Good afternoon, ladies and gentlemen. Members may remove their jackets and, because of the health warning—exceptionally—if Members or civil servants wish to remove their ties, they may do that as well. Please understand that that is not a precedent.

Clause 7

Education and training

Amendment proposed (this day): 33, in clause 7, page 4, line 31, at end insert—

“(2) Training under subsection (1)(a) includes training in general health determinants as defined by section 107ZB of the Local Democracy, Economic Development and Construction Act 2009.”—(Peter Prinsley.)

This amendment would place a duty on the Secretary of State to ensure that the health and care workforce is adequately trained in the wider determinants of health such as housing standards, exposure to air pollution, occupational risk, and use of harmful substances like tobacco.

Question again proposed, That the amendment be made.

I remind the Committee that with this we are discussing the following:

Amendment 50, in clause 7, page 4, line 32, at end insert—

“(4) After subsection (2) insert—

‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”

This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.

Amendment 54, in clause 7, page 4, line 32, at end insert—

“(4) The Secretary of State must exercise functions under this section with a view to ensuring that managers in the NHS, who have appropriate clinical training, must also undertake clinical care.

(5) The Secretary of State must record the proportion of direct clinical care provided by those with professional qualifications both in terms of the proportion of their areas and full time equivalent by pay grade, and the Secretary of State must increase the proportion.”

This amendment would require the Secretary of State to ensure that NHS managers who are clinically trained must continue to undertake clinical care.

Clause stand part.

New clause 44—Medical training places—

“The Secretary of State must double the number of medical school training places to 15,000 by 2031-32.”

This new clause would put a duty on the Secretary of State to double the number of medical school training places.

New clause 45—Data collection: clinically trained staff—

“(1) The Secretary of State must collect and publish data on the numbers and proportion of NHS staff are qualified to deliver nursing and clinical care who delivering nursing care, or clinical care of any kind, and those who are not.Column 168is located here

(2) Information under subsection (1) must be collected according to HCAS pay scales.

(3) Information under subsection (1) must include numbers of nursing and midwifery staff.

(4) Information under subsection (1) must be published quarterly.

(5) The NHS and ICBs are under a duty to comply with any requests from the Secretary of State for data for this purpose.

(6) Information under subsection (1) must include the proportion of time spent delivering clinical care as a proportion of the individual’s total working hours.”

This new clause would require the Secretary of State to collect and publish data on the numbers and proportion of clinically qualified staff who are delivering clinical care, broken down by HCAS pay band.

Before the lunch break I was saying that, in essence, clause 7 states what the Secretary of State’s job is. It moves the function of planning the workforce from NHS England to the Secretary of State, which is a reasonable thing to do. I talked about the previous Government’s record on opening new medical schools and how that has helped with the number of clinical staff.

We also talked about workforce planning. The Government are due to produce a workforce plan, but it is not clear when it is due to come out. It was due to come out at the end of last year, but it did not; it was then due to come out in the spring, but now it is the summer. Given the Prime Minister’s resignation, it is not at all clear when it will come out. Will the Minister let us know whether it will come out before the summer recess, this week or whenever?

I quoted some of the concerns of the Royal College of Nursing, the British Medical Association, of which I am a member, and others. Those concerns include the workforce plan. Those organisations have seen what we have not seen, so they have been asked to comment on something that we have yet to see. That brings me to new clause 44, which is in my name.

Before the general election, Labour promised that it would double the number of medical school places. The now Chancellor of the Exchequer promised to double the number of medical school training places, as did the now Secretary of State for Science, Innovation and Technology. Once the general election had passed and Labour was in government, the promise was reiterated. At oral questions in October 2024, the now former Health Secretary said:

“This Government are committed, as we were in opposition, to doubling the number of medical school places”.—[Official Report, 15 October 2024; Vol. 754, c. 683.]—

but there has not really been any progress.

During a debate this year on the junior doctors’ foundation programme, I asked the Minister for Care whether the Government’s intention was still to honour that pledge. He said:

“Yes, that is the Government’s intention.”—[Official Report, 22 April 2026; Vol. 784, c. 133WH.]—

only to later submit a written correction stating that the Government had never committed to doing so. Are they going to, or not? It is not clear.

Labour promised to double the number of medical school places, but now that pledge appears to have been airbrushed out of history. Can the Minister please explain why she and her colleagues deemed the workforce pledge essential before the election but not after it? Can she tell us whether it is Government policy? In essence, Column 169is located here

New clause 44 is very simple: it stipulates that the Secretary of State must double the number of medical school training places by 2031-32. That is what Labour promised, so it should be fairly easy for Labour Members to vote for it. I hope that the Committee will support the new clause, which only requires Ministers to do what their party promised before it came into government.

If the Government are not keen on committing to clear targets, they can at least commit to full scrutiny of their workforce plans. Of course, there is a risk that the House has been misled. Either the promise was made or it was not. The Minister for Care said that it was promised and then submitted a written correction to say that that was inaccurate and that it was never Government policy, but if it has been stated by the Secretary of State at the Dispatch Box, representing the Government, then it is Government policy. Can the Minister help to clarify that point? If the House has been misled by either her former boss or the Minister for Care, perhaps she can clear that up for us. Perhaps the vote will help.

Does the shadow Minister agree that if we doubled the number of medical students, we would simply not be able to accommodate those people as young doctors unless we also doubled the number of training places? After five or six years, those medical students become young doctors. If we are to correct any problem with the medical workforce, it is insufficient to simply state that we will double the number of medical students.

The hon. Gentleman is right. When all the new doctors that the Government have promised have been trained, they will need jobs and postgraduate medical training, and there are issues with that. Nevertheless, the Government asked the public to vote for them on the basis that they would double the number of medical school places. Many of the hon. Gentleman’s colleagues produced little videos to that effect, which can be viewed on Twitter. They toured the newsrooms saying, “Please vote for us, we’re going to double the number of medical school places.” They suggested that there would be a revolution in Government to make sure that there were enough doctors. This is important—more doctors would help.

All new clause 44 does is ask the Government to commit to doing what they have said that they will do—or to say that they will not. Either way, we have had the Secretary of State saying one thing and a Minister saying the opposite and then correcting it, so we need clarity. The public deserve that. The Minister herself said that they would double the number of medical school places so that we have the doctors that our NHS needs. If they do not double the number of medical school places, it follows that they will not have the number of doctors that the NHS needs. Presumably that is in their workforce plan, but it needs to be cleared up.

Amendment 50 would put a duty on the Secretary of State to publish independently audited forecasts of the NHS workforce every five years. The logic is straightforward: Column 170is located here

The workforce affects whether patients can be seen on time, maternity wards are safely staffed and elderly patients get the dignity they deserve. It is the difference between the NHS meeting the challenge of an ageing population or slipping into decline. If Labour Members are confident that the Minister’s workforce planning is robust, I expect that they will support my amendment, which requires an independently audited forecast. If they are not willing to support it, that suggests that they know this Government cannot be trusted to deliver the workforce that patients need.

Amendment 54 and new clause 45 were also tabled in my name. Amendment 54 would require the Secretary of State to look at the amount of clinical work that NHS managers undertake. As a clinician, I have increasingly noticed that highly qualified clinical practitioners come in, become the person on the ward who can be relied on, and then go off because they get promoted to a nine-to-five job that is easier and pays more, but does not deliver clinical care.

