All 55 contributions to the Health and Care Act 2022 (Ministerial Extracts Only)

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Wed 14th Jul 2021
Health and Care Bill
Commons Chamber

2nd reading & 2nd reading
Tue 7th Sep 2021
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Health and Care Bill
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Health and Care Bill
Commons Chamber

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Tue 7th Dec 2021
Health and Care Bill
Lords Chamber

2nd reading & 2nd reading & 2nd reading
Tue 11th Jan 2022
Health and Care Bill
Lords Chamber

Committee stage & Lords Hansard - Part 1 & Committee stage & Lords Hansard - Part 1 & Committee stage: Part 1
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Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Lords Hansard - Part 2 & Committee stage: Part 2
Thu 13th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Lords Hansard - Part 1 & Committee stage: Part 1
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Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Lords Hansard - Part 2 & Committee stage: Part 2
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Lords Hansard - Part 1 & Committee stage: Part 1
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Lords Hansard - Part 2 & Committee stage: Part 2
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 3 & Lords Hansard - Part 3 & Committee stage: Part 3
Thu 20th Jan 2022
Mon 24th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Committee stage: Part 1
Mon 24th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Committee stage: Part 2
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Committee stage: Part 1
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Committee stage: Part 2
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 3 & Committee stage: Part 3
Mon 31st Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Committee stage: Part 1
Mon 31st Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Committee stage: Part 2
Fri 4th Feb 2022
Wed 9th Feb 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Committee stage: Part 1
Tue 1st Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Report stage: Part 1
Tue 1st Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Report stage: Part 2
Thu 3rd Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Report stage: Part 1
Thu 3rd Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Report stage: Part 2
Mon 7th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Report stage: Part 1
Mon 7th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Report stage: Part 2
Wed 16th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard _ Part 1 & Report stage: _ Part 1
Wed 16th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Report stage: Part 2
Wed 23rd Mar 2022
Health and Care Bill
Lords Chamber

3rd reading & 3rd reading
Wed 30th Mar 2022
Health and Care Bill
Commons Chamber

Consideration of Lords amendments & Consideration of Lords amendments
Tue 5th Apr 2022
Health and Care Bill
Lords Chamber

Consideration of Commons amendments & Consideration of Commons amendments
Mon 25th Apr 2022
Health and Care Bill
Commons Chamber

Consideration of Lords amendmentsConsideration of Lords Message & Consideration of Lords amendments
Tue 26th Apr 2022
Health and Care Bill
Lords Chamber

Consideration of Commons amendments & Consideration of Commons amendments

Health and Care Bill

(Limited Text - Ministerial Extracts only)

Read Full debate
2nd reading
Wednesday 14th July 2021

(2 years, 11 months ago)

Commons Chamber
Health and Care Act 2022 Read Hansard Text Watch Debate

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

Sajid Javid Portrait The Secretary of State for Health and Social Care (Sajid Javid)
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I beg to move, That the Bill be now read a Second time.

The covid-19 pandemic has tested our country like never before, and nowhere more has this been seen than in our health and care system. Everyone delivering health and social care in this country has risen to meet these tests in remarkable new ways. We have seen bold new ways of working, of overcoming bureaucracy and of people working seamlessly across traditional boundaries. New teams were forged, new technologies adopted and new approaches found.

There is no greater example of this than the extraordinary success of our vaccine roll-out, where health and care colleagues have been able to draw on the collective scale and strengths of our Union to deliver one vaccination programme for the whole of the United Kingdom. Today, I can confirm to the House that two thirds of adults have received both jabs against covid-19 one week earlier than planned. It is a remarkable achievement. Everyone working in the NHS and social care can be proud of what they have achieved, and we are all in this House very proud of them.

As we look to the post-pandemic world, we know there is still no shortage of challenges ahead—an ageing population, an increase in people with multiple health conditions and, of course, the chance to embrace the full potential of data and technology.

Jim Shannon Portrait Jim Shannon (Strangford) (DUP)
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Will the Secretary of State give way?

Jim Shannon Portrait Jim Shannon
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It is just, Secretary of State, because you mentioned the issue I wanted to bring up about people getting older. I spoke to your colleague, the Minister for Health, yesterday and I am appreciative of that—

Jim Shannon Portrait Jim Shannon
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Recent statistics show that over 40,000 people under 65 in the UK have dementia, and many more have not been diagnosed as of yet. It would seem that these figures are not addressed in the Health and Care Bill, so can I ask the Secretary of State what more will be done to offer support to those suffering with dementia and Alzheimer’s in the UK through this social services care Bill?

Sajid Javid Portrait Sajid Javid
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I am pleased that I gave way to the hon. Gentleman as he raises a very important issue. In this Bill, as I will come to, one of the central themes is integration. When I come to that, I hope he will see how that integration between NHS and social care will help to deliver a better service for those with dementia.

Everything I refer to—these challenges—are all in addition to the challenges of the pandemic that of course we still face and the elective backlog that we know is going to get worse before it gets better. Meeting the future with confidence relies on learning lessons from the pandemic—what worked and what did not work—and building on a decade of innovation in health and care.

Sometimes the best intentions of the past cannot stop what is right for the future. Bureaucracy can still make sensible decision making harder, silos can stifle work across boundaries and sometimes legislation can get in the way. We have seen how unnecessary rules have meant contracts have needed to be retendered even where high-quality services are being delivered, we have seen the complicated workarounds needed to help the NHS and local government to work together, and we have seen the uncertainty about how to share data across the health and care system. People working in health and social care want the very best for people in their care. That is what they have shown time and again, not least in the way they have embraced integration and innovation to save lives through this pandemic. They want to hold on to the remarkable spirit of integration and innovation, but they want to let go of everything that is holding them back and we want to help them to do it.

Edward Leigh Portrait Sir Edward Leigh (Gainsborough) (Con)
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On that point of bureaucracy, I recently saw the apotheosis of the NHS, where an Anglican church had draped an altar with a flag saying, “O Praise the NHS”. So when we have a new Secretary of State, can we have a really hard-hitting attitude to NHS bureaucracy? We all praise our doctors and nurses, but the fact is that, like any other bureaucracy, it is prone to underperformance, waste and incompetence. There is no harm, as long as we preserve the principle of being free at the point of delivery, in having innovative private sector solutions.

Sajid Javid Portrait Sajid Javid
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I hear what my right hon. Friend has said and I think that, as I progress through my opening remarks, he will like what I have to say about integration and cutting bureaucracy.

All these things that I refer to and all these changes we want to make are exactly what this Health and Care Bill will do. I want to thank the thousands of hard-working staff who, through two years of consultation and engagement, have come forward and told us what they think works and what they think needs to change. In the words of Lord Stevens, chief executive of the NHS, the overwhelming majority of these proposals are changes that the health service has asked for. The Bill supports improvements that are already under way in the NHS. It builds on the recommendations of the NHS’s own long-term plan. It is a product of the NHS, it is for the NHS, and it is supported by the NHS.

I am grateful to all the organisations that have helped to shape these important proposals—everyone from the NHS Confederation to the Local Government Association. I have spent many of my early days in this job talking to them, and they have all told me the same thing, which is that they are ready to take forward the reforms. I want to continue to work with them and to listen to their specific concerns, just as much as I want to listen to the concerns raised by hon. Members across the House and by Members in the other place.

Sajid Javid Portrait Sajid Javid
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With that, I want to listen to this particular hon. Member.

Munira Wilson Portrait Munira Wilson
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The Secretary of State referred to Lord Stevens and what the NHS has asked for in trying to get rid of things that stand in its way. Something that it has not asked for is a massive power grab by the Secretary of State, which is in the Bill and will lead to political interference in day-to-day operational and reconfiguration decisions, which may not always be in the best interests of patients. Why does he think that that is a sensible way forward and something that the NHS wants?

Sajid Javid Portrait Sajid Javid
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Clinical decisions should always be made by those with clinical expertise—I think everyone in the House would agree on that—and that should be independent of any outside interference. The Bill does nothing to alter that. What it does is recognise that the NHS is one of the public’s top priorities. We spend over £140 billion of taxpayers’ money on the NHS, and it is right that there is proper accountability for that spending to Ministers and therefore to the House. I think that most people would welcome that.

Rachael Maskell Portrait Rachael Maskell (York Central) (Lab/Co-op)
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The Secretary of State has talked about people he has consulted, so would he confirm that he has consulted the trade unions, particularly on schedule 2, which says that integrated care boards may appoint employees to address remuneration, pensions and terms and conditions. Can he confirm that that is a departure from Agenda for Change terms?

Sajid Javid Portrait Sajid Javid
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There have been wide-ranging consultations on the Bill, as I mentioned, which have taken place over the past two years. While I cannot say specifically which trade union or which particular organisation has been spoken to, as I was not in the Department at the time, I know that the conversations have been wide ranging.

The Bill is not the limit of our ambitions on the nation’s health. We are also transforming public health; we are bringing the Mental Health Act into the 21st century; and, by the end of this year, we will set out plans putting adult social care on a sustainable footing for the future.

We are also ambitious for our workforce. I have commissioned Health Education England to refresh its strategic framework for health and social care workforce planning. HEE will work in partnership across the sector and gather views from the widest possible range of stakeholders to help us to shape a workforce with the right skills, the right knowledge and the right values for the year ahead.

Kevin Hollinrake Portrait Kevin Hollinrake (Thirsk and Malton) (Con)
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My right hon. Friend has set out his plans to introduce a plan for social care by the end of the year, and I know that he is looking for a cross-party solution. In a joint inquiry by two Select Committees—the Housing, Communities and Local Government Committee and the Health and Social Care Committee—one of the recommendations was a system with a German-style social care premium. Would that potentially feature in his recommendations, and does he agree that that is a much fairer system than a Dilnot-style system that incentivises people to spend their assets or move them somewhere where they cannot be touched?

Sajid Javid Portrait Sajid Javid
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First, my hon. Friend is right to say that it would be great if all or most Members of this House, and certainly the different parties, could agree on a new system. I look forward to speaking to all hon. Members about what a future social care system could look like. In terms of the detail, I am afraid that he is just going to have to wait a moment longer, but I agree that the work by the Select Committees will, of course, inform our decisions.

I turn in a little more detail to the measures and themes that are captured in the Bill. The first is more integration. We know that different parts of the system want to work together to deliver joined-up services, and we know that, when they do that, it works. We have seen that with the non-statutory integrated care systems in the past few years. They have united hospitals and brought together communities, GPs, mental health services, local authority care and public health, and it works. We recognise that there are limits on how far this can go under the current law, so this Bill will build on the progress of integrated care systems by creating integrated care boards and integrated care partnerships as statutory bodies. England’s 42 ICSs will draw on the expertise of people who know their areas best. They will be able to create joint budgets to shape how we care for people and how we promote a healthy lifestyle. With respect to the specific geographies of the ICSs themselves, as I have said elsewhere, I am willing to listen.

Bernard Jenkin Portrait Sir Bernard Jenkin (Harwich and North Essex) (Con)
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In passing, may I congratulate my right hon. Friend on his appointment? I also very much welcome part 4 of the Bill, which introduces the health services safety investigations body. This is a great innovation that was promoted by the Public Administration Committee and scrutinised by the Joint Committee that I chair. Can I just reinforce the points that I know he is now receiving from NHS England with a warning about changing the boundaries of the integrated care systems that are already operating? In Suffolk and north-east Essex, we have a very high-functioning de facto integrated care system operating already. Please will he not change it?

Sajid Javid Portrait Sajid Javid
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My hon. Friend has raised an important point, and this may be on the minds of other hon. Members as well. It is important to point out that several factors will be helpful in fostering stronger partnerships between the NHS and local authorities, including the alignment of boundaries. Earlier this year, the former Secretary of State asked NHS England to conduct a boundary review of integrated care systems, to understand the best way forward and the best alignment where local authorities currently have to work with more than one ICS. I have met my hon. Friend and other hon. Members, and I know that hon. Members may have made representations to my predecessor. I have been informed of those, and where the information might not be remembered easily, I am sure we can get hold of some video evidence. [Laughter.] I want to thank all hon. Members for their input into this, and I stress that no final decisions have yet been made on the boundary review.

Tim Farron Portrait Tim Farron (Westmorland and Lonsdale) (LD)
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Will the Secretary of State give way?

Sajid Javid Portrait Sajid Javid
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If it is on this issue, yes I will.

Rosie Winterton Portrait Madam Deputy Speaker (Dame Rosie Winterton)
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Order. Just a reminder that interventions need to be short and to the point, because there is a lot of pressure on time in this debate.

Tim Farron Portrait Tim Farron
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My point is about boundaries. Lancashire and south Cumbria have a perfectly reasonable boundary, but does the Secretary of State agree that there is concern that, because most rural communities are attached to bigger, more populated urban ones, that can lead to an imbalance in decisions? One of the proposals that our community faces is that the Preston and Lancaster hospitals could be replaced by a single super-hospital somewhere in the middle. HIP2—the health infrastructure plan 2—is a good thing, but that would be very bad thing, because it would mean that people in south Cumbria could have a two-hour round trip just to get to A&E. Will he intervene and ensure that any proposals under HIP2 that undermine access to healthcare in rural communities are taken off the table?

Sajid Javid Portrait Sajid Javid
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I listened carefully to what the hon. Gentleman said. As I have said, no final decisions have been made, but if he would like a meeting with a Health Minister, we can arrange that so that the matter can be discussed further.

I am also very grateful to another of my predecessors, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), first for his leadership of the Health Committee, whose valuable report and recommendations we have taken on board, and secondly for his tireless dedication to the cause of patient safety, which sees its culmination in the Bill’s creation of the Health Services Safety Investigations Body. We must continue, in his words, that quiet revolution in patient safety. I have asked my officials to consider whether the Care Quality Commission could look broadly across the integrated care systems in reviewing the way in which local authorities and providers of health, public health and social care services are working together to deliver safe, high-quality integrated care to the public.

Kevan Jones Portrait Mr Kevan Jones (North Durham) (Lab)
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The Secretary of State talks of patient safety. May I ask him why the Bill contains none of Sir Bruce Keogh‘s recommendations on the cosmetic surgery industry, which are now 10 years old? In response to questions that I have asked, Ministers keep saying that the recommendations are going to be implemented. Could this not be an opportunity to improve patient safety in that area?

Sajid Javid Portrait Sajid Javid
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The right hon. Gentleman has raised an important matter. There are issues surrounding the cosmetic surgery industry, and I know that he has spoken eloquently about them in the House before. I do not necessarily agree that this Bill has to be the vehicle for any change, but if he wishes to discuss the matter further, I should be happy to meet him in due course, because it is important and it does require a fresh look.

Whenever the NHS is subject to change, it is tempting for some, who should actually know better, to claim that it is the beginning of the end of public provision. We know that that is complete nonsense, and they know it is nonsense, but they say it anyway. So let me very clear: our integrated care boards will be made up of public sector bodies and those with a social purpose. They will not be driven by any private interests, and will constantly make use of the most innovative potential of non-NHS bodies.

The spirit of this Bill is about holding on to what is best about the NHS and removing what is holding it back. That is something that we all want, and I am looking forward to a mature debate—[Laughter.] Perhaps that is too much to ask in this Chamber with this Opposition Front Bench, but I hope for, and I think the public expect, a mature debate on the Bill and on how we can achieve these sensible changes together.

In that spirit, the second theme of the Bill is cutting bureaucracy. As we have been tested during these past months, we have looked at the rules and regulations through new eyes. It has become increasingly clear which of them are the cornerstone of safe, high-quality care, and which are stifling innovation and damaging morale. It is that second group of rules and regulations that the Bill strips away, removing the existing procurement regime and improving the way in which healthcare services are arranged. Yes, this is about how we deliver better value for the taxpayer, but fundamentally it is about how we can free up NHS colleagues to deliver better care. We know that patients are better served when experts are free to innovate unencumbered by unnecessary bureaucratic processes. That is why the Bill will repeal section 75 of the Health and Social Care Act 2012, giving the NHS the flexibility for which it has been asking. I know that this is a point of agreement with the Labour party—

Sajid Javid Portrait Sajid Javid
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The Labour party said it not just 10 years ago but in 2015, 2017 and 2019—in all those manifestos—so I am sure that its members agree with this direction. [Interruption.]

Rosie Winterton Portrait Madam Deputy Speaker (Dame Rosie Winterton)
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Order. If Members want to intervene, let me say to them that the Secretary of State has been very generous in giving way, but just shouting at him is not working.

Sajid Javid Portrait Sajid Javid
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They are excited, Mr Deputy Speaker, and I understand that. Let me excite them much more.

The third theme of the Bill is greater accountability. We have never seen so clearly as we have in the past 16 months how critical the health of our constituents is for the House. The Government of the day always work hand in hand with the NHS to deliver that priority. That is what people would expect from a responsible Government. People also rightly expect there to be clear lines of accountability for how this priority is delivered. Accountability is the foundation of our democracy, and on that I hope we all agree.

On the nation’s greatest priority, our health, this Bill sets out clear lines of accountability to the people we all serve. The Bill simplifies what has been a complex structure, bringing the three different bodies that oversee the NHS into just one, as NHS England. NHS England will continue to have clinical day-to-day operational independence, but it is right that the NHS must be accountable to Ministers, and Ministers must be accountable to Parliament, where we are all accountable to the people we serve.

Naturally, that accountability will extend to these integrated care systems. The right hon. Member for Leicester South (Jonathan Ashworth) is on the record, in an interview with the Health Service Journal in December 2019, as saying that he agrees with the principle of the legislative changes that had been put forward by the NHS for “democratically accountable” ICSs. He cannot have any objection to this point. We will see what he has to say from the Dispatch Box.

I hope we can all agree that this is a sensible and pragmatic step. Let me quote once more:

“We will reinstate the powers of the Secretary of State for Health to have overall responsibility for the NHS.”

Those are not my words but the words of the 2017 Labour manifesto. I look forward to working with the shadow Health Secretary on this and other aspects of the Bill, and I urge him to set aside petty party politics and point scoring and do what the NHS wants him to do, which is to back this Bill.

Before I finish my opening remarks, I turn to the reasoned amendment in the name of the Leader of the Opposition and other Opposition Members. What is claimed by the reasoned amendment is entirely wrong. This is exactly the right time for these reforms. The response to covid-19 has quickened the pace of collaboration across health and social care, showing what we can do when we all work together, when we adopt new technology and when we set aside bureaucratic rules. The pandemic has also brought home the importance of preventing ill health in the first place. The Bill lays the framework to achieve all that.

More than that, this Bill is what the NHS has been asking for. It builds on the NHS’s long-term plan and the work the NHS has already started to do voluntarily. We have invested record sums in the NHS, both before and, of course, during this pandemic, and we will continue to do so.

The systems are telling us that they are ready, that they want us to go ahead with this Bill. They do not want to see any delay, which is why this is important work for all of us. Hopefully Parliament can deliver what the NHS is asking for.

The unprecedented challenges of the pandemic have only deepened our affection for the NHS, and it has reinforced the noble idea that the NHS is there for all of us when we need it. I started learning about the NHS from a very early age when I used to go to check-ups with my mum and translate for her. It was there for her, it has been there for me, it has been there for my family, it has been there for my children and it has been there for all of us and our constituents.

Even in this fast-changing world, with the new and evolving threats to our health, the founding principles of the NHS are as true today as they ever were. It is our responsibility to build on this incredible inheritance. Our NHS is the envy of the world, so it is right that this Government should work across health and care to shape a system that is truly fit for the future. Our colleagues in health and social care have achieved extraordinary things in the most extraordinary times, and we in this place must give them the firm foundations they need to build back better in the years that lie ahead.

--- Later in debate ---
Edward Argar Portrait The Minister for Health (Edward Argar)
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Before winding up this important debate, I would like to put on the record, as I always do and as I know the shadow Minister does, our gratitude to all the staff in the NHS, social care and local government, and other key workers, for everything they have done in recent months. This Bill is evolution, not revolution. It supports improvements already under way in our NHS and it builds on the recommendations of the NHS’s own long-term plan, laying the foundations for our recovery from this pandemic. This Bill is backed by not only the NHS, but so many others working across health and care. A joint statement from the NHS Confederation, NHS Providers and the Local Government Association reads:

“we believe that the direction of travel set by the bill is the right one.”

It notes that working in partnership at a local level is “the only way” we can address the challenges of our time. The chief executive of Age UK has said that ICSs are to be embraced and made as effective and inclusive as they can be, and the King’s Fund is calling for us to press ahead. The list goes on; the NHS wants us to press ahead, and in the words of Lord Stevens, “The overwhelming majority of these proposals are changes the health service have asked for.” So it is vital that we in this House do right by them and by patients at this critical juncture. It is the right time for this Bill. We legislate, Opposition Members obfuscate. I remind the shadow Secretary of State of his 2017 manifesto, which stated:

“We will reinstate the powers of the Secretary of State for Health to have overall responsibility for the NHS.”

With this Bill, we put increased accountability for the Secretary of State at the heart of this, yet now the shadow Secretary of State no longer seems to agree with himself and characterises his own proposals as “meddling”. I know that he is dextrous in his politics and in his policy position, which is probably why he has survived under multiple Leaders of the Opposition, but this is stretching it a bit.

We have sought, in getting to this point, to work on a collaborative basis at every stage, and hon. Members can be reassured that we will continue to adopt that approach in the weeks ahead as we proceed with this Bill, when we hope it goes into Committee. My right hon. Friend the Secretary of State set out in his opening remarks his willingness to listen. In particular, he highlighted that in the case of ICS boundaries no decision has yet been made. As he set out, we are determined to embrace innovative potential wherever we find it. That is quite different from many of the accusations we have heard here today. I know it is tempting for some—even when they know better, and they do—to claim that it is the beginning of the end for public provision. It is not and they know it. They know it is scaremongering rather than reality. They know that there has always been an element of private provision in healthcare services in this country, and they should know that because, as the Nuffield Trust said in 2019:

“The…evidence suggests the increase”

in private provision

“originally began under Labour governments before 2010”.

The shadow Secretary of State should certainly know that because he was a special adviser in the Treasury and in No. 10 at that time.

With regard to the implementation of the Bill, the NHS itself wants, subject to legislation, to move at pace to implement statutory arrangements for ICSs by April 2022. That is why NHS England is beginning preparatory work, including publishing an ICS design framework. Further work, including on integrated care board design and consideration of appointments and staff from CCGs will take place, after Second Reading, of course; this is all subject to the passage of the Bill.

Let me turn to some of the specific points raised by hon. and right hon. Members. The hon. Member for York Central (Rachael Maskell) asked about “Agenda for Change”. I can reassure her that it is not the intention that ICBs depart from “Agenda for Change”. The Bill’s drafting and wording is in line with existing arrangements for other NHS bodies with regard to “Agenda for Change” and translates it into this context. However, I am always happy to discuss that with her further if she wishes. Her suggestion that this was conceived, as she put it, in a bunker is quite simply not the case. Indeed, all the stakeholders, including the NHS, have said that this is one of the most collaborative pieces of legislation development they have seen.

