Education (Careers Guidance in Schools) Bill
(2 years, 6 months ago)
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The Chair
Good morning. Before we begin our scrutiny, I have to make a few preliminary remarks. I remind members of the Committee to switch off or silence any electronic devices. I encourage hon. Members to wear masks when they are not speaking; this is in line with the current guidance of the House of Commons Commission. Please also give one another and members of staff space, both while seated and when entering and leaving the room. I remind everyone that they are asked by the House to have a lateral flow test twice a week if they are coming on to the parliamentary estate; this can be done either at the testing centre in the House or at home. Hansard colleagues would be grateful if hon. Members emailed their speaking notes to hansardnotes @parliament.uk.
My selection and grouping list for today’s sitting is available online and in the Committee Room. No amendments have been tabled.
Clause 1
Extension of duty to provide careers guidance in schools
Question proposed, That the clause stand part of the Bill.
The Chair
With this it will be convenient to discuss the following:
Clause 2 stand part.
Clause 3 stand part.
Mark Jenkinson (Workington) (Con)
It is a pleasure to serve under your chairmanship, Mr Davies. I am grateful to you and to fellow Committee members for joining me today. We have an opportunity to drill down into the finer detail of this important legislation, which will ultimately make a positive difference in the lives of young people across England.
At present, the statutory duty to provide careers guidance falls on maintained schools, special schools and pupil referral units, but not academies, although many academies now have that duty through their funding agreement. The Bill would address that anomaly by placing the same requirement on all types of state-funded secondary school.
Addressing these disparities will ensure consistency across the board, and is central to the creation of a more level playing field. We cannot leave the future of our young people to blind chance. Whether a child succeeds or fails cannot be determined by a postcode lottery. If we mean what we say when we talk about levelling up—if the phrase is to be more than a political slogan—we are duty-bound to address these anomalies and embrace the spirit of greater fairness.
Equality of opportunity must be embedded in the education system. Advice must be consistent, of the highest quality and accessible to everyone. It is also important that we give our young people the best careers advice as early as possible. It has to start at the very earliest opportunity, and it must be regular and ongoing as they make their journey through school towards their chosen career. Such early, regular interventions will not only equip them for the world of work, but stop them straying down a dead end. It will light their way to greater things.
Many of us spend much of our life in work. It is therefore important that we give our young people the tools to find a career that suits their personality and talents and that they find rewarding. Choices made at school help to define what we achieve, and even how happy and fulfilled we are later in life.
I am not surprised that many young people are anxious and uncertain about their education and employment prospects in these unprecedented times. Covid has brought huge disruption and forced many young people to re-evaluate their options. Unexpected change and challenges can open new doors, encourage us to be adaptable in our goals and help us to discover reserves of resilience and even talents that we did not know we had, but we must also have the appropriate support and guidance in place to help young people negotiate the obstacles and encourage them to make the most of their talents.
I am deeply conscious of the stark disadvantages facing many young people who have so much to contribute but are often written off too soon. Giving children access to good careers advice is one of the most effective ways of addressing that inequality. Providing enhanced careers guidance also makes financial sense as we build back better, because it will contribute to the high-skills, high-productivity recovery that we seek to develop. It will support all young people in developing the skills and attributes to succeed in the workplace, and in some cases it will nurture the community leaders of the future. The Bill would therefore extend careers guidance from year 8 down to year 7 to ensure that our children are given the best information to make the best choices.
Creating this level playing field will also give Ofsted the tools that it needs to guarantee that our children benefit from first-rate careers advice. As a direct result of the Bill, approximately 650,000 year 7 pupils across England will be entitled to additional careers guidance. The Bill will introduce additional provision for 2,700 academies. It will put into statute the Government’s commitment in the White Paper, “Skills for Jobs: Lifelong Learning for Opportunity and Growth”, to the UK’s post-pandemic recovery, and it will build on the important work already under way to develop a coherent and well established career guidance system.
Lia Nici (Great Grimsby) (Con)
I congratulate my hon. Friend on bringing this private Member’s Bill forward, and thank the Minister for his hard work in this field. As we know, the matter of skills in schools is absolutely, utterly vital. The extension of careers guidance to those in year 7 is important, because as my hon. Friend said, quite often, children and teachers do not really know what opportunities are available on their doorstep. In seats such as mine of Great Grimsby, and in Workington and other red wall seats, we see a disparity: children do well in primary school, but we lose that impetus when they get into secondary school. Careers guidance, making school relevant to young people, and teachers interacting more effectively with local business leaders and companies will make a real change to progress and attainment in schools. I congratulate and support my hon. Friend wholeheartedly.
Peter Kyle (Hove) (Lab)
It is the first time I have served under your chairmanship, Mr Davies, and I am grateful for the chance to do so. I again pay tribute to the hon. Member for Workington for bringing forward the Bill; I did so on the Floor of the House, and am happy to repeat the compliment today, because it is a real tribute to him that he has got the Bill this far. Speaking as a relatively new MP, I have to say to him that getting a private Member’s Bill past Second Reading on the Floor of the Commons and into Committee is the political equivalent of getting a golden ticket to Willy Wonka’s chocolate factory—not that I am calling anybody here an Oompa-Loompa, and especially not you, Mr Davies.
At a time when businesses around the country are facing massive skills shortages, it is vital that careers education matches the scale of the challenge, and the hon. Member for Workington understands this. We welcome the Bill. It is short, but its significance is not dampened by its brevity—if anything, it is enhanced by it.
For years, both main parties have been gripped by the debate on structural reforms in schools. Academies were, after all, a Labour invention spearheaded by Lord Adonis and others as a way of turning around failing schools. We stood against the forced academisation of large swathes of schools throughout the 2010s, and do not support universal academisation now, but given the years of disruption caused by structural reform, our immediate focus now must be on making sure that all schools deliver top-quality preparation for life, no matter their governance arrangements. Many academies have replaced local authority control with governance by a multi-academy trust that pools expertise and resources among a group of similar schools. Most of these trusts are highly effective, but a minority has been marred by accusations of off-rolling and high executive pay.
All schools, regardless of their governance structure, should provide excellent careers education. That is the outcome that the hon. Gentleman’s Bill seeks to deliver. The Labour party will always welcome steps towards embedding careers education in schools, and elevating its position and importance, yet only 30% of schools and colleges have stable careers programmes. That is not in the interests of pupils, schools, businesses or the whole economy—a point worth making on Budget day.
Expansion of the legal duty is welcome, but the Government must go further. Cuts to schools’ budgets have had a real-terms impact on the ability to provide high-quality careers education. When budgets are tight, school leaders are forced to prioritise traditional academic subjects. That is not helped by the Government’s narrow curriculum reforms over recent years. Where is the Government’s engagement with business? Where is the strategic vision? During the Labour conference, the Leader of the Opposition laid out an ambitious programme to ensure that every child leaves school job-ready and life-ready. Now is the time for the Government to meet that ambition for young people. Once again, I congratulate the hon. Member for Workington.
The Parliamentary Under-Secretary of State for Education (Alex Burghart)
It is a real pleasure to serve under your chairmanship in this, my first Bill Committee as a Minister, Mr Davies. I hope it is not my last. I must congratulate my hon. Friend the Member for Workington; he is, as the hon. Member for Hove said, the boy with the golden ticket. He may remember what happens to the boy who finds that golden ticket: Charlie goes on to run the chocolate factory. I can think of no finer job for my hon. Friend. It is a real achievement to get this Bill into Committee, and we in the Government are delighted to support it, because it really supports the aims of our skills reform agenda, which will drive up the quality and availability of technical skills for young people, and that will help them to get the great jobs that they deserve—the great jobs of tomorrow.
I pay tribute to my predecessor, my hon. Friend the Member for Chichester (Gillian Keegan), who has gone on to an even greater job, in the Department of Health. I cannot hope to match her panache and stylishness, but I promise the House that I will do my best for this agenda, because it is something I believe in deeply. I also thank the Opposition for their support for the Bill and the cross-party consensus that has broken out over this important agenda. I hope such consensus will continue throughout the day, as we go on to the Chancellor’s statement.
