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Showing every spoken contribution, including 12,942 under 12 words. Hide short remarks
I accept the point about the plethora of businesses in the food supply sector, but my amendment simply seeks commonality with what the European Union has pushed for. Why can it not be the right thing for the UK Government to do as well?
On a point of order, Madam Deputy Speaker. I wish to raise with you my concern about comments attributed to the right hon. Member for North West Essex (Mrs Badenoch), who I understand has described my right hon. Friend the Member for Houghton and Sunderland South (Bridget Phillipson) as acting like a Gestapo officer—I think that is the term she used. This is extremely alarming, particularly on this day of all days. In recognition of Jo Cox’s assassination, I just ask that all of us around this place temper our comments and calm down the rhetoric. I simply ask your advice, Madam Deputy Speaker, on how to take that matter forward.
I thank the Secretary of State for her statement and for robust way in which she is standing up for residents and the environment on this very important issue. My constituents are appalled by the sewage pollution in the River Thames and by the poor quality of customer service offered by Thames Water. We have had numerous breaks in supply and there was an issue with subsidence that closed a road in Reading. Can she tell me more about the process that will be followed by Ofwat and the action she will take through the clean water Bill?
I beg to move, That the Committee has considered the draft Digital Waste Tracking (England) Regulations 2026. It is a pleasure to serve under your chairmanship, Mr Vickers. I begin by wishing my hon. Friend the Member for Newcastle upon Tyne North a happy significant birthday, and I look forward to celebrating with her later and at various points throughout the week ahead. The draft regulations were laid before the House on 23 April this year. More than 200 million tonnes of waste are produced in the UK each year, and there is currently no comprehensive way of tracking it. Legislation relating to the transport, management and description of waste has been introduced in a piecemeal fashion over the last 30 years. Large amounts of waste movement data recorded through the current system are either not collected or are required to be submitted only each quarter and, of course, they are collected on a paper-based system. As a result, at a national level, it is difficult to determine where waste is from and what happens to it. At a local level, it is difficult for waste producers to check that their waste has been handled appropriately. The system’s lack of transparency gives waste criminals opportunities to undercut legitimate waste businesses and to cause harm to our environment and communities. This crime costs the UK economy an estimated £1 billion each year, due to activities such as fly-tipping, deliberate misclassification of waste to avoid paying landfill taxes, illegal waste exports and the operation of illegal waste sites. For investigations, regulators usually need to request individual waste records by serving legal notices, which is time-consuming and prone to document falsification. Replacing the outdated paper-based system will give the Environment Agency much-needed compliance oversight and help to close the loopholes that rogue operators exploit. The regulations will support those who do the right thing, not those who undercut them and think that “muck” is an accurate waste description or that providing a partial postcode for the source of waste is acceptable. By requiring near real-time information about waste movements to be recorded on a centralised system, the regulations will enable officers to identify unusual patterns, pinpoint high-risk operators, intervene earlier and shape targeted initiatives. We are shifting from reactive investigation to proactive prevention. The regulations are the crucial first step in transforming the waste industry so that regulators—the Environment Agency—have timely data on waste movements from production right through to disposal. The previous Government consulted on these reforms way back in 2022. They responded to the consultation the following year, but critically, they did not introduce these changes. This Government are acting. The first set of regulations will mandate that waste receivers operating under an environmental permit make a digital record of waste that comes into their facilities and submit that information to the digital waste tracking system within two working days of the waste being received. A second statutory instrument will be laid before the House next year to extend requirements to capture the full end-to-end waste journey information. Before I turn to the detail of the legislation, I acknowledge the work of the Secondary Legislation Scrutiny Committee. Its report highlighted a point of interest on how digital waste tracking will interact with the new packaging extended producer responsibility scheme, or pEPR. Of course, once it is fully implemented next year, the data submitted to the digital waste tracking system will help to reduce fraud in the pEPR system as well. I turn to the detail of the legislation, which provides a new statutory framework to tackle the problem of waste tracking. It designates the Secretary of State for Environment, Food and Rural Affairs to establish, maintain and operate the digital system. It requires that permitted waste receivers make digital records of specified information, as set out in schedule 1, before submitting it on to the system. There is a requirement for operators to pay an annual fee of £26, which will be used to recoup the costs of establishing, operating and maintaining the system. Although there will also be transition costs to businesses of just over £1.5 million over four years between 2026 and 2029, and costs to obtain software estimated at under £39 million over 15 years, those costs are significantly outweighed by the future benefits of businesses no longer having to submit quarterly waste returns and, of course, the reduction in waste crime, which gives legitimate operators more waste to legitimately dispose of. Together, those savings are estimated at nearly £600 million over the 15-year appraisal period. As the illegal businesses—the criminals—leave the industry, there will be reduced unfair competition, more waste for the compliant operators and increased revenue. The draft regulations introduce a new offence of failing to comply with the legislation and make provision for criminal penalties and civil sanctions, with unlimited fines available to punish offenders. Those who try to commit fraud by entering false information on to the system can also be prosecuted under section 44 of the Environmental Protection Act 1990 and receive up to two years in prison. The introduction of digital waste tracking is a cornerstone of the Government’s waste crime action plan, the toughest ever crackdown on illegal waste activity. Through the action plan, we are strengthening regulations; pursuing the criminals responsible with more boots on the ground, more drones in the air, advanced technologies and stronger punishments; and accelerating the clean-up effort. We are doubling the Environment Agency’s enforcement budget with an additional £45 million over the next three financial years, on top of the £5.6 million increase we had already announced for this financial year—£50 million in total over three years. That will bring waste crime enforcement funding to more than £30 million a year, compared with a miserly £10 million a year in 2023-24. We believe in regulation for the environment, whether that is in the water sector, as we heard today with the Secretary of State’s statement to the House, or in the waste system. We are also introducing the waste carriers, brokers and dealers reform, tightening the waste exemption system and giving courts the powers to put up to nine points on the licences of fly-tippers. My message to the waste criminals is clear: we are coming for you, we will track you down and there is no longer anywhere to hide.