Turning to the workforce, as my hon. Friend the Member for Winchester (Steve Brine) said, we cannot legislate to address workforce challenges but we can and we will look very carefully at the recommendations of the Select Committee and of my right hon. Friend the Member for South West Surrey (Jeremy Hunt).

While we do not always agree on everything, the hon. Member for Twickenham (Munira Wilson) made sensible points, although I would slightly tease her that she argued against the principle of the Secretary of State taking powers in reconfiguration and shortly afterwards her hon. Friend, the hon. Member for Westmorland and Lonsdale (Tim Farron), intervened on him asking him to do exactly that.

Munira Wilson Portrait Munira Wilson
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I did point that out.

Edward Argar Portrait Edward Argar
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She did.

In response to the hon. Member for Central Ayrshire (Dr Whitford), I am again grateful for her comments and happy to accept her kind invitation to join her on a visit to Scotland.

The right hon. Member for North Durham (Mr Jones) made a very important point. In doing so, he rightly paid tribute to the work in this space done by my hon. Friend the Member for Sevenoaks (Laura Trott) with her recent private Member’s Bill. As the Secretary of State said, either he, I or the relevant Minister will be happy to meet him to discuss it further. My hon. Friend the Member for Meriden (Saqib Bhatti) was right to talk about the need for local flexibility. That is what we are seeking to do.

The hon. Member for Eltham (Clive Efford) asked more broadly about public spending constraints after 2010. He is brave, perhaps, to mention that. I recall the legacy of the previous Labour Government, which the right hon. Member for Birmingham, Hodge Hill (Liam Byrne) summed up pretty effectively in saying,

“I’m afraid there is no money.”

On social care, which a number of hon. and right hon. Members mentioned, we will take no lessons from Labour. In 13 years, after two Green Papers, a royal commission and apparently making it a priority at the spending review of 2007, the net result was absolutely nothing—inaction throughout. We are committed to bringing forward proposals this year. Labour talks; we will act.

The NHS is the finest health service in the world. We knew that before the pandemic, and the last year and a half have only reinforced that. It is our collective duty to strengthen our health and care system for our times. I was shocked, although probably not surprised, that the Opposition recklessly and opportunistically intend to oppose the Bill—a Bill, as we have heard, that the NHS has asked for—once again putting political point scoring ahead of NHS and patient needs. For our part, we are determined to support our NHS, as this Bill does, to create an NHS that is fit for the future and to renew the gift left by generations before us and pass it on stronger to future generations. We are the party of the NHS and we are determined to give it what it needs, what it has asked for and what it deserves. I encourage hon. Members to reject the Opposition amendment, and I commend the Bill to the House.

Nigel Evans Portrait Mr Deputy Speaker (Mr Nigel Evans)
- Hansard - - - Excerpts

I apologise to the 30 Members who did not get to speak in this important debate, some of whom are currently in the Chamber.

Question put, That the amendment be made.

--- Later in debate ---
19:00

Division 55

Ayes: 218

Noes: 359

The list of Members currently certified as eligible for a proxy vote, and of the Members nominated as their proxy, is published at the end of today’s debates.
--- Later in debate ---
19:11

Division 56

Ayes: 356

Noes: 219

Bill read a Second time.

Health and Care Bill (First sitting)

(Limited Text - Ministerial Extracts only)

Read Full debate
Committee stage
Tuesday 7th September 2021

(2 years, 9 months ago)

Public Bill Committees
Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 7 September 2021 - (7 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

None Portrait The Chair
- Hansard -

Some of our witnesses will be giving evidence today by video link, while others will appear in person. It is helpful, particularly when witnesses are giving evidence by video link, if Members could direct their questions to specific witnesses. Before calling the first panel of witnesses, I remind all Members that questions should be limited to matters within the scope of the Bill and that we must stick to the timings in the programme motion that the Committee has agreed. We have until 10.30 for our first panel. Do Members wish to declare any relevant interests in connection with the Bill?

Jo Churchill Portrait The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)
- Hansard - - - Excerpts

I have no relevant interest to declare, but we are unable to see a screen. Would it be possible to erect a screen so that we can see those giving evidence?

None Portrait The Chair
- Hansard -

Yes, we can do that. As there are no witnesses giving evidence in person, it would be okay for Members to sit at the witness table, if that would be better.

Jo Churchill Portrait Jo Churchill
- Hansard - - - Excerpts

That would be great.

Philippa Whitford Portrait Dr Philippa Whitford (Central Ayrshire) (SNP)
- Hansard - - - Excerpts

I want to declare an interest as a medical practitioner, although not commonly practising, and as a member of the British Medical Association.

--- Later in debate ---
None Portrait The Chair
- Hansard -

Thank you. I call the Minister.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

Q Thank you, Mrs Murray. I will try to be brief, with just two questions. Morning, Danny; morning, Navina. My first question is this: what do you see as the potential role of legislation in addressing future workforce needs— both the limitations of legislation in doing it and the opportunities?

Dr Navina Evans: I will start with the opportunities. We in HEE are really pleased to see that workforce is prioritised in the way that it has been. For us, that means that there is an expectation and an understanding of the need to tackle complex issues of future workforce planning, and that is hugely important. We can do it; it is a difficult task, but through collaboration and bringing people together, it is something that we simply must do, so that we can have more and different, and we can be really future-focused and progressive in the way that we deliver health and care. It is all down to our workforce. So that is the huge opportunity, as we see it.

There are risks. For us, one risk is that too much bureaucracy and added layers of hoops will get in the way, and the other risk is that we have to work hard to make sure that we address culture and collaboration to make this truly successful.

Danny Mortimer: The opportunity, we believe—along with colleagues across the health service—is in clause 33, going further and deeper there in terms of the assessment of need, as well as an assessment or a description of process. Clearly, what legislation cannot do is set out the kinds of behaviours that make that a well-informed and inclusive process. To reassure the Committee, though, what I do see is that the way of working we experienced during the development of this Bill, the way of working we are experiencing with Dr Evans in terms of the process she is leading at the moment—the long-term framework—is inclusive. It is trying to bring different voices in. Difficult decisions may well need to be made about prioritisation, and we understand that, but that is much easier to do and much easier to understand if it is based in that kind of process and behaviour. However, clearly, that is one of the risks.

As I have already said, we have had an increasingly centralised healthcare system over these last few years, and that is also one of the risks. If we stifle the local leadership and local innovation, and if we do not seek that local input in terms of how the development of local services needs to inform, in particular, the long-term planning for workforce, then that is a real risk for the legislation.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. One final question from me, if I may, Mrs Murray. I think it was Dr Mortimer who touched on a couple of points in his comments. One was that the way it is envisaged that this will be implemented would minimise any impact or burden, as it were, on the system, and I think that both witnesses touched on the learnings from the pandemic—the opportunity to build on what was done during that. To what extent, or not, would the witnesses consider that this is the right time to be doing this?

Dr Navina Evans: We in HEE think this is absolutely the right time to be doing this. We are at a moment where we have a lot of learning from what we have been through this last year. We have a real opportunity where many different pieces around innovation and improvement are coming together, and we have learned a lot from our previous experience of delivering the Health and Care Bill. For us, we think that this is absolutely the right moment to be doing this work.

Danny Mortimer: We would agree. NHS Confederation members were clear about the need for this approach before the pandemic, and I think that is even more pressing because of the pandemic. Actually, given the announcements that the Prime Minister is expected to make later today, it reinforces that need to better integrate health and social care, so the timing is very good.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you both. Thank you, Mrs Murray.

None Portrait The Chair
- Hansard -

Thank you, Minister. As there are no further questions from Members, I thank the witnesses for their evidence. We will now move on to the next panel.

Examination of Witnesses

Amanda Pritchard and Mark Cubbon gave evidence.

--- Later in debate ---
None Portrait The Chair
- Hansard -

Before I call the Minister, I remind Members that there will be a hard stop at 11.25 am. If witnesses could keep their answers as brief as possible, it would be much appreciated.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you, Mrs Murray. I will try to rattle through three quick questions. I think this is my first public opportunity to put on record, as the shadow Minister did, my congratulations to you, Amanda, on your appointment.

If I recall correctly, your predecessor, now Lord Stevens, says that about 85% of provisions in the Bill were things that the NHS asked for in its 2019 consultation. Do you recognise that figure, and how would you characterise the approach that has been adopted to the development of the Bill?

Amanda Pritchard: Thank you. I would struggle to give an exact percentage, but the Bill certainly contains widely supported proposals for integrated care. We have been working very closely with our stakeholders, colleagues across the system, you and others to ensure, as far as possible, the same approach to consultation, listening and hearing. You cannot please everybody all the time, but we want to reflect what feels genuinely like a consensus view about what will best help the NHS deliver on all the challenges we have discussed. That is reflected in the Bill, so thank you for that. As it goes through Parliament, we very much want to continue to see that spirit of joint working, consensus building and engagement, so that when it hopefully becomes legislation in April ’22, it lands with all the support that I think it currently has.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I will confine myself to one more question, Mrs Murray, to make sure that we do not run up against the time limit. This question has been asked of other witnesses, and I suspect it will be asked of others. To what extent is this the right time to make these changes?

Amanda Pritchard: As I said, I genuinely think that our experience across covid has strengthened the argument for moving to legislation now, because our way of working in the past two years has been characterised by integration and partnership, and that is how the NHS and partners need and want to work—now and as we head into next year, facing that set of challenges that people are so very committed to continuing to tackle together. Yes, Minister, I think this is an important Bill. The integration agenda is not the whole answer, but it is an important component of it, and the sooner it comes, the better.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Mark, in the minute or so before Mrs Murray closes the proceedings, is there anything you want to add on those two questions?

Mark Cubbon: All I would say is that collaboration and partnership work is a key feature of our response to covid. It is ever more critical, in the light of the question of how we will approach our recovery. Fantastic working has been enabled locally through necessity; now, we hear from the whole service that we want to build on that. We look forward to the future with that in mind; the Bill allows us to do that.

None Portrait The Chair
- Hansard -

As there are no further questions, I thank the witnesses for their evidence. That brings us to the end of our morning sitting. The Committee will meet again at 2 pm in this room to take further evidence.

Ordered,

That further consideration be now adjourned.—(Maggie Throup.)

Health and Care Bill (Second sitting)

(Limited Text - Ministerial Extracts only)

Read Full debate
Committee stage
Tuesday 7th September 2021

(2 years, 9 months ago)

Public Bill Committees
Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 7 September 2021 - (7 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

Q I hope that this is in scope, Mr McCabe. I have just come from the Chamber, where the Prime Minister is still on his feet. He talked about integrated care records, but I am not quite sure if we are discussing the same thing. This may not be news to you, Mr Madden, but could you clarify whether we are all talking about the same thing? I appreciate that you were not there to hear the Prime Minister, but is it your understanding that what we are hearing today about social care is the same as the conversation we have been having about integrated care records, personal care records and so on?

Simon Madden: Forgive me, but I will take full advantage of the fact that I was not there and have not seen the statement that the Prime Minister made. A feature of our plans set out in the data strategy—not so much in terms of the Bill itself—is for each integrated care system to have a basic shared care record, so that throughout their whole health and care journey a patient or citizen does not have to do simple things like repeat test results or repeat their prescriptions, and so that their care journey between health and social care, with provisions for safeguarding and safeguarding information, is seamless.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

I will ask a couple of questions, if I may, Mr McCabe, and then perhaps the hon. Member for Nottingham North can come back in if we have time. Moving away from what has been explored by colleagues so far on the extremely important protections around data sharing and data use, can you set out how the changes set out in the Bill relate to and will help you deliver the data strategy that you have in place?

Simon Madden: It is important to set out that these provisions alone, while they do much within the Bill, must be seen in the context of that wider data strategy. They support our ambitions, and the integration and collaboration that is described in the Bill will be a huge enabler for the ambitions set out in the strategy itself.

The provisions themselves focus to some extent on tidying things up and providing a degree of clarification. I mentioned the provisions for clarifying NHS Digital powers: currently, there is sometimes confusion around what data NHS Digital can share and in what circumstances it can share it. Sometimes, that leads to problems when data may need to be shared for very good reasons—for justifiable reasons—but NHS Digital is sometimes not convinced that it has the legal power to be able to share the data. This puts beyond doubt its ability to share data appropriately.

Another provision is on information standards. We are making a provision in the Bill to mandate standards for the storage and collection of data. That is important to ensure that data can flow between different IT systems and organisational boundaries in the health and care system. That will then help individual patients and improve health outcomes. We want to ensure that providers of health and care services purchase only technology that adheres to that set of standards, so that we have that interoperability, and those improved outcomes for patients, through that mandation of information standards.

We have also put in clauses around sharing anonymous health and care information, which help to essentially set a duty to share anonymous information when it is legally permitted to do so. One of the lessons that we have learned over the pandemic has been that, although it is perfectly permissible for data to be shared—it is legally permissible to do so—the shift from “can” to “should” has a great impact within the system.

Our invoking of the control of patient information regulations under existing legislation, to enable that sharing of data and to say, “You should share data in these circumstances,” has significantly helped the free flow of data safely and securely within the health system. That has had an impact on patient care. I think that the duty to share anonymous data will help to put on a more permanent footing some of those provisions that we have seen during the pandemic.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q To what extent would you consider it a fair characterisation that this is, in a sense, evolutionary, and that, actually, to a large extent, the provisions related to data—to go back to what you said—add greater transparency and legal clarity around some things that may have had to happen during the pandemic, and give them a longer-term basis in statute, as debated by this place? Do feel entirely free to disagree with that characterisation, I hasten to add. I am not leading you in any way, but to what extent would you consider that to be a fair reflection of these provisions?

Simon Madden: I think it is a fair reflection, to a certain degree. I think that the thing that we must always be conscious of, particularly in the field of data and technology, is that we see advances but legislation often does not keep up with those advances. It is about ensuring that everyone understands their responsibilities—not just that the public understands the responsibilities of organisations that are safeguarding data, but that those organisations themselves have the right powers to be able to share data safely and securely. I think it is evolutionary in that sense, but it is also about making sure that the provisions in the Bill are keeping pace with the development of technology and how data is used in the real, modern world.

Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

Q I will ask two questions in finishing, if I may, Mr McCabe. The first is a final one on the GPDPR promise. Mr Madden, you said that that is a separate process to the one in part 2 of the Bill—which I completely agree with—but that in the public’s mind, the two are likely to be conflated, and that now would be a good moment to reset the relationship between people and their data. Again, I completely agree with that. Is there any technical reason why we could not run those two processes not as two but as one?

Simon Madden: I should perhaps caveat my previous comments by saying that they very much are, in our mind; it is all about health data. The focal point for us at the moment, which we are working through with Ministers, is the formulation of the final version of the data strategy. Of course, the legislative provisions are within the data strategy. It is very much the case that the publication of that document, I think, is the right moment for that reset where we have more intensified engagement with the public and we really step up the narrative around how health data is used. As one of your colleagues said, the real detail comes in regulations, if there are any regulations around that; and of course there would need to be consultation before the regulations were put in place.

Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

Q Finally, I remember from my time in local government that we would talk about the desire in social care to share data with the health service. We talked about, obviously, regulatory barriers that stopped us and we would welcome provisions that removed that, but a very practical obstacle on our list of things in the way was that the systems did not necessarily speak to each other. Do you think that health service systems and social care systems are ready to speak to each other now, or will there need to be, across all integrated care systems, a whole new provider brought in?

Simon Madden: Obviously, interoperability is absolutely key. The information standards piece that I spoke about is part of that, but also, outside the legislative piece, work is going on to create a unified data architecture. This is not about driving or having everything from the centre, so that everybody uses the same things, but about making sure that the architecture enables that interoperability so that the systems can speak to each other. There is certainly a degree of levelling up to do in terms of digital maturity, which is another area in which NHSX is involved, supporting the Department and NHS England. But yes, interoperability is key. We are not there yet; we have some way to go to make sure that everything will flow as it should and the systems speak to each other.

Jo Churchill Portrait The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)
- Hansard - - - Excerpts

Q Mr Madden, I would like to know specifically how the strategy will help us to deliver integrated care within the confines of the Bill, so that we can give better patient outcomes, because ultimately that is what I have assumed the Bill is striving for. You did allude to how that interoperability gives us greater vision into the system. I wonder whether you could help us by bringing that to life. Thank you.

Simon Madden: The best example is something that I have already cited to a certain degree, which is the shared care record. To some degree, that would happen irrespective of whether ICSs and the Bill were in place, because health and social care need to come together; that is something that needs to happen in any event. But what the Bill does is create the proper framework of integration and collaboration. There are other powers in the Bill, for instance the duty to co-operate and collaborate, that I think are going to be absolutely crucial. From a public perspective, they see the NHS and see one organisation, whereas we all know that it is a confederation of organisations, each sometimes with different aims, pulling together. The ICS structure set out in the Bill, plus the data provisions that support that broader approach, will help provide that free flow of information so that clinicians and care professionals have access to the information they need to be able to treat patients in the most effective way.

None Portrait The Chair
- Hansard -

Anyone else? I will assume there are no more questions. Mr Madden, I thank you very much for your evidence.

Examination of Witnesses

Saffron Cordery and Matthew Taylor gave evidence.

--- Later in debate ---
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Q On the Secretary of State’s powers of intervention on reconfigurations, is it your understanding that a local system could agree across the board that particular changes were necessary and actually that it was important for reasons of patient safety that those changes were made but that the Secretary of State could intervene at any time to stop them?

Matthew Taylor: Yes, unfortunately that is our understanding, and we think that it would be a retrograde step. It is not a power that I would want if I were a Secretary of State and I wanted to focus on strategic policy questions. I would not have advised the Secretary of State to want those powers.

Our view would be that we should remove the extension of the Secretary of State’s power entirely, but, failing that, we should put some guard rails on in relation to hearing the views of local health overview and scrutiny committees, getting local clinical advice on what is best and having a public interest test that should be passed. If those guard rails were in place, we could cope with this.

What we do not want is a chilling effect on the capacity of local leaders to make the decisions that they need to make to use their resources effectively. The third element of the triple mandate is the effective use of resources, and that involves making decisions at a whole variety of levels around how you configure services. If you feel you are going to go through that process and potentially engage local populations in difficult conversations, and then at the end of the day a local MP, for whatever reason, is going to kibosh that by appealing to the Secretary of State, why would you embark on the process in the first place? That is why, while we are very supportive of the Bill, as you have heard from both Saffron and me, we do think that the powers of reconfiguration are the Achilles heel. I appeal to you to recognise that that is unnecessary and goes against the spirit of the Bill.

Saffron Cordery: I wholeheartedly support what Matthew says, and it speaks to a point I made earlier about adding to existing structures in a way that really is not necessary. I notice that you have representatives from the Local Government Association as witnesses later on. I am pretty sure that they will have some strong views about what these measures do for the powers of local health overview and scrutiny committees, because they already have the power to refer to the Secretary of State should they need that to happen. The powers that are currently in place are a really effective way of doing it. People getting something past a local health overview and scrutiny committee is a really important hurdle for any service change. It is already well respected, well used and very effective. This is one of those elements that at best is redundant and at worst is going to create a lot of work and a lot of unnecessary tension and friction where we already have challenge.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I have just a couple of questions, because a lot of the issues have been explored. My first one is something that we have not touched on yet in our questioning of witnesses. I welcome both your thoughts on the proposals in the Bill to delete and replace section 75 of the 2012 legislation, around procurement, and your reflections on the opportunities or challenges that that presents.

Saffron Cordery: As we see a change in the system, obviously the nature of how we have procured services in the past does have to change. It is obviously a complex area, but one of the things that we really need to look at is the effectiveness of the current contracting regime, which for certain parts of the provider sector in particular is incredibly burdensome. If you sit in a mental health or a community trust, you are subject to a whole host of retendering, which can have a potentially far-reaching impact on your trust’s sustainability or the future operation of key services. For many bits of the system, that will be very important.

The procurement regime is fundamental. It underpins how this will operate. We need to make sure that the elements of fairness are upheld and that it does not disproportionately put a burden on any one part of the system in particular.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Matthew?

Matthew Taylor: I agree with that. It is important to remember that one of the goals of the Bill is to reduce the weight of bureaucracy in the system. If we can reduce the weight of bureaucracy as it applies to procurement, that is only a good thing.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q My second question—I think this has come through in what both of you have said, but feel free to challenge it when you answer if I have misrepresented what you have said—involves one of the key things I have detected, which is that we must be careful not to forget that no one size fits all in this context. Back in the dim and distant past when I was a councillor, I sat on a primary care trust board as a local authority representative, and I found that joint working could be highly effective, so what is the right balance? You have touched on this in some of your previous answers. Recognising that it is sometimes as much about relationships as about formal structures, what do you think is the right balance between permissive and prescriptive in what we are trying to do here? How do we strike that balance appropriately, and have we struck it appropriately?

Matthew Taylor: Of course, one of the most challenging questions in all parts of central Government is to get that balance right. The one point that I want to make is about the nature of system leadership. If you lead an organisation—I lead an organisation—the parameters of what you do are reasonably well defined and you lead that organisation as best you can, and you can be regulated as an organisation in relation to its objectives. The thing about system leadership is that it involves developing a concrete and specific account of how you want to add value in a particular local circumstance—how is it that, working as a system, you will make a difference?

By looking towards population health and engaging local people, that proposition will vary from place to place. It is important that, when we look at how systems work, we allow them to develop a value proposition that is specific to their local circumstances and their local needs. That is why, for example, we would be very resistant to any kind of Ofsted inspection regime for systems, because systems are not the same as hospitals or as schools; they are very different and their aspirations will be very different.

When you look at the Bill, the reality of central-local relations is that rules are set out in legislation, but then there is the custom and practice of how Departments and other bodies actually work. Sadly and inevitably, the drift of custom and practice tends to be towards centralisation. That is why it is important to avoid things in the Bill that create an opening—this is why we can have our concerns about reconfiguration—which can get ever wider and thus undermine the key principles that lie at the heart of the Bill. So we are happy with the intentions of the Bill, but we are worried that there are certain elements of it and certain elements that might be involved in the operationalising of it that could undermine its intentions.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you. Saffron?

Saffron Cordery: I go back to a point that I made earlier in this session, which is that this balance between permissiveness and prescriptiveness is critical. The August 2019 agreement, when all the stakeholders came together to look at how we might legislate for an integrated care system that got that balance right, I think is there. You have to remember that what sits around a set of proposals will have a massive impact on it, so the Secretary of State’s powers as we have seen them, and the operating environment overall, will have an impact on how these proposals will be implemented, and how effectively they will be implemented.