The Government support the Bill because we want to level up opportunity. The reforms set out in our “Skills for Jobs” White Paper will give people a genuine choice between a high-quality technical route and a high-quality academic route. As part of that, it is vital that everyone has access to careers guidance of the very highest standard.
Alex Burghart
I am honoured to give way to my opposite number for the first time.
Mr Perkins
Does the Minister agree that in order to meet the careers guidance needs of every child, we need to meet every child, and so every child should be entitled to face-to-face careers guidance during their career journey?
Alex Burghart
I thank the hon. Gentleman for his contribution. I know that we will not always agree as we stand opposite each other, but I know that he cares deeply about the prospects for young people, and I hope he respects that I do, too. Obviously, it is important that young people get high-quality careers advice, and it would be difficult to justify giving that without a degree of face-to-face support, but we respect schools’ abilities to find new, interesting ways of delivering this agenda.
As we emerge from the pandemic, it is important that we make sure that all young people have access to high-quality guidance, because if they do not, they will not know whether they are making the right choices and taking the right opportunities.
Sally-Ann Hart
Does my hon. Friend the Minister agree that the fact that the Bill has been extended to alternative provision academies matters a lot, because some of the most vulnerable children from disadvantaged backgrounds are in alternative provision, and we really need to get them the same opportunities as all other children?
Alex Burghart
I could not have put it better myself. It is very important that everyone in state education, particularly young people with the most disadvantaged starts in life, has these opportunities, and that is what the Bill will achieve. Having at different times of my career worked closely with those who run alternative provision, I know, as does my hon. Friend, that they have an extraordinary job on their hands. The contribution that they make to young people’s lives is often really remarkable.
Now more than ever, good-quality careers advice, information and guidance is essential to build a workforce that is dynamic and flexible. It is critical that young people are provided with good-quality information about future labour market opportunities in growth sectors, so that they can learn the skills that they need to be successful in our fast-paced, changing jobs market.
Many in-demand jobs and sectors are a product of the modern world, including space exploration, green energy, digital architects and data scientists. As new technologies and industries emerge, young people need insights into the breadth of careers and opportunities available to them, so that they can make informed decisions about the future, including, crucially for my brief, the value of technical and vocational pathways to employment. Good-quality careers advice is essential if we are to ensure that we meet the higher technical skills needs in our country. That is why the Government are investing over £100 million in the financial year 2021-22 in the direct delivery of careers information, advice and guidance. That funds the direct delivery of careers advice to people of all ages through the National Careers Service. We also support the development of careers infrastructure through the Careers & Enterprise Company to help schools and colleges to improve their careers programmes in line with the world-class Gatsby benchmarks. The Bill will support the Government’s wider skills reforms, and will provide a legal framework for guaranteeing high-quality, independent careers guidance to all young people in state secondary schools.
It takes a wise man to devise a simple Bill, and this is a simple Bill. Clause 1 amends the scope of section 42A of the Education Act 1997—the statutory duty on schools to secure independent careers guidance. The Bill extends career advice provision to all pupils in state secondary schools, bringing year 7 pupils into scope for the first time. It also extends the duty to all academy schools and alternative provision academies. Clause 2 covers consequential amendments and revokes 2013 regulations that extended the careers guidance obligations to pupils aged 13 to 18; they are no longer needed, because the Bill extends to all secondary-age pupils.
What the clauses mean in practice is that all pupils, in all types of state-funded secondary school in England, will be legally entitled to independent careers guidance throughout their secondary education. That means high-quality guidance for every single child in every single secondary state school in every single local authority, without exception.
Simon Baynes (Clwyd South) (Con)
I would like to put on record my thanks to my hon. Friend the Member for Workington for bringing the Bill to the House and to this Committee. I want to clarify a point: page 6 of the explanatory notes says that the provisions do not extend to Wales—I speak as a Welsh MP—but where the notes say,
“Would corresponding provision be within the competence of Senedd Cymru?”,
the answer is “Yes” for both clauses 1 and 2. Has the Minister had any contact with the Welsh Government to see whether they are bringing in a similar programme of careers guidance in Wales?
Alex Burghart
We are in constant contact with our colleagues in Wales, but I am as yet unaware of whether they have similar plans. I am happy to write to my hon. Friend if I discover that they do.
By extending the lower age limit to those in year 7, the Bill brings the career guidance duty in line with the Government’s careers framework for schools, the Gatsby benchmarks, which apply from years 7 to 13. This fulfils a commitment in our “Skills for Jobs” White Paper and will reach over 600,000 pupils in year 7 every year. By starting in year 7, we can give children early exposure to a range of employers, so that they gain experience of the workplace, ask questions and develop networks. They can begin to learn about the local labour market, because the skills needs of Cumbria may be different from those of Essex. Early careers guidance can support important decisions that need to be made from year 14 —for example, on the choice of GCSE subjects or on whether to go to a university technical college.
The Bill will establish consistency by applying the statutory careers duty to all types of state-school settings. This will bring approximately 2,700 academy schools and 130 alternative provision placements into scope. We support the Bill’s intention to require all academies via statute to have regard to statutory careers guidance. That is already the case for maintained schools. If the Bill is passed, we will make it easy for schools to understand the changes to the law, and what actions they need to take. These changes to the law will allow Ofsted to focus clearly and consistently on how every school is meeting its statutory duty by providing independent careers guidance to every pupil throughout their secondary education.
Mark Jenkinson
May I put on record my thanks to everyone who has contributed to this short, constructive debate, and to all Members who agreed to serve on this Committee? I thank all those who contributed more widely to the small but incredibly important changes in the Bill, and ask that everyone continues their cross-party support until we get the Bill over the line.
I thank my local enterprise partnership, careers hub and education leaders for their input as the Bill took shape. I also thank my hon. Friend the Member for Castle Point (Rebecca Harris) and the Minister for their support throughout, and Opposition Members, particularly the hon. Member for Hove. May I also thank you, Mr Davies, the officials from the Department, the Hansard writers, and the Clerk, Adam Mellows-Facer, who has been incredibly supportive throughout the process? I look forward to Third Reading, hopefully on 14 January.
The Chair
Well done.
Question put and agreed to.
Clause 1 accordingly ordered to stand part of the Bill.
Clauses 2 and 3 ordered to stand part of the Bill.
Bill to be reported, without amendment.
Health and Care Bill (Eighteenth sitting)
Wednesday 27th October 2021
(2 years, 6 months ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 27 October 2021 - (27 Oct 2021)
The Committee divided: - Ayes: 6 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 9 / Noes: 5 - Question accordingly agreed to.
The Committee divided: - Ayes: 9 / Noes: 5 - Question accordingly agreed to.
The Committee divided: - Ayes: 6 / Noes: 9 - Question accordingly negatived.
The Chair
Before we resume, it might be helpful for me to give the Committee a few preliminary reminders. Please switch all electronic devices to silent. No food or drink are permitted during sittings of the Committee except for the water provided.
I encourage Members to wear masks when they are not speaking, in line with current Government guidance and that of the House of Commons Commission. Please also give each other and members of staff space when seated and when entering or leaving the room. Hansard colleagues would be grateful if Members could email their speaking notes to hansardnotes@parliament.uk.
I remind Members and staff that they are asked by the House to take a covid lateral flow test twice a week if they are coming on to the parliamentary estate. That can be done either at the testing centre in the House or at home.
Clause 130
Power to make consequential provision
Dr Philippa Whitford (Central Ayrshire) (SNP)
I beg to move amendment 114, in clause 130, page 111, line 15, at beginning insert “Subject to subsection (4),”.
This amendment is consequential on Amendment 115.
The Chair
With this it will be convenient to discuss the following:
Amendment 115, in clause 130, page 111, line 25, at end insert—
“(4) Regulations may only be made under this section with the consent of—
(a) the Scottish Ministers insofar as they make provision for any matter which falls within the legislative competence of the Scottish Parliament,
(b) the Welsh Ministers insofar as they make provision for any matter which falls within the legislative competence of Senedd Cymru, and
(c) The Northern Ireland Ministers insofar as they make provision for any matter which falls within the legislative competence of the Northern Ireland Assembly.”