The chief medical officer, for example, still delivers clinical care, and the amendment probes the Government to consider how many nurses and clinicians in hospitals are delivering clinical care. I asked that in written questions, and the Government did not know the answer. It is materially important information, particularly when looking at the Dash report, which talks about an explosion in the number of people who are clinically trained but not providing clinical work—instead, they are creating guidelines and monitoring whether other clinicians are doing the work. If more of those people were engaged in clinical activity, that might improve the quality of both the guidelines and care, because more junior staff would have senior staff around to help them.

I strongly support the argument that clinical staff, even if they progress into a senior role, should carry out some sort of clinical practice. Does the hon. Lady agree that that is what went wrong over the past few years, especially when NHS England was created? Many senior clinicians who were moved into management posts had no contact with clinical areas. That is what this Government are trying to fix by abolishing NHS England.

I am talking predominantly about clinicians working in trusts who are trained and very experienced, but then move to work in the same trust but in a more managerial role that does not involve clinical care. I am not saying that every single person needs to be delivering clinical care—there may be exceptions, of course; people do have career changes—but I encourage the Government to reflect on the number of posts being created that take people away from the clinical arena, and on the effect that that has. When the Minister is presented with the number of nursing or midwifery-qualified staff working in a particular department, that may not reflect the Column 171is located here

Amendment 33 would place a duty on the Secretary of State to ensure that the workforce is trained on the wider determinants of health, such as housing standards, air pollution and the use of harmful substances. In my many years as a paediatrician, I have yet to meet a nurse, doctor, surgeon, porter or care co-ordinator who does not know that damp and mould are bad for people’s health, and I have yet to meet a fellow employee who does not know that air pollution causes asthma, or that tobacco use increases the risk of chronic obstructive pulmonary disease, cancer and a whole host of other ailments.

Considering the many pressures on NHS workers, I do not believe that mandating a new programme on health determinants is a good use of time. I fear that it is rooted in the agenda of creating more and more mandatory training, and I would actually encourage the Minister to look at rationalising mandatory training to that which is absolutely necessary. Control of the curriculum for such staff is dealt with separately, so I object to amendment 33.

It is a pleasure to serve under your chairmanship, Sir Roger. Clause 7 says—I abbreviate:

“The Secretary of State must exercise functions…with a view to ensuring that…there are sufficient people with appropriate education and training to meet the workforce needs of the health service, and…there is an effective system in place for the planning and delivery of education and training of people to meet those needs.”

That is all very nice—who couldn’t agree with that?—but amendment 50, tabled by the shadow Minister, would add a means by which the public, in the interests of transparency, could make an assessment of that by requiring the Secretary of State to publish independently audited forecasts of the NHS’s workforce needs every five years. That seems entirely sensible, it is something that I am sure any Government would want to do anyway, and it would add meaning, assessment and transparency to what is already in the Bill.

New clauses 44 and 45 would do something similar in relation to the number of medical school places. As the shadow Minister said in response to an intervention, new clause 44 seeks to do only what the Government have already said they want to do. Hopefully, the Minister can give us some clarity on whether that is still the Government’s intention and, if it is, what aversion she has to including it in the Bill.

Separately, new clause 45 seeks to establish a benchmark of data collection. Of course, duties and requirements placed on a Secretary of State, such as those in clause 7, can be delivered only if we start with the proper collection of data and, in the interests of transparency, publish it. For that reason, I also support new clause 45.

I thank hon. Members for bringing this discussion before the Committee. The Government are committed to ensuring Column 172is located here

Before turning to the clause, I will address some of the issues raised during the debate and in the amendments. I understand the intention behind amendment 50, but I cannot accept it. The 10-year workforce plan will set out the staffing needs of the NHS for the next 10 years. That goes further than the amendment calls for and will be updated every two years in line with our manifesto commitment to publish regular, independent workforce planning. It is only because the Government have set such a clear direction for the service through the 10-year health plan that we can credibly set out a sustainable approach to staffing the NHS over the long term.

As hon. Members will understand, workforce planning is a complex topic. It is closely related to the wider service planning, which is why we have engaged so widely with independent experts to develop our forthcoming workforce plan. To divorce the process of workforce planning from service planning in the way that is suggested by amendment 50 would not produce a more reliable or useful set of forecasts. However, it would reduce the potential for innovation and reform of the kind that is needed and which the Government have set out so clearly in the 10-year plan for the NHS. I can only conclude from listening to Opposition Members that they really did learn absolutely nothing from their time in office or, indeed, from the problems with their workforce plan, which focused on headcount but notably did not reform care, did not look at new patterns of care, did not look at retention or training, and created some of the bottlenecks and problems that we have had to deal with.

Our commitment will be guided by the workforce plan, which is why we cannot accept new clause 44. Decisions on training numbers must be guided by workforce need, and that will have to be considered as part of the forthcoming plan. Adding to the point made by my hon. Friend the Member for Bury St Edmunds and Stowmarket, whatever the Government’s position on the number of medical school places that will be required in the future, fixing a number in primary legislation would be unhelpful as it would limit our ability to adjust target training numbers subsequently to reflect any changes in workforce need.

I was asked about correcting the record. The last Government did double places in their 2024 workforce plan, and I commend the movement of medical schools across the country. If the former Secretary of State is reported in Hansard as having said something contrary to the correction of the record by my hon. Friend the Minister for Care, we will of course pick that up.

Amendment 54 and new clause 45 look to reduce flexibility and increase bureaucracy for a workforce that is simply trying to deliver what is best for patients. On amendment 54, I think we can all agree that we need strong leadership and management to deliver national priorities, including the 10-year plan’s three shifts. Having Column 173is located here

New clause 45 would require the collection of further data on the proportion of time spent on clinical care. Detailed statistics on the number of staff working for NHS provider trusts broken down by profession and pay band are already published by NHS England on a monthly basis. Adding requirements to that is not simple. There is not a centrally held collection of data about NHS staff time, and setting one up would have costs both centrally and for NHS trusts to collect specific data. It is also not easy to separate out clinical care meaningfully. Clinicians spend time in supervision, education, safeguarding, quality improvement and clinical leadership, and the amount of time they spend on different activities can vary from month to month. The new clause risks putting more burdens on NHS staff if they are being asked to record what they are spending time on beyond existing procedures. We therefore cannot accept it.

I turn to amendment 33, which was moved by my hon. Friend the Member for Bury St Edmunds and Stowmarket, on workforce training. It would require the Secretary of State to intervene in the content and design of healthcare programmes. Standards of proficiency, conduct and performance of registered professionals are the statutory responsibility of independent healthcare regulators, although universities and practice partners develop the specific content and design of programmes to meet those standards. It is vital that the independence of regulators and universities is maintained to respect their expertise in designing standards and curricula that ensure public safety.

We have published our 10-year health plan setting out major NHS reforms, including moving from sickness to prevention. Supporting healthcare workers to address the wider determinants of health will be essential to delivering that shift. That is why we are providing the “All Our Health” e-learning on critical public healthcare topics for people working in the health and care sector, and revitalising the “making every contact count” approach to ensure that every contact that a person has with the healthcare system supports a shift to prevention.

I assure colleagues that our upcoming 10-year workforce plan will set out plans for ensuring that we train the staff we need so that we have the brightest people and the right skills to support patients. For those reasons, I ask my hon. Friend to withdraw the amendment.