We cannot forget covid in this. We cannot forget the extreme financial pressures that we are seeing. We cannot forget demand. We cannot forget an incredibly tired workforce. That is not going to change any time soon; that is going to be for the next few years, so we are implementing something against that backdrop. But if we go back to the slightly lighter touch of the August 2019 proposals, we will probably get to a place that would hit the spot, as it were. I reiterate that we support collaboration in systems and the direction of travel.

None Portrait The Chair
- Hansard -

Given the time, we will leave it there. I thank our witnesses, Saffron Cordery and Matthew Taylor.

Examination of Witnesses

Ian Trenholm and Keith Conradi gave evidence.

--- Later in debate ---
None Portrait The Chair
- Hansard -

Do have anything further you want to add? No. Minister.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you both for your evidence. I have one question for Mr Trenholm, two for Mr Conradi and then one for both of you, if I may, time permitting, Mr McCabe.

You will have heard in the evidence just before, Mr Trenholm, the comments by Matthew Taylor about the difference between assessing a system versus a provision. How do you see how the CQC would square that circle, because he highlighted the very different approaches and his reservations about some of that? How do you see that issue being resolved, or what would you like to see in that space?

Ian Trenholm: If I compare one large hospital with another large hospital as a comparison in terms of what we do now, one would argue that they are quite different enterprises, differently run and serving different communities. There are some common themes, but equally there are some differences. We built a methodology that was able to be applied to both of those very separate entities and to provide a common rating at the end of it.

I would see a version of that at a system level: there would be things that we would want to see that would be common and necessary— decent quality governance, for example—as well as a lot of things that many of you were raising as questions and concerns. But equally we want to see some evidence that the partnership board was cognisant of its local community and it was genuinely delivering a suite of services that its local community genuinely wanted and that was consistent with the needs of that community.

Over the next 18 months or so, we will be building our methodology in collaboration with the people who are also building the ICS boards and frameworks. I am hopeful that we can get to a point where we have a methodology that gives you, as parliamentarians, and local people the assurance that things are working well locally. However, it is not just about what is not working, but about looking for really good practice and looking to accelerate that. Previous people have made the point that doing things differently often leads to good practice and innovation, so how can we help accelerate that innovation through the work that we do. That is broadly how I see it working.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. Mr Conradi, the first question is probably a relatively quick and simple one, but I will not prejudge your response. Given that the HSSIB aspects have been in preparation for quite some time—I am alluding to the work that Dr Whitford and other colleagues did some time ago—what would your view be on the appropriateness of getting this done and the timeliness of bringing these measures forward? I am asking a number of witnesses whether this is the right time to be doing what we are proposing. In the case of HSSIB, is it the right time?

Keith Conradi: Absolutely.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I suspected that might be the answer, but I did not want to prejudge. My second question goes to a slightly knottier area, and one that you have already alluded to. I think you have said—by all means correct me if at any point I misinterpret what you have said—that ideally you would prefer the safe space to be as absolute as possible, given the nature of what you are seeking to do. There is, as we recognise in the Bill, a challenge about the specific statutory rights of coroners as members of the judiciary; I note what you have said about that. Would it be fair to say, first, that notwithstanding that, you would not want that safe space to be eroded further for other groups? I think you have been clear that you would prefer it not to be eroded at all, but you would not want its erosion to go further. The second element is this. Although you would prefer it to be preserved intact, do you think that if there is going to be that exception in the case of coroners, for example, the High Court is the right level of arbitration in something like that? I know you suggested that it might be.

Keith Conradi: I certainly think so. My previous experience in aviation is that we had a similar space, and only the High Court could overturn or order disclosure. It was used on a handful of occasions, and it produced very interesting debate. The balancing test—testing whether the benefits of the disclosure outweighed the adverse reaction that there might be to future investigations—was well argued in each of the cases. I think that is the appropriate place to do it.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. My final question is to both of you. Your organisations are separate but key elements focused on patient safety and the safety of outcomes for individual patients. How do you see the work of your two organisations fitting together and complementing each other, while recognising that they are both very distinct?

Ian Trenholm: We do work at the moment in terms of registering and regulating individual providers, and we do that right across the country, so we have a picture of health and social care right across England. Part of the Bill will give us enhanced powers looking at the way in which individual systems and individual ICSs work. Our view is, if you like, a broad and moderately shallow view, whereas I think Keith’s team do more in the way of specific investigations. I am sure Keith can talk to that.

Keith Conradi: I would characterise the relationship as a healthy tension. We make very few recommendations to the CQC, but the vast majority of recommendations we make will, we hope, have an impact on the work that is going on across the system. The ideal people to have a look and see whether that is having an effect will be the CQC, from time to time, as it comes across things that have changed as a result of what we have done. I think the relationship works very well, in that respect.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you very much.

None Portrait The Chair
- Hansard -

Mary, did I see you trying to come in with another point?

--- Later in debate ---
None Portrait The Chair
- Hansard -

I am going to go to the Minister now because of time.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Good afternoon, Councillor and Professor. I have two or three questions; we will see how we do on time. I will get through as many as I can, and if I do not get through them all, I do not get through them all.

Back in the day, I served as a councillor and cabinet member for public health, adult social care and health, and worked very closely with my then local PCT, which probably shows you my vintage. One of the things that I found was that the structures were important, but the relationships and how it worked on the ground, and the ability to be flexible and build up the trust between the two organisations was more effective in getting better outcomes. We have heard from previous witnesses about the importance of local flexibility to adapt to local work arrangements and conditions. Do you think we are striking the right balance between being permissive in allowing that flexibility and not being too prescriptive, or do we need to go a little more in a different direction?

Professor Maggie Rae: In my experience, with the way that the ICS has been set up, we very much hope that we will not start from scratch again, because those organisations have been working on this agenda for quite some time. I think there would be cries of horror if we said, “We are going to throw out the work you’ve already done.” Many of them have been on this journey for a while, and the leaders in those systems have indeed made some good progress. I think it is a delicate balance.

I will not repeat the points I have already made about strengthening the links to public health and making sure that is not forgotten. We will have 600 public health people going back into the NHS, but we very specifically have not changed the legislation that put directors of public health in England into local government. Of course, directors of public health in the three devolved nations are currently in the NHS. If you do not give people flexibility, you run the risk of your system not working. If we ensure that the framework and assurance process are right, the legislation takes us part of the way, but we want some checks and balances in relation to those freedoms, to make sure that there is a basic minimum standard across the country. If you have an ICS that is not working with its local authority, that is not a level where the ICS should be signed off. The ICS should be asked to go and demonstrate the commitment that the flexibility has allowed them. There is a statement in the framework that was released a couple of months ago, which said that the directors of public health will have an official role on both boards. I found that a pretty good statement to have, but it is only a statement that is effective if there is some assurance that that can be delivered on, and there need to be some checks and balances in order to make sure that those kinds of things are not ignored. Because of the variety—some ICSs cater for 2 million or 3 million people, and some for 1 million—you need the flexibility. If you want them to own and deal with the problems of their population, having a little bit of flexibility is the right approach, provided that the minimum standards are met across the whole country.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. Councillor Jamieson, I have seen that councils can often be at the forefront of leading innovation and driving change in a dynamic way. From the LGA’s perspective, do you think that we are striking the right balance between permissive and prescriptive, and is the approach to the ICP board and ICB an appropriate balance?

Cllr James Jamieson: From a legislative perspective, largely yes. I reiterate the point that I have made a couple of times already: the statutory and non-statutory guidelines will be critical in this area. We need to get them right and ensure that there is real embedded consultation. There are a couple of things that we are concerned about. I have not mentioned them yet, so I will use this opportunity to do so. One is the increase in the powers of the Secretary of State to call in NHS reconfiguration proposals and so forth, and the risk that that would undermine the existing local government influence, overview and scrutiny, so we would ask for a change to schedule 6 of the Bill in order to ensure that there is consultation at a local level before those powers are enacted.

The second area—it is probably not what you are asking about, but it is important that we raise it—is assurance around social care. It is good to have assurance around social care, but we need to make sure that that assurance is proportionate and is in context. Bearing in mind how stretched social care is from a financial perspective, it would be unreasonable to expect social care to do more than its budget allows it to do. In the same way, social care is also very dependent on the performance of the NHS, community care and so forth. We have some concerns around that assurance framework, which needs some work.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you, both. Mr McCabe, I am conscious of time and our programme motion, so I will pause there.

None Portrait The Chair
- Hansard -

Thank you, Minister. I thank both our witnesses for their evidence.

Examination of Witnesses

Eluned Morgan, Lyn Summers and Mari Williams gave evidence.

--- Later in debate ---
Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

Q That is helpful, thanks. To change tack slightly, in 2016 the Welsh Government brought in legislation around safe staffing levels. Are you able to talk us through that and say, five years on, what impact that has had?

Eluned Morgan: This is in relation to nursing. We have a law on safe staffing levels in nursing. Not only has it been implemented, but it has been extended since we brought in that Bill. It is something that the Royal College of Nursing is hugely appreciative of, and something that we are keeping an eye on. It has made a difference to patient safety, and we in the Welsh Government take it very seriously.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Good afternoon, Minister and colleagues. Thank you for your evidence and answers so far. By my reckoning, of the nine issues on which we had a discussion, we reached an agreement on seven. I think there are two outstanding, which are the ones you have highlighted in your evidence. I owe you an answer to your letter, but I think we are meeting shortly to further discuss that.

I want to pick up on something that colleagues have touched on and which you have highlighted around the model of integration in Wales—the unitary model, for want of a better way of putting it. I acknowledge that you said it was early days, but I would like to get a sense of how you feel that model is delivering a national system but allowing local flexibility, and of the extent to which it is delivering, even in its early days, improved health outcomes for patients in Wales. As we look at ICSs and closer working between local authorities and the NHS in England, it may be instructive for us to learn from your experience, even if it is not a direct parallel, and from what you are seeing, even in these early days.

Eluned Morgan: We had a parliamentary review that looked at our NHS and care system, and went into a lot of detail about what we could change. A lot of it was about the need to integrate—[Inaudible.] What we have done as a result is take an interim step towards better integration. We not only set up the legislative framework for that, but put significant funding into driving these health and care systems to work together. We had an integrated care fund and a transformation fund. We found that both the health service and the care service really liked the new approach. They really have engaged. We have kind of allowed a thousand flowers to bloom here, and there have been some really innovative ideas and work. How do we get people out of hospital quicker? How do we drive that change? There have been some great examples.

What we are still struggling with, if I am honest, is that we are still finding difficulty getting both the health service and the care service to understand that what they have changed and what works well now needs to be mainstreamed. There cannot be additional funding forever. The purpose of that additional funding was to give the confidence to do it in the mainstream. We are finding that they have pocketed that money, saying, “This is great. Can we have more, please?” We have tried to make it clear to them that that was never the idea. The idea was for them to have that transformation funding to drive change.

That is our next challenge, and that is what we are working on now, but there are ways of doing that. Clearly, this is a difficult time to be doing it, but some health boards are frankly being driven into closer working relationships, because there are so many examples of delayed transfer of care given the infrastructure at the local government level. Do not forget that in Wales we have not seen anything like the cuts that have happened in England, but even we are feeling the pressure in quite a significant way, and we are having some real issues in relation to recruitment to the care workforce in particular. That is the biggest challenge for us at the moment.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q That is really helpful, thank you. As ever, I am grateful for your candour, because that will help us to learn from your experience. I am always frank with colleagues about the fact that we will look around to see whether we can learn from Cardiff, Edinburgh or Belfast. That is what we should be in the business of doing. You mentioned using transformation funding to allow local flowers to bloom. That goes to the heart of something we have discussed in a number of sessions today. To what extent, in how you are approaching this greater integration or joint working, have you adopted either a permissive or a prescriptive approach? How have you sought to balance those two ways of doing things to get the best outcome?

Eluned Morgan: It has been quite interesting. With care, for example, we have found that a lot of competition was going, such as between the independent care providers and the local authority—they were poaching from each other. All of that was damaging to the public purse and to the provision that we could give. Now we are in the process of developing an all-Wales framework within which people who want to provide care in Wales will work. That is what we are working on—a new legislative framework that will provide the infrastructure and give the minimal standards that they will have to meet. It is also making sure that we are driving quality through the system.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I am conscious of time, but I have a final question that refers back to my first one. Do you have any evidence, whether anecdotal or that you will not share with the Committee, on how the approach is improving or changing health outcomes for NHS patients in Wales, quantitatively or qualitatively? What benefits are you seeing? Is there any evidence behind that? That is something we have explored with other witnesses—how ICSs will seek to do that—but given that you have started down this road already, is there anything you can share?

Eluned Morgan: What is difficult is that we started this process pre-pandemic but, clearly, with the pandemic we are in a very different situation. It is difficult to say what the model would look like in normal times, because we have had 18 months of something very different. It is hard for us to assess that evidence in the light of our circumstances at the moment, if I am honest.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

That is fair. Thank you, Minister.

None Portrait The Chair
- Hansard -

No one else? As there are no further questions, I thank you, Minister Morgan, and your officials for the evidence that you have provided today.

Eluned Morgan: Diolch yn fawr.

Ordered, That further consideration be now adjourned. —(Maggie Throup.)

Health and Care Bill (Third sitting)

(Limited Text - Ministerial Extracts only)

Read Full debate
Committee stage
Thursday 9th September 2021

(2 years, 9 months ago)

Public Bill Committees
Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 9 September 2021 - (9 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Thank you very much.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

Q Sara and Chand, welcome. I will try to get through three questions, but, if I run out of time, I will settle for two. We heard from a significant number of witnesses on Tuesday; you will have seen or read what they said. The overwhelming majority said that now was the right time to do this. Sara, I noticed that, in your evidence, notwithstanding the challenges you posed about some of the content that you would disagree with, you highlighted that this was due in 2019, on the basis of the original consultation, and asked why it had taken so long.

To both of you, do you think that now is the right time? I know that Chand has answered that, but this second part might apply to him: if it is not, when is the right time?

Sara Gorton: We were strong opponents of the 2012 legislation, so, in our view, the right time to do this would have been to not put that legislation through. However, we have been waiting for this batch of changes for some time. It has been evident, from 2013-14, and certainly since the “Five Year Forward View” was published, that what we were doing was having a structural workaround with people tacitly agreeing to almost ignore legislation. That is just not acceptable in the system.

Certainly, for my members who have been moved into new arm’s length bodies, moved around those bodies, and are now subject to another change, they want the security of knowing who is going to be employing them this time next year. In our view, the changes, both to the competition and procurement regime, and to clarifying how the new bodies will operate and what powers they will have, cannot wait. There are lots of other aspects that, as you can see from our briefing, we suggest could wait for future debate.

Dr Chaand Nagpaul: I want to be clear: we do not support the status quo. There is a pressing need to repeal much of the 2012 Act. However, I cannot overestimate how much the pandemic has affected us. We have not been able to be engaged, so it has to be asked: why do we need the Bill at this moment in time, when we are all absolutely overwhelmed? We know that any reorganisation of the health service means that people get distracted from their core work. The process of reorganisation takes human resource time. We have not been able to engage with this as we should, so we do not think that this is the right time.

The right time would be decided by two factors: first, when we are through the worst of what we are going through at the moment, and secondly, when the legitimate concerns we have are addressed, and there are the amendments that we would like to see. This Bill can shape the future of our health service. Get the right Bill, at the right time.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I have read your evidence very carefully, and your views on the 2012 Act are clear. To put in context what sort of changes—not withstanding your evidence—the BMA is and is not supportive of, which of the 1999, 2001, 2003, and 2006 Acts did the BMA come out fully in support of?

Dr Chaand Nagpaul: I am afraid I will have to let you know later, as I do not, off the top of my head, know exactly what those Bills contained.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. Feel free to write to the Committee. This is my final question, so that we finish on time. This relates directly to the BMA’s evidence, but Sarah may want to come in on this afterwards. You both touched on the procurement regulations in section 75 of the 2012 legislation; why are saying that NHS, or public sector, provision should be the default, rather than whatever provision provides the best outcome for patients? You highlighted the very clear view that NHS and public sector provision is the most cost-effective and the most clinically effective; it would therefore succeed anyway if the question is what delivers the best outcomes. Why preset that default?

Dr Chaand Nagpaul: First, the rules at the moment do not factor in that the NHS provides, in addition to the service, a complete, full body of care for patients. The same money would go on a hip replacement in the private sector. Secondly, there is the training element that I mentioned earlier. Thirdly, no acute NHS trust can walk away after two years—it is there to provide care to its population—but Serco was able to walk away after two years. We have many examples of private companies that have ended their GP contracts. Serco left an out-of-hours contract in Cornwall; that does not happen in the NHS. My local hospital has been there for as long as I can remember—it cannot walk away. The NHS provides accountability and duty, but more importantly, it is actually cost-effective. The staff have national terms and conditions; they provide huge amounts of good will and work above their contracts. It just makes sense to be resourcing our NHS.

Every time you take a contract away from the NHS, it is defunding the local system. We want taxpayers’ money to bolster an NHS that is co-ordinated, because we also want changes in the legislative requirements for foundation trusts and other NHS bodies to collaborate.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q In the minute left, Sarah, is there anything you wanted to add?

Sara Gorton: What the legislation sets out is a proposal for system working. Therefore, having something that disrupts that system is potentially counterproductive. I strongly support putting the NHS first—the NHS default—into the provider selection regime that is listed in clause 68.

None Portrait The Chair
- Hansard -

Thank you very much. We are making excellent time.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

On a point of order, Mrs Murray. On the Minister’s question to the BMA witness about previous Acts that the BMA may have endorsed, that would clearly be out of scope as evidence. I would not want Dr Nagpaul to waste time researching an answer that the Committee could not take into account.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Further to that point of order, Mrs Murray. Would it help if I set out the context in which I believe that question relates directly to the content of the Bill? Much of what is discussed in the Bill relates to previous legislation that has grown up over time; understanding which pieces of legislation the BMA supports will help us to better understand the evidence it has put forward on this legislation, and its context.

None Portrait The Chair
- Hansard -

Mr Madders, I think that the Minister has taken on board your point of order and paid attention to it. Thank you, Minister.

As there are no further questions, because we are out of time, I thank our witnesses very much for their evidence. We will move on to the next panel.

Examination of Witnesses

Professor Martin Marshall, Pat Cullen and Professor Helen Stokes-Lampard gave evidence.

--- Later in debate ---
None Portrait The Chair
- Hansard -

Thank you. We now go to Minister Argar.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you, Mrs Murray. I will endeavour to be relatively brief, as I am conscious of time.

Welcome and thank you very much for your evidence this morning and your frank answers to the questions posed. I want to ask a question in the context of what a number of you have raised about the different voices and the extent to which they need to be represented at the different decision-making levels of the new structure. We heard from previous witnesses, for example in the context of public health voices also, about the value that they add. The principle behind this legislation is that it is permissive rather than prescriptive. Therefore it is possible to have a lot more voices; there is only a de minimis level specified as prescribed. What is your view as to whether the appropriate balance between permissive and prescriptive has been struck in the Bill? If you think it has not been, where do you think the balance between permissive and prescriptive has been missed? Shall we start with Pat and then work our way along?

Pat Cullen: I have said very clearly that I believe the nurse needs to be represented at the board, and that needs to be an executive director of nursing. That needs to be prescriptive; it is not good enough to have it placed within mandatory guidance, it needs to be within the Bill. That is a red line for our nurses, and it will remain a red line, and we will be putting it forward as a red line.

Professor Helen Stokes-Lampard: I am going to be slightly subtler with what I say about this. I think the legislation, as drafted at the moment, is very enabling, and the implementation of it is where the great improvement in how we deliver care will come. I do think it is permissive, and I do think that it is enabling, and I completely understand my colleague’s desire to include specific words relating to nurses, GPs and whoever. What is vital for me is that the clinical voice is loud, clear, and can be influential. That is about implementation, culture and behaviour at a local level. Once we have the words for the final legislation, it is a question of how on earth we deliver it and support people to do it well, and how we learn from the best practice that is out there. That would be my—and our—view.

Professor Martin Marshall: In my 30 years as a GP, I cannot think of a single piece of legislation that has directly changed my practice on the ground. What I can see is the extent that legislation sets a tone and a culture within which clinical care is provided. I think this Bill is appropriately permissive, but, given the variation in all the challenges that we have identified, it needs to be permissive with really good oversight to ensure that the consequences of implementation do not lead to dramatic variation across the country.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. I have three minutes left, so I may try a follow up. That is really helpful, and thank you again for the candour of your answers. Much as it may sometimes pain us in this place, we do recognise that legislation can be an enabler, but we cannot sit here and solve problems on the ground simply by legislation. I sat on a PCT board many years ago, and the culture and the working relationships were almost more valuable than the framework that sat around them.

Going back to Pat’s evidence, but also to all of you: we have heard in our evidence today, and we heard it on Tuesday, a lot of different, vital parts of the system arguing the case for why they should be represented in a prescriptive way. Equally, we will have others arguing that a committee beyond a certain size becomes less effective. In terms of numbers, we have set a minimum. You are entirely entitled to say that you do not have a view on this, but how would you see the balance being struck between different groups making the case for representation, but, equally, having an effectively sized decision-making body? We will start with Martin, and then work backwards.

Professor Martin Marshall: I am glad to say that I do not have a view, but I do think that the boards should be small in order to be effective. They need to listen to advisory groups and sub-boards below them; it is the structures below the board level that will really make the difference.

Professor Helen Stokes-Lampard: Formally, the Academy of Medical Royal Colleges does not have a view. Personally, I have chaired boards from as few as five people, through to boards of 70 people, all of which can be hugely effective if managed well. However, the larger the board gets, the tighter the management has to be, because it is harder to get voices heard and for everyone to feel represented. Essentially, I am saying the same as Martin: smaller boards are generally more effective at getting through the agenda, but there has to be a high degree of trust in those that are actually on the board, and strong lines to sub-groups, for them to function with maximum effectiveness.

Pat Cullen: The board needs to comprise the right people. It is not about numbers; it needs to have the right people with clinical focus and patient care driving the outcomes for patients, and it needs to make sure that it does not develop a financially focused agenda. As director of nursing I have been there too many times: the table loses focus on the patient’s voice and needs. There needs to be a clinical focus and the right people at the table.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you all very much, I have no more questions.

None Portrait The Chair
- Hansard -

Thank you very much. As there are no further questions, I thank our witnesses for their evidence. That brings us to the end of our morning session. The Committee will meet again at 2 o’clock this afternoon to take further evidence.

Ordered, That further consideration be now adjourned. —(Maggie Throup.)

Health and Care Bill (Fourth sitting)

(Limited Text - Ministerial Extracts only)

Read Full debate
Committee stage
Thursday 9th September 2021

(2 years, 9 months ago)

Public Bill Committees
Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 9 September 2021 - (9 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

None Portrait The Chair
- Hansard -

I had better move on at this stage. I am really sorry, Nigel. Minister?