This amendment would require the Secretary of State for Health and Social Care to obtain the consent of the relevant devolved government before powers in this clause falling within the legislative competence of a devolved institution are exercised.
Clause stand part.
Clauses 131 to 135 stand part.
Dr Whitford
I rise to speak to amendment 115, which is the main amendment. Amendment 114 is consequential on it. The amendment comes back to the main theme: the clause contains significant Henry VIII powers for the Secretary of State to change the Bill or any Act of the devolved Parliaments relating to it.
When the Minister rises to speak, he will say that the power is only for tiny things such as changing names or tidying up, but the Bill is so extensive that the power to introduce some of the themes and policies contained in it into the NHS in Scotland is something that people in Scotland—and, I am sure, in Wales and Northern Ireland—would not be happy with. There is no limitation to this power.
Again, there is no mention of consulting, let alone consenting. It has been the convention for over two decades that if the UK Government legislate in clearly devolved areas, there should be legislative consent. Before this Henry VIII power is used by a Secretary of State, legislative consent should be sought from the devolved Parliaments in Scotland, Wales and Northern Ireland.
Justin Madders (Ellesmere Port and Neston) (Lab)
Mrs Murray, it really is a pleasure to serve under your chairmanship this morning. I echo the comments from the Scottish National party spokesperson. She is correct that the Bill gives the Secretary of State extensive powers—almost carte blanche in some areas—to change the law. We think that taking back control means Parliament taking back control. Elected politicians are meant to serve the people, not the other way round. Some very valid points have been made about the themes and issues across the Bill, and we echo those.
Edward Argar
It is a pleasure to see you in the Chair again, Mrs Murray, and to hear of the inadvertent promotion of the shadow Minister. I am sure it is only a matter of time, certainly if his longevity in his current post and being master of his brief are anything to go by.
I am grateful to the hon. Member for Central Ayrshire for raising this matter. I will address amendments 114 and 115 together, as one is consequential on the other, and then I will address the clauses. As the hon. Lady rightly says, she has raised this matter with me not only in this Committee but outwith it. I would have been surprised had she not wished to air it in Committee, which is exactly what we are here for.
The amendments would require the Secretary of State to seek the consent of Ministers of the relevant devolved Administrations before making a consequential amendment to any matter that falls within the competence of the devolved legislature. Provisions such as clause 130—she suggested I might say this—are perfectly common in UK Acts of Parliament, and we believe they remain within the spirit of the devolution settlement. The UK Government’s clear position is that, in and of itself, clause 130 would not give rise to the legislative consent motion process, for reasons that I will set out. We deem that a requirement for the consent of the DAs for its use would therefore be inappropriate.
This power will enable the UK Government to make consequential amendments that might be necessary following the passage of the Bill. That includes most of the amendments that need to be made to secondary legislation as a consequence of the Bill’s provisions As such, amendments were not included in the Bill. There may also be minor changes, such as amendments to names of particular bodies—the hon. Lady knows me and the position that Her Majesty’s Government take on these things extremely well—as a result of measures in the Bill.
It is also prudent to retain the power to amend legislation in the event that anything has been missed. It is important for everyone concerned that we have the ability to make such amendments should they be needed to ensure that the legislation works as intended and that we are able to do so quickly, as required.
As I said, this power is quite common in UK legislation, particularly in a Bill as large as the Health and Care Bill, which—as we know, as we reach the end of the current set of clauses—comprises 135 clauses and 16 schedules. There are many examples of similar powers to clause 130 in existing legislation. Perhaps the one with the greatest relevance, giving the most directly analogous example, is section 303 of the Health and Social Care Act 2012.
As a general principle, it is appropriate that the authority passing the legislation makes the consequential provisions that flow from it, as that authority will be most familiar with the provisions of the legislation and the changes to other legislation that it necessitates. We are seeking legislative consent from the devolved Administrations in respect of a number of provisions in the Bill and we have debated those in recent days, but clause 130 does not, in and of itself, give rise to the LCM process. It is the substantive provisions in the Bill, on which any amendments under clause 130 would be consequential, that do or do not, as the case may be, give rise to the LCM process.
Finally, although this power will enable the UK Government to make consequential amendments to devolved legislation, in practice, any amendments would be discussed with the DAs, officials and legal advisers prior to and throughout the drafting process. These arrangements follow wider good practice and expectations of collaborative working.
Edward Argar
Yes, but I am not sitting down just yet, so the hon. Lady will have more opportunities to intervene.
Dr Whitford
I just remind the Minister that the Cabinet Secretaries in the devolved nations saw this huge Bill the day before it was launched, so although there may have been engagement with officials, that does not suggest that there was engagement with the Governments, which he is saying we should depend on, along with close working.
Edward Argar
I take the hon. Lady’s point but, on engagement with officials, I would argue that it is in a sense a matter for officials in the Scottish Government whether they communicate with the Cabinet Secretary. They were not prohibited from doing so. I will not go into the inner workings of the Holyrood machine, just as, I suspect, the hon. Lady would not wish to go into the inner workings of the Department of Health and Social Care. However, that dialogue has taken place since February this year. I appreciate that there has been a slight challenge with that, given the Holyrood elections and purdah, where, although officials can continue to talk, there was rightly a bit of stepping back at a political level so that democracy could take its course. It took its course and the same party continues to run Scotland, so those conversations resumed. My point is that those discussions at official level have been long standing and extensive, I would hope. I suspect that officials have shared elements with the Cabinet Secretary—perhaps not the entirety, but they have been very much engaged.
I hope that that explanation provides some reassurance to hon. Members, although I suspect that it may not. I suspect that the hon. Lady anticipated that explanation, and it may therefore not add further reassurance, but I hope that it does to a degree.
Let me move on to clauses 130 to 135 stand part of the Bill. As we heard in the foregoing debate, clause 130 allows the Secretary of State to make provision by regulations, which is consequential on the Bill. The Bill contains a significant change to the legal framework of the health service. As a result, numerous consequential amendments to other pieces of primary and secondary legislation are required to reflect those changes.
The power is limited to making amendments consequential to the competence of the Bill and is therefore a narrow power. It is, as I said, a standard provision in a Bill of this size and complexity. A considerable amount of secondary legislation will require amendment following the merger of NHS England and NHS Improvement and the change from clinical commissioning groups to integrated care boards. It would not be appropriate to use primary legislation to list all of those secondary legislative changes. Therefore, the consequential power will be used to make such changes in secondary legislation.
The power extends to making consequential amendments to primary legislation passed by the devolved legislatures, because devolved legislation contains references to UK legislation or bodies that may need to be amended in consequence of this Bill. The power applies only to existing primary legislation—this Bill itself, or primary legislation passed during this Session—and therefore future primary legislation may not be amended under the power conferred by this provision.
Clause 131, again, is a common part of a Bill. It sets out the scope of regulation-making powers in the Bill generally and the parliamentary procedure for making such regulations. Subsection (1) provides that regulations made under the Bill may include
“consequential, supplementary, incidental, transitional or saving provision”
and can make
“different provision for different purposes.”
Subsections (3) and (4) set out the parliamentary procedure for making regulations under this legislation.
Clause 132 is also a standard clause concerning financial provision. It simply provides that any expenditure incurred by the Secretary of State under the Act shall be paid out of the consolidated fund, in accordance with the Supply and Appropriation (Main Estimates) Act 2021.
Clause 133 sets out the territorial extent of the provisions of the Bill. It provides that while most of the provisions in the Bill extend only to England and Wales, a small number extend UK-wide. In addition, the bulk of the England and Wales-only provisions—in particular, the vast majority of part 1—will in fact apply only in England, as they concern the health service in England only. The following provisions, listed in subsection (2), extend to England, Wales, Scotland and Northern Ireland: the renaming of NHS England in paragraphs 1(3) and 1(4) of schedule 1; the Secretary of State’s powers to transfer and delegate functions in part 3 of the Bill; and the carve-out of the health services safety investigations board from any legislative provision to require disclosure of information in clause 109.
