill proposes to abolish the Health Services Safety Investigation Body (HSSIB) and transfer its functions into the Care Quality Commission (CQC). 

As a result, the CQC would be responsible for two discrete functions relating to regulation and patient safety investigation. The government has said that HSSIB’s legislative 'safe space' safeguard, which ensures information shared with investigators is confidential and cannot be disclosed, would be maintained and it would operate as a 'discrete unit' within CQC. 

We identify three areas that require further scrutiny. 

1. Whether the rationale for changing the current model holds up. On the one hand, the proposals appear to simplify arrangements, merging two organisations into one. But in reality, the change risks adding complexity, given the commitment to retaining the HSSIB’s 'safe space' model and the challenges in maintaining the necessary separation between these two distinct functions within one legal entity. 
2. Past experience demonstrates that organisational mergers are usually more costly and time-consuming than politicians expect (or hope), and it is unclear whether the potential proposed benefits outweigh these costs. 
3. CQC’s substantial organisational and operational challenges are well documented, and rebuilding the organisation and its credibility will take considerable time and resource. This is far from the ideal context for implementing a complex and effective merger and maintaining the necessary focus on such a critical function. 

Penny Dash’s review correctly diagnosed the issue of a 'cluttered landscape', with too many recommendations that are not implemented. However, the government needs to do more to explain how the abolition of HSSIB and transfer of its functions to CQC will meet its aim of reducing complexity and, most importantly, maintain the essential focus on improving patient safety.

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 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 institutionally independent voice. 

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, 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.

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 the current Healthwatch setup:

1. some degree of independence from the NHS and government, as 50 years of policy has attempted
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.

The UK’s health is declining and health inequalities are widening. The gulf in healthy life expectancy between the most and least deprived parts of England is now 19.4 years for males and 20.3 years for females. 

In 2025, 8.7 million working-age people reported a work-limiting health condition, while the proportion of young people not in education, employment or training (NEETs) reporting a condition that limits their ability to work increased from 26% in 2015 to 44% in 2025, fuelling the risk of a 'lost generation' identified by the Milburn review of young people and work.

As well as taking a substantial human toll, declining working-age health is resulting in significant economic costs. Turning the rising tide of ill health requires a new approach that establishes rebuilding the UK’s health alongside delivering economic growth 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, including Labour with its now largely abandoned 'health mission', have understood this but failed to take the necessary action.

This goes well beyond the scope of legislation. However, the bill provides an opportunity to strengthen the current statutory framework for improving health and reducing health inequalities. Clause 4 of the bill replicates the existing duties on the Secretary of State and NHS England to have regard to the need to reduce health inequalities. As the Health and Social Care Committee recommended in their report on the bill, this duty should be strengthened to mirror the new duty on Strategic Authorities introduced in the English Devolution and Community Empowerment Act. 

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. Amendments to achieve this are being promoted by Health Equals, the campaign coalition to reduce health inequalities.

With the UK’s health declining and disparities in health between the most and least deprived parts of England widening, the bill provides an important opportunity to strengthen the statutory framework for improving health and reducing health inequalities.