It is a pleasure to respond to that short but pithy and valuable debate. I am grateful to the Opposition spokesman, the hon. Member for Epping Forest, for his comments. He is beginning to remind me a bit of St Augustine, who was famous for his prayer of, “Grant me chastity, Oh Lord, but not yet”, because, as he said, he laid the foundations for some of this work while in government. That includes the EPR system, which he voted for in 2024 along with all his Conservative colleagues. He now stands loudly lamenting EPR, but I just remind him that it is something that his party developed in government and voted for less than two years ago. I share the hon. Gentleman’s frustration about NOx canisters. I am still mystified as to why they are on sale in the UK. I know they are useful for whipping cream, but we see when we go on Amazon, as I did a couple of years ago, that people who bought NOx canisters also bought little canisters to sell it for £1, £2, or whatever it is they do to create further litter. It is absolutely clear that there is not a sudden, massive interest in whipping cream across the festivals and parklands of this great nation. In fact, nitrous oxide is a highly regulated substance and a fluorinated gas that we need for some medical emergencies. I remember the glory days of British dentistry, where any time someone went for a filling they got the happy gas so that they did not really mind what was happening to their teeth. Those of us who are old enough will remember that—[Interruption.] I can see nods of recognition. There were various bans of nitrous oxide, but it is still used for women in childbirth. If we have a quota for fluorinated gas, under various UN conventions, we should keep that quota but reduce it and save it for absolutely medically necessary issues, and not allow a huge black market to proliferate in this thing that is allegedly used for whipping cream. Last Friday, I was out picking up litter and a variety of other things, including a wendy house, that had been fly-tipped in Willenhall in Coventry, and I picked up three nitrous oxide canisters. The day before that I had been to an incinerator, an energy-from-waste plant, where they had shown me how these canisters can burn at incredibly high temperatures. They told me that the canisters should never be put into any sort of incineration, because that presents a danger to workers both on the journey towards incineration and at the incinerator—even though they can come out of the incinerator safely because they are tested to such a high engineering capacity. I thought, “Right, I will not just leave these canisters for the council to pick up; I will take them to a metals recycling facility.” I took them to European Metals Recycling, which is close to my office in Coventry, where I was told, “We don’t take these.” I am not clear where these canisters are meant to be safely disposed of, and if I am the waste Minister and I do not know, I am not clear what everyone else is supposed to be doing. I will start my little battle on NOS—watch this space. Let me talk to some of the other points that were raised. First, charities and local authorities will have to pay the fees. With this waste system, we have essentially mirrored what His Majesty’s Revenue and Customs has done through Making Tax Digital. We have done something that is legible and readable through the back end and that can be used by proprietary software providers, rather than building our own proprietary software and making it clunky and rubbish, which is what Government software schemes are famous for doing. We thought, “How can we turn this on its head and do something that can be used and is fungible and readable across other databases?” We watched what had happened with HMRC and fundamentally designed that in. The system is in beta testing because I believe in making haste slowly. I do not believe in big-bang changes. I believe in working with a coalition of the willing to test, refine and improve. The fee is set at £26. That includes charities, local authorities—anyone operating permitted waste facilities where commercial waste activities are carried out. The fee recovers the cost of establishing, operating and maintaining the services. It includes costs for things like the digital system build, the ongoing hosting cost and the operation of the helpdesk for users, which is run through the Environment Agency. The total costs were estimated over a 10-year period and averaged over the total number of operators expected to be using the service once it has been fully delivered, ensuring that those in the first phase will not pay more, so people are not penalised for being one of the good guys. That approach has been agreed by Treasury. We intend to review the service charge once the system is fully operational and we have more accurate data about the number of users on the system. Of course, one of the issues is that lots of people are not on the system, and we do not know where they are, so we will amend the service charge through legislation as needed. The service fee is paid annually to the Department for Environment, Food and Rural Affairs by users as part of their account registration. One of the main aims of introducing digital waste tracking is to reduce waste crime. Regulators need to distinguish between someone who is digitally excluded and someone who is deliberately not complying with the regulations. There are provisions in the statutory instrument for the digitally excluded—although in this day and age, if someone is running a company without any sort of computer, we do have to wonder. By not having a criminal sanction for failing to apply for a digitally excluded number or recording that number on written records, it may give the impression that this is less important than digital users applying. It may lead to digitally excluded operators choosing not to comply and there would be gaps in waste movement records, which would undermine the whole system, so we have included that. On packaging extended producer responsibility, one of the questions that has been around for at least the last decade—it is not a new one; the hon. Member for Epping Forest will have heard it, as I have—is about the need to reduce fraud in the producer responsibility note and the producer export responsibility note system. We have already introduced a number of measures to address that fraud. All reprocessors and exporters who handle any packaging waste will now have to register, collect and report data on packaging waste received, processed, rejected and exported. The pERP regulation will place requirements on accredited reprocessors and exporters, including monthly reporting of packaging waste reprocessed or exported and monthly data on packaging recovery notes/packaging export recycling note prices by material. Exporters will need to provide proof of receipt at the final overseas destination site to issue a PERN and retain records of the recycling of the packaging waste. Critically, there will also be a new fit and proper person test for operators as part of the accreditation process. In addition, DEFRA has recently consulted on further proposals to enhance the PRN system, target fraud and ensure that packaging waste is managed in an environmentally sustainable way. The results of that consultation will be published shortly. Digital waste tracking is being introduced in phases, but we intend to mandate the recoding of information about exports of green list waste, also known as article 18 waste, in the system from 2027. So it will come here in April next year and we will look to introduce it from October 2027. The increased visibility of export data will also help to combat fraud in the system. On litter, local authorities already have powers to take enforcement action. We have been encouraging them to make good use of those powers, because under the previous Government they did not have the cash to pursue prosecutions and actions against offenders. We have published new statutory litter enforcement guidance: “Litter enforcement powers—when and how to use them”. Local authorities now have a legal duty to have regard to that guidance, which will lead to a more consistent approach to tackling litterers across the country. We have also published a refreshed code of practice on litter and refuse, which sets out the standards expected of local authorities and other duty bodies with regard to keeping land clear of litter and refuse. I pay tribute to the many Wombles and clean-up squads across the country that are doing such great work, but we want to get to a stage where there is no littering and people understand and respect the areas around them. I will add a final thought on fly-tipping: councils already have powers to seize and search the vehicles of suspected fly-tippers. Again, to support them making better use of that power, we have published best practice guidance and case studies on the website of the National Fly-Tipping Prevention Group. We have also secured powers in the Crime and Policing Act 2026 to provide statutory fly-tipping enforcement guidance on using their powers and powers for the courts to award between three and nine penalty points on the driving licences of those found guilty of fly-tipping. Often, we find that fly-tippers are doing a little job for their mates on the weekend. They might be drivers in the week, and this is a little weekend side-hustle. The penalty points would make it harder for offenders to continue dumping illegally if they are disqualified from driving and send a clear warning: fly-tipping is not to be tolerated.