In addition, the amendments to other legislation made by the Bill will have the same territorial extent as the provision that is being amended. Examples of this include clause 120, which makes provisions about reciprocal healthcare arrangements, and clause 85, which allows provision to be made for the establishment of medicines information systems. A full analysis of territorial extent and application in the UK can be found in the explanatory notes. In earlier sittings, we debated the consequences of the Bill in Wales, Scotland and Northern Ireland and any issues relating to devolution as and when they have arisen. I suspect we may return to those issues on Report, and that their lordships may wish to debate them in the other place.
Clause 134 sets out when the provisions in the Bill will come into force once it has been passed. Most of the Bill will be brought into force on a date to be set in regulations, as provided for in subsection (3). Again, that is a common approach for a Bill of this type, and allows for flexibility. While the Government are committed to implementing the vital reforms to the health service that are contained in the Bill, we will be able to confirm the precise date on which provisions will come into force when it has completed its parliamentary passage—clearly, we cannot pre-empt Parliament. It is likely that it will be appropriate to bring different provisions of the Bill into force at different times.
Finally, clause 135 provides that, once passed, the Bill may be cited as the Health and Care Act 2021. I therefore commend these clauses to the Committee.
Dr Whitford
I appreciate that the vast majority of consequential changes that might be made by the Secretary of State would be minor, and most of them would apply to England. However, I am sure the Minister will also understand that the United Kingdom Internal Market Act 2020, which has taken away powers over certain aspects of public health, environmental control, infrastructure and so on, is felt in Scotland as a direct threat to devolution. Such clauses are therefore seen as threatening, in that the Bill is so big that it would allow extensive consequential amendments, particularly—as the Minister referred to himself—under clause 131(1)(b), which allows for
“different provision for different purposes.”
Many Opposition Members find the undefined scope disquieting, and we have seen this extensively over the past three years. I would therefore wish to press amendment 114 to a Division.
Question put, That the amendment be made.
The Chair
That completes line-by-line consideration of the existing clauses of the Bill, and we will now consider new clauses. New clauses that were grouped for debate with amendments to the Bill will not be debated again, but if the Member who tabled the new clause indicated in their speech that they wished to divide the Committee, they will have the opportunity to do so. I remind Members who wish to press a grouped new clause to a Division that they should indicate their intention when speaking to the clause. We start with Government new clause 59, which was debated yesterday.
New Clause 59
Care Quality Commission reviews etc of integrated care system
“(1) Chapter 3 of Part 1 of the Health and Social Care Act 2008 (quality of health and social care) is amended as follows.
(2) After section 46A (inserted by section 121 of this Act) insert—
‘46B Reviews and performance assessments: integrated care system
(1) The Commission must, in accordance with this section—
(a) conduct reviews of—
(i) the provision of relevant health care, and adult social care, within the area of each integrated care board, and
(ii) the exercise of the functions of the following in relation to the provision of that care within the area of each integrated care board: the board; its partner local authorities; and registered service providers,
(b) assess the functioning of the system for the provision of relevant health care, and adult social care, within the area of each integrated care board (taking into account, in particular, how those mentioned in paragraph (a)(ii) work together), and
(c) publish a report of its assessment.
(2) The Secretary of State—
(a) must set, and may from time to time revise, objectives and priorities for the Commission in relation to assessments under this section, and
(b) must inform the Commission of the objectives and priorities.
(3) The Commission—
(a) must determine, and may from time to time revise, indicators of quality for the purposes of assessments under this section, and
(b) must obtain the approval of the Secretary of State in relation to the indicators.
(4) The Secretary of State may direct the Commission to revise the indicators under subsection (3).
(5) Different objectives and priorities may be set, and different indicators of quality may be determined, for different cases.
(6) The Commission—
(a) must prepare, and may from time to time revise, a statement—
(i) setting out the frequency with which reviews under this section are to be conducted and the period to which they are to relate, and
(ii) describing the method that it proposes to use in assessing and evaluating the functioning of the system for the provision of relevant health care, and adult social care, within the area of an integrated care board, and
(b) must obtain the approval of the Secretary of State in relation to the statement.
(7) The statement may—
(a) make different provision about frequency and period of reviews for different cases, and
(b) describe different methods for different cases.
(8) Before preparing or revising a statement under subsection (6) the Commission must consult—
(a) NHS England, and
(b) any other persons it considers appropriate.
(9) The Secretary of State may direct the Commission to revise the statement under subsection (6).
(10) The Commission must publish—
(a) the objectives and priorities under subsection (2),
(b) the indicators of quality under subsection (3), and
(c) the statement under subsection (6).
(11) For the purposes of this section—
“adult social care” means social care for individuals aged 18 or over;
“partner local authority”, in relation to an integrated care board, means any English local authority whose area coincides with, or includes the whole or any part of, the area of the integrated care board;
“registered service provider” means a person registered under Chapter 2 as a service provider;
“relevant health care” means—
(a) NHS care, or
(b) the promotion and protection of public health.
(12) Regulations may amend the definition of “relevant health care” to include health care which is provided or commissioned by a public authority (but which does not amount to NHS care).’
(3) In section 48 (special reviews and investigations), in subsection (2), after ‘46A’ (inserted by section 121 of this Act) insert ‘or 46B’.
(4) In section 50 (failings by English local authorities), in subsection (1), after ‘46A’ (inserted by section 121 of this Act) insert ‘or 46B’.
(5) In section 162 (orders and regulations: parliamentary control), in subsection (3), after paragraph (c) insert—
‘(c) regulations under section 46B(12) (amendment of definition of relevant health care),’.”—(Edward Argar.)
This new clause imposes a duty on the Care Quality Commission to carry out reviews and assessments into the overall functioning of the system for the provision of NHS Care and adult social care services within the area of each integrated care board.
Brought up, read the First and Second time, and added to the Bill.
New Clause 60
Default powers of Secretary of State in relation to adult social care
“(1) In section 7D of the Local Authority Social Services Act 1970 (default powers of Secretary of State as respects social services functions of local authorities)—
(a) in subsection (1), for the words from ‘imposed’ to ‘2002’substitute ‘referred to in subsection (4)’;
(b) after subsection (3) insert—
‘(4) Subsection (1) does not apply in relation to a duty imposed by or under—
(a) the Children Act 1989,
(b) section 1 or 2(4) of the Adoption (Intercountry Aspects) Act 1999,
(c) the Adoption and Children Act 2002, or
(d) Part 1 of the Care Act 2014.’
(2) The Care Act 2014 is amended in accordance with subsections (3) and (4).
(3) After section 72 insert—
“Default by local authority
72A Default power of Secretary of State
(1) Where the Secretary of State is satisfied that a local authority is failing, or has failed, to discharge any of its functions under or by virtue of this Part to an acceptable standard, the Secretary of State may give to the local authority any directions that the Secretary of State considers appropriate for the purpose of addressing the failure.
(2) The directions may include provision requiring the local authority—
(a) to act in accordance with advice given by the Secretary of State or a person nominated by the Secretary of State,
(b) to collaborate with the Secretary of State or a person nominated by the Secretary of State in taking steps specified in the directions, or
(c) to provide the Secretary of State or a person nominated by the Secretary of State with information of a description specified in the directions, on request or otherwise.
(3) If the Secretary of State considers it necessary for the purpose of addressing the failure, the directions may include provision—
(a) for specified functions of the local authority to be exercised by the Secretary of State or a person nominated by the Secretary of State for a period specified in the direction or for so long as the Secretary of State considers appropriate, and
(b) requiring the local authority to comply with any instructions of the Secretary of State or the nominee in relation to the exercise of the functions.
(4) So far as is appropriate in consequence of directions given by virtue of subsection (3), a reference (however expressed) in an enactment, instrument or other document to a local authority is to be read as a reference to the person by whom the function is exercisable.