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

Q Thank you, Mr McCabe. I will only ask the one question, because I am conscious of time and keen that Opposition Front Benchers have their time. My question goes to the heart of this, and I am afraid it is a subjective question, but with all your expertise in this space, your answers will be instructive. In framing this legislation, we sought for it to be both evolutionary in reflecting the changes that are already under way, and permissive rather than prescriptive. Do you feel we have struck the right balance in terms of permissive versus prescriptive? If not, where is that balance missing? Shall we start with Nigel, and then work along?

Nigel Edwards: I think we have shared our anxieties about the reconfiguration and direction powers. In terms of what this does to the organisational architecture, it seems to me to strike the right balance between permissive and directive.

Nick Timmins: I would echo that. I have major reservations about the new powers of direction and, I think, major reservations if you build in reconfiguration service changes. The good thing about this—it has been the good thing about the development of the integrated care system so far—is that it is quite flexible. That is unusual in the NHS’s history: we tend to come up with very prescriptive solutions for what the system should look like everywhere, when in practice the circumstances are different, so I think the balance is pretty good.

Richard Murray: You could easily criticise the degree of permissiveness; you could criticise the degree of direction in there. The question should be, “Can anyone come up with a better one?” We have not been able to do so, so I think it is a balance well drawn. Of course, a lot will then rest on the behaviours that are shown after the Bill is through—whether people live up to that kind of core belief around that permissiveness and the freedoms that have been given.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you all very much. No more questions, Mr McCabe.

None Portrait The Chair
- Hansard -

We have time to squeeze in one very quick one, if anyone has something else to ask.

--- Later in debate ---
Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

Q So in your modelling it would be a partnership of the two.

Louise Patten: It is both/and.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I only have a couple of questions, Mr McCabe. I welcome the witnesses and thank them for their evidence so far. One question will be one that I have asked witnesses in previous sessions. We are seeking with this legislation to recognise the existing evolution of the system and the limitations of legislation in driving implementation and behaviours on the ground, as opposed to people finding their own ways of working within a framework. We have therefore focused on a permissive as opposed to a prescriptive approach. Do you believe that we have got the balance right in seeking a permissive framework rather than a prescriptive one? Are there any examples that you would add to what you have already said to illustrate your perspective on that?

Dame Gill Morgan: Yes, I think you have got the balance, and that is the joy of working with a Bill team. I think the balance is right. You have tried not to be prescriptive and tie our hands, but you have been clear in the sense of setting a direction and focus that we will all take into account, so you do not have to tell us things to make the NHS do it. We do it because we pick up the runes.

On the issues that we would be more concerned about, I personally am concerned about the ability of the Secretary of State to call in changes. In part that is because the one thing I think the NHS has learnt in the time that I was out and came back is how to do relatively good consultations. We have just finished a massive consultation. Patients have gone with us. The local communities have gone with us, mostly. We have had citizens juries and all sorts of things to reach a consensus about the direction of travel. The worst thing in the world would be that people say, “There is no point in engaging in those mechanisms locally because, at the end of the day, we will just complain to the Secretary of State and it will not happen.” If that becomes the way people manage that part of the Bill, it will take us backwards, not forwards, in terms of proper citizen engagement.

Louise Patten: On balance, it is about the Secretary of State’s powers of reconfiguration, and NHS leaders in general are concerned about that. It is not so much about the Secretary of State having an early understanding of the reconfigurations or the intent, but about the fact that that decision could be taken at a point where all the evidence is not ready to be properly considered.

Building on Gill’s point, patients and the public would be very frustrated if they felt that they had not had an opportunity to be answered, so we are asking, if not for the clause to be removed, for at least the clinical case for change to be considered from the ICB. Coming back to clinical decisions about clinical services, we want that accountability to local communities, not just up to Whitehall, and some transparency about why the decision was made, and on what basis and information it was taken.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Thank you. My next question follows on from that, acknowledging that point about reconfiguration powers, and builds on your clear answer to Karin that you think that what is framed here strengthens local accountability and engagement, and relates to something that you may have mentioned earlier, Gill, in some of your answers. Do you think that it is the right approach, in terms of ICB membership and others, to set a de minimis core membership and then allow that local flexibility to reflect local needs, local accountability and local engagement, to expand it as the local system and local people feel appropriate? Do you think that strikes the right balance?

Dame Gill Morgan: I think you are absolutely right: de minimis. What I have argued throughout is that if the centre, if you and then NHS England, which issues guidance, are clear about the principle that we have a proper engagement mechanism with our local authorities and citizens, they need to ask us how we are doing that, and to ensure that our constitution meets that. There are plenty of checks to ensure that it happens without you telling us that we have to have this, this and this.

In our case, we will have mental health and social care around the table, not because we are told to but because we could not imagine how we could do our work at a local level without having those people feeling that they are full partners and sitting around the table. There is a set of concerns about having local government involved in making decisions about the expenditure of large amounts of NHS money. I do not care; they are the local people who need to be involved in the decision making. Actually, if they see the deliberations and challenge first hand we will get better-aligned budgets. At the end of the day, that is to everybody’s benefit.

Louise Patten: There are already five mandated board positions in the legislation. A further five will be in the mandated guidance from NHS England. We are up to 10 already. I think the most important thing here is: where do you stop? There is a risk that there is a perception of two tiers—that those who have a mandated position on the board are of more importance than others. That flies in the face of partnership working.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q A final question, if time allows. I entirely take on board your point about the aim, the underlying point about implementation being key here—almost more so than the legislative framework—and the point about a single pot and sense of ownership. I remember the old section 75 of the National Health Service Act 2006, rather than the Health and Social Care Act 2012, being the mechanism that I used when I was a councillor to work with the primary care trust. It worked, but it was a bit clunky at times. My question is one that I have asked other witnesses, so I suspect that it will not come as a surprise to you. Do you think that this is the right time to be introducing these changes and legislation and, if not, when would be?

Dame Gill Morgan: My view is that we are where we are and we need to progress. Going backwards would be a problem, but actually I am a bit more positive than that. Covid has demonstrated to people that if they think innovatively, out of the box and in partnership ways they can get solutions that are quicker than they would have been before, so in the system as a whole there is a recognition that partnership has offered more. We will all retrench as the world moves on from where we are, but there is real learning from covid on which we can capitalise. Many systems have done reviews of what worked and why, looking for the silver linings in that learning. I think the Bill goes with the analyses that have come out.

Louise Patten: At the NHS Confederation, we have that sort of umbrella view. We must not forget that, on collaboration and integration, people have been working to this for some time. There are some great examples of it, and this legislation moves that opportunity to really accelerate it. People recognise that it is a tight timescale, but they are absolutely committed to doing it.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you both very much. No more questions, Mr McCabe.

None Portrait The Chair
- Hansard -

Dr Whitford, did you have anything else?

--- Later in debate ---
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Q I have one more question, Mr McCabe. One of the consistent points we have heard from witnesses is that they are not convinced that the provisions in the Bill on workforce are sufficient to deal with the workforce challenges that the NHS faces. Would that be something that you feel is also the case for mental health professionals?

Andy Bell: This is incredibly difficult. We have some very ambitious plans now—the NHS long-term plan ambitions for mental health. There is, quite rightly, an awful lot of money going into that, because we have a very big gap in our ability to meet people’s needs. The only way that is going to succeed is if we have a very significant expansion in the mental health workforce.

We need to remember that that workforce is not just what people think it is. It is obviously nursing and obviously psychiatry, but it is also social work—a lot of really important mental health provision is in local government under social care. We need to think about the importance of advocacy and the importance of peer support, the importance of employment and housing rights workers, who we know make a big difference to people’s lives. There is also the key role of the voluntary sector in providing forms of support that may not come under traditional clinical headings, but none the less make a huge impact in people’s lives. We need to build the workforce.

The Bill gives some steps forward and summary assurances. In some ways, it is not quite the right place to be dealing with this. This is about whether the various parts of the system—the health education system, the NHS itself and its partners in local government—have the resources and the right ways to encourage people to come and work in mental health. It would be great to see the kind of recruitment campaigns we have had for the NHS as a whole to really help bridge that very big gap in the mental health workforce. At the moment, I think the Bill is probably neutral on it. It would be good to see some stronger assurances, at the very least holding the Secretary of State to account for how they are achieving the workforce ambitions set out in the long-term plan and future policies that will have to come.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Good afternoon, Ed and Andy. Andy, in my first question, can I pick up on something you said there, before I broaden out to a question to you both? You talked there, quite rightly, about the importance of parity of esteem for mental health. As a local councillor years ago, I saw how important local councils and the NHS working hand in glove on mental health provision is, because if we get one half right but not the other half, it just does not work.

Building on what you have already said about the legislation, what would you identify as the opportunities of the legislation, if properly implemented or interpreted in the right way, for furthering that linkage and that joined-up mental health provision? Obviously, that goes beyond local council services and the NHS. There are a whole wraparound series of services that impact on someone’s mental health. What do you see as the opportunities in the legislation that we either need to draw out further or at least not lose sight of?

Andy Bell: This is about building real, sustainable, long-term partnerships. One of the things I know colleagues in the NHS and local government find very frustrating is that they just find a way of working with each other and then the legislation changes again and they have to start all over, so it is about having a system that actually works and stays working, that builds on the best of what is there already. I think there is some frustration in places where they spent a long time building relationships between clinical commissioning groups and local authority colleagues, sometimes with jointly employed staff, and now they have to start all over again because we are moving to a different thing. That will be immensely frustrating for many folk.

If we take the principle that this is about integrating care and equal partnerships between different players, including the voluntary and community sector, and if we give that time to work, we will enable partnerships to form with a clear voice for people—for example, in the case of mental health, for people living with mental health difficulties—so that decisions are being made with and in partnership with the people who use them rather than remotely by professional experts on their own.

Collaboration is incredibly important too. One thing we really welcome about the Bill is that it is moving us away from a system of competing providers to providers working collaboratively—literally, in providing collaboratives. There is a slight risk that all the power will be vested in one organisation and there will not be that check and balance between commissioner and provider. But some of the early provider collaboratives working in children’s mental health services that we have looked at have made really huge strides really quickly to reduce, for example, the number of children forced to go to hospital outside their local area in a mental health crisis. They have come together, looked at what support is needed for children in a crisis and put community services, in particular, in place to achieve that.

One further thing that will be important is that there is some positive provision in the Bill to ensure that ICBs—I think it is ICBs, yes, it is—have to take into account inequalities in access and outcomes. That is great, but there is not that requirement to pay attention to inequalities in health and to go out and identify which groups of people are experiencing health inequalities and what the system can do to deal with that upstream rather than waiting for people to need formal healthcare. That would be the other part that would really help in the Bill—to build on some of the positive noises and moves in the right direction in collaborating at the level of prevention and on the things that determine our health as well as in the provision of services when things have reached a point where people need care.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q In the two and a bit minutes I have, in order not to get cut off by Mr McCabe, I will direct my question to Ed and will bring you in, Andy, if I have time. We have heard about how what is proposed in many ways enhances local accountability and local authority involvement in decision making, but to go back to your earlier comments, would it be fair—you are entirely entitled to say that it would be unfair, and that I am misinterpreting—to say that alongside that your request was a request that in enhancing that we should not lose the local accountability mechanisms and processes that have already grown up over the years in local authorities, be that health and wellbeing boards, joint overview and scrutiny committees, or whatever? Is that a fair characterisation? Feel free to correct it.

Ed Hammond: Broadly speaking, yes, that is fair. My central point would be that those structures and the opportunity that local government has through this Bill for more direct and active involvement in health and care decision making are good, but there still needs to be that separate independent source of accountability that we feel sits properly at a local level with democratically elected local councillors who have powers through health scrutiny committees to talk to local people about their needs. That needs to be there and needs to be strengthened. In respect of the Secretary of State powers I was talking about, my worry would be that we would see ICBs and ICPs looking over their shoulder at what the Secretary of State might want to do rather than looking down to local communities to understand where local need lies, with decision making being led somewhat by what people think national priorities should be.

Part of the solution to that problem is the things we have proposed around, for example, requiring the Secretary of State to consult with local scrutiny committees before exercising those powers, having the powers for local scrutiny committees formally to escalate things to the Secretary of State to act on, and what we have suggested for more effective joint scrutiny by multiple councils of the ICB at system level as well. Those are all part of that strength and accountability framework. It is about saying, “Okay, we have involved local government in decision making through the ICPs and through continuing the health and wellbeing process, but in doing so we also have to enhance and build on our existing health scrutiny arrangements.” As things stand, the Bill removes elements of those by removing the power of referral. It is about having a balance of accountability arrangements and ensuring that that strong external accountability continues.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you.

None Portrait The Chair
- Hansard -

We had better leave it there. We are out of time. I thank you, Andy and Ed, for your evidence today.

Examination of Witness

Sir Robert Francis QC gave evidence.

--- Later in debate ---
Alex Norris Portrait Alex Norris
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Q Thank you.

We will move on to something else that you said in your written evidence. On Tuesday, we had a very good conversation about data, but the whole thing was about quantitative data. In your written evidence, you talk about qualitative data, and it is very easy for us, as Members of Parliament, to conceive of the importance of that, as it is something that we routinely draw on. With your insight from leading Healthwatch, how can we develop systems that properly trap that, use that and prioritise that just as much as the quantitative data?

Sir Robert Francis: Technically, these days, that is no problem at all. You will not expect me to explain that to you, but the qualitative data—comments from the friends and family test, or similar things—is easily mined these days. You can develop a view of the sentiment that comes through it, and you can then dig down more closely into specifics if you need to. That information is extremely valuable to Healthwatch in determining what people think about a particular subject or services, and we feel that there should be a recognition that that data, in that form, should be capable of being shared with a statutory body like Healthwatch, and possibly others.

We also think that—I am sure others might agree—while quantitative data is extremely important, it is informed by qualitative data. The personal impact—good or bad—of things that happen in the service are best described by the people who have received that service. If you just look at figures—I am afraid that this was a problem at Mid Staffs—you lose a great deal, and the trigger for change and improvement is lost.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q I will try to be brief in the five minutes that we have left. Sir Robert, I have two questions: one with your Healthwatch hat on; and one in your personal capacity—and also as an eminent lawyer.

We sought with this Bill to be permissive rather than prescriptive; behaviours, and how things work on the ground, are often as, if not more, important than the framework. Notwithstanding your on-the-record comments about Healthwatch participation in ICB levels as a formal member, what else would you draw out as opportunities within the framework to build on patient participation and accountability to those who pay for, and use, the service? Are there other opportunities, that, with a small tweak either in guidance or in the Bill, we could seize more effectively?

Sir Robert Francis: I suspect that there is something around reporting, particularly with the oversight of quality, inequalities and matters of that nature, which would be of assistance. I agree that flexibility of engagement is really important, and Healthwatch claims no monopoly over this. I see it taking place in guidance. If the emphasis is to change culture to one where the service is being responsive to people’s needs, as opposed to providing them with what the service thinks they need, there could be greater emphasis in the Bill on ensuring there is a strategic plan for engagement. There could be more emphasis on how the ICS is going to engage with local people and communities, and an actual requirement that it provides comprehensible information to the community about how people should be able to communicate with it. I know they sound like matters of detail, but if there is an obligation to make such things clear, it does not prevent flexibility, but it does oblige organisations to actually do it—and mean it. There will be lots of other ideas, I am sure.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q That is useful, and builds on your written evidence. What do you think in a personal capacity? This builds on Dr Whitford’s questions and acknowledges Keith Conradi’s preference that the safe space be not qualified. If one accepts that it is qualified in respect of aspects of the judiciary—he acknowledged in those circumstances that he would accept that—would you consider that a High Court judge is probably the most appropriate person to make such a judgement on whether something should be taken out of the safe space and made available to a coroner?

Sir Robert Francis: In relation to a decision of whether information should be capable of being used in legal proceedings, there is no better qualified person than a High Court judge—so, absolutely. My advocating that there should be some qualification in relation to the family does not mean, in any way, that I suggest they should then be able to use that for litigation or other purposes. Indeed, some of the conditions you might impose on them in order for them to get the information are that they do not do those sort of things. There will be areas where it can be said that it is too sensitive for that. Of course, there may need to be a balancing of people’s rights of privacy. It is really about ensuring that families feel that they are not being excluded or that something is being hidden from them. We need to build trust. I do not think that that decision needs to be taken by a High Court judge, because it is not about legal proceedings; it is about something really quite private.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

That is extremely helpful, thank you very much.

None Portrait The Chair
- Hansard -

Thank you, Sir Robert.

Examination of Witnesses

Stephen Chandler and Gerry Nosowska gave evidence.

--- Later in debate ---
None Portrait The Chair
- Hansard -

Right. We have two Ministers now. Jo, did you want to ask something?

Jo Churchill Portrait The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)
- Hansard - - - Excerpts

No, my question was covered earlier. I had assumed that I would be called as a Back Bencher, if you see what I mean, as I am not the lead Minister on this Committee.

None Portrait The Chair
- Hansard -

I apologise for that, but I understood that we had decided to share the time between Back Benchers and Front Benchers, and I counted you among the Front Benchers. There we go. Never mind.

Jo Churchill Portrait Jo Churchill
- Hansard - - - Excerpts

Q I will ask a supplementary. We have spoken about discharge. I have a particular interest in how we develop the system by the use of ICBs and ICPs in order to highlight prevention. Very often, admission is the result of issues before, and as Stephen highlighted and Gerry alluded to, carers and families all take the weight of the stress when somebody is admitted, and when somebody is discharged and needs reablement. What does the Bill do, or what would you like to see in it, to help prevent people falling ill?

Stephen Chandler: The Bill reaffirms and formalises the requirement to plan very carefully for the population at a place level first, and then at a system level. In doing so, it sets up an integrated care partnership with a clear set of objectives, based on the population. Of course, it emphasises the importance of prevention as a way of helping people remain healthy and well for longer.

In Oxfordshire, we have set up our shadow partnership, and one of the areas we are looking at is our out-of-hospital support—particularly how we can avoid the need for hospital admissions. Again—this goes back to a point I made earlier—in doing so, we are looking at how we as a system can contribute individually, and therefore collectively, to reducing crisis and therefore the need for hospital admission. It has changed the tone of the discussion from, “Isn’t that an NHS responsibility, whether primary care or secondary care?” to, “How can we do better for our population?”.

You might say, “Well, hold on. That sounds like a very subtle change.” Let me be clear: some of these subtle changes really do make an impact. Coming back to an earlier question about resources, this also enables us to have the conversation around the prioritisation and impact of those resources. Instead of saying, “Here is the county council’s budget plan and here is the NHS’s”, we can ask how we make best use of that collective resource. The Bill helps by formalising that and providing some additional structures and focus on that.

The Bill is helpful, but it will be interesting to see how it works where, perhaps, systems have not had positive relationships or have had a more adversarial approach. I was really lucky in Somerset, because the emerging ICS there was coterminous with the local authority. It was a single provider. It was perfect in a way. I am in an ICS now where there are three different population groups. We know some ICSs have significantly more.

The opportunity is there to be grasped. This provides a fantastic focus if it can be ensured. In fairness to colleagues, the focus seems to be “start at place and work upwards”, rather than “start at system and work downwards”, in order to make really good differences to people, particularly around hospital admission avoidance. It also gives me, from a local authority point of view, greater leverage to challenge my NHS colleagues around their investment in secondary care and community care resources, because that area has, unfortunately, seen significant reductions over the years.

Jo Churchill Portrait Jo Churchill
- Hansard - - - Excerpts

Q So you might see a positive outflow, in terms of more investment in community, in order to keep people well?

Stephen Chandler: Absolutely.

Jo Churchill Portrait Jo Churchill
- Hansard - - - Excerpts

Q Thank you. Gerry?

Gerry Nosowska: Prevention is always undermined by the resources moving into urgent and acute needs. In practice, social workers are not able to do therapeutic, restorative support work that they would be able to if they had the time to spend with people who need that. There is a fundamental resource issue that the Bill does not address directly, but it may help with the potential for pooling resources. Again, people in the community do not care whether it is a health or social care resource. If there is a need emerging that can be responded to, and preventive work can be done, it should happen without health and social care arguing about exactly whose purse it comes out of.

There are some really successful examples of reablement and preventing avoidable hospital admissions. We know it is possible. Scarcity does breed competition rather than collaboration, so that is something to think about. As for what the Bill might also do, the partnership strategy ought to have a very strong preventive element to it, and that needs to be dug down into locally—into particular communities, neighbourhoods and streets. That is where you really need lived experiences. I have a question about the regard that the integrated care board would have to that, and the potential for a wonderful, collaborative partnership strategy around prevention to be disregarded because of an acute need. I was listening to Robert Francis, and I think his suggestion that there be a written explanation to a local community if that happens is very good.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Q Just one question to both of you, if I may. First, thank you for all that you and your members have done and continue to do. I say that as a former council cabinet member for adult social care and health and public health. I know the shadow Minister will share that sentiment. When I was doing that job some years ago and I was not quite so grey, the director of adult social services with whom I worked was a lady called Marian Harrington, who had been working in adult social care for a long time. A key point that she always emphasised to me was the importance of a close working relationship between the NHS locally, social care and the local council, particularly on discharge, but also on the ongoing care of people with multiple needs who were receiving social care. She would always say to me that although the framework was important, equally important were the culture, the behaviours, and trusting relationships between organisations in the framework.

I will turn to Stephen first and then to Gerry. We have sought to be permissive rather than prescriptive in this Bill. Have we struck broadly the right balance, or are there areas where it might need to be tweaked, either in legislation or in guidance?

Stephen Chandler: Your director colleague was absolutely right. I think that you have got the balance right in relation to permissiveness. I worry that the guidance does not prescribe directly how we should develop that culture, but having worked as long as I have, I realise that you cannot prescribe how relationships are formed and how cultures work. You have to create the conditions for success. Some of those conditions are in the Bill. I have talked about some of them in relation to the pooling, the boards and the assurance methodology. What has to be absolutely clear—and I am hearing it clearly, so it is not that I have not heard it—is the importance of seeing this as a vehicle for meaningful change to people’s lives, not a restructuring of health and social care. Rather, this is a vehicle for improving the lives of people in communities and systems, and for allowing health and social care professionals to maximise their individual abilities for that collective good. In a way, there is a duty on me as a leader in the system to create that culture and environment.

You have not gone into the area of assurance, but for me it is really important that when assurance looks at a system, it looks at the leadership and how that leadership translates the freedom, the permissiveness, but also the accountability, clearly. The feedback I am hearing from our members is, “We favour the permissive approach that is taken in this.” We would not say that the tolerance should be changed one way or the other.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Gerry?