I thank my hon. Friend for his kind words. I also pay tribute to his council in Oldham, which wrote to me about a very thought-provoking motion that the council passed. The leader of the council—I am sorry; his name escapes me—said that environmental justice goes hand in hand with social justice. These environmental crimes are predominantly perpetrated against poorer communities. There is a kind of social injustice there that we must not lose sight of. There are certain parts of Coventry that are spotless and have no litter or fly-tipping, and other areas, like Foleshill, the ward where my office is, where fly-tipping is absolutely endemic. I will conclude by talking about our manifesto commitment to forcing fly-tippers and vandals to clean up their mess. We will soon consult on giving local councils the powers to issue fly-tippers with conditional cautions, one of a range of pre-court community-based sanctions that could see offenders completing up to 20 hours of unpaid work cleaning up streets and parks and paying back the cost of cleaning up the waste that they have dumped on public land. If an offender admits to the crime, agrees to the caution and complies with those conditions, they will not face prosecution. Anyone who spends a couple of hours cleaning up litter and sweating in the hot sun, as I did on Friday in Willenhall, will be very keen not to repeat the experience. Nationwide waste tracking does not exist, so the costs are uncertain at the moment because we do not have a baseline to go from. However, we have used HMRC’s Making Tax Digital as an assumption as it is a similar digital delivery policy. We have put in a 400% optimism bias to account for underestimation because we do not know what we do not know—the unknown unknowns. There are more firms in scope for Making Tax Digital compared with digital waste tracking—obviously, because not everyone is doing waste. Therefore, economies of scale will differ. With that, I thank the Committee for its attention, good humour and positive comments this afternoon. I commend the fact that the legislation is widely supported by stakeholders for whom it could not come soon enough and who have been begging for it since the previous Government’s waste and litter strategy was published back in 2019. The hon. Member for Epping Forest asked about the circular economy growth plan. That is going through the normal Government channels and processes. I am sure he will be very excited when it is eventually produced, because that is our whole economy plan: to be a resilient, clean and highly efficient materials nation. The legislation has been highly anticipated by our stakeholders. I am delighted that it is supported by Members on both sides of the House and am thrilled to have been able to present it here today. Question put and agreed to. Resolved, That the Committee has considered the draft Digital Waste Tracking (England) Regulations 2026.
Does the hon. Gentleman have any insight into why the previous Government did not follow through and actually implement the regulations they consulted on?
My part of the world has already had a hard lesson in what a serious cyber-attack can do, and I thank the Liberal Democrat spokesperson, the hon. Member for Harpenden and Berkhamsted (Victoria Collins), for mentioning it. In 2020, Redcar and Cleveland council was hit by a cyber-attack that has been attributed to the Russian Conti syndicate, and around 135,000 residents were left without online public services. Systems were disrupted, and the cost was put at more than £10 million. That is a story that has been repeated across our public and private sectors, and we have heard other examples today—my hon. Friend the Member for Leeds Central and Headingley (Alex Sobel) spoke about the NHS, and my hon. Friend the Member for Warwick and Leamington (Matt Western) spoke about manufacturers such as JLR. I echo their calls in the amendments they have tabled today, particularly about the need for last-resort powers in relation to data centres, but also for a national conversation about these issues. I have had discussions with constituents who are sceptical that the Russian state might attack a little council like ours, and it is important to get across the point that it is precisely because ours was low-hanging fruit that it was such a target for Russia. That is exactly why this Bill is needed. Since the NIS regulations were introduced in 2018, the threat has changed; we are more interconnected and more reliant on cloud services, managed IT providers and data centres than ever before, often across long and complex supply chains. As such, it is very welcome that this Bill gives Ofcom a clearer role and brings significant data centre services into the regulatory framework, as well as relevant managed service providers and critical suppliers. The new reporting regime is a practical improvement as well—a 24-hour initial notification and a fuller report within 72 hours will help regulators and the National Cyber Security Centre to spot patterns, warn others and build a better national picture, which is especially important when we consider hostile states. Cyber-security is plainly now a frontline part of our national defence—we have seen how Russian military intelligence activity is targeting Government and critical infrastructure, and we need to be equipped to respond. I am sympathetic to new clause 3, which relates to the role of foreign state bodies, but it ought to be broadened beyond critical and essential services. I will give an example that concerns the security of British citizens’ data from foreign Governments. Right now, the largest leveraged buy-out in history is under way—the takeover of global videogames maker Electronic Arts by Saudi Arabia and Jared Kushner’s Affinity Partners. They are buying access to the sensitive personal and behavioural data of 700 million players worldwide, as well as the ability to expand foreign influence in Britain. I urge the Government—both DSIT and the Department for Culture, Media and Sport—and the CMA to look at this deal with their eyes wide open. Ministers should be prepared to stand up for UK data, UK jobs and UK security. The Chair of the Science, Innovation and Technology Committee, my hon. Friend the Member for Newcastle upon Tyne Central and West (Dame Chi Onwurah), mentioned interconnectedness between data security and national security. I endorse her amendments dealing with internet-of-things modules and the potential threat of hostile states switching off various pieces of infrastructure around our country. I also urge Ministers to keep pushing further on the threat of hostile state disinformation on social media, which has also been referenced in this debate. That is a fundamental security issue. Russia and others do not only try to knock systems offline; they also try to rot public trust, spread falsehoods and undermine democracy, so the technical threat and the information threat are part of the same hostile playbook. I do wonder whether regulators have sufficient resources to act, and I will listen carefully to the Minister’s remarks on new clause 7. Ultimately, this Bill does not solve every problem, but it is a serious and necessary step forward. It strengthens resilience, widens responsibility, improves reporting, and gives Government clearer powers where national security is at risk. As such, I support the Bill.
9. What diplomatic steps her Department is taking in response to settler activity in the west bank.
May I echo what hon. Members have said about Jo Cox? One Palestinian child has been killed every week in the west bank since January 2025. Hundreds remain in detention, and many more face significant disruption to their education. What steps are the Government taking with international partners to improve the safety of children in the west bank and to ensure that they can enjoy an education free from violence?
Every year, billions of pounds never make their way to the Treasury coffers because of British tax havens, such as the British Virgin Islands. The upcoming illicit finance summit offers us a real opportunity to tackle tax evasion and dirty money in these havens. Ahead of the summit, does the Minister agree that we must ensure that these havens finally throw open their books, and that tackling tax dodging must be top of the agenda?