(5) If directions given by virtue of subsection (3) expire or are revoked without being replaced then, so far as is appropriate in consequence of the expiry or revocation, a reference (however expressed) in an instrument or other document to the person by whom the function was exercisable is to be read as a reference to the local authority to whom the directions were given.
(6) The Secretary of State may, for the purposes of cases in which directions are given under subsection (3)(a), make regulations disapplying or modifying an enactment which confers a function on the Secretary of State in respect of a function of a local authority.
(7) Directions under this section may require the local authority to provide financial assistance to the Secretary of State, or a person nominated by the Secretary of State, for the purpose of meeting costs incurred by the Secretary of State or the nominee as a result of the directions.
72B Default power of Secretary of State: supplementary
(1) Before giving directions under section 72A the Secretary of State must give the local authority concerned an opportunity to make representations about the proposed directions, except so far as the Secretary of State considers that it is impractical to do so for reasons of urgency.
(2) The power to give directions under section 72A includes a power to vary or revoke the directions by subsequent directions.
(3) Subsection (1) does not apply in relation to proposed directions varying previous directions if the Secretary of State does not consider the variations to be significant.
(4) Directions under section 72A must be in writing.
(5) The Secretary of State must publish—
(a) any directions given under section 72A, and
(b) the reasons for giving them.
(6) Directions under section 72A are enforceable, on the Secretary of State’s application, by a mandatory order.”
(4) In section 125(4) (regulations and orders subject to affirmative procedure), after paragraph (k) insert—
‘(ka) regulations under section 72A(6) (modification of enactments where local authority functions are exercised by the Secretary of State or a nominee);’.”—(Edward Argar.)
This new clause would create a new power for the Secretary of State to intervene where local authorities are failing in the exercise of functions under Part 1 of the Care Act 2014 (adult social care) and make consequential amendments.
Brought up, and read the First time.
Question put, That the clause be read a Second time.
Edward Argar
I beg to move, That the clause be read a Second time.
New clause 62 adds to section 164 of the National Health Service Act 2006, enabling regulations to be made that would allow further products to be centrally stocked and supplied free of charge to community pharmacies without the need for reimbursement under the standard NHS arrangements. This would allow Ministers to create limited additional exemptions to the exemptions that can already be created by the regulation-making power introduced in 2017 for unlicensed medicines, more commonly known as “specials”.
As was recognised in 2017, the legislative framework for pharmaceutical remuneration established by section 164 is predicated on the basis that community pharmacies will be reimbursed for the products they supply. Unique conditions required the unlicensed specials medicines amendment to be tabled in 2017 due to an unconventional supply chain. Unusually, there was no competition and, therefore, no incentive for community pharmacies to seek value for money for unlicensed medicines.
Under normal conditions, a virtuous competitive circle would encourage community pharmacies to try to source the lowest cost product and, in doing so, force overall prices down. The 2017 amendment allowed for regulations to be made so that the process of sourcing the relevant products could be by central procurement and subsequently there could be direct supply to community pharmacies. No such regulations have yet been made, but the matter remains under review.
The amendment only seeks to further add, in a limited way, to the current powers to make regulations to provide for an exemption from the ordinary requirement to reimburse. The only products that it will cover are vaccines, pandemic treatments, and associated products such as diluents and syringes. There are various reasons why we may seek to procure centrally vaccines or products used to treat a pandemic, for example when the typical competitive supply chain and reimbursement arrangements cannot be relied on, because pressures from global demand mean that central purchasing and direct supply to community pharmacies is critical to maintaining continuity of supply for UK patients.
In those circumstances, if centrally purchased products, rather than being supplied directly to pharmacies, were sold to wholesalers, that would risk wholesalers exporting or selling the stock at a much higher price than is usually paid, thereby playing the market. In this example, that would defeat the original purpose of the central stockpile.
When supplying products directly to pharmacies free of charge, we do not want to reimburse pharmacies as well as purchasing the stock, as that would mean the Government or taxpayer paying twice. Currently, as I have indicated, the legislative framework only makes provision for the reimbursement price of specials to be set at zero. We are restricting those to vaccinations and immunisations, medicinal products used for the prevention or treatment of disease in a pandemic, and associated products. By carving out these niche, critical—but understandable, I hope—exceptions in the legislation in that way, we recognise the importance of not undermining the supply and reimbursement arrangements more generally and broadly across the piece. Furthermore, the legislation will also ensure that in the case of pandemic treatments, once the disease is no longer a pandemic, the appropriate arrangements will be put in place to transition back to normal supply and payment arrangements.
The new clause is important to ensure that centrally purchased stock of essential medicines intended for patients in England can be distributed to community pharmacies to meet clinical need and support patient access, whether that applies to a vaccination or treatment in connection with a pandemic. For those reasons, I ask the Committee to support the new clause.
Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to serve again with you in the Chair, Mrs Murray. As I said yesterday, we are grateful for the Minister writing with his explanation of this and the other new clauses ahead of time. That was helpful.
As the Minister explained in his letter, the new clause will simplify and safeguard the process of remuneration where the Government centrally procures vaccines, immunisations or products used to treat a pandemic, as well as other listed products, replacing “special medicinal products” under the previous legislation, in particular when there is significant international demand. That is very topical and we have a rich understanding of it given the events of the past 18 months, so it makes sense to the Opposition and we will not dwell on it long, nor will we press the new clause to a division. However, I seek clarity from the Minister on a couple of issues.
In the Minister’s letter, he cited the risk of wholesalers exporting the products or selling them at a much higher price if they were fed into the conventional supply chain. He characterised that as market failure. Community pharmacies would then be claiming reimbursement from the NHS based on the drug tariff determinations. I do not doubt the risk of that, and it is a foreseeable one, but am keen to hear from the Minister whether he is able to quantify the risk or demonstrate examples in either case. For example, during this pandemic, did that happen at the beginning? What was the cost if that took place? Have there been examples of profiteering preventing necessary products from reaching the patients for which they were intended?
In a second point, I am curious about the arrangements put in place to transition back to normal payment arrangements, once the disease in question is no longer pandemic or at risk of becoming pandemic. Again, I think we would always want restoration of normal circumstances at the first appropriate moment. In his letter, the Minister describes the arrangements as “appropriate”, while the new clause reads:
“Where…the Secretary of State considers that the disease to which it relates is no longer a pandemic disease or at risk of becoming a pandemic disease, the Secretary of State must revoke that provision within such period as the Secretary of State considers reasonable”.
Given that section 164 of the National Health Service Act 2006 also allows the Secretary of State to determine remuneration, that feels a little like the Secretary of State being allowed to mark their own homework. It could leave such measures in place for as long as suits them, rather than for as long as necessary, because the only determination of their need sits with that person. Will the Minister offer some reassurance that the power is for an emergency and is exceptionally limited, and give the Committee some comfort about the oversight and how Parliament perhaps will be given the chance to challenge the Secretary of State, so that the measures are not kept in place for any longer than necessary?
Dr Whitford
I have a small comment following on from the hon. Gentleman, who was asking for evidence of profiteering on specials. I was on the Committee considering the Health Service Medical Supplies (Costs) Act 2017 and brought the issue of specials before the Committee. These are often personalised medicines. In Scotland, they are produced centrally by the NHS, but there is certainly huge evidence of profiteering on them within NHS England, with hundreds of pounds being charged for simple ointments. While we may not have evidence on vaccines, evidence of profiteering on specials is long standing.
Edward Argar
I am grateful to the hon. Lady for helping to reduce the number of the shadow Minister’s questions that I need to answer. The hon. Lady makes her point well. We saw early on in the pandemic the challenges of a globally competitive market and the incentives and disincentives that can create around supply. I will not go into other aspects of supplies purchased for the NHS during the pandemic, but we have seen what happens when a market becomes super-saturated with demand versus a very limited supply, hence why we believe the steps in the new clause are prudent.