Gerry Nosowska: Apologies, I think I lost my connection for a moment, so I might repeat some of the things that Stephen said. On the balance between permissive and rigid, we have an interest in the consistency of opportunity and outcomes for members of the population. Areas face different challenges, so it is important that locally there is flexibility around how those challenges are met. What will hold those models together are the principles of ensuring transparency around decision making; the involvement of lived experience and clinical expertise in both social care and health; and real local accountability. Certainly, more local community decision making, planning and work, and less centralisation, is much more in tune with responding to the lived needs of people and their day-to-day priorities.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Thank you, Gerry and Stephen. I have no further questions, Mr McCabe.

None Portrait The Chair
- Hansard -

May I thank our witnesses for their evidence? That brings today’s oral evidence sessions to a close. The Committee will meet again on Tuesday in Committee Room 14, with Mr Peter Bone in the Chair.

Ordered, That further consideration be now adjourned. —(Maggie Throup.)

Health and Care Bill (Fifth sitting)

(Limited Text - Ministerial Extracts only)

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Committee stage
Tuesday 14th September 2021

(2 years, 9 months ago)

Public Bill Committees
Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 14 September 2021 - (14 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

This information is provided by Parallel Parliament and does not comprise part of the offical record

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

It is a pleasure to serve under your chairmanship today, Mrs Murray, and to serve on the Bill Committee.

The amendment was moved in my name and that of my hon. Friends. The Minister whom I shadow is helpful—we will see how helpful during the course of proceedings—and we start in a spirit of optimism. I am grateful for the support of my colleagues on the Opposition Benches who, between them, contribute some relevant and highly knowledgeable experience. They are all passionate, as we all are, about the national health service and the care system, which are the subject of the legislation.

With your indulgence, Mrs Murray, I take this opportunity to make a few short points about the general context of the legislation. First, this is an important Bill. It could easily have been two or three pieces of separate legislation, so it requires proper consideration. We have a concern about whether enough time has been allocated to deal with everything in the detail that we would like, but we will do our best to get through it. We intend to make our contributions short but relevant and, we hope, persuasive.

Secondly, we share the apparent desire of the Government to repeal the worst aspects of the disastrous Lansley Act. Many of our amendments will be directed at trying to ensure that, in doing so, the baby is not thrown out with the bathwater. Thirdly and finally, as stated by the chair of the British Medical Association in the evidence sessions last week, we remain of the view that the Bill is the wrong Bill at the wrong time.

The amendment seeks to define the composition of the board of NHS England to align better with what we see as the new requirements set out elsewhere in the Bill. In looking at the issue of who should be on the board, we all ought to agree that it should not be open only to the friends and relatives of Ministers. Board members in our view should be subject to more independent assessment of their value and must pass at least some fit and proper test to avoid obvious conflicts of interest.

The amendment would ensure that the key influences on the board come from public health, local government, the patients themselves and the staff, without whom the NHS does not exist. At this point, I take the opportunity to place on the record, as I often do, Labour Members’ thanks to those in the NHS who have been so magnificent, not just over the past couple of years but over many years. They deliver a service that is rightly a source of great national pride. They deserve a seat at the table, as do patients. The Bill does not do enough to amplify the patients’ voice. We will be discussing a number of amendments over the coming weeks by which we will hope to change that.

We also need to look at what NHS England mark 4 will be required to do if the Bill becomes an Act. Other parts of the Bill deal with the powers and duties of this new version of NHS England, originally the NHS Commissioning Board. It is, in many ways, the pinnacle of the reversal of the Lansley position. The new NHS England does not bear much resemblance to what was envisaged under the Health and Social Care Act 2012. That is a good start, but one aspect of the Lansley view—that the NHS requires some degree of operational independence—has been shown to have some merit. Every clock is right at least twice a day, and we have found the one piece of the 2012 Act that proved to be correct. We will discuss some amendments later on to limit the power of Ministers to interfere with those who we believe should be operationally independent.

The new NHS England is pretty much in place anyway, as a result of the actions of those managing the NHS over the last few years. They desperately and very innovatively at times tried to find ways to circumvent the edicts of the 2012 Act, while Ministers looked on passively. It has been an unusual and interesting passage of time in the history of the NHS. We have seen legislation simply ignored and Ministers have allowed that to happen. It is little wonder, given the experiences of the 2012 Act, that many of the NHS witnesses we heard from said they wanted as little prescription as possible. They have had their fill of prescription. We would differ, I think, on the level of prescription necessary in the Bill.

New NHS England will be an amalgamation of the old NHS England, Monitor and the NHS Trust Development Authority. It will commission some specialist services. It will be the regulator, regulating a market that no longer exists. It will performance manage both commissioning by the integrated care boards, which, for the purpose of brevity, we will refer to as ICBs, and the provision of services by trusts and foundation trusts. I am afraid that how that wide range of responsibilities sits with the role of the Department is as vague as ever. The ability of Ministers and others to interfere and micromanage depends on whether the rest of the Bill survives in its current form.

Above all, the board oversees the operational running of the NHS, shaped by the mandate, which gives the direction of travel. Perhaps the most crucial policy change is that new NHS England sits at the top of the system, based on the integrated care boards as the major commissioner of services. That means who sits on the board is highly relevant.

The explanatory notes and the Government pronouncements about the new integrated bodies strongly assert that the role is to drive the reintegration of the NHS, repairing the worst of the fragmentation caused by Lansley and, I hope, once and for all, ending the obsession with marketisation, which has been shown to be a failure. We need board members on NHS England who might be seen to be more in tune with the new philosophy of partnerships and collaboration—not markets and competition, not business leaders, hedge fund managers, marketing experts.

In the new world, we want the NHS to be bound by its core principles—comprehensive, universal, free and funded from general taxation. That is a topic that we may touch on later; it may also be discussed in other business of the House today. What should be valued in board members is that they have some record of commitment to those principles. They should have some claim to be aligned to the new values, which favour a stronger role for patients; the public to have influence; a view that the NHS is contributing to reducing inequalities, as well as improving wellbeing; and the greater alignment of NHS services with local government.

The current make-up of the board is, put simply, the chair plus five other non-executives, all appointed by the Secretary of State, and then of course the appropriate executive directors. This amendment deals only with the non-executive directors. Given the huge importance of the NHS, it is appropriate that the chair and at least some of the non-executive directors are appointed by the Secretary of State. We will concede that. In another world, perhaps they could be elected in their own right, but we will not be travelling down that road on this occasion. However, we cannot ignore some of the headlines over the last 18 months and the huge media coverage of quite blatant abuse of patronage in appointments in the NHS more generally in recent years. Cronyism, I am afraid to say, has become a default position, and we think that has to be challenged.

To be fair to past Ministers, the NHS itself can also appoint people for the wrong reasons, moving out disgraced leaders if they go quietly, only for them to re-emerge somewhere else in the system. If the NHS is an organisation—it is a stretch to use that term after the mess created by the 2012 Act—appointments should accord with the highest standards of fairness, and inclusion is notably absent, so let us change the approach. Let us set the tone from the very top and enshrine in law the kind of people whom we as a Parliament would like to see—not, of course, specifying individuals but setting out in general terms some of the main interest groups that contribute towards the NHS and that we think should be at the very top table.

The amendment therefore seeks to give some direction to the Secretary of State in making these appointments and to ensure that at least one non-executive director is put on the board through a genuinely independent process and is not simply placed there by the Secretary of State. The kind of representative appointments that we set out in the amendment should, in our opinion, really be the standard. We would hope to see a similar standard adopted for the ICBs. We should appoint people who can really contribute to the future, with direct experience across the board in terms of the integration that the Bill seeks to achieve. The amendment also sets out how the Secretary of State must appoint suitable people and be able to justify their appointments against some sort of standards.

I hope that the Minister will at least acknowledge that some of the recent questionable behaviour around appointments needs to be addressed. No doubt he will refute the allegation of cronyism, but he cannot deny that there is at least a very strong perception that that is what has happened with some appointments.

In conclusion, I draw attention to how the NHS has already, effectively, blatantly put up two fingers to this Committee and anything we might decide, because it has already decided for itself how it will appoint people to roles within the new integrated care boards and has appointed some already, with the remaining positions, as we have seen from newspaper headlines, up for advertisement. That does not actually do us any favours, because Parliament has not decided that that is what we want to do, but we will see whether we get to that point later. That is all I have to say on the amendment.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

It is a pleasure, once again, to serve under your chairmanship, Mrs Murray. I fear—predict—that there will be occasions when the shadow Minister, the hon. Member for Ellesmere Port and Neston, and I may not be entirely of the same mind, but it is a pleasure, as always, to serve opposite him on this Committee, because I know that even where we may disagree, the debate will be measured and reasonable. I will address the amendment tabled by the shadow Minister and, in the same speech, clause 1 and schedule 1 stand part if that is appropriate and in order.

As has been the practice on numerous occasions in these Committees, I will start by expressing a view shared by all members of this Committee. It has already been expressed by the hon. Member for Ellesmere Port and Neston, and we join with him in expressing our gratitude to those who work in our NHS and in care services and—as he and I have often said in this place—all those, including in local government, who work in this space and have done amazing work over the past year and a half particularly.

As ever, the hon. Gentleman picked his example carefully in citing some of the witnesses whom we heard in oral evidence. As he will know, the overwhelming majority—possibly with only two exceptions—stated that this was the right Bill at the right time, albeit they may have picked up on particular clauses or elements. They did state that this was the right time for this legislation.

As the shadow Minister has set out, amendment 18 in his name and those of his hon. Friends seeks to make changes to the make-up of the board of NHS England, the provisions for which are currently set out in schedule A1 of the National Health Service Act 2006. It also outlines conditions that should be met in relation to the appointment process. I share his view that it is vital that robust governance arrangements are in place for overseeing public appointments. It will not surprise him that I refute his assertion that in the case of NHS England board appointments there is a so-called cronyism or a suggestion that any of those people are appointed on anything other than merit. However, I believe that those strong and robust governance arrangements are already in place for managing appointments to the board of NHS England. Those appointed already are deemed to be fit and proper people to hold those appointments.

The existing provisions, which the shadow Minister alluded to, setting out the membership of the NHS England board in the National Health Service Act 2006, provide the flexibility required for the fully merged NHS England to lead our more integrated health and care system. The clauses we will be addressing this morning in this part of the Bill reflect the evolution of NHS England and NHS Improvement and what has happened on the ground since they were originally formed. With this, we seek to create a legislative framework that catches up with where they are and is permissive, rather than prescriptive. That is something else the hon. Gentleman and other members of the Committee will have seen from the evidence sessions. Witnesses were clear that the Bill struck the right balance between permissive and prescriptive.

As we look to continue the fight against the covid-19 pandemic and, in parallel, prepare for the recovery of our health and care system, it is imperative that the most suitably experienced and knowledgeable candidates are appointed to the Board. I know the shadow Minister will share that sentiment. Unlike appointments to integrated care boards, the appointment of the chair and non-executive members of NHS England are rightfully public appointments made by the Secretary of State and managed in line with the governance code for public appointments and regulated already by the Commissioner for Public Appointments. The appointments are made on merit in a fair, open and transparent manner and in line with that governance code. They also require due regard to ensuring they properly reflect the populations they serve, including a balance of skills and backgrounds, supporting the Government agenda of promoting more diverse public sector organisations and board appointments.

The role of non-executives on public bodies includes helping set the strategic direction for the organisation, ensuring the organisation meets the highest standards of good governance and holding the executive to account for day-to-day business delivery. They come from a variety of backgrounds and bring a valuable range of skills and experience to a board position. It is important to note that they are not routinely or normally appointed to be representative of a particular sector or group. They are on the board in their own right and their independence in that context is paramount.

All public appointees are expected to uphold the standards of conduct set out in the Committee on Standards in Public Life’s seven principles of public life, as included in the code of conduct for board members of public bodies, and they must adhere to that. The code sets out clearly and openly the standards expected from those who serve on the boards of UK public bodies and includes a clear process for managing any conflicts of interest. The Commissioner for Public Appointments regulates those appointments to ensure they are upholding the values of that Government code and works with Government to encourage candidates from a diverse range of backgrounds to consider applying for such public appointments.

Finally, while I share the shadow Minister’s view that it is hugely important to have diverse representation on the board of NHS England and to ensure that diverse voices and viewpoints are reflected, the duty under section 13H of the 2006 Act already requires NHS England to actively

“promote the involvement of patients, and their carers and representatives”

without the specific need for a named non-executive patient representative. It is clear that comprehensive processes and codes are already in place to regulate public appointments such as those we are discussing in the context of clause 1 and amendment 18, as well as schedule 1, including on diversity, conflicts of interest and conduct in office. I emphasise once again that the role of non-executive members is not that of representing a specific or particular sector, which could be at odds with the independent and broad approach they are required to bring to the role.

I now move specifically and briefly to clause 1, which changes the legal name of the NHS Commissioning Board to NHS England, and also to schedule 1, which contains consequential amendments where the changes will take effect in another Act. Since 2013, the NHS Commissioning Board has been operating under the name NHS England, and I think it is fair to say that that is how all of us in this room, and the public, know it, rather than by the slightly clumsy name of NHS Commissioning Board. This move reflects what the public already regard as the body’s name. The organisation, including the new functions provided to it by the Bill, will continue to operate under the name NHS England; this clause aligns the legal and technical name with the operational and publicly used name for clarity, and updates associated primary legislation.

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Karin Smyth Portrait Karin Smyth (Bristol South) (Lab)
- Hansard - - - Excerpts

I support the words of my hon. Friend the Member for Ellesmere Port and Neston. The Government would be wise to take note of the proposal. As my hon. Friend said, many hours, days and weeks have been spent by not only Members of Parliament, but expensive lawyers and lots of concerned constituents across the country, arguing—as I have often thought myself at times—a slightly nuanced point, which is lost on people. I have absolutely been persuaded, however, that it is important to restore that duty. If the Government are rightly binning the Lansley Act, the amendment is an obvious one to consider and accept, as it puts the duty absolutely beyond doubt.

Running throughout the Bill, as we will discuss over the next few days and weeks, is a real problem of clarity and accountability. We should not let the Bill out of this place while it leaves that lack of clarity on duties, responsibilities and accountability for the NHS to decide, along with local government. There is a balance between permissiveness and diktat, and starting with clear duties on the Secretary of State would help. Later, we will discuss how the Government seem to want to give the Secretary of State enormous power to interfere in the most minute aspects of healthcare in our constituencies, something that concerns a great many people, organisations and the NHS itself.

If the Government are serious about rehabilitating themselves as the supporter of the NHS following the Lansley Act, an amendment to clarify that absolutely central role would be a wise thing to accept.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Amendments 36 and 37 and new clauses 20 and 21 are in the name of the shadow Minister and his colleagues. I do not believe that what is being proposed reflects the reality of the role of the Secretary of State or what it should be, which is a strategic oversight role with the ability to intervene when necessary to ensure accountability. The hon. Gentleman might correct me, but I think he cited Mr Lock, who said that there was no substantial change in practice. That goes to the heart of why I am unpersuaded by the amendments.

As the hon. Gentleman knows, the idea that the Secretary of State himself provides services has not reflected the reality of the structure of the NHS for many years, not least since 2003-04 with the introduction by the Labour party when in government of foundation trusts as independent entities in the health system. That purchaser-provider split, long established in the NHS and retained in the Bill, allows some of the health services in England to be provided by those such as NHS foundation trusts, which are legally distinct from the Secretary of State.

In the years since those changes, and as the many vigorous debates in Parliament since and during the passage of the 2012 legislation have demonstrated, there has rightly been no loss in the strong sense of governmental accountability for the NHS felt by Governments of all parties and by parliamentarians. As the proposers of this group of amendments have themselves been among the most eloquent and capable colleagues in holding Ministers and Government to account for the NHS, I find it slightly strange that they feel that their amendment is necessary.

At the time of the 2012 Act, as the shadow Minister alluded to, there was a great deal of debate in the other place on the value or otherwise of this wording. Eventually, the noble Lords concluded that it was better for the law to reflect the reality of the modern NHS. However, it remains the case that the Secretary of State has a firm duty to continue the promotion in England of a comprehensive health service in practice. He does this through setting the strategic direction and his oversight of NHS England and the other national bodies of the NHS, and in the future, subject to debates in this place—I do not want to prejudge what the Committee and the House may determine on those clauses—through the extra lever of the proposed power of direction. At all times, he remains responsible to Parliament for the provision of the health service in England.

NHS England also has a duty to arrange for the provision of services for the purpose of the health service in England and a concurrent duty to promote a comprehensive health service. Integrated care boards will, subject to parliamentary approval of the Bill, also have functions in relation to arranging the provision of services.

I understand the point that Opposition Members are seeking to make with the amendment, but it is entirely unnecessary as law. The Secretary of State has the duty to promote the competence of the health service in practice. He is accountable to Parliament for the comprehensive health service, and I believe that local NHS leaders and NHS England are best placed to know what is needed to serve individual communities.

This goes to the heart of what I suspect will come up a number of times in our debates in this Committee, which is the extent to which the legislation should be prescriptive, or permissive and flexible. I suspect the shadow Minister and I will disagree on where the balance should lie, in a number of areas. We believe that the Bill strikes an appropriate balance.

The shadow Minister talked about flexibility in redefining the boundaries of what the NHS does. Throughout the history of the NHS, there have been tweaks along those lines. The Labour party introduced charges for glasses and dentures; the Conservative party introduced charges for prescriptions shortly afterwards; the Labour party abolished them, and then reintroduced them two years later. I use those examples because I think we should be wary about being overly prescriptive in primary legislation.

Clause 2 makes a number of amendments to the power allowing the Secretary of State to require NHS England to commission certain prescribed services. It ensures that the Secretary of State can still require NHS England to commission specialised services and facilities, but recognises that aspects of the commissioning might be carried out by other NHS bodies through joint or delegated working arrangements or by directing integrated care boards to provide those services.

Specialist services are commissioned to support people with a range of complex and rare conditions. Those services could involve the treatment of patients with rare cancers, genetic disorders, and complex medical or surgical conditions, for example. As such, it is right that NHS England has overall responsibility for the services and can decide whether they might be better delivered through joint or delegated working arrangements or through directions to ICBs—I am happy to adopt the shadow Minister’s suggested shorthand, otherwise we will be taking a very long time repeating the same words on multiple occasions.

The clause also removes the requirement of the Secretary of State to consider the financial implications for CCGs—to be replaced with ICBs—when requiring NHS England to commission certain services. The change focuses the decision about categorisation of specialised services on the complexity and impact of the service and the ability of ICBs to support commissioning services for their populations, reflecting the fact that ICBs are significantly larger than CCGs and, correspondingly, so are their financial resources. In some circumstances, NHS England may request that a service is no longer nominated as a specialised service or facility—that could be used, for example, as the technology improves and it becomes more appropriate for it to be commissioned by an ICB instead. The clause inserts a new provision in the NHS Act 2006 which requires the Secretary of State to provide reasons for any refusal to requests from NHS England to revoke provisions requiring NHS England to commission specialised services.

I therefore encourage the shadow Minister not to press his amendment to a vote.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful for the Minister’s comments, not least the promotion he inadvertently gave me by referring to me as shadow Secretary of State. We should have a Division on that, should we not? I understand what the Minister is saying, but our aim with this amendment is to reflect the new reality. No one has really got to the bottom of why the wording came out in 2012, but we are clearly moving back into a pre-Lansley era and the end of the marketisation, so we should go back to the previous wording. In terms of the services and duties in our new clause 21, I do not think the Minister said he disagreed that any of them should be provided. I am trying to do him a favour here and help him to avoid the Bill being bogged down in the Lords. If it comes back in ping-pong, we will quote the relevant new clause and say, “This is something that could have been avoided.”

I understand that the Minister does not want to be too prescriptive. He is right that the Bill will centre largely on the right balance between permissiveness and prescriptiveness, and we will no doubt have disagreements on that. I have tried to be helpful to him, but he does not want to accept that assistance on this occasion, so I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 2 ordered to stand part of the Bill.

Clause 3

NHS England mandate

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Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

I echo the comments of my hon. Friend the Member for Ellesmere Port and Neston. The mandate is important. It is awaited by clinicians and managers in the health service as it affects how they are to operate in the forthcoming year. Often guidance arrives the week before Christmas, as I remember from my time in the NHS, so we were starting to plan for the very short term, which really is unhelpful. It is a regular statement intent, and it is a way in which the public can see what is happening or is due to happen to their services.

My hon. Friend the Member for Ellesmere Port and Neston quoted from the King’s Fund’s written evidence, which mentioned the

“multiple plans and strategies in each ICS”

and the need for a “more ‘local’ place level”. As we heard in our evidence sessions, this is already a very confused picture, and one that we are going to try to navigate our way through. Although I do think that there should be greater permissiveness, so long as it is accountable at local level, the mandate gives us a degree of accountability at national level, on the Government’s intent, published in their stated aims, and that gives the general public and taxpayer confidence.

On our amendment about 18 weeks, that target was often criticised as not being clinically referenced. It was brought in after the then Conservative Government talked about an 18-month target being highly ambitious for people waiting to be seen clinically—some of us are old enough to remember those dreadful days, to which we have returned. Now, we could argue whether 18 weeks was the right number, but it was something that drove up standards of care, and it meant that the NHS said to the taxpayer, “We accept that you deserve a better standard of care and treatment, and it is completely unacceptable to be on a waiting list for 18 months to two years”—it was often longer. It focused minds, drove service redesign and made clinicians go back over their lists, because if someone has come on to a list two and a half years earlier, many things would have happened and, sadly, in many instances that person would have died.

By supporting our amendment, the Government would show that they are ambitious for the NHS and the people it serves. If the Minister is not prepared to support that 18-week commitment, what is acceptable to the Government? We and all our constituents know that waiting lists were rising out of control before the pandemic, and that the target had not been met for several years. Clearly the pandemic has exacerbated the situation, but let us be clear that targets not being met was a pre-pandemic problem.

We hear utterances from the Government in the newspapers about what they think about the targets—“nonsensical” is what the Secretary of State said at the weekend. The targets were put in place to give people confidence that their taxes were funding a service that they could hold to account in some degree, and it drove some positive behaviour. It will take a massive effort to get waiting lists down, so what discussions has the Minister had with clinicians and managers about the loss of targets? Why would he not support putting that target back in the Bill? The long waiting lists are miserable for everyone concerned. They need to be published. We need to let people know what they can expect from our service. I strongly urge the Minister to accept the amendment, or at least its intent. If he is not prepared to do so, what does he think is an acceptable length of time for people to be on a waiting list?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The hon. Member for Ellesmere Port and Neston is having a good day; I promoted him to shadow Secretary of State and I think the hon. Member for Central Ayrshire made him a member of the Privy Council, so he is doing well this morning. Although we may resist many of his amendments, I take the point that he did not table them from a partisan perspective but genuinely approached them with sincerity. He mentioned that on a previous occasion the Bill Committee had to be run twice. Fond of him as I am, I think both of us would prefer not to have to do this twice together.