Finally, I turn to clause 7. The Secretary of State already has an overarching duty in relation to the education and training of the NHS workforce. Currently, that duty is partially delegated to NHS England. NHS England also has a duty to ensure that there are sufficient numbers of appropriately trained healthcare workers Column 174is located here

The Secretary of State will be entirely responsible and accountable for exercising relevant functions with a view to ensuring that there is an effective system for the planning and delivery of healthcare education and training, and that we have enough healthcare workers with the right training to meet England’s health service needs. Bringing those duties directly under the responsibility of the Secretary of State will reduce bureaucracy, streamline oversight and enable the Government to provide national strategic leadership across the NHS workforce.

I reassure colleagues that accountability will not be diluted. Bringing these responsibilities into the Department will create clearer, stronger lines of accountability with the education and training of the NHS workforce. Ultimately, the Secretary of State will continue to be accountable to Parliament for the health service in England, including for the planning of education and training and ensuring sufficient numbers of trained healthcare workers. I commend the clause to the Committee.

I am happy with those assurances, so I beg to ask leave to withdraw amendment 33.

Amendment, by leave, withdrawn.

Amendment proposed: 50, in clause 7, page 4, line 32, at end insert—

“(4) After subsection (2) insert—

‘(2A) The Secretary of State must publish independently audited forecasts of the NHS’s workforce needs every five years.’”—(Dr Caroline Johnson.)

This amendment would require the Secretary of State to publish independently audited forecasts of the NHS’s staffing needs every five years.

Question put, That the amendment be made.

Clause 8 will give the Secretary of State the power to direct integrated care boards to exercise his or her functions. This power, similar to that currently Column 175is located here

With our plans to abolish NHS England, the Secretary of State will again have broad powers and responsibility relating to the health service, and so this power encompasses a wider range of functions. Unlike the delegated frameworks set out under sections 65Z5 and 75 of the 2006 Act, which are entered into voluntarily, any integrated care board directed under this power would be obliged to carry out the stated functions.

I reassure the Committee that, while the ICB will be legally responsible for how it discharges a function, overall accountability will remain with the Secretary of State. Furthermore, the Secretary of State might also use directions to place restrictions on the onward delegation of any functions, preventing delegation where it may be inappropriate. Finally, any directions must be published, ensuring transparency and allowing proper accountability.

This measure will empower the Secretary of State to assign functions to ICBs where most appropriate. It aligns with and facilitates our broader direction of travel towards flexibly planned and delivered local services. I therefore commend the clause to the Committee.

Clause 8 is essentially about the control that the Secretary of State has over ICBs. When we discussed the clause abolishing NHS England, we talked a lot about the balance between democratic accountability on the one hand and independence from political interference on the other.

The Government suggest that the Bill is a decentralising Bill. What this clause does is essentially to recentralise by default. As the Minister has just said, the Secretary of State can change what the ICB is doing if they think that it is inappropriate. What does “inappropriate” mean exactly, and how will that power be used? It may be used very infrequently—perhaps the current and previous Secretaries of State think that the power would be used infrequently—but equally it could be used in response to considerable pressure from MPs, lobbyists and campaign groups. Instead of issuing directions sparingly, we may end up in a position where the Secretary of State is issuing day-to-day instructions.

The Government want ICBs to take greater responsibility for commissioning decisions, but then they want to be able to undermine them by direction from the Health Secretary. The Health Secretary will never have as good a grasp of the situation in the local geographic area as local leaders, but he has the power to tell them what to do and issue blanket instructions with different characteristics. That will be inherently inefficient. ICB leaders will be under pressure, knowing that if they make a particular decision they can be removed or be told to do something different. They have the job and they have the power, but they haven’t really—all at the same time.

There is also the plan, as the Minister outlined, to make directions something that the Government publish. The clause says that directions must be published by the Secretary of State, but onlyColumn 176is located here

“as soon as reasonably practicable”.

The intention behind requiring the prompt publication of directions is to reduce the surface area for back-room pressures, but the lack of a clear timeframe makes it rather a weak measure.

We currently have a Government who seem open to greater use of the private sector, whether in financing projects or in delivering out-patient care. Well, our Prime Minister resigned yesterday, and there is no guarantee that the Government of the right hon. Member for Makerfield (Andy Burnham) will take the same approach. Will the Minister confirm whether the powers in clause 8 could be used by a Health Secretary to instruct ICBs to stop using a specific type of provider?

I would not dispute the idea that the Secretary of State needs to be able to exercise some control over the health service now that NHS England is being abolished, but the clause seems contrary to the Government’s stated vision for health management. I am not sure whether it is in the best interests of patients.

It is a pleasure to serve under your chairmanship, Sir Roger. I agree heartily with the shadow Minister, and a couple of other things concern me about clause 8.

On the one hand, the clause appears to bring more centralisation, but on the other hand it pushes things down to an ICB level at the same time. I am worried that if we have individualisation of ICBs, we will only exacerbate the disparity of services across regions. I would be interested to understand from the Minister how the Secretary of State’s functions will allow the independence of ICBs and, where an ICB understands its local population well, ensure that patients do not end up in a postcode lottery based on which ICB area they happen to live in.

The danger here is that if the Bill does not deal with those problems and close regional gaps, it is not immediately clear from the clause how the Secretary of State could intervene to ensure that ICBs have the autonomy to make decisions based on their local populations and ensure at the same time that patients do not receive a worse service just because they happen to live in one ICB area rather than another.

I recognise that this is a subject of some debate; we may discuss it further when we come to the part of the Bill on ICBs. The abolition of NHS England and transferring all its functions to one body has a consequence, which is that the Secretary of State retains that accountability and power. We are keen to have that power clear but flexible in order to empower local systems. That remains the intent.

The power is necessary for the Secretary of State to update national commissioning standards, for example. The ICBs will have wider roles as strategic commissioners. We expect them to take on formal responsibility for a number of services delegated by NHS England. That allows us to issue a common set of commissioning standards, on the point made by the hon. Member for Farnham and Bordon about variability in different places. There need to be common standards across the piece: eligibility criteria, the treatments the provider Column 177is located here

The shadow Minister raised the timetable. The Opposition will recognise that there needs to be flexibility for the Secretary of State and Ministers to respond to unforeseen or changing events. That is why it is purposely broad, because the range of events that can impact the NHS is clearly very broad. We cannot predict the future.

The hon. Member for Farnham and Bordon said that the Bill needs to deal with all these problems. The Bill needs to give enough flexibility to the system and devolve as much power to the system. The Bill needs to make sure that the powers are in the right place, but it is for the local systems to respond to their local needs within that framework. They will be held accountable, for example through the NHS oversight framework and through ICBs’ normal accountability frameworks.

The Minister is talking about flexibility. I understand that if a Minister is responding to an unforeseen circumstance, he or she may be very busy, but where a direction has been made, it should not take very long for a member of staff to publish it, because it will already have been written and sent. I understand that a Minister might take a day or so to sign it off because they are so busy, but it should not take months. The addition of a deadline is therefore not an unreasonable request.

With due respect to the hon. Lady, it is not a matter of the Minister being busy, whether that is me or anybody else. It is about the operational running of a £200 billion organisation with 1.5 million staff treating millions of people every day. I am sure we all remember from our own experience incidents and unforeseen events that have happened in the local system, and sometimes very tragic events that have required the Secretary of State to take action. We are trying not to increase the number of reports and documentation and to rid the system of bureaucracy by putting something out in that timeline.

Will the Minister give way on that point?

No, I have finished.

Question put and agreed to.

Clause 8 accordingly ordered to stand part of the Bill.