I am co-chair of the Unison group of MPs, which is linked to Managers in Partnership.
Q Dr Dash, you have explained why you believe that the changes to Healthwatch will strengthen patient responses. How do you think that could be strengthened to ensure that the levers really are being pulled for patients? That seemed to be the case. Dr Dash: There are a few different things. First, we have talked about appointing a director of patient experience. They will report directly to the chief exec of the NHS. That is crucial; it is about emphasising the importance. We are about to do the interviews for that person, so I hope they can be in post very quickly. Secondly, we are hopefully about to publish the quality strategy. Within that strategy, which has come out of the 10-year plan, we are very clear about the three dimensions of quality. Those are: safety, so ensuring that basic standards are in place; effectiveness, so making sure that patients receive the right care in the right place at the right time and it is delivered to a high standard; and, crucially, patient experience. In the quality strategy, we emphasise that all three of those are crucial. You need to have all three and all three need to be done really well. We then go on to talk about different mechanisms for improving those dimensions. Crucially, we have a set of 183 metrics, which we will review within the NHS England quality committee while it still exists, and then within the National Quality Board. We also expect every region to review those metrics, as well as others, and every ICB and provider to review the ones that are relevant to them. So the next bit is to have all those different metrics. Thirdly, we need wider transparency. There are way more than 183 different metrics and we need to have far more on patient experience. They need to be routinely collected in the same way that we do surgical audits or audits of GP work. Those all got in the public domain; that was a big element of the 10-year plan. Finally, as I said before, we need boards to take full responsibility and accountability for all aspects of quality, which includes patient experience. As I go round and meet individual hospital boards, I ask them about that. I spend quite a lot of time with chairs and new non-executive directors coming into NHS providers, and I continually emphasise, “This is a crucial area for you to focus on as a board.” What are you asking your exec colleagues? Who have you put in place as your director of patient experience within the organisation? How are you routinely collecting information from a whole spectrum of users from the whole of society? How are you doing that in a confidential way for the reasons we spoke about earlier, and then ensuring that people are acting on it? I do not think we are doing anything like enough of that, and we need to get much better and do far more of it.
Q Ms Woolnough, you have talked about the abolition of NHS England, and, as I understand it, you are dealing with what the position is rather than taking a stand. Beyond the legislation, what are the key things that we should be looking at to get the transfer of functions to ICBs and DHSC right? Sarah Woolnough: We have talked quite a lot about the culture in the NHS and whether these changes enable the sort of shift that lots of people talk about wanting. Let us be really serious about devolving power and earned autonomy, and about the balance between politicians rightly being held accountable for high-level metrics but with enough operational freedom to allow local systems—services close to people and patients—to get on and do the best for them? We have a slight concern that, even though the Carltona principle should mean that the Secretary of State will enact powers in a way that does not slow things down, because of the broad sweep of powers given back to the Secretary of State, and the quite extensive powers of direction, politicians come under extreme pressure to intervene in certain cases or when there has been a scandal or patient safety issue, and that could lead to things clogging up. Fundamentally, our worry has been—again, this goes beyond the legislation—how do you genuinely create a system where the culture is not as paternalistic as it has traditionally been, where you are empowering both staff and patients and citizens to have more say in their care, and where system leaders are not constantly looking up for permission, worried they may be held to account for quite a narrow set of metrics? Although managing money and constitutional standards is very important, if we are to deliver the 10-year plan aims and improved patient care, it is more than that. Our worry has been that the abolition of NHS England by the legislation will narrow things. We do not know, because it is broader than legislation, but how do we fundamentally shift the culture? I know that that is the Government’s intention, but it is about more than legislation. Where is the work to make that happen?
And do you think—
Q Sir Ciarán, the 10-year health plan, which is behind a lot of this, demands that we are really ambitious in involving patients and communities in shaping the services that they need. How can we best support ICBs, local authorities and other organisations to drive that change? Sir Ciarán Devane: I go back to our having to convince people. Many people are convinced—that is probably the first thing to say. But we have to convince people of the benefit of doing this. Delivering the ambitious neighbourhood health plans that James describes will happen only if everybody is in the room and doing it. I do not necessarily think that the legislation can mandate that belief or the way to do that. However, it can set an expectation for the ICB that, in developing its plans, it should be able to demonstrate that it has engaged with the local authorities, patient organisations and the public local to it. The legislation can set an expectation that the ICB is using population evidence to make the right commissioning choices and that, if reconfigurations, which may well be locally contentious, are to happen, engagement happens beforehand. As elected Members, the Committee will know that those conversations should start early and that local populations should not just be bounced into something. It will be incumbent on the new department to set those expectations with the ICBs about the new way of working. That is the only way we are going to create an NHS that will be able to cope with the number of frail, elderly people with multiple morbidities. Those people are a consequence of the success of the NHS over decades. People are living longer with cancer; the prevalence of cancer—the number of people alive with cancer—has doubled in 20 years. But that means that there are four million people who are not necessarily well. The only way to cope with that is to make a significant and radical change to the neighbourhood health plans and bring the public with us. That will happen only with proper patient and public engagement.
Q Do you think that there are any good examples we can learn from? Sir Ciarán Devane: Yes, I do. I was in Epping recently, at St Margaret’s. I talked to the lady who runs the patient engagement: she is a volunteer and is a patient herself. They are a very good example, because they have said, “If we want to provide good services and avoid people turning up at the A&E in Harlow, we can do a neighbourhood diagnostic service.” The patient representatives got in very early. They ran some public meetings ahead of it and said, “We are thinking of doing this: what do you think? We’ll feed it back.” Everything good is happening somewhere. It is the variability that is causing the problem. We need to make sure that good practices are deployed across the sector. That has to be the expectation: if this reform, which is huge, is to deliver value, that is the value that it has to deliver.
Q You all represent patient organisations in different ways. I would like to put this in the context of the 10-year plan and the shift to involve patients and communities in shaping services. From your patient perspective, how can we best support ICBs, local authorities and other people to drive that change for patients? James Cooper: It is key that ICBs are given that support. In the conversations that Together for Short Lives and the services we represent have with ICBs, we certainly get the sense that they want support. They want to know how much they should be funding certain services, and they want to know how to plan. A lot of guidance is already out there, particularly in children’s palliative care, where we have service specifications and NICE guidance and quality standards—there is even a legal duty to ensure that ICBs commission palliative care for children and adults. That accountability and support from the centre, and making sure that resource is there, is key.