The shadow Minister will be familiar with approach in the new clause; it was used, for example, for covid vaccines, which were centrally secured and supplied directly to pharmacies. While we felt that supply could be justified on the basis of conventions of statutory interpretation that allowed us necessary flexibility in those exceptional circumstances, we think it is appropriate that we put such measures on a proper legal footing—through debate and, if necessary, Division in the House—to future-proof our arrangements. We are not trying to radically alter NHS pharmaceutical service provision or the payment mechanism. The aim is actually to strengthen the legal basis, and indeed the democratic oversight of that legal basis, through this debate in this Committee, for scenarios in which usual supply routes need to be bypassed.
The shadow Minister also raised a couple of other points, mainly about the Secretary of State’s power and Parliament’s role going forward, if I may paraphrase it in that way. I take his point. Judgments will obviously be based on advice from officials and legal and scientific advisers, but to a degree it is in the nature of ministerial accountability that there is an element of subjectivity when the Secretary of State is obliged to make a judgment. I appreciate the point, which I echoed in my remarks, on the need to turn these arrangements off or transition out of them as swiftly as possible, but we can see this pandemic declining and coming back at various times—that is the nature of the lifecycle of a pandemic; there are ups and downs before it finally burns itself out—and therefore the Secretary of State will ultimately need a degree of discretion and subjectivity in their judgment about the right moment, although obviously they will take advice.
On the House’s ability to challenge that, as the shadow Minister will possibly expect me to say, he and his colleagues and other Members will have ample opportunity, not only at Question Time but also, as I have discovered, through urgent questions, which I have answered on behalf of colleagues in the Government on occasion. There are plenty of opportunities for Members to summon Ministers to the Dispatch Box, or through written questions, to challenge and to probe and hold Ministers to account. I hope that hon. Members feel that this is a pragmatic and proportionate measure to address something we have identified in the course of the pandemic as needing resolution, and in so doing to put it on a surer and clearer statutory footing.
Question put and agreed to.
New clause 62 accordingly read a Second time, and added to the Bill.
New Clause 1
Prohibition of virginity testing
“(1) A person is guilty of an offence if they attempt to establish that another person is a virgin by making physical contact with their genitalia.
(2) A person is guilty of an offence if they provide another person with a product intended for the purpose, or purported purpose, of establishing whether another person is a virgin.
(3) A person is guilty of an offence if they aid, abet, counsel or procure a person to establish that another person is a virgin by making physical contact with their genitalia.
(4) No offence is committed by an approved person who performs—
(a) a surgical operation on a person which is necessary for their physical or mental health; or
(b) a surgical operation on a female who is in any stage of labour, or has just given birth, for purposes connected with the labour or birth.
(5) The following are approved persons—
(a) in relation to an operation falling within subsection (4)(a), a registered medical practitioner; and
(b) in relation to an operation falling within subsection (5)(b), a registered medical practitioner, a registered midwife or a person undergoing a course of training with a view to becoming such a practitioner or midwife.
(6) There is also no offence committed by a person who—
(a) performs a surgical operation falling within subsection (4)(a) or (b) outside the United Kingdom; and
(b) in relation to such an operation exercises functions corresponding to those of an approved person.
(7) For the purpose of determining whether an operation is necessary for the mental health of a girl it is immaterial whether she or any other person believes that the operation is required as a matter of custom or ritual.
(8) This section applies to any act done outside the United Kingdom by a United Kingdom national or resident.
(9) A person who is guilty of an offence under this section is liable, on summary conviction, to imprisonment for a term not exceeding 12 months, to a fine, or to both.
(10) The court must refer the case of any person guilty of an offence under this section who is subject to statutory professional regulation for investigation by the relevant regulator.”.—(Alex Norris.)
Brought up, and read the First time.
The Chair
With this it will be convenient to discuss new clause 2—Prohibition of hymenoplasty—
“(1) A person is guilty of an offence if they undertake a surgical procedure for the purpose of re-attaching membrane tissue, creating scar tissue or otherwise attempting to re-create the hymen in the vagina of a patient.
(2) A person is guilty of an offence if they advertise the service of hymenoplasty or any service that purports to ‘re-virginise’ or otherwise re-create or re-attach the hymen of a patient by way of surgical procedure.
(3) A person is guilty of an offence if they aid, abet, counsel or procure a person to undertake a surgical procedure for the purpose of re-attaching membrane tissue, creating scar tissue or otherwise attempting to or re-creating the hymen in the vagina of a patient.
(4) This section applies to any act done outside the United Kingdom by a United Kingdom national or resident.
(5) A person who is guilty of an offence under this section is liable, on conviction, to imprisonment for a term not exceeding 5 years.
(6) The court must refer the case of any person guilty of an offence under this section who is subject to statutory professional regulation for investigation by the relevant regulator.”.
Alex Norris
I want to speak to new clause 1 in my name and seemingly in the name of half the House. With pleasure, we have reached the new clauses. A central theme runs through the new clauses that my colleagues and I have tabled. If the Government are adamant that now is the time for this Bill, and we have well-established issues with that, then given the significant and growing challenges facing health and social care in this country we really ought to put things in the Bill that will make a difference. Too much of what we have discussed over the previous 18 sessions—give or take—has been about structures and moving things around; this is fundamentally likely to make little to no difference on the frontlines to practitioners or the people that we work for. These new clauses, and the new clauses in general, seek to try and redress that balance and put things in the Bill that will make an impact in this country.
Dr Whitford
I rise to support new clauses 1 and 2. Although this issue would be within the devolved space, as a doctor, I think that any practice that is in essence being called a medical practice but is not for the benefit of the patient is unjustifiable. I have to say, I think that extends to X-raying child refugees’ teeth or exposing their limbs to radiation for no clinical reason; I find that unjustifiable. The difference with what these two new clauses deal with is that both involve absolute violation of women and girls, and therefore they are way beyond what we would discuss in other spheres. Although these measures would not apply in Scotland, they are about things that are indefensible, as are other practices that we have heard about, such as female genital mutilation, and so on, which some have tried to disguise as cultural, religious or other practices. Therefore, I totally support the principle and the idea behind these new clauses.
Edward Argar
While, on occasion, there has not been unanimity in this House, I share the sentiments expressed by the hon. Lady and the shadow Minister, the hon. Member for Nottingham North.
I am grateful, first to my hon. Friend the Member for North West Durham (Mr Holden) for his private Member’s Bill on this issue, which originally raised it, and I am also grateful to the shadow Minister. I do not always say that about some of his amendments, but I am grateful to him and his colleagues for tabling this new clause, which gives us the opportunity to debate this issue in Committee. I am aware of the work that my hon. Friend has done to raise the issue and I know how strongly the shadow Minister feels about it as well.
First, I want to reassure the Committee that safeguarding vulnerable women and girls is a key priority for the Government, which is why on 21 July we announced our commitment to ban virginity testing in the Home Office-led tackling violence against women and girls strategy, so I think we are of one mind on the principle. I will talk a little bit about the mechanism, the drafting and similar, but it is fair to say that we are of one mind on the principle here. Such tests are, as the shadow Minister said, a violation of human rights and are clearly known to have an adverse and long-term impact on women and girls’ physical, psychological and social wellbeing.
New clause 1, which the shadow Minister tabled and spoke to, gets to the very heart of what we intend to do with regard to virginity testing: ban it. I wholly agree with the spirit of new clause 1; however, I fear that we cannot accept it as drafted. There are several reasons for that, which I will outline. Nevertheless, I hope that in my opening remarks I have reassured him that we are of one mind on this issue, and I will set out the next steps.
By way of further reassurance, may I also say to the Committee that the Government have clear plans to introduce our own legislation, at the appropriate moment and at the nearest opportunity, to criminalise virginity testing? There is work to be done on the drafting and, as the shadow Minister would expect, through discussions within Government. However, I can put on the record in this Committee that it is absolutely our intention to legislate in this space.
While the wording of that legislation will differ slightly from the wording of the new clause, I want to reassure the shadow Minister and other Members that the policy intent and policy outcome will be exactly aligned. Parliamentary drafting is not only an art but a significant skill, and a very technical one. Therefore, we are utilising the best drafting we have available to see how we might achieve the outcome in the appropriate way, subject to cross-Government approvals.
