NHS reforms risk sowing confusion and undermining safety, MPs warned

A bid for more control over the NHS by ministers risks undermining patient safety and sowing confusion over who is ultimately responsible for services, MPs have been warned.

The Commons Health Select Committee was told the proposals, set out in a new white paper published last month, lacked detail on the involvement of patients in local services and needed urgent clarification of the new powers the health secretary will have.

The plans will give ministers new powers over the independent Healthcare Safety Investigation Branch (HSIB), including being able to tell it what to investigate and the power to remove protections for NHS staff who give evidence in secret.

Last week experts warned the plans for HSIB could undermine its role and have lasting consequences on efforts to encourage NHS staff to be honest about errors. Under the proposals the health secretary would be able to remove so-called “safe space” protections for evidence given by NHS workers.

Sir Robert Francis QC, who led a public inquiry into poor care at Stafford Hospital, told MPs it was important staff knew where they stood, adding: “HSIB is being set up in order to be an independent investigator, and I'm not sure the extent to which political power to change the rules or the playing field is necessarily beneficial.

“I can see [like] in other areas of [the] secretary state's power, there may be extreme examples where that might be appropriate, but it's quite difficult to envisage what they are.”

Chris Hopson, chief executive of NHS Providers, told the committee hospitals were worried about the plans.

He said: “We are very nervous about this relationship between the secretary of state and HSIB. In order for it to be an effective independent organisation, it does need to be free from the appearance of any kind of political control. There's a very high degree of nervousness about the ability to somehow switch safe space on and off. People need to know where they stand.”

Under the government’s plans to reform the NHS, local commissioning groups set up in 2013 will be swept away and replaced by new larger integrated care organisations. The aim is to encourage closer collaboration between the NHS and councils to deliver population-level healthcare for 42 separate areas of England.

The proposals also include new powers for the health secretary to intervene in local reconfigurations “at any point”, and take more direct control over the NHS with a power to instruct NHS England on actions it should take.

Mr Hopson said there was a lack of clarity about the extent of the powers the secretary of state would have to direct and intervene in the day-to-day operation of the NHS.

He told the committee: “I think we'd all agree that it can't be right for a secretary of state to have power to direct money to flow to certain areas of the country.

“It can't be right for a secretary of state to be able to just stop, on their own initiative, very carefully and well worked-up local reconfiguration plans because he or she is coming under inappropriate pressure from, let's say, a fellow cabinet minister or a speaker of the House of Commons.”

“There are clearly a number of areas where the NHS’s operational independence is absolutely fundamental. But we can't really assess how much that is under threat, until we see the detail of the power that's being proposed here.”

He added: “We need to be absolutely precise about who is responsible and accountable for what. There is a danger that if you have that many players on a pitch, there is an opportunity for duplication and overlap.”

He warned that one of the criticisms from Sir Robert Francis’ report into Stafford Hospital was that multiple bodies in the NHS were not clear on who was responsible for safety and quality, a problem which he said could reoccur without clear structures being created.

Hugh Alderwick, head of policy at the Health Foundation, warned there were still lots of questions about what exactly the new integrated care system (ICS) organisations would do and how they would work.

He said: “I think there are big opportunities to improve some of the pretty murky accountabilities at a local level to provide more clarity about who's in charge. But at the moment, it's not really clear how much power ICSes will really have over providers [hospitals].

“This is another NHS reorganisation, so there's the obvious risks with that of disruption and distraction. Creating agencies is much easier on paper than it is in practice.

“The experience from the long history of NHS reorganisations tells us that moving agencies around, changing who's in charge, and setting up new governance can distract from service improvements, that's a big risk that's going to need to be kept a close eye on when we think about the implementation of the proposals.”

The government has said it will bring detailed legislation in the coming months but has so far not revealed any solution for social care, which the committee was told risked undermining the overall intention to improve care.

Sarah Pickup, deputy chief executive at the Local Government Association, told the committee the sector was “beyond distraught” at the delays in bringing forward solutions. She added: “It's a false economy to not sort out the social care challenge, while trying to sort out the health service because it won't work.”

Boris Johnson promised in July 2019, on his first day as prime minister, to fix social care with a “clear plan we have prepared”, but early in 2020 admitted he did not have such a plan. Last month, Matt Hancock said a proposal would come this year.

Committee chair and former health secretary Jeremy Hunt also cited the failure of the government to come up with long-term workforce plans for the NHS.

Danny Mortimer, chief executive of the NHS Confederation, said he believed the new integrated care system organisations could become “an engine” for producing workforce plans that were based on the needs of their populations. He added: “The plan needs to be developed in a way which is rooted in that need of patients and isn't conditioned and restrained by the short-term view of the Treasury.”

He warned that constraining budgets ended up costing the NHS more in the longer term.