Clause 9

Secretary of State’s power to provide assistance

Question proposed, That the clause stand part of the Bill.

Clause 9, which will insert new section 12DA into the National Health Service Act 2006, will give the Secretary of State a clear statutory duty to provide financial, staffing or other practical assistance in connection with the health service. The power may be used to support persons providing, or proposing to provide, services as part of the health service or which are beneficial to the interests of the health service. It may also be used to support public authorities where Column 178is located here

The clause will support the wider purpose of the Bill by enabling a small centre to act in a supportive and enabling way towards the wider system. Where appropriate, the Secretary of State will be able to provide assistance directly to those delivering or supporting health service activity. The clause is needed because the existing statutory framework does not include a clear power that enables the Secretary of State to provide practical support across the full range of health service activity. Relevant support may be financial, practical, staffing-related or connected with education and training.

Without this clear power, there is a genuine risk of confusion about the basis on which such support may be offered, particularly where the Secretary of State is acting to facilitate the delivery of services by others. The power is permissive and facilitative: it does not require the Secretary of State to provide assistance, and it does not require any person or body to accept it. The power is also limited by its connection to the health service and matters relevant to education, training or activities considered beneficial to the health service. Its exercise remains subject to ordinary public law principles and public financial controls. For those reasons, I commend the clause to the Committee.

In a system as large as the NHS, covering an area as diverse as England, it is necessary that the Government be able to deal with unexpected situations. The pandemic may be half a decade behind us already, but the Committee will remember that the previous Government had to act quickly and part with a lot of money in a short time. In such instances, it is essential that Ministers have the power to provide financial assistance. It is not only about crises, however; ordinarily, there are occasions when a Government will want to roll out a new prevention programme or address deficiencies in care in particular areas. I know that health policy is always evolving, and the case for flexibility is clear. The Health Secretary may need to be able to provide financial assistance in pursuit of supporting the health service.

I am sure that hon. Members are familiar with the existing legislation. Section 12D of the National Health Service Act 2006 gives the Secretary of State, NHS England, an ICB or the local authority the ability to make direct financial payments as an assistance to persons or bodies. Clause 9 would new section 12DA of the Act, under which the Secretary of State would be empowered to provide assistance to any person or body carrying out, or proposing to carry out, activities that they deem beneficial to the service.

This is where semantics are important. The existing legislation allows the Secretary of State to make payments, but clause 9 is different: it would allow the Secretary of State to provide financial assistance and to make available persons employed by the civil service or any other resources that the Secretary of State has. This is a remarkably open-ended power that would allow the Secretary of State to spend taxpayers’ money while bypassing standard scrutiny. When NHS England spends Column 179is located here

Transparency builds trust in the system and disincentivises wasteful spending. Where will parliamentarians or the public be able to see the financial expense of civil servants, or literally any other resource that the Secretary of State may offer in support? For the first time, the Health Secretary will have the power to insert politically directed civil servants into elements of the health service that are not under public ownership.

As clause 9 is drafted, the Secretary of State could provide civil service labour to private or mutual health providers that work within the NHS. Will the Minister elaborate on how that would be used, and how it would be beneficial to the taxpayer and the health service? The number of civil servants taking home more than six figures has increased under this Government. Their time should be focused on delivering public services, not propping up providers, especially ones that are private businesses.

It is also unclear where the legal liability lies under such arrangements. If something goes wrong and the human resources provided by the Secretary of State are responsible, is the Secretary of State responsible or the entity into which those staff have been inserted? Can the Minister clarify that?

It may be politically beneficial in the short term to provide state support, but it can be costly to the public purse and damaging to markets in the long term. By allowing the Health Secretary to issue assistance in the form of free civil servant labour, clause 9 effectively creates a new type of off-the-books subsidy. How can Members of the House or NHS providers tell whether assistance is operational support or a de facto subsidy? It could undermine the idea of a level playing field for firms contracted to deliver NHS services.

There is also the question of when assistance crosses from operational support into running a provider or firm. We do not necessarily want to be in a position where the Bill is used to bail out failing private firms with NHS contracts. I return to the phrase

“any other resources of the Secretary of State”.

It is difficult to understand why the legislation was written in this way, allowing financial assistance, the provision of labour, and then the use of absolutely any other resource at the Health Secretary’s disposal. As with several other provisions in the Bill, it seems another sign that the legislation was rushed. Instead of circumscribing power tightly where it is needed, the Bill gives huge sweeping powers while claiming that it decentralises.

The Minister has described clause 9 as a discretionary power intended to support the effective functioning of the health service and its workforce. Although that may be what she sought to achieve, that is not the reality. The clause paves the way for arbitrary and unaccountable deployments of state resources, and that should concern all hon. Members.

I endorse the comments made by my hon. Friend the Member for Sleaford and North Hykeham.Column 180is located here

I am particularly concerned about subsection (2)(a) of proposed new section 12DA. On examination, this provision raises significant concerns about the control of public expenditure and the efficient use of resources within the health service, and I find it rather vague. There is no definition of the terms used, no indication of scope and no express limitation on how the power is to be exercised.

When read together with subsection (1) of proposed new section 12DA, the effect, as I read it, is to allow the Secretary of State to provide funding to an extremely wide category of recipients. That includes not only public bodies and established NHS providers but, as my hon. Friend the Member for Sleaford and North Hykeham has said, private entities, charities, individuals and any person engaged in activities that the Secretary of State considers to be beneficial to the health service.

That breadth is not accompanied by a corresponding statutory safeguard. The clause does not set out criteria for eligibility, priorities for funding or principles to guide decision making. It does not impose limits on the sums that may be disbursed, nor does it require any structured process for allocating funds. There is no express provision for transparency, such as publication of decisions or reporting obligations to another body such as Parliament. That absence is significant.

Control over public expenditure ultimately lies with Parliament, yet the clause delegates a wide and flexible spending power to the Executive with little direction as to how that power is to be exercised. While it may be said that Treasury rules, audit requirements and general public law principles continue to apply, those are external controls and they do not substitute for clear statutory discipline within the provision itself.

The practical consequences of such a broad power need to be considered. The NHS is already under considerable financial strain; as we all know, demand is rising and resources are constrained, and there is a continuing need to ensure that funding is allocated in a way that delivers measurable improvements in outcomes. In that context, certainty, prioritisation and efficiency are essential. By framing this power in such open terms, the clause risks undermining those objectives. It will create the possibility of fragmented funding decisions, with resources distributed across a wide range of initiatives without clear and consistent frameworks, and it may lead to duplication of effort or to supporting projects with benefits that are uncertain or difficult to evaluate. Without clear criteria or structured oversight, it will become more difficult to ensure that funding is directed to the areas of greatest need.

In concluding the debate on this part of the Bill, the Opposition have helpfully made most of my arguments for me. The hon. Member for Sleaford and North Hykeham opened with reference to the pandemic and the unusual circumstances in which we have found ourselves. It is obviously important that this Government learn the lessons from that pandemic in the round, that we are prepared and that, as NHS England is abolished, those powers come back to the Secretary of State so that we can respond to any eventuality that comes before us.

As the hon. Member for Farnham and Bordon said, there are existing standards and rules of procurement. Any spending that happens through the Department and the NHS will be publicly recorded and published in the Department of Health’s consolidated accounts. Those come before Parliament, so there is direct transparency through the parliamentary process in the usual way and, as we all know and as the hon. Member for Farnham and Bordon said, Treasury rules apply.