I will also say that the Government absolutely share the shadow Minister’s concerns about how virginity testing is essentially driven by a repressive approach to female sexuality and is a form of violence against women and girls that must be eradicated.
Our concerns about the drafting of the new clause include that it does not specify where in the United Kingdom the offence would apply. It is unclear whether the offence would apply in each of the four nations of the United Kingdom or in England only. That is a drafting technicality, but we think that clarity is important. We are in the process of seeking four-nation-wide agreement on virginity testing in each of the nations, and we are working through options on what that might look like, reflecting our shared view that virginity testing has no place in any part of our United Kingdom, and that the safety of women and girls is paramount wherever they are in the four nations.
Another concern about the drafting is the inclusion of defences. The new clause would provide that in certain circumstances, such as in the course of a surgical procedure undertaken by an appropriate medical professional, an offence would not be committed. The Department’s internal review of virginity testing and hymenoplasty found that virginity tests have no clinical or scientific merit, as the hon. Member for Nottingham North said. There is no reliable way to establish virginity, nor is there any clinical reason to know if a woman or girl is a virgin. As such, we are clear that there is no clinical reason for such an examination or operation to be carried out, and we therefore question the legitimacy of including such a defence in the new clause.
I have set out some of the key drafting challenges in the new clauses and I hope that I have given a flavour of the Government’s thinking. The drafting detail of our policy approach is being carefully considered, with the safety of vulnerable women and girls as our guiding principle. The hon. Gentleman may be reassured that the spirit and policy intention of the new clause will be reflected in future legislation as swiftly as we can draft it and secure agreement to bring it forward.
New clause 2, which was tabled by my hon. Friend the Member for North West Durham and supported by the hon. Member for Nottingham North, seeks to ban hymenoplasty in the United Kingdom. While the Government share the concerns underpinning the new clause—that hymenoplasty is driven by a repressive approach to female sexuality and closely associated with virginity testing, so it is right that we debate the new clauses together—we also have concerns about timing and process.
After the Department of Health and Social Care conducted an internal review of virginity testing and hymenoplasty, the Government announced in the tackling violence against women and girls strategy that they would convene an expert panel to explore the clinical and ethical aspects of the procedure in more detail. The Government’s primary concern after the initial review was that there was no clearly defined consensus on whether hymenoplasty should be banned. As a Minister, I will not go as far as the hon. Member for Nottingham North while a review has been commissioned, or comment on what that review might say in detail. Arguments have been made on both sides. The hon. Gentleman has a clear view, and he may suspect he knows what my view is, but it is right to allow the expert panel to do its work swiftly and clearly and to use it as our evidence base.
It is fair to say that the overwhelming majority of stakeholders are clear that hymenoplasty perpetuates harmful myths about virginity and could constitute a form of violence against women and girls. Concerns have been expressed about whether banning the procedure could push the practice underground. It is important that the expert panel bottoms out those arguments and gives us a clear basis for proceeding. My challenge with the new clause is simply a matter of timing: it is important that we have the report from the expert panel.
To ensure balance and impartiality, the expert panel is co-chaired by Professor Sir Jonathan Montgomery and Dr Pallavi Latthe, both of whom are well respected in their areas of expertise. Both have extensive experience in this area of health ethics, and it is important that we let them do their work and then consider what they say. We will consider their recommendations as soon as they are brought forward, and I hope that will happen swiftly.
The recommendations will need to be fair, objective and based on evidence, so I hesitate to go beyond that in expressing a view on the substance of the new clause until I have that expert panel report before me. It will be presented for Ministers’ consideration, and I assure the hon. Gentleman—I can see where he might go with this—that the intention is to publish it before the Christmas recess. It is a swift piece of work. We will consider the report and, depending on its contents, bring forward legislation if or as appropriate, considering everything it contains in the context of vulnerable women and girls’ safety.
Alex Norris
Let me come back briefly on a couple of issues. First, I am grateful for the contribution of the hon. Member for Central Ayrshire and, in particular, her point about non-medical practices dressed up as medical practices. That is a particularly insidious way to inflict abuse on another person, and I completely agree with her that that is an absolute violation—it is as totemic as that.
We will all have taken great encouragement from the Minister’s response. I am grateful for that. I associate myself with the comments he made about the hon. Member for North West Durham—I should have said that in opening. Between us, we will ensure that he sees a copy of the proceedings, and he can take great encouragement from what the Minister said.
It was particularly welcome to hear that the Government intend to legislate in this space, with the intent for that to be at the earliest opportunity. That is good news, and the Opposition will support them in that process. I gently say—I know he enjoys these exchanges—that we are currently considering primary legislation, so this is definitely the earliest opportunity. If there are moments for the Government to revisit this issue on Report or in the other place, he will find colleagues very welcoming of that.
I do not want to shatter the consensus that has grown by dividing the Committee, so I do not intend to press either new clause to a Division. However, on new clause 2, we will look at what the expert panel says. I will be interested to see the divisions in opinion—I have not been able to find them. We look at these things on their merit, but the commitment to see the report before Christmas was welcome and will give great heart to campaigners in this space. The Opposition look forward to seeing the proposals and will be keen to support them if they can achieve the goals that we seek. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 3
Annual parity of esteem report: spending on mental health and mental illness
“Within six weeks of the end of each financial year, the Secretary of State must lay before each House of Parliament a report on the ways in which the allotment made to NHS England for that financial year contributed to the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of mental illness.”—(Justin Madders.)
This new clause would require the Secretary of State for Health and Social Care to make an annual statement on how the funding received by mental health services that year from the overall annual allotment has contributed to the improvement of mental health and the prevention, diagnosis and treatment of mental illness.
Brought up, and read the First time.
Justin Madders
I beg to move, that the clause be read a Second time.
The Minister referred to my longevity in post, which gives me the advantage of having had this debate with him previously. That does not make it any less important; in fact, the subject has only risen in importance in the intervening period. That is why the Opposition were pleased to put our name to the new clause, which was tabled by the hon. Member for Newton Abbot (Anne Marie Morris).
In March, the Centre for Mental Health reported:
“There are…many areas where parity of esteem has not yet been realised. Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”
Parity of esteem is the principle by which mental health must be given equal priority to physical health. Many of us assumed that it had always been there, but debates have gone on over the years and, as that figure suggests, it is still some way from being achieved. The founding National Health Service Act 1946 spoke of a comprehensive health service, securing the improvement of both physical and mental health, and the National Health Service Act 2006 said the same. That principle was enshrined in the Health and Social Care Act 2012—at least, the parts of it that remain.
In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through the NHS mandate. However, there are reports that this requirement falls down at a local level. Certainly as a constituency MP, I have a whole range of stories of people not being able to access treatment in a timely manner, or being pushed around the system with very little effect and discharged from care before it was appropriate, with consequences we can all imagine. It is difficult to overestimate how challenging that is, not just for the individuals, but for the local commissioners when they face competing pressures.
We are not suggesting that the 20% to 30% gap should be closed entirely, but we should be looking to at least get on the road towards delivering true parity. There was a missed opportunity earlier in this Bill when we suggested that one of the mandated positions on the integrated care board should be a mental health representative. Should that have been accepted, the ambitions behind the new clause would have been much easier to achieve. It is about not just getting on the road to financial parity, but actually changing the culture so that disparities can be addressed. It does sometimes seem that mental health is the Cinderella service: the one that gets cut first at the expense of the more visible services where people, understandably, can see if a particular service is shut down.
It should go without saying that it is part of the Secretary of State’s normal duties to promote mental health care, but that is something that has been sadly missing. While we do not want to get into an exact science on spending, we do think that much more can be done in terms of delivery and outcomes. Looking at some of the hard facts, it is clear how far we have to travel. One in four mental health beds has been cut since 2010; just last year, 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic, and I am sure most Members will have similar stories from their own constituencies of people in desperate need of help—young people whose entire lives could change by getting the right help at the right time, but who are not able to access services despite there being an obvious clinical need.