Q Minister, we have talked a lot today about ICBs, the local government Healthwatch and the single patient record, and we have heard some interesting comments. Can you summarise why you believe it is important that we look at this legislation now? Karin Smyth: I will come to the single patient record because I think it is a gamechanger. We have heard today from some fantastic experts about the work they are doing to identify how it might work and how we might bring patients and the public with us. Again— I do not think we should just bank this—we have not heard anybody object to it. We did have some evidence highlighting how things have gone wrong in the past. I worked at a primary care trust and clinical commissioning group at the time when care.data was brought forward. We can all point to where it has gone wrong, but nobody has said that this is not the right thing to do. That is good, but there is still a lot of detail to go through. We need to keep highlighting the benefits. We heard from Peter Prinsley about whether patients have more control—we do think this is about empowering patients. That was what we said in the 10-year plan. The 10-year plan is about empowering patients in this very large system, for which they are now paying £200 billion of their taxes. We heard from the excellent clinical panel. I defer to clinicians about what they need, both if they are dealing with chronic long-term conditions—we heard that it can sometimes take two and a half hours for an assessment—or if they are working in a busy emergency department. The fact that this is needed will be controversial. There will be a lot of questions about it and a lot of concern about privacy, data, cyber and so on. We need to hold on to those benefits, which are huge in clinical terms and for patients. Another point we heard, which is also true, is that people think this already happens. People do not understand why, when they turn up at an A&E in Whitby, as we heard, or somewhere else, and then go back to central London, the systems cannot talk to each other. For me, that is about people’s trust and belief in what is a public service. It is a really important part of that. On abolishing NHS England, I do not think anyone has come to one of my constituency surgeries and said, “Please do this,” or talked about it in great detail, but people do understand. My experience in opposition and so far in government is that MPs are perplexed when they try to intervene on behalf of patients, or to get an answer locally as to why on earth chief executives of ICBs or trusts sometimes do not respond even to a Member of Parliament’s requests for meetings. I find that shocking, but it does happen. How on earth is a patient or somebody struggling through the system expected to get a response? Getting it right is not black and white, and it is not easy to get the balance right between the Secretary of State’s democratic oversight and autonomy at a local level, but the Bill starts the process of doing that, and it is fundamentally important. Regarding the other provisions, I accept that great work has been done by many people in Healthwatch and its predecessor organisations, and by people working in the patient safety landscape, but again it is not working. I think that those bodies have been allowed to abdicate responsibility for the core role of patient experience and patient voice. That is not their homework; it is their actual job. It is not something that should be outside, and that is why I think this Bill is really important.
Q To go back to the single patient record, I see huge potential—at least in my constituency, where we have real challenges with GPs and hospitals not talking to each other or sharing information. Nor do trusts and local authorities across Buckinghamshire, Bedfordshire and Hertfordshire share that information. Sarah has touched on this a bit already, but I am interested to hear from our other witnesses on how they think the single patient record would improve patient experience, and on how we would go about building public understanding and trust in a new system. James Cooper: There are some big opportunities in the single patient record, with the caveats that Sarah mentioned on data governance and consent. For families of children who are seriously ill, it presents huge opportunities, as I said earlier, because of the complexity of their needs. Often, huge amounts of information need to be conveyed to any professional who the children come into contact with, wherever that is across health, education or social care. Many professionals have a long-standing relationship with such families, whether they are NHS community children’s nurses, consultants with a speciality in the child’s condition or children’s hospice teams, but families often need to access emergency unplanned care, perhaps in the middle of the night or at weekends. In those instances, when they speak to paramedics and emergency doctors, it is imperative that they can convey the information as quickly as possible. In those instances, I can see huge benefits. With issues such as advanced care planning, to reflect the needs and wishes of those families, in particular as the child is coming towards the end of their life, I think it is critical that the whole range of professionals involved in the care of children has access to that information. I will welcome much more clarity from the Government about when the families will benefit from that particular initiative. Professor Croisdale-Appleby: May I add a short comment?
Q I come from a county with really significant health inequalities—people in the wealthy parts of the county live 10 or 12 years longer than people in some of the more deprived parts of Aylesbury, which I represent. I would love to hear your thoughts on how we ensure that local authorities, ICBs and the voluntary sector continue working well together through this, and specifically how we do that in a way that drives the reduction we need in health inequalities. Maria Higson: I think we are all agreed that working at the neighbourhood level is absolutely the right way to go about that. That is where health inequalities can best be addressed, because that can be most nuanced and tailored. Working on that smaller footprint is really important. You mentioned voluntary, community and social enterprise organisations, and I think that is a hugely important part that has broadly been missed out from the conversation around these changes. We work closely with VCSE partners and we know they deliver huge amounts for the communities and understand the communities in which they are embedded very well, so making sure that the VCSE voice is part of those neighbourhood teams will be important for that nuance and tailoring in the local element. Councillor Wright: I agree entirely. Local authorities are in a good position to engage the voluntary and community sector. But again, we are fighting for a voice with the NHS and they are fighting for a voice with us, so we need some honest conversations with ICBs, and a real strategy looking at those health inequalities and what is driving them. It will not purely be access to hospitals; it will also be access to meaningful employment, housing, transport, mental health or social isolation—there will be so much driving those wider determinants of health that are affecting healthy life expectancy. Local authorities are in a prime position to do that, and they need to be listened to. I think the challenge will be how we collectively say, “What needs to be done, other than implementing the Bill? How do we look at the whole health inequality picture and address it?” Sally Burlington: I would agree with the others: tackling health inequalities is really difficult. Doing it the same way in every area would not work, particularly in a world where there is not enough resource to do everything we would all like to do. You have to tailor how you approach local service delivery and what is needed locally according to local needs, the local community capability, how people work and what their preferences are locally, and the neighbourhood health agenda is our best shot at tailoring in that way. I think you will come on to Healthwatch, but we would have concerns that, in separating the Healthwatch duties to look at NHS and social care, we risk missing some of those who are most likely to need both, and that that could exacerbate health inequalities rather than make them better.
We all have examples of Thames Water letting our residents down. Just last week I heard from one of my farmers, who has had Thames Water discharging raw sewage into the ditch next to his fields. It has flooded his fields and contaminated the land, which is no longer in use. I welcome the progress made by the Secretary of State, but as she acknowledges, more may well be needed. Will she reassure my constituents that she will always put the interests of consumers, the environment and public health ahead of the interests of investors?