The point about the use of civil servants has been made. Again, it is really important that we recognise that we are bringing together NHS England, NHS staff and civil servants in the Department. It is right that the Secretary of State, in whatever eventuality comes before him or her, is able to deploy the right person for the right job, be they a civil servant or someone currently under NHS staff terms and conditions, to support that work going forward. The clause is necessarily flexible and broad to provide for those eventualities, and to enable the necessary assistance to be deployed. I commend clause 9 to the Committee.

Question put and agreed to.

Clause 9 ordered to stand part of the Bill.

Clause 10

Secretary of State’s duty as respects variation in provision of health services

I beg to move amendment 53, in clause 10, page 6, line 21, leave out from “interests” to end of line and insert “of patients”.

This amendment would only allow the Secretary of State to vary the balance between the public and private sectors in the NHS where it is in the interests of patients to do so.

With this it will be convenient to consider clause stand part.

This is perhaps the oddest provision in the Bill. Since time immemorial, the Labour party has accused its political rivals of wanting to privatise the health service. In the early 2010s, the then shadow Ministers indulged the idea that the Health and Social Care Act 2012 was a Trojan horse for privatisation. Several years later, after the Minister had herself joined the House, claims continued. The then leader of the Labour party urged the previous Government to

“undo the very damaging privatisation of so much of our NHS”. —[Official Report, 23 October 2019; Vol. 666, c. 960.]

In the 2019 election, the public were even presented with a dodgy dossier—not Labour’s first—that purported to show that the NHS was on the table in negotiations for a trade deal. We now have a trade deal and the NHS is still intact.

Even though Members know full well that no sensible opposition party is advocating for abandoning our NHS system, they keep saying that Governments have been selling off the health service through the back door. Today, private providers deliver only about 10% of NHS care and the system continues to be free at the point of use.

That brings us to the deep irony of today’s debate. After years of peddling the NHS privatisation myth, the Labour party has introduced legislation to make privatisation possible. The Health and Social Care Act 2012 inserted a safeguard against privatisation, section 12E, into the NHS Act 2006. That section prohibits the Secretary of State from exercising his functions for the purpose of “causing a variation” in the proportion of services provided by the public or the private sector.

Clause 10 substitutes the text in that section and makes two small but significant changes. The first change is to expand the type of providers beyond public and private to

“different kinds of legal entity”.

That is probably a good change, because it encompasses the mutual and voluntary sectors, which do have an important role to play in health provision going forward.

The second change is what has caused alarm. The Secretary of State cannot alter the provider mix unless they deem it to be

“in the interests of the health service.”

Could the Minister set out some scenarios when it would be deliberately beneficial to privatise provision or, indeed, when it would be beneficial to deliberately nationalise provision? I cannot recall an instance where Ministers needed to privatise an entire service to ensure patients did not lose access to care.

In February, the Minister of State for Secondary Care told the House that lessons had been learned from private finance initiatives. Yet the Government announced that 80% of neighbourhood health centres will be privatised through public private partnerships. The Government are able to use these partnerships to loan money outside their limits, but it tends to be more costly than public sector borrowing. Essentially, it is borrowing, but not borrowing on the balance sheet.

What is the effect of these private initiatives? I remember receiving my own office on being promoted as a doctor to consultant. It is quite an exciting moment; before Column 183is located here

So my great big whiteboard sat there, propped against the wall. Periodically, I would move a piece of paper, knock the bottom of the whiteboard and it would tip and fall on me when I was sat at my desk. I did suggest putting it up myself, but that would also incur a charge through the PFI contract—for modifying things without getting them to do the modifications—so I just had to sit there with it propped up against the wall, ad infinitum.

The Government are on the hook for more than £100 billion of payouts, simply for the use and maintenance of PFI facilities. The Labour scheme was a shambolic waste of taxpayers’ money that could have been spent on improving care. When my hon. Friend the Member for Hinckley and Bosworth (Dr Evans) asked the Minister about public private partnerships, she told him she was

“very proud of the capital investment under the last Labour Government”.—[Official Report, 4 March 2026; Vol. 781, c. 386WH.]

But is clause 10 simply a mechanism for Ministers to develop further private finance initiatives? If Government spending is under pressure, may Ministers seek to shift provision even if it proves more costly in the long run?

There is another side to the conundrum of clause 10. Instead of a Health Secretary intent on privatisation, what if we get one intent on squeezing out private sector provision? Who our new Prime Minister will be, we do not know, but one of the candidates has called for the country to abandon 40 years of neoliberalism. Perhaps the Minister could elaborate on what that means, since the tax take as a percentage of GDP is the highest it has been in 40 years. To me, it signals a potential hostility towards choice and competition. We do not want to be in a situation in which the decision is made to alter the provider mix in service of ideology, rather than in the best interests of patients.

I am aware of several private firms that provide services to the NHS and are concerned that clause 10 could be wielded against them. If a future Health Secretary decided to reduce private provision on the basis of ideology, what would happen to the 10% of planned activity that is currently delivered by for-profit entities? NHS providers could not feasibly handle such a surge in demand, waiting lists would increase further, and patient choice would suffer. It would also be expensive. If private providers fear that the NHS is no longer a reliable customer, and that they may suddenly lose their contract if this clause is invoked, they will charge a risk premium on their services—that is what firms do when they face shifting regulatory goalposts. That would only damage the public purse.

Under clause 10, it would be legally possible for the Health Secretary to alter the provider mix. As a result, it would be worth it for several types of providers and ideologically motivated groups to spend vast sums of money hiring lobbyists to convince Ministers that their sector deserves favourable treatment and that they serve the interests of the NHS. Organisations would invest less in resources and more in influencing the rules, which is not a good outcome either.Column 184is located here

All those issues are compounded by the fact that clause 10 is imprecise. What does the Minister define as

“the interests of the health service”?

I am not trying to catch the Minister out; I just want to illustrate the problem with legislation drafted in such terms. It is difficult to prove that the Health Secretary has not acted in what they thought were the best interests of the health service. What could that refer to? It could refer to the interests of patients, to the interests of NHS staff or to the financial stability of the health service—it is entirely subjective. What is the health service there for? It is there for patients, which is why I tabled amendment 53.

Amendment 53 would revise clause 10 to specify that the Secretary of State must not alter the provider mix unless doing so is in the interests of patients. I would like to place patients at the centre of the Bill’s changes, in recognition that we do not have the numbers on the Committee to change the clause altogether. My revision would make it harder for the Health Secretary to justify altering the provider mix if it harms patient access or reduces their choice. It would make NHS providers less fearful to know that the Health Secretary would be subjected to a better defined legal threshold.

The shadow Minister has outlined a couple of hypotheticals for the future, when we have a different Prime Minister and a different Secretary of State. One might go down a route of more privatisation, another down a route of removing the private sector from health service provision. My concern is more practical and for the here and now: if the clause stands part of the Bill, it must be because the Government have some desire to do one of those two things now. Would it not be a good idea to hear from the Minister which of those two options it is?

It does raise questions about the point of new section 12E. That provision was not there before; there must be a reason for adding it. Either the Government want ideologically to reduce the amount of private provision in the NHS, or they want to increase it. The clause gives them the power to do both.

Labour politicians very often tell the public that the NHS is being privatised. Data has shown that that is not happening, but that did not matter; they found the myth politically advantageous and repeated it ad nauseam. Now, the Minister and her colleagues are in office—they have the levers of power—and are proposing to change the law to make it easier to change the provider mix. That is not only ironic but deeply misguided.