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Division 1

Ayes: 6

Noes: 9

Clause 3 ordered to stand part of the Bill.
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Hywel Williams Portrait Hywel Williams (Arfon) (PC)
- Hansard - - - Excerpts

To encourage the Minister to accept the amendment, I point out that addressing health inequalities would coincide with the Government’s stated aim of levelling up, so there is a happy coincidence there that might persuade him. Health inequalities are reflected geographically, and large parts of the country clearly suffer from them more than others. That pertains to England, but were I standing in the Senedd in Cardiff, I would say the same about Wales. That is slightly off the point, but there we are.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I am grateful to the shadow Minister and all other hon. Members who have spoken for the expertise that they bring to this debate. It is one of the quirks of this House that lawyers are hon. and learned Members and members of the armed forces are hon. and gallant Members, but we do not have an equivalent for those who serve in the medical profession. Perhaps we should think about that.

I am very grateful to hon. Members for bringing this debate to the Committee by tabling these amendments, which relate to the important issue of health inequalities, in the context of the new triple aim duty set out in the Bill. Even though we may not reach the same conclusions about the best way to do it, it is right that we debate this crucial issue in Committee.

With your consent, Mrs Murray, and that of the Committee, I will start in reverse order with new clause 13, and then work my way through the amendments of the hon. Member for Nottingham North. The new clause would place an additional duty on the Secretary of State to produce a report setting targets on the improvement of the physical and mental health of the population and the reduction of health inequalities.

I appreciate and understand the intention behind the hon. Gentleman’s new clause. He is right: health is the nation’s greatest asset. Preventing ill health, improving people’s health and wellbeing, and tackling long-standing inequalities are all fundamental to the economic and social strength of our country. However, the creation of a new statutory duty to set the type of target identified in the new clause is not necessary, in the light of the existing duties on the Secretary of State around improving public health and seeking to reduce health inequalities, as provided for in the 2006 Act. I may not agree with everything in it, but I pay tribute, where it is due, to the Labour party. Labour Members will hear a number of references to what is in that Act and to the retention of what is in that Act in many areas.

Of course, ICBs, too, have duties to have regard to the need to reduce health inequalities whenever they are exercising their functions, to promote integration where it would reduce health inequalities and to set out how they will tackle health inequalities in their plans.

I hope I can reassure members of the Committee that the Government are already taking strong action in these areas and that there are already a number of targets relating to improving the population’s health that cannot be met without addressing those underlying inequalities. For example—I know that this is something that the hon. Member for Nottingham North feels very strongly about—we cannot achieve our existing commitment to a smoke-free generation by 2030 if we do not address as a priority the needs of those people and populations with the greatest levels of need and help people to give up smoking. He is right, and this involves the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Bury St Edmunds. I suspect that when we reach the latter parts of this legislation that are about public health more specifically, this issue may feature, rightly, in the Committee’s discussions again.

To support our strategy to improve the population’s health and reduce health inequalities, at the beginning of October we will launch the Office for Health Improvement and Disparities within the Department. We have also announced that we will create a cross-Government ministerial group with a remit specifically to identify and tackle the wider determinants of poor health. Our broader focus on levelling up, to which the hon. Gentleman alluded, recognises the wide range of factors such as good jobs, homes and local environments in which we can take pride, alongside a range of other factors, that all support and interact with our physical and mental health.

In contrast, I fear that the new clause, although I can see its intent, could make it more difficult for us to swiftly focus on ensuring that such inequalities are identified and acted on. Had we a fixed, five yearly set of targets to work towards, I fear that it would introduce more rigidity, rather than the agility and flexibility that we seek in meeting the changing assessments of what underlying health inequalities must be tackled as a priority. I hope that I can persuade members of the Committee, although perhaps not all of them, that a five-year fixed plan is potentially inflexible and is not necessary in the context of this legislation.

I turn now to the amendments that relate to the duty known as the triple aim. Amendments 21, 23 and 25 would add a fourth limb of tackling health inequalities for NHS England, ICBs and NHS trusts. As I have stressed, we do recognise the importance of tackling health inequalities, but again, we do not feel that the amendments, however well intentioned, are necessary. As we have discussed, there are existing statutory duties on bodies in this area, many of which relate specifically to health inequalities. NHS England and ICBs will have to have regard to such duties alongside the limbs of the triple aim. NHS England will also have to consider such duties when it produces the guidance on the triple aim.

The triple aim is compatible with and conducive to addressing health inequalities and furthering the delivery of these duties. Indeed, tackling health inequalities is a theme that runs throughout the duties. Having organisations consider the wider effects of their decisions will, we believe, encourage greater collaboration and engagement with communities on how best to meet their needs, which in turn will assist with tackling health inequalities nationally, but also flexibly at a local level.

The triple aim duty requires consideration of the health and wellbeing of the people of England. As the shadow Minister alluded to, that would also include consideration of the health and wellbeing of those who are not accessing health services. Similarly, it is a key element of the second limb of the triple aim—the improvement of the quality of services—to consider those areas where services are in most need of improvement. We expect guidance from NHS England to make clear how bodies can discharge the triple aim duty in a way that is fully commensurate with the reduction of health inequalities.

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Division 2

Ayes: 6

Noes: 9

Clause 4 ordered to stand part of the Bill.
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Question proposed, That the clause stand part of the Bill.
Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The clause places a new requirement on NHS England to consult and involve carers and representatives of those individuals to whom health services are provided when exercising its commissioning functions. NHS England is currently required to involve and consult individuals to whom healthcare is provided when carrying out its commissioning functions; the clause extends that existing requirement to consulting with their carers and representatives as well. We want to ensure that we have a health and care system that is accountable and responsive to the people who rely on it.

The clause recognises the immensely important role that carers and representatives play in supporting our health and care system, and ensures that our legislation remains in step with current practice within that system. I therefore commend the clause to the Committee and hope that all Members feel able to support it.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am sure we are all excited to get this one passed—I am certainly not going to oppose it. However, I have a couple of questions of clarification.

Health and Care Bill (Sixth sitting)

(Limited Text - Ministerial Extracts only)

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Committee stage
Tuesday 14th September 2021

(2 years, 9 months ago)

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Health and Care Act 2022 Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 14 September 2021 - (14 Sep 2021)

This text is a record of ministerial contributions to a debate held as part of the Health and Care Act 2022 passage through Parliament.

In 1993, the House of Lords Pepper vs. Hart decision provided that statements made by Government Ministers may be taken as illustrative of legislative intent as to the interpretation of law.

This extract highlights statements made by Government Ministers along with contextual remarks by other members. The full debate can be read here

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Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

It is a pleasure to see you in the Chair this afternoon, Ms Elliott.

We were left on a cliffhanger before lunch. I was about to ask the Minister some questions. He might have preferred the advantage of having two and a half hours in between to think of an answer, but I am sure he will cope. Actually, it is a fairly straightforward question, so I hope for a fairly straightforward answer.

The clause refers to carers and their representatives. Will the Minister clarify who that is? Is that carers’ groups or, for example, someone who might hold power of attorney? That is really the only comment I wanted to make on clause 5.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - - - Excerpts

It is a pleasure to serve under your chairmanship, Ms Elliott, I think for the first time in Committee.

To answer the shadow Minister briefly, I certainly envisage that the clause encompasses those with power of attorney, because in effect and in law they are the legal representatives of individuals who do not always have capacity to speak for themselves. In that context, I also hope that we will see carers’ organisations, as well as others who do not necessarily have power of attorney but act as advocates or representatives for individuals, having their views heard and taken into consideration. I hope that gives the hon. Gentleman some reassurance.

Question put and agreed to.

Clause 5 ordered to stand part of the Bill.

Clause 6

Support and assistance by NHS England

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The clause confers a power to provide assistance and support to NHS foundation trusts, NHS trusts and other persons providing services as part of the health service in England to work to secure continuous improvement in the quality of the provision of such health services and their financial sustainability. That new power replaces a range of existing support functions sitting with NHS England and the NHS Trust Development Authority. In particular, it replaces the function of the NHS Trust Development Authority to take steps to assist health service providers as conferred by directions. It also replaces the existing power of NHS England to support clinical commissioning groups and primary care providers, which enables NHS England to provide direct financial support to integrated care boards and providers within the scope of the provisions, and to provide other support and assistance to all those bodies exercising functions within or part of the health service.

The clause is an example of the positive improvement that the merger of NHS England, Monitor and the NHS Trust Development Authority will bring to the health service. It will allow NHS England to take such steps as it sees as necessary to identify and address areas of concern early, while also providing support to leadership and guidance where required to shape the services that are delivered for the greatest benefit of patients. I therefore commend the clause to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

The Opposition will not oppose the clause, but I have one or two queries that we hope the Minister will be able to answer. Obviously, it is a broad power. I assume that the reference in proposed new section 13YA(1)(a) to “person” relates not just to individuals. Perhaps the Minister will expand on what that is meant to cover.

Also, specifically, at proposed new subsection (3), on integrated care boards and the provision of financial assistance, as we remember from the evidence sessions, there was not a great deal of clarity about the costs that NHS England anticipated might be incurred as a result of the legislation. Will the Minister assist us by providing some estimates of that, as well as whether the powers under clause 6, including the financial assistance, are subject to any limits or reporting requirements back to the Secretary of State, and whether Parliament would have a role in that at any point?

Proposed new subsection (2) talks about providing

“employees or any other resources of NHS England.”

The Minister said that “employees” could include secondees. I think it is clear from the guidance that certain roles on the ICB should not have any, for want of a better description, conflicts of interest or hold any other roles within the wider NHS. I want to make sure that the Minister is clear that that requirement is not going to cause us any difficulties.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I am grateful, as ever, to the shadow Minister for his succinct questions. I will try to address them all in turn. He referenced the term “person” in proposed new subsection (1). It is a legal definition. In the context of the services provided—I mentioned primary care—it could be a GP practice. Having gone through the drafting with officials, my understanding is that it is a legal term and does not alter what is currently possible.

I may take the questions slightly out of order, and I hope he will forgive me. On proposed new subsection (2), I think he was referring to subsequent new clauses and amendments he has tabled around ICBs, who the suitable persons to sit on them are and the management of conflicts of interest. I suggest to him that, given the amendments he has tabled, the most appropriate time to discuss those issues would be in the context of how we do or do not further refine the definitions around memberships of ICBs. The Committee will reach that on Thursday, I suspect. On reporting and transparency, I entirely share his view and reassure him that I expect transparency to play a key role when public moneys are spent this way.

Finally, on proposed new subsection (3) and the cost to the NHS and the Exchequer, no specific limits are stated in the legislation, but, obviously, any assistance provided would need to meet the purpose set out in the Bill and be transparently awarded. I hope that gives him some reassurance, but I am always happy to revert to him if he wishes to follow up on any detail—either now or in writing.

Question put and agreed to.

Clause 6 accordingly agreed to stand part of the Bill.

Clause 7

Exercise of functions relating to provision of services

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I am getting my exercise today in bouncing up and down in my seat. Clause 7 enables NHS England to direct one or more integrated care boards to exercise certain NHS England functions and to fund the exercise of those functions. This relates to NHS England functions such as the commissioning of specialised services, health services in justice settings and armed forces settings, primary medical services, dental services, primary ophthalmic services, pharmaceutical services, and any of the Secretary of State’s public health functions that are exercisable by NHS England on his behalf. In future the intention is that ICBs be responsible for the majority of health service commissioning in England. This approach will ensure that decisions about services are made closer to the patient and in line with local population needs, enabling greater integration in the way that services are arranged and delivered.

Clause 7 ensures that NHS England has the appropriate powers to make sure we achieve our policy objective, by allowing flexibility for ICBs to take on these additional commissioning responsibilities as delegated functions from NHS England. We intend that this can be used by NHS England to delegate primary care functions while ICBs mature, before we transfer them fully to ICBs at the appropriate time using clause 16 and schedule 3, which we will debate in due course. This will allow NHS England to keep a closer watch on how ICBs are discharging these functions, and managing the transition, before they are fully delegated to and embedded in ICBs.

The Secretary of State will have the ability to make regulations under this clause, meaning that, where appropriate, certain conditions or limitations can be placed on NHS England’s power to direct ICBs, including the ability to prescribe functions that the power does not apply to at all. Any directions issued by NHS England under this clause must be published. I know that the transparency point is one that the shadow Minister has raised on a number of occasions, so I reassure him that they must be published ensuring that such directions are made transparently, and that responsibilities between NHS England and ICBs are clearly set out.

This clause is essential to give NHS England the flexibility, and the appropriate mechanisms, to delegate the commissioning of these services when the time is right to do so. Therefore, I commend it to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

We will not be opposing this clause. Clearly, as the Minister has set out, it is necessary to enable the functioning of the health service.

I have one question about the powers under proposed new subsection 13YB(4), which are effectively prohibitions on the ICBs from delegating arrangements further. Will the Minister set out what circumstances are envisaged, if any, where this power may be necessary? There will obviously be delegations, not only to the services listed there, but to place-based organisations. In that situation, what does the Minister see the role of the ICBs as? Will it be the ICB itself that delivers those functions, or will it be another body?

--- Later in debate ---
In my experience, the evolution from the CCG was muddled and meant stasis for a long time in any development of those services. We want to avoid that, because some of those organisations will be ready to go now and some of them may never be ready. As my hon. Friend says, is that an acceptable position for the Government in this new area of local permissiveness?
Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The hon. Lady is absolutely right about the importance of trying to join up different primary care services and the commissioning arrangements. There has been, under Governments of all complexions, a fragmentation in that, with some services commissioned nationally and others locally, and the Bill gives us an opportunity to create a more coherent, place-based commissioning approach.

On the specific point the shadow Minister asked about proposed new subsection (4) and the

“direction under subsection (1) to include provision prohibiting or restricting the integrated care board from making delegation arrangements in relation to a function that is exercisable by it by virtue of the direction”,

my understanding is that it is a pragmatic clause, basically limiting the ability to sub-delegate further. We would envisage this being a consensual and collaborative approach between us and NHS England in the region, and of course the Government would be guided by NHS England.

In the nature of having to make regulations in this House to do it, the wording reflects the fact that it will be the Government laying those regulations, but we would envisage that being guided and led by the NHS. As the hon. Member for Bristol South rightly said, the NHS region will often be the best place to advise on the readiness or otherwise of different ICBs at different stages in the process.

Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

Would somebody be able to appeal to the Secretary of State if they disagreed with that delegation, for example?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

My understanding is that there is no formal right of appeal in this context. I suspect that dispute resolution and formal rights of appeal is something we will come back to in other contexts.

Clause 7 ordered to stand part of the Bill.

Clause 8

Preparation of consolidated accounts for providers

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Clause 8 places a duty on NHS England to prepare, in respect of each financial year, a set of accounts that consolidate the annual accounts of English NHS trusts and foundation trusts. The transparency of financial reporting across NHS providers will be diminished without this provision, as the consolidated provider accounts collate the financial reporting of all NHS trusts and foundation trusts to give an NHS provider position that is laid before Parliament, and has been since the 2017-18 financial year.

In addition, NHS England has a duty to provide a copy of the consolidated accounts to the Secretary of State and the Comptroller and Auditor General, and a duty to lay copies of the consolidated accounts and the related report before Parliament. To ensure adequate financial scrutiny, the Secretary of State has the power to give directions to NHS England on the principles and methods to be applied in preparing the accounts and their content and form, and can direct that the accounts must be accompanied by any reports or information deemed necessary. The Comptroller and Auditor General must, as their responsibilities stand currently, examine, certify and report on the consolidated accounts and send copies of the report to the Secretary of State and to NHS England.

The provisions set out in this clause not only provide continuity to the system but place in law strong levels of oversight relating to both NHS trusts and foundation trusts. That ensures the transparency that we would all wish to see and the robustness of the process and procedures governing financial health at a local level. This clause is an important way of ensuring NHS England discharges its responsibilities as system regulator in delivering appropriate and adequate stewardship of the health system and, ultimately, public money.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Again, we will not oppose the clause, but I have a query about the powers under proposed new section 65Z4(4), particularly in the context of what the Secretary of State said at the weekend about targets being a lot of form-filling and nonsense. It seems rather odd to give himself powers to direct trusts to provide any reports or information that he requires when, clearly, the Secretary of State gets all sorts of information and reports from the NHS at the moment. Could the Minister say what he is not receiving at the moment that he thinks the powers will allow him to ask for?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I consider proposed new subsection (4) to be purely pragmatic, as there will be circumstances with individual trusts and situations where clarifications to accounts or data may be required. Therefore, it is prudent to give the Secretary of State the power to ask for further clarification. He will be accountable to Parliament for how the money is spent, so it is entirely appropriate that he has explicit power, given by Parliament, to ask for information over and above the de minimis specified in the Bill, to ensure he can be completely transparent with Members and the public more broadly.

Question put and agreed to.

Clause 8 accordingly ordered to stand part of the Bill.

Clause 9

Funding for service integration

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Currently, one of the objectives of the Government’s mandate to NHS England—a process we discussed in Committee this morning—is that an amount of the annual sum paid to NHS England must be used for service integration. In practice, that must be contributed to the better care fund. The better care fund is the national policy driving forward the integration of health and social care in England. However, as we have discussed, other provisions set out in clause 3 will remove the requirement for a mandate to be published every year. As a result, the mandate will no longer be an appropriate vehicle for setting an annual ring fence for service integration. Therefore, the clause will put in place a new power to allow the Secretary of State to direct NHS England to ring-fence an amount of its annual allotment for health and social care integration through the better care fund, to continue the work of that fund and to direct it on how that amount should be used.

The change will have no impact on the operational policy intent of the better care fund; the provision will simply ensure the better care fund can continue to be set annually, notwithstanding changes to the mandate, which will not be made annually in the future, should this legislation be passed. The better care fund has enabled and improved co-operation between health and social care partners at local level. It is therefore important for it to continue. This clause ensures that that will happen, regardless of proposed changes to the mandate.

Further minor amendments are made to NHS England’s corresponding power to enable it to require that an amount of the sum paid each year to an integrated care board be used for service integration. That power exists currently in relation to clinical commissioning groups, and the amendment seeks to ensure that the better care fund continues to operate effectively once ICBs are established.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Again, I will not detain the Committee for long: I just have a question for the Minister. The more we get into the Bill, the less permissive it appears to be. I have no doubt that will still be used by the Minister in defence against various amendments we will move later today. Given that we have been told that the role of ICBs is to direct health systems in their local areas, it is not at all clear what the situation is if the powers under this clause require them to set aside a certain amount of money for service integration, but doing so would mean a reduction in service elsewhere in the system. How would that dispute be resolved? Who would have the final say?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

As I made clear in my remarks, the clause does not so much direct ICBs specifically; it is primarily about setting aside an amount of the annual sum paid to NHS England to go to the better care fund, which is then allocated. This technical change will have no impact on the operation or policy intention of the BCF, and it should not have an impact on ICBs’ ability to operate. The intention is simply to make sure that as we move away from an annual mandate with an annual financial settlement for the BCF, we can still set an annual amount to go to the BCF so that it can continue its work, and for that to then be allocated to systems.

Question put and agreed to.

Clause 9 accordingly ordered to stand part of the Bill.

Clause 10

Payments in respect of quality

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The clause removes the Secretary of State’s powers to make regulations about payments by NHS England to CCGs in respect of quality. We are not abolishing quality payments, but in future they will be made to integrated care boards rather than CCGs—hence the change. However, the current clause conflicts with clause 37—General power to direct NHS England—which provides the Secretary of State with broad powers to give directions to NHS England. Clause 10 removes the power to make regulations setting out the principles or other matters that NHS England must consider in assessing any facts in relation to payments to a clinical commissioning group. However, clause 37 will allow the Secretary of State to use the general power to direct NHS England if required, including in relation to quality account. That will give additional flexibility to shape quality payments in order to better incentivise quality, reflecting our priorities and changing circumstances.

I reassure the Committee—I am not sure whether the shadow Minister will take the reassurance, but he may do—that there is no intention to use these powers frequently, but they will ensure that we have a robust legislative framework that is flexible and responsive enough to support the health and care system in future, in the event that such powers are needed. If Ministers were to direct NHS England in this area, they would be required to do so in writing, ensuring that the direction is in the public interest, and to publish that direction. That will ensure transparency, so that Ministers can be held to account. I suspect that we might return more broadly to that underpinning principle when we come to debate further clauses relating to it in the coming days. I commend the clause to the Committee.

Question put and agreed to.

Clause 10 accordingly ordered to stand part of the Bill.

Clause 11

Secondments to NHS England

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I have only a couple more of these clauses before the shadow Minister will have his turn with a few amendments.

Secondments can be an extremely useful way of bringing key expertise and resource into an organisation at short notice. We have seen the benefits of such a flexible approach in a number of organisations, including NHS England, and particularly during the pandemic. The clause builds on the practical importance of secondments and makes it clear how they can be used by NHS England, by amending schedule A1 of the National Health Service Act 2006, which sets out the constitution and membership of NHS England.

The Bill has given us an opportunity to provide NHS England with powers to appoint secondees across the organisation and use them in the same way as its own employees, and it allows secondees from specified NHS bodies and health arm’s length bodies to be appointed to NHS England’s board. The power to allow employees from specified NHS bodies to be seconded to NHS England and appointed to its board will allow those individuals to exercise NHS England’s functions on the board’s behalf, in the same way as other board members.

As we continue the fight against the covid-19 pandemic and, in parallel, prepare for the recovery of our health and care system, it is imperative that NHS England has access to the most suitably experienced and knowledgeable candidates for executive roles, and that those holding the roles be part of the important decisions that the system will face. The clause will assist NHS England in doing just that.

The clause also includes a regulation-making power, allowing the Secretary of State to make it clear that a reference to an employee of NHS England in the context of the National Health Service Act 2006 should include people seconded to NHS England, should that be considered appropriate in future. That power will ensure that the legislation assesses the continued effect of operation of secondment arrangements throughout NHS England. Any regulations—again, I hope that this offers some reassurance to the Opposition Front Bench—made under that power would be subject to the affirmative procedure in the House, so I commend the clause to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I will not repeat my earlier comments about secondees and ICBs, because we will pick that up later. In our evidence sessions, the role of the healthcare safety investigation body and its independence from NHS England was raised. Is the Minister comfortable that that role will not be compromised in any way by the requirements of the clause?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I assume—and the hon. Gentleman will probably shake or nod his head—that in this context he is referring both to the Care Quality Commission and HSIB—[Interruption.] Yes, I am reassured and confident that the provisions in clause 11 will not impact negatively in any way on the ability of either safety organisation to conduct inspections and do the work that we envisage them doing. In the case of HSIB, we may return to that when we discuss the relevant clauses. I believe that what is proposed remains consistent with their specific roles, responsibilities and obligations and what we are seeking to achieve for patient safety.