1. What assessment she has made of the potential implications for her Department’s policies of the level of risk to countries arising from environmental change in the Tibetan plateau. [R]
Mr Speaker, I echo what you said about Jo Cox. I think her message is more important today than it ever was. I thank the Minister for her response. China’s actions, from environmentally destructive mining to building dams to divert water sources, will have consequences far beyond the Tibetan plateau, as she says, as will the failure to address the impact of climate change on the third pole. What steps can the UK take to raise these issues at a global level? Does the Minister agree that the voices of Tibetans should be heard in any such talks?
I commend the hon. Member for South Cotswolds (Dr Savage) for securing this debate and for giving me the opportunity to talk about my experiences of the benefits and challenges of community and cottage hospitals. I do so in the knowledge that healthcare in Scotland is devolved and so is not under the purview of my hon. Friend the Minister. Prior to my election to this place, I spent nearly 23 years working with volunteers in the health services in Lanarkshire, a job that was highly pressured, but also highly rewarding. An absolute highlight of my day or week was visiting the volunteers in either Kello hospital in Biggar, in the constituency of the right hon. Member for Dumfriesshire, Clydesdale and Tweeddale (David Mundell), or Kilsyth Victoria Memorial cottage hospital, in my constituency. This debate is timely, because it was in the day room at Kilsyth Victoria that I heard the horrific news of the murder of Jo Cox, 10 years ago today. Attempting to stay professional and encourage two new teenaged volunteers to have conversations with patients while trying to digest what I saw on the large screen less than 10 feet away will stay with me forever. I send my love to Jo’s family today. Like many cottage hospitals, Kilsyth Victoria dates from before the NHS was created. In our case, the hospital was created by the local miners as a miners’ hospital in 1903; the part of the hospital that can be seen from the road dates back to that time. The main patient areas are within a more modern extension—I say “more modern”, but it is still older than me. The hospital now comprises a day room, a dining room where all patient who are able can have meals together, and a range of two-bedded and four-bedded bays, as was standard at a time when patients were not used to the space or the individual and ensuite rooms that are considered the norm and expectation today. The minor injuries unit disappeared in the days before covid, and the physiotherapy and out-patient clinics have been moved to the health centre. In the brief time that I have, I want to talk about how the benefits of hospital services in the heart of communities, which are often remote from big district general hospitals, are outweighed by the considerable challenges that they face. As times have changed, our expectations of healthcare have changed. When I started working at Kilsyth cottage hospital, the patients were all registered with Kilsyth general practitioners. It was unusual for patients not to be from Kilsyth; if they were not, they were from the neighbouring villages, Croy, Queenzieburn or Banton. The GPs knew the patients, and they provided medical care for the hospital. The staff were all generally local people themselves. Patients were admitted for intermediate, respite and end-of-life care. My experience is that where hospitals have closed, it is because GP cover has been withdrawn. The GPs in Kilsyth still provide the medical care, but in reality it is nurse-led care, with medical cover on the end of a telephone line or a video call, and which presumes good technological connections in a former mining village. Do not get me wrong: I am a big fan of nurse-led care. Registered nurses who work in community hospitals are highly skilled in the types of care that these patients need. It is heavy work, as patients need a lot of physical care, but it can also be isolating. On a night shift, there might be only one registered nurse in the hospital, which means no break on a 12-hour shift and, with many of these hospitals are miles away from assistance, they might not be able to get help from a registered nurse on another ward. Patients are more likely to have a dementia diagnosis than 20 years ago, which means that the type of care provided has changed. It was in these hospitals that I learned how important it is to look at a patient’s feet: if they were wearing slippers, it probably meant that they were not meant to have their hat, coat and handbag and be on their way out of the door. Even having barriers with entrance codes did not manage to stop people, because they were all from the village, so they knew what the codes were—they did not forget those. It can be difficult to recruit staff, who often have to travel long distances, because there is a lack of understanding of how rewarding it is to work in a cottage hospital in the middle of the community. However, what these hospitals provide is the epitome of care in the community. For those who are unable to look after themselves in their own home and who might be thinking about what it means to go into long-stay care or to move into a care home, community hospitals provide that transitional step. They are much more than buildings; they meet a need at a difficult time in people’s lives, and they are absolutely vital.
I am a member of the Managers in Partnership trade union, which is giving evidence this afternoon.
Q As you outlined in your review, there are 150 organisations in this area. How do you see the new patient experience directorate in the Department working to give confidence in this area and to try to make sense of some of that and improve it? Dr Dash: One of the things that I observed when I was doing the review, and that I have observed even more so now that I am in post, is that we do not have effective mechanisms of really learning from patients and patient experience. If I compare how the NHS works with how other large organisations in our country work, we are not systematically collecting patient information, we are not looking at that in detail, we are not segmenting it into different groups of people, and we are not systematically bringing it into board meetings, which is where it should be in order to drive improvement. We are hoping, or expecting, that the new director of patient experience will take a real leadership role in this and will improve the way in which the centre works but, more importantly, will be working with organisations right across the NHS to build those skills and capabilities, and to put patient experience feedback and improvement in patient experience right at the centre of every discussion on improvement.
Q Accepting what you have said about delays with staff—we absolutely recognise that—do you think that the abolition of NHS England is the right thing to do? Sarah Woolnough: As an organisation, we have taken the view that we would not necessarily relitigate the decision. I think you can argue it both ways. I understand the desire to reduce duplication and to have clearer lines of accountability. Our concern has been the opportunity cost and everything that you are not doing at the time that you are spending so much energy and resource driving the abolition through. Jacob Lant: I would echo everything Sarah says. From the work that we do, we see that decision making is taking longer, programmes are taking longer and it is taking longer to secure an impact on things. That is very frustrating, and underpinned by the massive change that is ongoing. Let us take as an example a programme exploring the experience of waiting for hospital care—of being stuck on waiting lists. Jim Mackey spoke about that at the NHS ConfedExpo last week. It is a major focus for the NHS and new guidance is expected by the end of the month. We have been waiting for that since 2021. The most recent effort towards it has been about 18 months. I can only think that drags on because we have so much other change going on in the system. I wish we focused more on doing things directly for patient care.