I tabled amendment 53 to require any changes to the provider mix to be in the interests of patients. If the Minister is unwilling to support that, will she offer a compelling explanation why? Clause 10 has alarmed stakeholders across the health sector and the political spectrum. That really ought to tell us something. I look forward to her response.

It is a pleasure to serve with you in the Chair, Sir Roger. I have concerns similar to those of the shadow Minister about clause 10. Proposed new section 12E allows Ministers to vary the proportion of activity by provider, and I am interested in the rationale behind that. The powers to retain the Column 185is located here

As we heard earlier when discussing ophthalmology, there are risks to using private provision for certain NHS activities, as there can be unintended consequences—a bit like the deregulation of buses. In ophthalmology, private providers do thousands of cataract operations very efficiently, but the less exciting and more critical work of preventing people from going blind, which is done in NHS hospitals, is under threat because so many people want to work in easy and profitable areas. I am concerned that that will occur in more areas of the NHS if the Bill allows more privatisation. Although I do not have an ideological problem with the NHS contracting out to private providers—that has worked well to bring down elective waiting lists, for example—the provisions to protect the mix are important.

I am not sure that amendment 53 really moves us forward; it just requires the Secretary of State to consider who benefits from the change in mix.

It is true that the situation in ophthalmology is now quite serious, but is the hon. Lady aware of the problems in radiology and pathology? Some hospitals are unable to recruit histopathologists or significant numbers of radiologists, who provide key services, because the personnel necessary to run those services have been attracted into a private system, although they are contracted to the NHS. That jeopardises the ongoing services for urgent and emergency care.

The hon. Gentleman outlines an unintended consequence of the NHS contracting out to private providers. There are ways to get the pricing of those services right, but the clause could introduce that unintended consequence.

Why is this proposal included in the Bill, and what does the Minister see it being used for? Is there a risk that a future Government might use it to bring much more privatisation into the NHS? The general public consensus is that that would be a bad thing. What safeguards can she put in place to ensure that does not happen?

I will respond to that question before picking up the other comments. If I do not address all the Committee’s comments, I will come back to Members.

Everyone would expect this, but let me be clear: this Government are absolutely committed to a free-at-the-point-of-use, taxpayer-funded service. We also think that unless it is reformed and changed, it is an existential problem for the British public, who will not continue to support the service. As Members know, one Parliament can never bind another one, so I cannot predict what a future Government will do. There is talk from some of our Reform colleagues about an insurance-based system. There are people who were in the Conservative party but have moved over who think that, so obviously I cannot—

Will the Minister give way on that point?

I will make some points, and then I will be happy take the hon. Lady’s intervention if I do not address what she was going to say.Column 186is located here

The hon. Member for North Shropshire outlined some of the history. This clause seeks to strike a balance. The governing principle behind it is that the decisions of the Secretary of State must not vary the proportion of providers by the type of legal entity that they are. Decisions must be taken according to what serves the health service and the people who depend on it. The clause permits, by way of exception, the balance between sectors to be varied purposefully, but only where doing so would be in the interests of the health service. That would, for example, prevent the Secretary of State from deliberately choosing to grow the proportion of NHS services delivered by private providers for solely ideological reasons.

I understand the concern that drives the amendment. It is that the exception might be relied on to support the convenience of those already providing the service, without taking into account what is best for patients, as the hon. Member for Sleaford and North Hykeham said. That is not the Government’s position, and the clause does not lead to that outcome. The test that it creates is whether the interests of the health services are served.

As the hon. Member for Sleaford and North Hykeham also said, the definition of the health service—as defined under section 1 of the National Health Service Act 2006—is not separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness. A decision to rely on the exception must be justified by reference to that duty; one taken merely because it was easier or more convenient for existing providers or any other group, with no such justification, would be unlawful. The protection that she seeks is, in substance, already secured by the clause.

The amendment would also create another difficulty. Section 1 of the 2006 Act reaches the entire population and includes the prevention of illness before anyone becomes a patient at all. The “interests of patients” reaches only those already receiving care, which is a narrower test than I think the hon. Lady intended, and would allow a Secretary of State who was so minded to provide a landscape that ignores vital preventive health and wellbeing concerns. I hope that she will take from my remarks an assurance that the clause already meets her concerns.

The hon. Lady also highlighted the example of PFI—a subject of much discussion over many years—and of being unable to change her whiteboard. That is absolutely one of the lessons that needs to be learned from the way in which some past PFIs were procured and dealt with. For example, as a new Government, we outlined proposals for a new model of public-private partnerships for neighbourhood health centres, among other things. The previous Government could also have learned the lessons and done something about that, but they chose instead to completely halt the building of any kind of facilities. That is one reason why we are in such a shocking state at the moment. The new proposal outlines, as I think the Opposition know, an 80:20 funding route, exactly to make the point about which is the most efficient way forward. That will absolutely drive measures for growth and create more jobs in the sector.

I want to take the Minister back to her rejection of the amendment of my hon. Friend the Member for Sleaford and North Hykeham on the basis that—I paraphrase—she felt the definition of “patients” was too limiting because it would not count people who had not entered the health system at that point. The clause itself, however, refers to the benefit for the health service. Is the Minister suggesting that the health service, as defined in the Bill, includes what happens before people enter what I would describe as the health service? Is it something before that point? She seems to be saying that our definition is too narrow, but her definition in the Bill must apply to those who have entered some kind of formal setting. Or is the health service wider than that?

I refer the hon. Gentleman back to my comments. The health service is defined under section 1 of the NHS Act 2006 as not being separate from the people it exists to serve. It is defined as “a comprehensive health service” for “the people of England”, directed at improving their health and at the “prevention, diagnosis and treatment” of illness—so, yes.

At this juncture, I will explain a number of other features of the clause. In particular, I draw the Committee’s attention to the fact that it builds on section 12E of the 2006 Act to cover the Secretary of State’s health functions, powers and duties. It recognises that, with the abolition of NHS England, the Secretary of State has a far more substantial role to play—as a commissioner of services, for example—than previously. I also put on the record that whenever the Secretary of State takes a decision in this space, the general NHS procurement requirements and other statutory duties will continue to apply.

Finally, the NHS relies on privately owned providers, as well as charities and community organisations, to provide a range of important NHS-funded services across the country. As such, it is important to ensure that, where there is a mixed-market provision between public and private for providers of a particular service, the Government’s powers are not used to distort the provision and potentially discourage important investment from outside the NHS. Conversely, they should not be used purposefully to favour independent providers over NHS providers for reasons unrelated to the quality or efficiency of NHS-funded healthcare.

If I heard the Minister right, she said that the clause did not provide for changes on the basis of ideology. However, it says that changes are not to be made

“unless the Secretary of State considers that to do so is in the interests of the health service.”

A Secretary of State whose ideology is that the private sector is bad, good or whatever else could well believe that it is in the interests of the health service to be private or not private. How does the clause prevent an ideologically driven Secretary of State from changing the health service on the basis simply of his ideology, rather than of patient or clinical need?

The hon. Lady tempts me to delve into the politics of future Secretaries of State. They will respond according to the manifesto on which they are elected by the British public. That is the point of a Column 188is located here

Question put, That the amendment be made.

I beg to move amendment 47, in clause 11, page 8, leave out lines 15 to 30.

This amendment prevents the Secretary of State from removing the Chief Executive of an integrated care board.