Question put and agreed to.

Clause 11 accordingly ordered to stand part of the Bill.

Clause 12

Role of integrated care boards

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The clause replaces section 1l of the National Health Service Act 2006, which sets out the general function of clinical commissioning groups, with new section 1l, which sets out the general function of integrated care boards. It provides, in a similar way to CCGs, that ICBs have the function of arranging for the provision of services for the purposes of the health service in England. As a result, ICBs will now be the new commissioner responsible for the majority of health service commissioning in England. Later clauses will set out the details of the services that ICBs are responsible for commissioning, but we intend that they should include those currently commissioned by CCGs and some that are commissioned by NHS England, as we discussed in relation to a previous clause, such as primary care, dentistry, pharmacy and optometry services.

The clause is crucial to establish ICBs as the new key commissioners for the NHS in England in future. Our proposals bring together leadership across the health and care system, and without the clause ICBs will simply not have a clear purpose. It seeks to manage effectively in legislation the smooth transition from CCGs to ICBs, and I commend it to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Obviously, we will spend time this afternoon discussing ICBs, so I will not discuss this clause in particular. I will draw attention to proposed new section 14Z26, especially the proposals in subsections (2) and (3) for integrated care boards, which effectively allow clinical commissioning groups to determine their own processes to consult on ICBs. We do not think that the consultation process has been adequate—indeed, it has been non-existent in some situations—but we will probably return to the question of ICB geography later in this sitting.

Question put and agreed to.

Clause 12 accordingly ordered to stand part of the Bill.

Clause 13

Establishment of integrated care boards

--- Later in debate ---
We need to thank the managers for the way they have worked, particularly over the pandemic. They have managed to go to extraordinary lengths to develop services. It does the Government and other politicians no credit not to recognise that, if the boards are going to work, they are going to need highly skilled people to balance all the competing interests and to make the best use of permissiveness. I think the Government are probably envisaging that they can just hand the mess over to them, but someone is going to have to make it come together locally. As local representatives, we are going to want to go and talk to somebody and to be able to hold them to account on behalf of our constituents. That is what we are seeking to do with further amendments today, and later in the Committee.
Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I am grateful to hon. Members for their contributions on the amendment. I may disappoint the shadow Minister—I will not accept it. I hope he will let me address why and deal with some of the questions that have been raised.

The amendment would place a requirement on NHS England to consult relevant NHS trusts, foundation trusts, trade unions, patient representatives and local authorities before revoking or varying an ICB’s establishment order. We consider it unnecessary, because under clause 13, proposed new section 14Z25, NHS England is already required to consult any integrated care board that is likely to be affected before varying or revoking an integrated care board’s establishment order. Given that each ICB will have a strategic view of the health service and population needs in its area, and given that ICBs will have members from different NHS trusts and local authorities, we consider that they remain the best-placed bodies to bring those views together to reflect opinion on what is an appropriate boundary or establishment area.

Section 13Q of the NHS Act 2006 already places a duty on NHS England to involve and consult the public in the planning of commissioning arrangements, including in respect of any planned changes to commissioning arrangements. That includes, for example, if NHS England plans to change the range of health services available to the public or the manner in which they are delivered. That ensures the voices of residents and patients—those who access care and support—as well as their carers are properly embedded in decision making.

I draw the Committee’s attention to the requirement in clause 13, proposed new section 14Z26, for CCGs to consult any person they consider as appropriate on the first ICB constitution. That constitution will also be required to set out the process for making further amendments to the constitution.

Turning to the points raised by the shadow Minister and other hon. Members, the boundaries on which we are seeing the footprint put forward at the moment effectively reflect the evolution of STP and ICS boundaries to this point. They reflect local authority boundaries. By and large, the majority of ICS boundaries reflect one or more upper-tier local authorities. That was the criteria set by the Secretary of State. There are some exceptions, which I will turn to in a moment. I will also turn to the comments from my hon. Friend the Member for Eddisbury.

As the shadow Minister will be aware, the previous Secretary of State set out a process where he wanted a presumption in favour of coterminosity—the shadow Minister appeared to be supportive of that—unless there were exceptional circumstances in a particular area that justified an exception being made. The principle of coterminosity is something that was argued against, in some cases, by Opposition Members—not Front Bench spokespeople, as far as I am aware, but Back-Bench Members of Parliament—and by some Government Members, in respect of where there should be specific exceptions.

The process, which was touched on, was entirely consultative. Local authorities were fully involved in those discussions. The local NHS was fully involved in the discussions. There were also what could be referred to as cosy fireside meetings, involving Members from across the House, reflecting their right as Members of Parliament representing their communities to write to and engage with Ministers, to reflect their views. There was a multi-layered approach, with the local NHS and local authorities working together to come up with recommendations, and then Members of Parliament having the right, as all Members do, to lobby Ministers and put forward their perspective on behalf of their constituents. The approach was transparent, as my hon. Friend the Member for Eddisbury alluded to. We published a written ministerial statement, setting out for the House what had been decided, and we showed the flexibility and pragmatism that I think those consulted would wish to see.

In the areas where exceptions were made—the east of England areas and Frimley—contrary to what the hon. Member for Bristol South said, these are some of the most exceptionally high-performing ICS areas. That is one of the reasons why we decided not to go for coterminosity, because those systems are working well, with established relationships with local authorities, acute trusts and primary care. We took the view that we should not disrupt something that is working well—if it ain’t broke, don’t fix it. That will not stop it being reviewed in future, should the local system feel that that would be appropriate. That was a pragmatic approach to the issue.

My hon. Friend the Member for Eddisbury raised the issue of Cheshire and Merseyside ICS—I know that this will also be of interest to the hon. Member for Ellesmere Port and Neston, given the geography of his constituency. The ICS did meet the coterminosity test of one or more upper-tier authorities being coterminous, but I know that hon. Members on both sides of the House have raised concerns about its size and about the differences between Cheshire and Merseyside proper, and between different parts of the area, and suggested whether it should more appropriately be split into a larger number of smaller coterminous ICSs.

In a sense, the reason that split did not take place goes exactly to the heart of what the shadow Minister was saying, which is our determination to engage widely, consult local authorities and the local NHS, and come up with a set of rigorously tested proposals. This was—for want of a better way of putting it—a late addition to the work being done earlier this year, because it was already coterminous and the commission was to look at things that were non-coterminous. However, in the light of representations made by my hon. Friend the Member for Eddisbury and others, the Secretary of State was clear that it should be reviewed.

Two years was deemed an appropriate time in which to do that review, to allow that consultation with Members and others, and so that it did not straddle—subject to the passage of this legislation—the establishment of ICSs just at the time they were coming into being, and we could do that preparatory work properly. I can give my hon. Friend the Member for Eddisbury the assurance that this is a genuine and rigorous review process. When I emerge from this Committee room, perhaps I may, with Members on both sides of the Committee, discuss further what that looks like and how that might most effectively be carried out.

What that process has shown up, however, is that there is rarely a 100% consensus from all local authority partners and the local NHS on exactly what the right solution is where there is not coterminosity and we are moving towards it. That is why I am cautious about some of the language that has been used thus far, which essentially appeared to imply that we would have to have consensus, and that one part or other of the system would have, if not a veto, a right to put the brakes on changes. Were we to go down that route, I fear that, given different perspectives in different local authorities and areas, we would run the risk of paralysing any possibility of change. I think the right balance needs to be struck.

Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

I hear what the Minister is saying, but on that basis—I think this is fundamental to all of this—why would we have local authorities or unitary authorities making any sorts of decisions? That is how local people exercise their democratic will. Bringing forward proposals in order to persuade sometimes results in a bit of stasis, but ultimately someone has to decide and break the deadlock, and the concern, as we come to some of the other amendments, is about how one does that. Local people should be able to have that in a transparent way.

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Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The approach that we have adopted thus far, which I believe is appropriate, is that we have that with local authorities and the NHS, but ultimately it is the Secretary of State who balances those in the case of these boundaries, and he is accountable to this House, so that strikes an appropriate balance. In the case of the East of England areas, certainly, we did have a very strong divergence of views as to what the right boundaries would be. It would be wrong if either local authorities or the NHS had the right to say, “No, it’s this.” That is where we have to have those views put forward together so that they can be considered in the round.

On the final point that the hon. Member for Bristol South made—I may have missed some points, but this is an important one that I want to put on the record—she is absolutely right to highlight the value of the work done by managers and administrators, or whatever title is used to describe them, sometimes pejoratively by some commenting on this matter. She is absolutely right about the value of their work. There is an analogy that I use all the time, with a much-hackneyed quote that Members will know: John F. Kennedy going to NASA, shaking the hand of the janitor and saying, “Thank you for putting a man on the moon.” What sits behind that goes to the heart of what the hon. Lady was saying. The NHS is a team. Without effective managers, people who can engage, and people who can manage budgets and ensure financial transparency and accountability, and without planning and people who make sure that patients are called and appointments are rescheduled, those on the clinical front line, if she will allow me to put it this way, would not be as effective at doing their job. It is not an effective use of a clinician’s time to ring up a patient to rearrange an appointment. Similarly, it would not be an appropriate use of the time of a highly skilled manager or administrator to be performing some other task. We have got to make sure that we have the right people in the right places, with the right skills.

The final point I would like to make again goes back to a point that the hon. Member for Bristol South made, about accountability. I think it was Amanda Pritchard, chief executive of the NHS—forgive me if it was Mark Cubbon, the chief operating officer—who highlighted, in asking who was accountable, that the ICB is an NHS body, working in partnership with the local authority, that is accountable for the funds it spends, which are voted on by Parliament. That is why it has an NHS official and there are routes of accountability up through the NHS to NHS England, and ultimately to the Secretary of State and this House. That is the structure of the NHS that has evolved over the past 70-plus years. I think that the hon. Lady sought—quite rightly—to press and challenge me on whether we think that evolution is the right approach, or whether we need to take a step back and challenge some of those assumptions. She is right to do that, but in this context, which involves the management of public money, the structures and accountabilities are correct.

I am sorry to disappoint the shadow Minister, as I fear that we will not be able to support his amendment. I hope he will not press it to a vote and that I have gone some way towards addressing the points made, particularly with regard to ICS boundaries and processes followed.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

We have had a fairly wide-ranging and useful debate. A number of issues have arisen that we will return to as the Committee makes progress. I am disappointed that the hon. Member for Eddisbury could not come on board; perhaps I should not have made my little dig about barristers this morning, otherwise he might have been more inclined to support us. I noted the sympathy he expressed and I think he articulated very well his knowledge of the geography of the area and why there are concerns locally about proper accountability in such a large area.

The irony of the whole debate, of course, is that we are discussing the Bill today, but before we have even got to the end, we know that the Cheshire and Merseyside ICS may not survive two years. Before the Bill has even become an Act, some of its constituent parts may be reorganised in future. We will see what happens on that, and I look forward to engaging with the Minister in that process.

Let us not forget that the genesis of what is before us was the STPs. How were they put together? I think local NHS leaders were sent a missive about three days before Christmas to say, “Can you give us an idea of what you think the most optimal design of your local NHS would be? By the way, we would like the response back by the end of January.” As we know, the NHS is traditionally extremely busy at that time of year, and Christmas is hardly a good time to be engaging with the wider public sector or indeed the community, but that was where the genesis was, and that is where the Cheshire and Merseyside STP and now ICS came from. It would be interesting to know how many of the 42 areas have changed since that original geography back in, I think, 2017—perhaps even 2016. It was clearly then, as it still is, a creature of the NHS, not the communities it represents.

--- Later in debate ---
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I thank the SNP spokesperson for her intervention. That is undoubtedly a risk. It is possible we end up with two or three areas out of that review. I hate to think it would get any bigger.

In terms of what people think is their relevant community, Merseyside has a metro Mayor now with very clearly defined geography, and Cheshire is a different area. As my hon. Friend the Member for Bristol South said, people do not take to the streets with banners saying, “Save our CCG!” I suspect the majority of people do not even know what a CCG is or the area that it is meant to cover. I suspect even fewer people know what an ICS is and what area it covers. That will definitely have to change if we are to have a truly integrated health and social care system.

The point made by my hon. Friend the Member for Bristol South about the defensive culture at times, alluded to by Sir Robert Francis, is a valid one. We may touch on that in the HSSIB elements of the Bill later on. She was asking the right questions—how can the board be challenged, and who is it accountable to? Those are points we will have to come back to, because there is, to our mind, a clear democratic deficit in the way these bodies have been structured.

Finally, the Minister referred to his guiding principle of coterminosity except in exceptional circumstances. Cheshire and Merseyside is coterminous, it is just coterminous for more than one local authority—and some pretty big ones at that—so I do not necessarily think that coterminosity is the answer.

The Minister referred to proposed new sections 14Z25 and 26 in regard to the duties to consult with members of the ICB. Some of the people named in amendment 49 might not actually be on the ICB, because they are not included in the legislation at the moment. We will come to our amendment on that in due course, and we might be able to change that. In proposed new sections 14Z26, CCGs must

“consult any persons they consider it appropriate to consult”.

That could be everyone and no one. I do not intend to press this to a vote, but I hope the Minister has taken on board several points that will lead to an improved process in the future. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I beg to move amendment 10, in clause 13, page 9, line 44, leave out from beginning to end of line 12 on page 10 and insert—

“(1) NHS England may, in connection with the abolition of a clinical commissioning group under section 14Z27, make a scheme for the transfer of the group’s property, rights or liabilities to NHS England or an integrated care board.

(2) NHS England may, in connection with the establishment of an integrated care board, make a scheme for the transfer of property, rights or liabilities to the board from—

(a) NHS England,

(b) an NHS trust established under section 25, an NHS foundation trust, or

(c) a Special Health Authority established under section 28.

(2A) NHS England may, in connection with the variation of the constitution of an integrated care board or the abolition of an integrated care board, make a scheme for the transfer of the board’s property, rights or liabilities to NHS England or an integrated care board.

(2B) The reference in subsection (2A) to the variation of the constitution of an integrated care board is to its variation by order under section 14Z25 or under provision included in its constitution by virtue of paragraph 14 of Schedule 1B.”

This amendment adds a power for NHS England to transfer property, rights and liabilities (including rights and liabilities relating to a contract of employment) from certain NHS bodies to an integrated care board on its establishment: see new subsection (2). In consequence, new subsections (1), (2A) and (2B) restructure material currently in subsections (1) and (2).

None Portrait The Chair
- Hansard -

With this it will be convenient to discuss Government amendment 11.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Both the amendments are technical ones. Amendment 10 amends proposed new section 14Z28 of the National Health Service Act 2006, which provides NHS England with the power to make transfer schemes to transfer property, rights and liabilities in connection with the establishment of, abolition of or change in the constitution of ICBs or the abolition of CCGs. The amendment widens the power to make transfer schemes when establishing integrated care boards, so that transfer schemes may include transfers from NHS England, English NHS trusts or foundation trusts, or English special health authorities.

We are widening the scope of those schemes to reflect further work done by NHS England, which has noted that a small number of people currently working in those bodies may need to transfer into ICBs. It is of practical importance for NHS England to be able to make transfer schemes that will ensure a smooth transition when ICBs are established, and for all the staff who may be transferring to newly established ICBs to be fully protected by such schemes.

For all but the most senior staff transferred from elsewhere in the NHS, I assure the Committee that NHS England’s employment commitment to continuity of terms and conditions, even if not required by law, will apply fully. That commitment is designed to provide stability and remove uncertainty during the transition. It is also possible for NHS England to use the schemes to transfer property and liabilities currently held by those bodies to ICBs on their establishment, although again we expect that to be rare in practice.

Proposed new subsections (1), (2A) and (2B) in the amendment restructure material in proposed new subsections (1) and (2) of the clause as drafted. That simply reflects the technical legal redrafting. The amendment therefore does not change the bodies that can be covered in transfer schemes relating to the abolition of CCGs or ICBs, or the variation of the constitution of an ICB. Those bodies continue to be CCGs, ICBs and NHS England.

Amendment 11 is consequential upon amendment 10 and is also simply a technical change. They are technical, but important amendments to ensure—and to be clear—that staff rights, liabilities and properties are in the right places in the NHS when we introduce ICBs into the system, and that the right protections are in place.

Amendment 10 agreed to.

Amendment made: 11, in clause 13, page 10, line 13, after “(1)” insert “or (2A)”.—(Edward Argar.)

This amendment is consequential on Amendment 10.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 38, in clause 13, page 11, line 10, at end insert—

Accountability

14Z28A  Reporting: duties on integrated care boards and the Secretary of State

(1) Integrated care boards must report annually to the Secretary of State on their actions and policies and the outcomes for patients of the services they commission.

(2) The Secretary of State must prepare and publish a report each year on the actions and policies of integrated care boards and the outcomes for patients of the services they commission and must lay a copy of the report before Parliament.

(3) A Minister of the Crown must, not later than one month after the report has been laid before Parliament, make a motion in the House of Commons in relation to the report.”

It is a pleasure to move the amendment in my name and that of my hon. Friends. The heading is “Accountability” and, as I am sure the Minister will have picked up by now, we think that accountability needs to be turbo-charged in the Bill. The new commissioning bodies, the ICBs, are directly accountable to NHS England and therefore on to the Secretary of State. That was explained by Amanda Pritchard when she gave evidence last week. Each year, the ICB has to prepare a report on how it has discharged its functions and specialist duties under the various headings—improvements in quality, public involvement and so on. It has to report under lots of headings. One has to wonder how it will be able to pick priorities from all that, but that is a matter for the ICB.

ICBs must also publish their plans. The NHS, in the form of NHS England, will then assess the performance of each ICB against how it discharges its functions. Presumably, that will be at least in part with reference to those plans.

The amendment, in essence, would add the accountability of the Secretary of State to what we would describe as a fairly cumbersome but necessary regime of performance management. The slant of the reporting in the amendment is less steeped in the kind of bureaucratic tick-boxing that we understand that the Secretary of State is not a fan of, and what has to be reported is outcomes to patients--perhaps, the thing that matters most.

In the recent comparative survey by the Commonwealth Fund, the NHS lost its top slot and went down to No. 4. It was close, but not close enough. Despite usually coming top, it does badly on one of the key metrics that goes into the assessment—patient outcomes. We do well on ease of access but not so well on outcomes, which is a sad reflection. The amendment makes outcomes a priority over other factors. While the ICBs may have much to say on the day-to-day running of the NHS in the area, the ultimate responsibility for the whole system lies with the Secretary of State, even though on a day-to-day basis it may be NHS England that does the real leg work of performance management. In its new integrated form, NHS England performance manages various trusts and foundation trusts. It also runs the failure regimes for them if needed.

Ways of managing providers are well developed, but most of the skills necessary to monitor whole system performance have been lost to some extent, as management capacity in commissioners has been nibbled away. That brings me to the current weakness in holding providers to account on outcomes. Payment by results was a euphemism, as the results did not matter: the process was the determining factor. Reports on outcomes, as with on patient satisfaction, are absolutely necessary. If any system is to be taken seriously, it must seek to improve. ICBs should not see this as added bureaucracy: they should see it as reporting vital elements of healthcare. I draw particular attention to the reference in proposed new subsection (1), which refers to outcomes specifically, because we do not believe that gets as much prominence as it should.

Leaving aside the desire to produce the right reports for the Secretary of State, there is also an issue about how to make ICBs more accountable to their communities—we will touch on that later. Giving them sight of a nice glossy annual NHS report will not be very enlightening, and it will not help communities understand what has been done on their behalf, even if they recognise the NHS as part of their community.

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Edward Argar Portrait Edward Argar
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It is a pleasure to rise to respond. The shadow Minister, the hon. Member for Ellesmere Port and Neston, is now having to do a lot of bobbing up and down with his amendments, and I am grateful to him for tabling this one. I fear he will not be entirely surprised that we cannot accept it, but I will try to explain to him at least why, and why I urge him not to push it to a vote, although obviously he will be the judge of that.

The amendment, as the shadow Minister has set out, would place new requirements on integrated care boards to report annually directly to the Secretary of State on their actions, and a duty on the Secretary of State to prepare and publish an annual report for Parliament specifically on the actions of the ICBs. It would also require a Minister of the Crown to propose a motion in the House of Commons in relation to the report no later than one month following its being laid in Parliament.

We entirely agree with the shadow Minister that there should be strong lines of democratic accountability from ICBs to Parliament. I hope I can give him at least some reassurance that the Bill already provides for much of the transparency and accountability that he is understandably seeking. The provisions in the Bill will create clear lines of accountability for ICBs to NHS England; they will be accountable through NHS England to national Government and ultimately, therefore, to both Houses of Parliament.

Proposed new section 14Z26 of the National Health Service Act 2006 already places a duty on ICBs to prepare an annual report explaining how the ICB has discharged its duties, particularly in relation to its activities to improve the quality of services, reduce health inequalities and have regard to the effect of its decisions on, and its involvement with, the public.

The report must also explain how the ICB has exercised its functions in accordance with its proposed forward plan and capital resource plan, as well as the steps it has taken to implement any joint health and wellbeing strategy. NHS England will also have the ability to give directions to ICBs concerning the form and content of the annual report, meaning that it could stipulate further reporting requirements for ICBs as necessary where information might be lacking. The report must be provided to NHS England and must be published

I hope the Committee will agree that that is already a comprehensive reporting requirement. Further, under proposed new section 14Z57, NHS England is also required to undertake annual performance assessments to review how each individual ICB has discharged its functions, including how it has delivered on its statutory duties. The Secretary of State will have the power to issue statutory guidance concerning performance assessments, meaning that national Government will be able to influence the methods and requirements of assessment if necessary. Again, NHS England must publish the results of each performance assessment, meaning that the public will have open access to information concerning the performance of their ICBs.

I hope the Committee will agree that the Bill therefore already provides much of the transparency and accountability that the hon. Member for Ellesmere Port and Neston is asking for, and that further duplicative reporting requirements would risk creating new and unnecessary bureaucracy. In respect of the ability of the House to scrutinise, he knows, and Opposition Members know, that they have many opportunities to table debates on a wide array of subjects. He and his colleagues have held me and other Ministers to account, not only in these Committee Rooms but on the Floor of the House in recent months, on a whole array of subjects. With the information I have set out that will already be published, for not only the House but the wider public to read, absorb and consider, there is scope for the hon. Gentleman or any other hon. Member to table a debate in which such reports can be considered if they so wish. I believe that that provides for sufficient transparency and accountability, and I encourage the shadow Minister not to press the amendment.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I understand what the Minister is saying. We still say there is not enough emphasis on outcomes and accountability to Parliament, but, as he has pointed out, there are other avenues that we can use to pursue those matters. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The clause, as we have touched on in the various discussions on amendments already, inserts new chapter A3 into the NHS Act 2006, which contains a number of duties and functions in relation to the new integrated care boards. A new duty is conferred on NHS England to ensure that ICBs cover England and details the required process for establishing the ICBs.