Q Sarah, I think you described the single patient record as “genuinely transformative”, and National Voices has also been really supportive of it. How critical do you think it is that we grasp that opportunity? Sarah Woolnough: It is a major opportunity. If they feel they have trust in the system, patients are generally supportive of a single patient record or joined-up records—they often assume one already exists. Of course, we have a patchwork across the country, and certain places are further ahead than others. The idea of having more national co-ordination and more infrastructure to drive progress in that area could be, and hopefully will be, transformative. I know from my previous work just how frustrating it is for so many people to experience fragmented care and to have to tell their story endlessly. We must be a little careful, because telling your medical history is often part of a good consultation, but the idea of care being more streamlined and patients and staff having better access to information is a huge opportunity. It must be balanced with sufficient safeguards to maintain trust. Previous attempts to drive progress in this area have so often fallen down. Ensuring the right balance of progress, and building trust and sufficient safeguards, will hopefully lead to the most progress. Jacob Lant: I have been working in patient and public engagement and involvement for about 15 years, and the most consistent theme in that time has been the frustration about constantly having to retell your story, and the fact that notes and information are not available for the care that people need in different settings. There is a golden opportunity with the Bill to get the single patient record right and meet a long-standing patient need for that join-up of information. We are very supportive of the single patient record, and the debate needs to move on from whether we need one to what the safeguards are and how we build public trust. I have two things to say on that. First, you cannot legislate for everything on this, but it is important to have a commitment to an ongoing public conversation around the risks and benefits of data sharing. The Department has done some really good work in this space, on its public deliberative on use of data—that should continue—but we understand that cannot all be put into the Bill. However, we know that the safeguards and red lines that we already have could be put into the Bill. For example, using patient data or non-consented data for insurance and marketing purposes is a red line that has been clearly talked about in policy for many year—we will not use data for that purpose. Why can’t we put that in the Bill to help build public trust? It would really help to be clear on red lines and what will not be included.
Q Finally from me, you highlighted your 15 years in the patient voice landscape. We could discuss at length whether you think that is going well and whether the situation that we inherited was a good one. What needs to happen to give patients confidence that the new system will be better? Jacob Lant: There are three things there. First, we need transparency about what is being heard by the system. Wherever we put patient voice functions, it is really important that what they hear from communities is clear and made available publicly, in terms of themes and demographics, so that we understand who is being heard and who is not. That is really important for the transparency of what is being heard and how it is being interpreted by the system. What has it understood from the feedback it has received, and does that resonate with what people are actually trying to say? The second thing is accountability. Can people see those voices leading to change—not just commitments to change, but following through? It is about evaluating where policy changes implemented as a result of patient feedback have improved patient experience, and drawing that golden thread through for people so they can understand how their feedback is making a difference. That is missing from the system at the moment. The last point is around equity. My big concern is that we might design a system that hears from more people, but whether it hears from the right people and there is equity of voice is a real concern. The resourcing and support need to be put in, particularly at a local level, so that they can engage communities who are marginalised and make sure we are hearing from the people who are basically getting the worst experiences and outcomes at the moment. If we can deliver on those three things—transparency, accountability and equity—we can build a system that is more effective than what we have at the moment. Personally, I think Healthwatch has done a fantastic job with the resources it has had available. It works out that less than 0.01% of the health and care spend is on Healthwatch, and that generates about 1.4 million interactions every year, either by gathering people’s experiences or by supporting them to navigate the health and care system. That is a really good return on investment, and it will be hard to find something more efficient. The challenge is in the system being more culturally open to listening and changing as a result of what people say, regardless of the way the evidence comes through.
Q Dr Dickson, can you describe how you think the single patient record could be transformative for patient care, given where we are? Dr Dickson: Part of it has been touched on by the previous panel, regarding patient experience. Patients come in, they give the same story again and again to different healthcare professionals in different settings, and that frustrates them. Patients are human. I forget what I did last week; patients forget what they did last week, let alone what they did 10 or 20 years ago, although that is still relevant, increasingly. If you go on holiday to Whitby, fall over and break something, have tests done and come back to your house in central London, you cannot see information about that; you cannot share that information. The opportunity to see everything on a patient across primary care, secondary care and social care is a huge benefit to them in terms of their view of seamless care, but also in terms of safety. I have a chronic health condition; part of my care is delivered by general practice and part by a hospital. At the start of the pandemic I was exceptionally clinically vulnerable; it took the NHS six weeks to tell me that. That is not safe.
Q What are the key things we need to get right to ensure that safety investigations in general and safe space in particular are made to happen in the new arrangements? Dr Benneyworth: The two key things have been touched on already. The first is the independence to choose what we investigate and make recommendations to any part of the system. The second area is around protected disclosure. The legislation needs to be much clearer around the protection of protected disclosure materials, to give the system confidence in our ability to hold and not share confidential information. At the moment, the legislation talks about connected individuals having access to the protected materials. The clauses outlining connected individuals mean that anyone working in the CQC could potentially have access to protected materials. That is a very large number of people, and it will create risk. There needs to be a legal duty on the CQC to protect the safe space. There is also something about maintaining an identity that gives people confidence that when they are talking to us, their information will not automatically go into the CQC regulatory functions. Some of that may be about perception rather than the reality of what is happening, but as we know, perception is very important. People will perceive that we are part of the regulatory system even if we have the same email address, for example.
Q Those things obviously are manageable in another system, but people need that safe space to come forward. You rightly outlined reality and perception, and perception is often important for confidence. You talked about the culture of fear, which I think we have recognised over time. We are all constituency MPs, so we recognise that. Can you say something about the opportunities for learning that could arise from working with the CQC, which is in that regulatory space? Dr Benneyworth: We already work very closely with the CQC. In fact, we meet with them on a very regular basis. They share their learning and concerns with us already. Some of our investigations have come from the learning that they have seen on inspection, so we have a very good relationship with the CQC. There are significant opportunities for the whole patient safety landscape. We are a tiny part of the patient safety landscape. We need to all work much more collaboratively right across the regulatory space—ourselves, the investigatory bodies and the wider system. The National Quality Board will have a significant role to play in that to share learning and identify key patient safety risks. That is already happening in our work with the CQC. This legislation will not significantly change that.