With this it will be convenient to discuss clause stand part.

Clause 11 is particularly interesting. In August 2025, Alan Milburn was asked about the abolition of NHS England on the Health Foundation podcast. He said that the Government wanted to see a model that was “more delegated…more devolved” and “more diverse”, which necessitated the centre being smaller. Considering that he is a former Labour Health Secretary and a non-executive director at the Department of Health and Social Care, I do not doubt his understanding of what the Government wanted to achieve.

When the former Health Secretary, the right hon. Member for Ilford North (Wes Streeting), announced the 10-year plan to the House, he also talked about dissolving power. He spoke of a

“brave new world of devolution of power, resources and control”.—[Official Report, 3 July 2025; Vol. 770, c. 469.]

That was repeated in the Government publications that accompanied the Bill:

“Empowering ICBs as strategic commissioners will support putting patients at the centre of care by devolving decisions to a local level where different services can better integrate… Reforms to the NHS FT model will give providers more flexibility to design and deliver healthcare around local needs.”

Between the announcement of the abolition of NHS England and the publication of the Bill, Ministers articulated a vision for a more decentralised system. There is expert consensus that decentralisation boosts performance, reduces health disparities and fosters innovation. After listening to remarks this morning, Column 189is located here

I mentioned in Committee last Thursday that the Liberal Democrats are worried about the risk in the Bill of political capture and the Secretary of State’s ability to meddle in day-to-day operations. As I am sure the Minister is aware, speaking at the NHS ConfedExpo this month, Sir Jim Mackey, the chief executive officer of NHS England, warned that the Bill may give Ministers too much control and that there has to be operational freedom; otherwise we will grind to a halt.

I want to probe the process by which we got to this point. Originally, there was discussion about whether the seven NHS regional teams should become independent arm’s length bodies to mitigate such a risk. NHS leaders argued that this would mitigate the risk of direct political control of the service and pointed out that the 10 regional strategic health authorities had played a useful role in running the service efficiently before the creation of NHSE. That proposal was rejected by Ministers, and it is not entirely clear why. I am interested to hear the Minister’s view on that.

It is now being reported that a fresh attempt is being made to argue that regional teams should be hosted by an NHS organisation—probably an ICB—to protect their employment terms and, as staff would remain public rather than civil servants, provide some brake on political control. Can the Minister shed any light on all this? Does she recognise the importance of maintaining operational freedom in NHS decision making?Column 193is located here

We have discussed the reality that current Parliaments cannot bind future ones, and I take that point on board. However, current Parliaments do set precedents and establish the legal frameworks within which future Governments initially operate until they change the law. With the potential for more extreme Governments, there is a risk of discrimination and political considerations entering what should be clinical decision making—for example, decisions on whether to place a trust into special measures or what services are offered, such as sexual health, IVF, outreach to migrant communities and so on.

We are concerned not about the current Secretary of State, or indeed the shadow Secretary of State, but about the risk of those sweeping powers being placed in the hands of an extreme Government. If we imagine for a moment that an incoming Government decided that they did not approve of diversity on an NHS board, for example, and replaced an executive with their own candidate, that would be a horrifying situation. I think we would all agree on that. It would be useful to include safeguards now and set a precedent that such action would not be acceptable under this Bill. Notwithstanding the fact that a future Government could come along and change that, they would have to be transparent about their reasons for doing so.

The former Health Secretary, the right hon. Member for Ilford North, claimed that he was taking powers back into DHSC in order to give them away to the system, but this Bill has a lot on taking those powers and very little on giving them to the system. How can we be sure that that will actually happen on the ground, and that ICBs, hospital trusts and other health trusts will have the opportunity to flex their local muscle and ensure that services are best shaped for the local population? The NHS Alliance has called for an operationally independent regulatory function in DHSC to oversee NHS organisations, or for an independent panel to make appointments. Will the Minister consider such practical changes to ensure that political capture is not an unintended consequence of the Bill?

I rise to support amendment 47, tabled by my hon. Friend the Member for Sleaford and North Hykeham, and to ask a few questions about clause 11. I completely understand the thinking behind the clause. The Secretary of State for Health and Social Care is probably the most politically impotent of all Secretaries of State: as my hon. Friend said, they pull levers and not much seems to happen, because they do not have the control over the health service that the public think they do—or indeed, that Members of Parliament think they do, judging by the number of us who stand up and demand that the Secretary of State do things in our local areas.

I understand the Government and the Secretary of State’s desire to change some of that, but there is concern about the potential politicisation of NHS leadership. Integrated care boards were established in various forms under the Health and Social Care Act 2012 precisely to remove politicisation to ensure that decisions in our healthcare service were made for the benefit of patients on the basis of clinical evidence and the needs of the local population, not on the whim of any Secretary of State or Minister. More importantly, ICBs were Column 194is located here

Those politically independent ICB chief executives were expected to exercise professional judgment, make difficult decisions about priorities and resources and sometimes deliver messages that Ministers, and indeed local Members of Parliament, found uncomfortable. If those leaders know that their continued employment ultimately depends on the confidence of the Secretary of State, there is a real risk that the independence of their judgment will be weakened and that patient safety will diminish.

The amendment tabled by my hon. Friend the Member for Sleaford and North Hykeham tackles a core question: should an ICB chief executive focus solely on what is best for patients and the local health economy, or should they have to consider whether their decisions may attract ministerial displeasure? Even if the power is rarely used, and even if, as my hon. Friend said, there are currently some guardrails in the clause, its existence will change behaviour—it must do. Leaders will become more cautious, perhaps more risk-averse and potentially less willing to challenge national policy when local evidence points in a different direction.

ICBs have benefited from the ability to speak truth to power. A system in which senior NHS leaders fear dismissal by Ministers risks discouraging precisely that kind of honesty. Do not get me wrong: there are good ICB chief executives and bad ICB chief executives, ones who understand their role well and ones who feel that they do not need to engage at all with their local communities. I have a very good ICB in what is currently Surrey Heartlands, soon to be a larger organisation, and an ICB that does not do the job as well—I will not name it, but any student of geography will be able to work out which one it is.

Secondly, excessive ministerial power blurs the lines of accountability. The Minister, in her defence, has argued that Ministers need powers because Ministers are accountable. I get that argument, but one of the most important principles of effective public administration is clarity of responsibility. If the Secretary of State gains extensive powers to appoint and dismiss local NHS leaders, it will become increasingly difficult to know who is actually responsible for outcomes. When performance improves, Ministers will claim credit; when performance deteriorates, local leaders may be blamed. If Ministers possess the power to select and remove those leaders, they will inevitably become more directly responsible for those management decisions, so far from increasing accountability, this might dilute it by creating uncertainty about where true authority lies.

Thirdly, there is a constitutional concern. Whether one likes it or not, the previous Act created a balance between democratic accountability and operational independence. Parliament rightly determines the funding, priorities and legislative frameworks, and Ministers rightly set national policy, but operational decisions have been made by healthcare professionals and the statutory bodies established for that purpose. That distinction exists for a good reason. No Secretary of State, regardless of ability or commitment, or indeed their own background in the health service, can personally manage every NHS organisation in England, and I do not think they should. The more powers we concentrate at the centre, the Column 195is located here

Fourthly, there is a practical problem. Supporters of ministerial intervention often point to examples of failure and ask what should happen when an ICB is underperforming. That is a fair question, but the answer is not that the Secretary of State must personally possess dismissal powers. A range of mechanisms already exist: ICB boards have governance responsibilities; NHS England has oversight powers; professional regulators oversee the conduct of clinicians; there are provisions in employment law for procedures when it comes to misconduct and capability issues; and auditors and inspectors can identify failings. It would be far better if the Bill strengthened those provisions to ensure that accountability was brought forward, rather than giving the Secretary of State the ability to fire and hire as he or she sees fit.

