Accountability and control are important for improving outcomes, creating better services, involving service users in decisions, and ensuring financial sustainability. The first line of the NHS Constitution in England is ‘The NHS belongs to the people’. The Co-operative Party believes that if the vision behind this statement is to realised there needs to be a real debate about increasing the accountability of the NHS to the individuals and communities it serves.

There is a fear that the bill will increase private sector involvement due to increases in flexibility of procurement rules, the ability for private providers to hold seats on integrated care boards, and potential conflicts of interests in the awarding of contracts. There are also concerns that the changes, especially where new services are being commissioned, would allow contracts to be awarded to new providers without sufficient scrutiny, or that it will result in more existing contracts being rolled over to the incumbent provider with little opportunity for co-operative, community or voluntary sector organisations to come forward.

The bill proposes significantly expanded powers for the Secretary of State to intervene earlier, be involved in many more decisions, and to direct NHS England. This means a much wider scope for political interference in everyday decision-making – potentially causing critical delays, decision-making logjams, and less independence for clinicians making choices that they have concluded will benefit patients.

The bill should deliver opportunities to better integrate health and care – there is an opportunity to use this to improve people’s outcomes and experiences of health and care services, but as explored in last year’s social care consultation, budget cuts cannot be the primary objective of integration. It is clear that what is made of this opportunity depends on implementation.

Diversity in NHS governance structures is poor. For example, a study by the University of Exeter in 2020 found that in 70 out of the 213 trusts all the board members were white. Overall BAME representation at board level was 8.9%. Medical directors of BAME ethnicity accounted for 19.4%, about the same as the overall percentage of BAME doctors. Statistics collected by the NHS show that women are underrepresented (43% board members, 77% workforce in 2017) and that disabled people are underrepresented (5.3% board members identify as having a disability compared with 17.6% of the population in 2017).

The NHS is the largest employer in England, with nearly 1.2 million full-time equivalent (FTE) staff working in hospital and community services. Throughout this pandemic, these workers have been on the frontline of the crisis, faced with especially challenging working conditions, pay freezes and long-term issues exacerbated - such as chronic excessive workload, burnout, stress, and inequalities experienced by many black and ethnic minority staff. As well as these issues causing high levels of turnover and absenteeism, the NHS faces serious staffing shortages. There is a shortage of nearly 84,000 FTE staff, severely affecting key groups such as nurses, midwives and health visitors. There is a shortage of about 2,500 GPs which is forecast to increase to a gap of 7,000 within five years. 28% of nurses and health visitors leave the NHS within the first three years of service. These have been compounded by Brexit with many nurses and midwives from Europe, for example, leaving the country and a 90% drop in new nurses and midwives from Europe arriving.

The UK is home to shocking health inequalities. There is a systematic relationship between deprivation and life expectancy – in the least deprived areas of the country, men live 9.4 years longer and women live 7.4 years longer. People in the most deprived areas spend around a third of their lives in poor health, twice the proportion spent by those in the least deprived areas. Many also experience barriers to accessing services – because of language, real or anticipated discrimination, or a lack of understanding of a complicated health system. This is often reported to be the case, for example, for asylum seekers and refugees, and Gypsy, Roma and Traveller communities. Studies show that this can especially be the case for disabled people who face barriers such as long waiting lists, long distances to access services, and difficulties accessing transport – which has only been exacerbated by the pandemic. The availability of services is also unequal - more deprived areas tend to have fewer GPs per head for example – as is the experience of them. According to Stonewall, 13% of LGBT respondents reported experiencing unequal treatment because they were LGBT, with this number rising to 32% for people who are transgender and 19% for Black, Asian and minority ethnic LGBT people. And outcomes are often, as a result, unequal. The data on maternity deaths in the UK, for example, show black women are four times more likely to die during pregnancy in the UK than white women. For Asian women, they are twice as likely to die. Another shocking example from a recent study shows that the UK has the largest female health gap among G20 countries and the 12th largest globally.

Given the strong correlation between socioeconomic factors and health, there is clearly a public health argument for tackling inequality and growing fairer more sustainable local economies. Whether it is access to good quality, affordable food or decent workplace conditions, the co-operative movement has long been part of this work. Community Wealth Building, too, looks at health and local economic outcomes and their relationship. In Cleveland, Ohio, the original Community Wealth Building work was led by the Cleveland Clinic who used the power of their procurement to invest in employee ownership and reinvestment of local wealth. There are also examples like the Lambeth GP Food Co-op who use innovative community models to do social prescribing.