The clause also makes provision for abolishing clinical commissioning groups, transferring staff, property and liabilities to ICBs, requiring the constitutions of ICBs to be published and requiring ICBs to make arrangements for managing conflict of interest effectively. The clause is essential for delivering on one of the core objectives of the Bill—creating statutory ICBs as a means to take an ambitious, collaborative approach to planning and delivering integrated health and care services in England. The clause will establish a smooth transition from CCGs to ICBs, providing clarity and consistency for patients as we move to these new arrangements, as well as creating continuity of employment for NHS staff.

Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

Will the Minister give way?

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

Yes, of course. I know the hon. Lady has a great interest in this.

Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

I hope the Minister will address my earlier comments about the policy direction of primary and community care being front and centre in the last 15-odd years. This is a very different beast. I think that has perhaps not come out in the debate. These are very different bodies, and I wonder how he will make sure that the majority of patient contacts and the majority of the work that is done in the health service is not lost in the new organisations.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

I hope that I can reassure the hon. Lady. Although these organisations move beyond the CCG model to be much more collaborative, with more partnership working with local authorities and others, and the genesis of the new model is to bring those two parts together, there is no intent for, and I do not believe the practical consequence of this would be, a diminution in the voice of and the need to pay heed to primary care. She is absolutely right. For the vast majority of our constituents, the front door to the NHS is primary care services. The majority of their appointments, their consultations and their engagement is with primary care services. That voice is hugely important. I see that continuing to be front and centre.

The Bill brings together a range of other NHS system providers and the local authority. We may come back to the point when we discuss further amendments. I emphasise what we heard in the evidence sessions, which is that the membership requirements are de minimis. There can be increased numbers of voices for primary care on these boards, as Dame Gill Morgan mentioned in the way she is managing Gloucestershire. That may not fully satisfy the hon. Lady, but I hope I can reassure her that I am in the same place as her in recognising the importance of primary care and that the expertise that has grown up in understanding local communities is vital in framing a system that works effectively.

In requiring ICBs to maintain and publish registers of the interests of their members and employees—I expect we will return to this point in the future, in a different guise—the clause is an essential part of guaranteeing the integrity of each ICB’s decision-making processes. It will ensure that any potential conflicts of interest are declared promptly by individuals and managed effectively. As a result, the public will be able to trust that decisions are made in a fair, transparent manner, in the best interest of the ICB’s local population. I commend the clause to the Committee.

Question put and agreed to.

Clause 13, as amended, accordingly ordered to stand part of the Bill.

Schedule 2

Integrated care boards: constitution etc

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 48, in schedule 2, page 119, line 18, at end insert—

“(c) the process by which any proposed changes to the policies of the clinical commissioning groups within the area for which the integrated care board is established will be consulted upon and agreed.”

This amendment would require ICBs to be clear about how they would make changes in clinical policies and established models of care that have already been established and are applicable to patients in the area for which the integrated care board takes responsibility.

We are certainly getting a good workout this afternoon, Ms Elliott—hopefully the Minister will now be able to catch his breath.

As the hon. Member for Eddisbury suggested earlier, we have seen a rapid reduction in the number of CCGs in Cheshire and Merseyside—there are now nine, but there were more than that not so long ago—and it is one of the biggest ICSs, if not the biggest, in the country. I am not going to take the Committee through the angst on that again, but even with sensible coterminous boundaries, quite a lot of ICSs will have more than one progenitor CCG.

Under the old regime, every CCG had its own plans, policies, care pathways and models of care. For example, many had different rules about gluten-free products being available on prescription, and most Members will be acutely aware of the manifest unfairness of the postcode lottery for IVF treatment. The number of cycles people were entitled to and how old they had to be to access treatment all depended very much on where in the country they lived. It is tempting to say that, rather than having all that variation, we should just level up—the Government’s catchphrase of the day—but that of course will not always be possible, and there will be variations in CCG policy that we cannot easily equate into one optimum outcome or standard, so how do we go about moving the many into the one?

The amendment would add a requirement that, in drawing up the initial constitution CCGs, which of course should be aware of the issues, make a start on place-based approaches, but there is an important job to do on harmonisation at the outset, and that is important for patients and the public. It will be contentious. We can all imagine the outrage if something that is offered in one CCG but not another is then removed from everyone in the process of forming an ICB. These are possible changes that we will see over the next 12 to 18 months, and they will be a real test of how responsive and engaged ICBs are in their local communities. We may indeed see people holding banners with ICBs on them if things are not handled well.

In the amendment, we say that the process of harmonisation or variation should be arrived at only after proper consultation. That fits in with the duty, which we have talked about already, on harmonisation, public involvement and consultation. It also highlights a gap in the specification for the job of producing the initial constitution for each ICB, which is given to the relevant CCG. As I have pointed out, it is very much up to them to decide who they consider it appropriate to consult. We want a much stronger and clearer commitment to consultation on changes that might affect patient care on the face of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

As ever, I am grateful to the shadow Minister for tabling the amendment in order to air this issue in Committee. I fear that I may have to disappoint him once again; it seems I am getting into a habit, although perhaps at some point I will suddenly surprise him.

We agree that it is right that there is appropriate consultation when making decisions about commissioning policies and care. The shadow Minister set out very clearly, as he always does, some of the reasons for that. I hope that I can give him some reassurance that the Bill already provides for much of what he is seeking in terms of outcomes. In clause 19, new section 14Z44 of the National Health Service Act 2006 already places a duty on integrated care boards to involve and consult the public in respect of the planning of commissioning arrangements, including on any planned changes. That would include, for example, plans by an ICB to change the range of health services available to the public or the manner in which they are delivered. This will ensure that the voices of residents, patients and those who access care and support, as well as their carers and representatives, are properly embedded in ICB decision making.

Schedule 2, which concerns the constitutions of integrated care boards, states that ICB constitutions must specify how the ICB plans to exercise its functions, including the duty to involve and consult the public. ICB constitutions must, moreover, specify the arrangements that the ICB will make to ensure transparency in that decision making. NHS England will ensure that they are appropriate and include the relevant provisions.

Under clause 13, and new section 14Z25 of the National Health Service Act 2006, NHS England will need to approve the constitution and make an establishment order for the ICB. In that respect, new section 14Z26 goes on to make it clear that NHS England can reject a proposed constitution if it is inappropriate. I hope that that offers some reassurance to the shadow Minister, and helps underline our commitment to ICBs being as transparent and as involving of patients and the public as possible. I encourage him not to press his amendment.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

In light of what the Minister has said, we will not press the amendment to a vote. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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Karin Smyth Portrait Karin Smyth
- Hansard - - - Excerpts

I will speak mainly to amendments 31 and 50. The case for an elected chair of an ICB is very strong. As my hon. Friend said, if we accept the need for an elected police and fire commissioner, why not for health? The amounts of money we are talking about and the influence on people’s daily life dwarf those even of my local council. That is what people on the boards will be responsible for. Social care is still provided through a democratically accountable local authority, so why not healthcare?

We are moving towards the NHS budget overall accounting for up to 40% of general Government spend—that is what we are looking at for the next few years. It seems to go against the grain of everything else—elected Mayors, devolution and so on—for Conservative Members to allow that quantity of Government funding from the taxpayer to be out in communities without any kind of more local democratic control. There would also be a lot more confidence that the days of crony contracts favouring friends, families and donors had been well and truly left behind were there independent heads of the ICBs. I do not know if the Secretary of State has as many close friends as the last one, but letting him make the appointments is not something that Conservative Members will want to defend.

We should therefore be electing a local health commissioner. The amendment reasonably allows a two-year period for the organisations to get established—they have enough to do at the moment—but it would then start to take away some of the problems that the Government will get into with their proposals for the integrated care board chairs. On the make-up of the boards, too, the Bill is a good opportunity, should they wish to take it, for the Government to move away from the terrible scenarios of the past few years in particular. That argument was made cogently this morning by the Minister himself, in terms of NHS England having non-executive directors, people of independence and so on as part of its board, and it can well and truly be made about these new local bodies.

We do not need to go back to the 1990s, when trusts were first invented. Friends and families were put on to those bodies, which were stuffed with worthies, with business people favoured over local people with strong links to the community. Surely we can learn from the past 20-odd years and from the past couple of years in particular. Place is central to what the Government are trying to achieve and is the general policy direction of the Minister’s Department and many others, so it has to mean something and it has to be accountable.

We will come later to some of my amendments on a good governance commission, for which I hope to gain Government support; on having fit and proper tests for people to be scrutinised as suitable to come on to the boards; and, without wanting to throw back to the past, on bringing people in from the community to make the ICBs reflect their local community. In all seriousness, in our sad political situation, most ICBs will be headed up not by people are particularly sympathetic to Labour, so this is not a partisan point. It is, as the Minister started to say about NHS England itself this morning, about having people with the right qualifications—some clinical, some not. Let us have some clear criteria for how we want the boards to be governed and the sorts of people we want on them.

As I said earlier, the Government have got themselves into a real mess with accountability and with how much work the Secretary of State is doing, given how much is put on his desk—this sort of circular NHS accountability thing—so the amendments are trying to offer the Government a way through that follows their general policy direction. That was raised by NHS Providers in its written evidence

“to make crystal clear the relationship between trusts and ICBs, and how the statutory accountabilities of trusts, foundation trusts and ICBs align. There also needs to be clarity within the legislation on how the roles and responsibilities of the current NHS England and NHS Improvement…regions, ICBs, ICPs, trusts, foundation trusts, health and wellbeing boards…places, provider collaboratives, neighbourhoods and primary care networks…will all fit together.”

We would all like to understand how that works, even those of us who follow such things.

I am not suggesting that an all-powerful elected chair will get that, but at least that skilled person bringing together the multiplicity of organisations, groups and people for the local community would be a figurehead who needs to understand and grapple with the issues. The chairs would need to be trusted and highly skilled. In that way, there can be further accountability back up the national system, either through NHS England or the Minister. Let us take all that away from the Secretary of State’s desk—he is going to be a terribly busy man over the next few years. Let us help him out.

The Government should support this and similar amendments to try to bring local accountability much more to the fore. That, in turn, would allow local people, who are expected to spend huge quantities of their taxes on health—increasingly so over the next few years—to be very clear about what the money funds, what they get for their money and how they can hold people accountable.

Edward Argar Portrait Edward Argar
- Hansard - - - Excerpts

The shadow Minister, the hon. Member for Ellesmere Port and Neston, said that his amendments would give me two years to work through this, if necessary. I am grateful for his confidence in my longevity in this post—only time will tell.

I am grateful for the opportunity to address amendments 31, 50, 51 and 52, which were tabled by the shadow Minister. I fear that I may not surprise him on this set of amendments. Under the Bill as drafted, the chair of the integrated care board will be appointed by NHS England, as he and other Members have highlighted. It is therefore rather disingenuous to suggest that friends and cronies will be appointed. This is an NHS England appointment, with approval from the Secretary of State. I am not quite sure what is being suggested about those at NHS England, but I suspect it is rather unfair.

The chair will be appointed by NHS England, with approval from the Secretary of State. That reflects the fact that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, this House. That goes to the heart of the comments made by the hon. Member for Bristol South on the balance to be struck between having local flexibility and accountability, and recognising that this is a national health service and the way in which it has evolved. The accountability mechanisms are also national to reflect that.

In answer to the hon. Lady’s questioning, the chief executive of the NHS, Amanda Pritchard, said very clearly of the ICBs:

“In the proposed future structure, they would be accountable to a combined NHS England and NHS Improvement structure. At the moment, we operate that through seven regions, and then through to the national NHSEI executive. We are, in turn, accountable to Parliament.”––[Official Report, Health and Care Public Bill Committee, 7 September 2021; c. 20, Q21.]

Amanda Pritchard was very clear that it is the integrated care board that carries that national statutory responsibility on behalf of the NHS, hence why we have structured the accountability requirements as we have.

That chain of accountability has been at the heart of the NHS since its inception. There is a difference, which I know all Members recognise, between the DNA—for want of a better way of putting it—of social care provision, which has evolved through the link to local authorities, and the NHS, which has a more vertical, national structure. That goes to the heart of the different DNA of those two complementary—vitally complementary—parts of the system. We have to remember that history.

That is reflected in the clear belief, which is shared across both sides of the House, that in various ways the Secretary of State is ultimately accountable to this House and, through that, to the public for the performance of the NHS. It is therefore only right that once NHS England has made the appointment, the Secretary of State, who is ultimately accountable, should give final approval for the appointment of the chair. It is an important role in the ICB, as I am sure all Members would agree, and it is right and proper that the Secretary of State ensures that the appointment is appropriate. That is why, I fear, we cannot accept amendment 50, which would remove that mechanism.

At this point, it might be helpful to address the shadow Minister’s point about councillors. We need to draw a distinction between their role on ICPs and on ICBs. ICBs are the NHS accountable body for the spending of public money. As is already the case, the NHS is clear that it does not approve of dual accountability, so when someone is directly accountable for the spending of NHS money, they are required to have that as their role and to not have multiple roles. That applies to the chair and the chief exec, as is consistent with current practice. I discussed that at some length with the chief executive of the NHS when she was chief operating officer. Quite rightly, given my background and the shadow Minister’s, I sought her guidance and that is the conclusion we reached.

Amendment 31 suggests that the chair of the ICB should be appointed via local elections. That brings in a new element to the accountability relationship, which, again, could give rise to the perception of conflicting accountability routes, given that the genesis of how the NHS is currently structured has been as a national health service. The amendment risks introducing a degree of tension into that relationship. Given the importance, as the hon. Member for Bristol South rightly said, of having the right, highly skilled and able people in all these roles, it is appropriate that the mechanism we propose seeks to balance local knowledge and national accountability.

The shadow Minister or perhaps the hon. Member for Bristol South—forgive me if it was—asked what happens if there is discord within an ICB or challenges to the authority, capacity or capability of an individual chair. Essentially, we come down to the constitution of the ICB. Paragraph 8 of schedule 2 sets out how that would work, and NHS England will be producing guidance. Ultimately, NHS England will have the power to remove a chair should issues arise that necessitate that, but there will be further guidance on how that would work and what thresholds there might be.

The hon. Member for Ellesmere Port and Neston raised an important point: what is the mechanism in the hopefully unlikely event that that should occur? Chairs are subject to normal recruitment processes, and NHS England’s approach to appointments has been to work with the existing ICSs, including both NHS providers and local authorities, to ensure that the chairs appointed are high quality, credible and have the confidence of their local systems. Similarly, to ensure democratic involvement, ICBs have strong duties in relation to public and patient involvement, and local authorities must appoint, by right, a representative to the ICB.

Before I turn to amendments 51 and 52, the hon. Gentleman raised some challenge about the design document, its status and whether it appeared to prejudge the House’s deliberations. I want to reassure him: the key word in terms of that document is that it is in “draft” form—it is not formalised, and it is not the final document, because he is right. However, it does allows the non-statutory ICSs to be given a degree of guidance to continue their evolution, rather than all work stopping while we deliberate. Should the House pass the legislation that means ICSs become statutory, that document would have greater force. However, we are not seeking to pre-empt or pre-judge the will of the House. In fact, even with that caveat, the hon. Gentleman will be aware that we did not publish the document in draft until after Second Reading. That recognised again that we wanted the House to have a say on the principles before we even published documents in draft form and that we are cognisant of the need to show respect to the House’s democratic processes.

Amendment 51 would mandate that NHS England consult with the board before appointing a chair, and amendment 52 would require the chair to consult with both the board and the integrated care partnership before appointing a chief executive. We fully accept the importance of both the chair and the chief executive having credibility among system leaders and the population they serve. That is why NHS England is working closely with local authorities, NHS bodies and others in the appointment process.

The Bill, at its heart—again, we will come to the question of balance—aims to strip out needless bureaucracy by removing processes that we believe add little in terms of ensuring high-quality or safe care and that could get in the way of collaborative, smooth decision making. The amendment to formally require consultation on the appointment of the chief executive would create an unnecessary formal requirement, as well as potentially duplicative work, given that we would anticipate this happening informally anyway, and having due regard to that.

We believe that the approach taken in the Bill ensures both patients and the public have a strong voice on ICBs while also ensuring that the accountability arrangements set out by the chief executive in her oral evidence are maintained upwards as well, to the House and the Secretary of State. I therefore ask the shadow Minister to consider not pressing all his amendments to a vote.

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Division 3

Ayes: 4

Noes: 9

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Division 4

Ayes: 4

Noes: 9

Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

I beg to move amendment 32, page 120, line 26, in schedule 2, at end insert—

“(d) at least one member nominated by the mental health trust or trusts that provide mental health services within the integrated care board’s area;

(e) at least one member nominated by the Directors of Public Health that serve each local authority within the integrated care board’s area;

(f) at least one member nominated jointly by any NHS trust, NHS foundation trust and local authority that provides social care services within the integrated care board’s area;

(g) at least one member nominated by the trade unions representing the health and social care workforce that serves the integrated care board’s area;

(h) at least one member appointed to represent the voice of patients in the integrated care board’s area.”

This amendment would require integrated care boards to have members nominated by Directors of Public Health, mental health trusts, social care providers and trade union representatives and a member representing patients.

The amendment seeks to enhance the prescribed members of the integrated care board. We have not been able to move the Minister on the chairing, but I hope we might be able to do a bit better on the board members.

These are exceptionally important roles. The decisions that these bodies make will shape communities and lives. As we have heard, the boards will be accountable for spending hundreds of billions of pounds of public money. We are banking on their leaders taking good care of that very profound responsibility, and taking integration from an academic concept, or something that is seen in some places, to a real-world idea across the country. That is a big ask, and we need the very best people on the boards and the best range of voices.

Prior to coming to this place, I was a system leader in my local health system. I chaired my health and wellbeing board for a number of years and led my council’s health and care functions. That dual responsibility is hard, because our every instinct is to think “system first”—certainly in local government, because we know that the best prize and the best step changes in the wellbeing of the community come when organisations work together. We know that, but we also butt up against the grinding realities of one-year budget cycles and diminishing financial resources, so we find ourselves in one meeting—a board meeting perhaps—where we are desperately trying to move forward the cause of integration, or the common cause of the shared vision in a community, but we know that when we get back we have to meet finance colleagues in local government, and there is a reality to that.

That duality is really hard. I always likened it—people rolled their eyes in my health and wellbeing boards, and they may roll their eyes in this Committee too—to playing for an international football team, because people come from their clubs, but they come together for a common purpose. They wear a different shirt. The reason that matters is that they do not forget who they were previously—none of that goes away—but in that moment, they are trying to work in a common cause and put aside any of the parochial or local differences they have. That worked best with a balanced and diverse set of voices and experiences around the table, and I do not think that the Bill supports the appointment and assembly of a balanced and diverse set of voices.

The more I have listened to the Minister, the more concerned I have become about that issue, because on two occasions he has characterised integrated care boards as essentially NHS fund-holding bodies that therefore sit within the NHS accountability structures. I absolutely agree that that is true, certainly in this schedule, but in that case, is this not just a bigger CCG with an integrated care partnership moored to it? What really is different here?

We have said throughout—and have been told that we are wrong, and perhaps overly cynical in saying so—that this is an NHS reorganisation Bill, not an integration Bill. I am afraid that the Prime Minister rather weakened Ministers’ arguments by saying that there needs to be an integration White Paper, which I thought was an extraordinary indictment of this legislation. If this is a Bill regarding integration, who is integrating with who? There do not seem to be multiple parties; there seems to be a single party, perhaps with different elements and slightly different email addresses, but still with broadly the same accountability structures. At this point, this does not feel like integration.

In the previous sitting, the Minister described the current composition of the boards as a de minimis one, and said that there could be more members. I hope there is an expectation—he might address this when he replies—that generally, there would be more than the five people currently set out. Paragraphs 3 to 7 of schedule 2 set out the minimum of five members who will form the integrated care boards: the chair and the chief executive—there must be two of them—and then one member to represent all the NHS trusts, one person to represent primary care, and one person to represent all the local authorities in the area. The first time I read about those three ordinary members, I thought, “Those poor people.” One person to represent all the trusts in an area? One to represent all the local authorities in an area? Goodness me, that is a challenge.

I understand that the Minister is not keen to be overly prescriptive beyond what is in the Bill, and that there is a desire to strike a balance between being permissive and being prescriptive—trust me, nobody gets more frustrated with people in London telling people in Nottingham what to do than I do. However, given what is in the rest of schedule 2, I think the Minister is in danger of undermining that argument.

As we have heard, paragraph 4 says that only NHS England can choose the chair; paragraph 5 says that only NHS England can remove the chair; paragraph 14(2)(a) says that NHS England can vary the constitution of a local integrated care board; and paragraph 14(2)(b) says that NHS England can stop any other amendments to that constitution. We should not give too much succour to the idea that this part of the Bill is going to be particularly permissive, and that there is not going to be prescription in there. Of course there is, because we want local communities to shape their planning and their approaches, but we also think that there are minimums—I think we could find a level of commonality relatively easily—and we want to establish them as a backstop. Obviously, we have five here, but I think we ought to go a bit further.

As such, my amendment suggests five other members, the first of whom would be a representative of a mental health trust or similar. Again, if the Minister thinks I am wrong or that I have misunderstood this, I would be keen to hear from him, but I think it is exceptionally unlikely that the ordinary member chosen to fill the role described in paragraph 7(2)(a) on behalf of NHS trusts in a particular integrated care board footprint would not be from the biggest acute trust in that patch, or at least from one of its acute trusts. Our big hospitals are the gravitational centres of a local health system. They are totemic to a local population, they are massive financially, and they are exceptionally powerful in terms of soft power in a community. That means that there is one place and that place is gone, so once again, there is nothing for mental health.

We talk so often in this place about the need for parity of esteem between mental and physical health, but this is an opportunity to demonstrate that in practice, and we are not taking it. Beyond the fact that we ought to be putting mental and physical health on an equal footing, so many of the knotty issues that we will want local health systems to tackle will be rooted in issues relating to mental ill health, so I think there needs to be a voice at that table that can give balance to the decision making.

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Philippa Whitford Portrait Dr Whitford
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I, too, rise to support the amendment. This is probably one of the most important amendments so far. In the witness discussion, we came back time and again to which voices would be on the ICB and would be able to influence. I agree that, with all the talk of parity of esteem, it seems incredible that there would not be a voice representing the importance of mental health on the board. Similarly, with the talk of moving to population health and wellbeing, there is a need for directors of public health to agree policy and to feed in informa