Of course, none of those mechanisms of accountability will disappear if amendment 47 is adopted. The amendment would not create any kind of immunity from accountability; it would simply ensure that accountability is exercised through the established governance structures, rather than through direct ministerial intervention on a chief executive. Indeed, one might ask whether a Secretary of State is really the best person to assess the performance of an individual ICB chief executive. Such judgments often require detailed understanding of local service pressures, workforce challenges, demographic factors, financial constraints and so on. Those are matters better evaluated by individual organisations with operational expertise than by politicians operating at national level.

Fifthly, I think the clause as drafted would present a risk to recruitment and retention. The NHS already faces significant leadership challenges. Senior leaders are expected to manage enormous budgets, oversee complex organisations and make difficult decisions under intense public scrutiny. If we create a system in which their tenure can ultimately depend upon ministerial whim, we may deter talented individuals from seeking those positions. As my hon. Friend said, the NHS needs leaders who are willing to innovate, take calculated risks and make difficult long-term decisions. It does not need a culture in which leaders are constantly looking over their shoulder, wondering whether a politically controversial but clinically necessary decision could threaten their position. Strong organisations attract strong leaders when governance arrangements are stable, predictable and professionally driven. They do not attract them through uncertainty and political intervention.

Sixthly, we need to consider the precedent being established. Powers granted to one Secretary of State are inherited by the next, as the hon. Member for North Shropshire said. Members may trust the intentions of the current Minister—I certainly do. They may also believe that these powers would be exercised responsibly—and at the moment I think they would be. However, legislation must be judged not on how it is going to be used by one individual, but on how it could be used by Column 196is located here

Finally, we must remember what ICBs were trying to achieve, even if we do not think that they have achieved it or performed in the way that we wanted them to. If we go back to the principle of why they were set up, they were designed to encourage collaboration rather than some sort of command-and-control structure. They were intended to bring decision making closer to patients and communities. They were established to support long-term planning across local health systems. Those objectives, I am afraid, are very difficult to reconcile with a model in which local leaders remain subject to direct ministerial dismissal. Partnership working flourishes when organisations have confidence in their independence and responsibilities. It is weakened when authority is increasingly concentrated at the centre.

For all those reasons, I believe that amendment 47 in the name my hon. Friend the Member for Sleaford and North Hykeham raises an important principle. It is not about protecting poor performance or shielding individuals from accountability; it is about ensuring that accountability is exercised through proper governance structures rather than political control. Expanding ministerial powers to hire and fire local NHS leaders risks undermining all of those principles.

We have a clear political and—as I think the hon. Member for Sleaford and North Hykeham said—philosophical division here. This Government believe in democratic accountability, in politics and in good government. I understand that both Opposition parties were architects of the 2012 Act, which created this huge, independent body to run what has become a £200 billion service that clearly has not worked, and that they want to hold on to some of that, despite not opposing the Bill on Second Reading and, actually, not really opposing the abolition of NHS England—I think we will keep returning to that—but we believe that, ultimately, the Secretary of State needs to be accountable for the service, which is not working as the British public deserve or expect.

The hon. Lady asked me to go into good variation and bad variation. Our drive has been to understand the variation. I know from Members of Parliament who have come to me in the past two years, and we understand from looking in detail at the variation across the service, that there is often no rationale for the variation. Local people do not understand why services work better in one part of their county, even, than in another. The hon. Member for Farnham and Bordon alluded to that when he mentioned some places in his area that are working better than others. That is why—and I personally wanted to drive this very strongly—we are getting more information out, releasing the outcomes framework and releasing information to all Members of Parliament about where and how the current data shows their local systems are performing. That is what local people need, and in my view good local parliamentarians, of whom there are very many, should be able to go back to talk to Column 197is located here

I stand by my comments that my approach is more local than centralised. This is about changing the culture, which we seek to do by making that happen more locally. I absolutely get the points about operational freedom and the balance that we will seek when we release the operating model, which is being worked on in the Department, as we bring the new system into being, alongside the Bill.

However, we want to be very clear that when an ICB has failed or is at risk of failure, and that failure is significant, it is right that the Secretary of State has the tools to minimise the impact on patients and the public and to act swiftly to put things right. The public rightly expect that, in such circumstances, Ministers will take the necessary steps to protect patients, taxpayers and the public. In some cases of significant failure, that may include directing an ICB and removing the chief executive.

I am sure that all Members here today will agree that effective performance management of ICBs will continue to be essential once NHS England is abolished, not only to support the provision of a quality service, but to reassure the people served by ICBs that when things go wrong, they will be put right.

I could not agree more with the Minister that when there is an obvious failure, either in a local system or in a trust, we would hope that the Secretary of State will intervene. She will know from our experience in Shropshire that, when a system is failing or underperforming, that intervention is welcome. But the Bill gives the Secretary of State power to intervene even when things are going well, which is quite an extension of power. Will the Minister comment on that?

I thank the hon. Lady for that intervention, and I will come on to the power.

As hon. Members are aware, NHS England currently holds similar powers, so it makes sense for these powers to be held by the Secretary of State once NHS England is abolished. I want to be clear—I hope that this will address the hon. Lady’s point—that our intention is to use these significant failure powers rarely and not as a first port of call. It is far better to work closely with ICBs and their leaders to spot issues and work collaboratively to resolve them before they have the opportunity to become significant, but it would be irresponsible not to have the power to intervene as a last resort.

I want to address the other elements of clause 11. The first part of the clause establishes a general power for the Secretary of State to direct integrated care boards about the exercise of their functions. Using that power, the Secretary of State could direct a singular ICB, a group of ICBs or all ICBs, depending on the scope of the direction. This power is a necessary step in restoring democratic control over the NHS. The public rightly Column 198is located here

The power is particularly relevant given the wider commissioning responsibilities ICBs will have in their role as strategic commissioners following the abolition of NHS England. By setting standards for all ICBs, the power will help reduce the unwarranted variation in the way that ICBs discharge their functions. It is also an important tool for enabling Ministers to respond to changing events. The lack of such a power has slowed the ability of NHS England to respond to unforeseen challenges within the health system.

I can also give the Committee an assurance that the clause includes a considered set of limits on the scope of the power. The Secretary of State will not be able to direct ICBs to appoint a particular individual, issue a direction about the services to be provided to an individual, or direct the use of a drug treatment or diagnostic technique where that is inconsistent with NICE guidance or recommendations. Equally, to maintain transparency in the health system, directions made under the general power to direct ICBs as to the exercise of their functions will be required to be made in writing and to be published as soon as reasonably practical. The power will enable the Secretary of State to uphold the standards that patients expect and deserve, while also protecting the principles of fairness and impartiality at the heart of the NHS.

We have already addressed much of the second part of the clause, but I should note that we have purposely placed the powers to intervene in cases of significant failure outside the general power of direction over ICBs. That is because it is important to be clear that those powers are expected to be used only rarely and in situations where an ICB is failing or at risk of failing.

I hope the hon. Member for Sleaford and North Hykeham feels able to withdraw her amendment. I commend the clause to the Committee.

Question put, That the amendment be made.