Q You have leant into my next question, Sir Jeremy. You are a former Chancellor of the Exchequer, so you understand some of these tensions. My question is about the number of recommendations and outstanding actions. As you said, honestly recognising that it happened during your time as well, this has all arisen over time. As a result, we are in the situation of having several independent bodies that are not required to take action, but the National Quality Board, which is outwith the legislation, is the place this could happen. Do you want to comment further on that? Sir Jeremy Hunt: I would just like this to have teeth, because I think people are fed up, as I say, with Governments of all colours receiving recommendations and then nothing happening. I would like the Bill to place a legal obligation on the Government, for a certain category of recommendation, that within a period of time a proper decision will be made with a timescale. If the decision is no, because the money is not available, that is fine, and the Government should say so, but people would prefer to have a decision than for Governments to continually say, “We are reviewing this.” Frankly, I am worried that inertia in the system, and the fact that it is always easier for Ministers to kick things into the long grass rather than give a yes or a no, means that a vague commitment that the NQB will do this job will not be enough. If it is the NQB, I would like there to be a legal obligation that, within six months of recommendations being made by public inquiries, Select Committees and HSSIB, the Government will give a proper yes or no, with a timescale if it is yes.
Q To move on to the transfer of NHS England’s functions, in your time in office NHS England was a new independent body. What are your reflections on how we can use the transfer of those NHS England functions back into democratic oversight to improve impacts on patients, particularly patient safety? Sir Jeremy Hunt: I set up NHS England, following the Lansley reforms, and it may surprise you that I have not opposed the Government’s decision to abolish it, for this reason. When it was set up, it did have a very valuable function, which is that it depoliticised a lot of very contentious issues. Typically, those were things such as the closure or downgrading of an A&E that was clinically advised as important, but very difficult politically, or, for example, which drugs are made available through the NHS and which are not. I felt that putting those decisions at arm’s length from Ministers was helpful. However, I think it became too big. My real problem is that I think the NHS has become the world’s largest health bureaucracy, in which it is very hard to get anything done because 1.5 million people are accountable to one person. The way the DHSC does this, as you know just as well as me, is through the ruthless imposition of targets, so every hospital has 18 monthly operational targets. That makes it very difficult to have any kind of local innovation or local autonomy, because everyone is performance-managed with incredible strictness—their whole career depends on it—by these targets. I felt NHS England was beginning to embody that targets system, so when the former Heath Secretary said he was planning to scrap it, I said, “That’s absolutely fine, as long as this is a decentralising move, and you don’t simply transfer that ruthless central control from NHS England to DHSC.” I have to say I am concerned that that is, in fact, happening—or that we are just getting all those targets recreated by DHSC, rather than NHS England, as I think former Health Secretary Patricia Hewitt has also gone on record as saying.
Q To pick up on Sir Ciarán’s comments about experiences being extremely rare, the changes in the Bill sit alongside changes to the national centre and clarity for ICBs, with very little change to providers. What would make the biggest difference to providers and commissioners to improve things? Sir Ciarán Devane: The biggest difference should be that the local providers and ICBs are incentivised to get together to make collective commissioning decisions. That means that, whether you call it a neighbourhood, footprint or local authority area, they make those decisions based on population evidence, which is why the single patient record is important, and they have the autonomy to do that with a lighter-touch centre that is set in guidance saying, “Look, this is broadly what we’d like you to do.” That guidance should be developed in conjunction with the people who have to do the job on the ground. That is what it should be; if the Bill allows that, that is fantastic. The second bit is that the mechanism—it is not necessarily a legislative thing—by which the NHS is managed day-to-day will still need to exist. Who is going to be keeping an eye on things 24/7, 365 days a year? What happens if there is a fire—maybe even a literal fire—in a hospital? How is the NHS going to be corralled and brought in to help out a trust where something like that happens? That management function—the day-to-day operational management—needs to remain strong enough in the target operating model, as it is called, in the Department. If it is not, that could prove very difficult. Not necessarily day to day or in the short term, but in the long term, that bit has to be got right. One of the big risks of the legislation—there is not a legislative solution to this risk—is how day-to-day management works. We all have views on the relative strengths of the regions, of NHS England and so on, but how is that going to work in the new world? If one loses “grip”—that word is used a lot—then the risk to service delivery is quite high, and the risk to financial control is even higher. James Blythe: Put simply, as an NHS organisational leader I think there are always a lot of things from which you can take your guidance on what you should be prioritising and focusing on as an organisation. If the result of this legislation is that we as organisational leaders have a really tightly defined set of priorities to deliver, articulated as far as possible as outcomes for local people and our population as a whole in terms of waiting times, quality and improving population health, I think that will allow us locally to get on with the partnerships that we already have as a day-to-day part of running local public services. We can focus on that very small set of things and do them really well. Over the last year, there has been a sense of increasing clarity about those priorities as NHS England and the Department of Health and Social Care have worked more closely together. The NHS has delivered on those priorities to a large degree, but it all comes down, as my colleague says, to how senior officials and Ministers operate the system, because there is to be significantly more freedom to set priorities, and to design and run the system that essentially delivers them for the NHS. How that is done, retaining clarity about the things that we want to have delivered through the system and empowering local systems to do them will be really important.
Q Sir Ciarán, may I clarify a point with you? I think you are not objecting to the abolition of NHS England—yes or no? Sir Ciarán Devane: No, we are not.
Q Because you also said that the risk of not having financial control is high. I would say that, over the last few years, financial control has been a massive problem, and we have put in much better financial control. I think that your concern is with the future rather than the legislation. Sir Ciarán Devane: Yes, completely.
Q Mr Blythe, what does the single patient record mean for you in running a big hospital? James Blythe: I think the single patient record offers enormous opportunities to improve patient care. We know that we see patients every day whose quality of care and patient experience would be improved through having access to a continuous record that ran through primary and secondary care, mental health care and other services. To my mind, having had experience of working with systems that have introduced to some degree the single record or a single care plan, it will be extremely important that we take the time to train our clinical staff and adapt our operational systems so they use a patient record productively and consistently in the interests of better patient care. If we just put a single patient record into clinical settings without doing anything with the staff or services to make it useful, at best it will be inconsistently used and sometimes it will just be missed altogether. If we are going to invest, which I think is right, in a single patient record, we also have to invest in those systems and human factors around it, and make sure that we train people to use it well.
Q As we have heard, despite 52 years of independent patient voice, 20,000 reports and many hundreds of recommendations, we have some of our worst ever patient satisfaction. We are also now more than 10 years on from the Francis report, but recommendations are not being followed through locally or nationally. It is pretty clear that the landscape does not work. Like many other Committee members, I represent communities that are not in that space and need to be represented in new way. What are the barriers to that? How can the single patient record, and the information we can create in different ways, help to reverse what is a shocking landscape for patient experience and patient voice? Professor Croisdale-Appleby: Sorry, I had some difficulty in hearing the question, but I hope I heard it correctly. Was it about the patient record?