That must change. We need parity to mean something in practical terms. We hope that the new clause would create a shift in culture by requiring the Secretary of State to lay a report before Parliament addressing whether the aim of parity of esteem has been delivered.
Dr Whitford
The shadow Minister speaks about people who have been referred to mental health support but are not able to get it. Is there not a need to be moving that further upstream? Young people in particular struggle to access child and adolescent mental health services, and often that is because there is not resilient support within schools and there is no counselling at an early point when they are struggling that might mean they do not need to go to a specialised service. As there is none of that, their mental health may deteriorate until the only option is to join a long queue to attend a hospital unit. Therefore, should we not shift to looking at wellbeing—both physical and mental wellbeing—and the resilience of children and young people who have suffered over the past 18 months?
Justin Madders
I am grateful for the intervention—that is a very fair point. I recently spoke to a CAMHS worker who made that very point. One of their frustrations was that problems were not being addressed by early interventions, which only stores up more difficulties for later. Again, that is a symptom of the fact that we do not have parity of esteem, because early interventions can ultimately make a huge difference. We would like to see better access to services and appropriate waiting times being established for a wider range of mental health services, so that people with mental health problems know the maximum time for treatment, as is the case for people with physical health problems. I know the Department has been consulting on that fairly recently, and we think it would be a step change in how we assess and prioritise mental wellbeing.
Parity of treatments is required. Psychological therapies that are approved and recommended by the National Institute for Health and Care Excellence should be delivered as per the NHS constitution, and they should be put on a par with NICE-approved drugs. People need 24/7 access to mental health teams. The A&E presentations that we hear so much about have to be considered—that is probably not the optimum way to deal with such issues. There is a whole range of matters that really could make a practical difference in delivering parity of esteem, and we think that the report proposed in the new clause would be a way to drive through some of those changes.
I will not push for a vote on new clause 3, but we wanted to highlight the urgent need for more support for mental health services throughout the UK. Hopefully, the Minister will at least acknowledge that more needs to be done in this area.
Edward Argar
I welcome the spirit in which the shadow Minister brings this issue to the Committee. He is right to highlight not only the words “parity of esteem” but what they mean in practice, the importance of mental health services—particularly after the past year and a half with the rise in people suffering from mental health problems—and the challenges posed every day to our mental health services, irrespective of the pandemic. I suspect that throughout their time in this place, all Members present will have had multiple pieces of constituency casework relating to this issue, and particularly to CAMHS.
It is absolutely right that the shadow Minister has focused our debate on ensuring that mental health services are sufficiently funded to improve access, care and outcomes for patients. We know that, historically, mental health services under successive Governments have not received the same level of funding as NHS-funded services for physical health. By virtue of section 1(1) of the National Health Act 2006, which was inserted by the Health and Social Care Act 2012, the Secretary of State has a “duty to promote comprehensive health service” in England
“designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of physical and mental illness.”
Although there may be many things in the 2012 Act that I suspect Opposition Members do not agree with, I suspect they will agree with that clear objective. Given what the shadow Minister said, I am sure they do.
In line with that duty the Secretary of State, through the NHS mandate, ensures that NHS England must seek to treat mental health with the same urgency as physical health. That is monitored through three metrics: mental health services’ real-term expenditure growth, the number of people accessing Improving Access to Psychological Therapies services, and the number of children and young people accessing NHS-funded mental health services. The Secretary of State has a legal duty to keep under review the progress in meeting mandate objectives. NHS England and NHS Improvement provide reports on the above metrics for the Government’s review on a regular basis, and they have governance mechanisms in place to monitor both mental health spend and service delivery.
Justin Madders
I am grateful for the Minister’s comments. If the investment standard is being met across the board, perhaps it is the investment standard that needs looking at rather than the services themselves. We are all aware that there is a lot more to do in this area. As the Minister rightly says, no doubt we will return to it, so I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
New Clause 5
Support provided by the NHS to victims of domestic abuse
“(1) Each Integrated Care Board must—
(a) assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services;
(b) prepare and publish a strategy for the provision of such support in its area;
(c) monitor and evaluate the effectiveness of the strategy;
(d) designate a domestic abuse and sexual violence lead; and
(e) publish an annual report on how it has discharged its duties relating to the provision of services to victims of domestic violence under the Care Act 2014.
(2) An Integrated Care Board that publishes a strategy under this section must, in carrying out its functions, give effect to the strategy.
(3) Before publishing a strategy under this section, an Integrated Care Board must consult—
(a) any local authority for an area within the relevant Integrated Care Board’s area;
(b) the domestic abuse local partnership board appointed by the local authority for an area within the relevant clinical commissioning group’s area under section 58 of the Domestic Abuse Act 2021; and
(c) such other persons as the relevant local authority considers appropriate.
(4) For the purposes of subsection (4), “local authority” means—
(a) a county council or district council in England; or
(b) a London borough council.
(5) An Integrated Care Board that publishes a strategy under this section—
(a) must keep the strategy under review;
(b) may alter or replace the strategy; and
(c) must publish any altered or replacement strategy.
(6) The Secretary of State may by regulations make provision about the preparation and publication of strategies under this section.
(7) The power to make regulations under subsection (7) may, in particular, be exercised to make provision about—
(a) the procedure to be followed by an Integrated Care Board in preparing a strategy;
(b) matters to which an Integrated Care Board must have regard in preparing a strategy;
(c) how an Integrated Care Board must publish a strategy;
(d) the date by which an Integrated Care Board must first publish a strategy; and
(e) the frequency with which an Integrated Care Board must review its strategy or any effect of the strategy on the provision of other provision in its area.
(8) Before making regulations under this section, the Secretary of State must consult—
(a) all Integrated Care Boards; and
(b) such other persons as the Secretary of State considers appropriate.”—(Alex Norris.)
This new clause would require Integrated Care Boards to publish a strategy for the provision of support for victims of domestic abuse using their services and designate a domestic abuse and sexual violence lead.
Brought up, and read the First time.
Alex Norris
I beg to move, That the clause be read a Second time.
For Opposition Members in Committees of this type, as we assemble the issues that we prioritise in proceedings, we have to be a bit of a magpie and pinch things along the way, so I want to recognise that this new clause is pinched from the hon. Member for Newton Abbot. I am grateful to her for tabling this and for the level of thought that she put into the amendment, which is a very good one.
Earlier in the proceedings, we discussed integrated care board plans and their responsibility to engage with the Domestic Abuse Commissioner. I was grateful for the commitments that the Minister made. There was a common understanding that the health and social care system has a crucial role in both preventing and tackling domestic abuse and in supporting victims and survivors. That sounds self-evident, but we are not in that position in this country yet, and we could do much better. I hope we can build on that consensus with the new clause, which requires integrated care boards to publish a strategy for the provision of support for victims of domestic abuse using their services and to designate a domestic abuse and sexual violence lead.
I will not repeat the arguments that I made earlier regarding the scale of domestic abuse, but it is worth reiterating top lines, particularly the global statistics from the World Health Organisation, which show that 30% of women have experienced some form of physical and/or sexual violence by an intimate partner in their lifetime. In this country it is one in four, so it is of a similar order of magnitude. The Government’s own estimate is that it costs health services £2.3 billion annually. A common refrain from the sector, with which I meet a lot, as I did before coming to this place, concerns the impact it could make with a fraction of that money if it was put into statutory services or the services that it provides. We should think about that investment model.
In discussing the new clause, I want to take the opportunity to cover something that we have not previously considered, namely domestic abuse, which tends to be against women but also concerns people with disabilities. According to Stay Safe East, disabled people and, most specifically again, disabled women, experience higher rates of domestic abuse than those who do not have disabilities. Abuse against women with disabilities is likely to be more violent and to happen over a longer period before the victim discloses it or can access help. The really sad thing is that if the victim––who is living with a disability––is not heard, there is a significant risk that they will then be sent home by the system to be cared for, in the very loosest sense, by their abuser. None of us would want that but it is the sort of thing that happens at the moment because we do not have a strong enough grip. I hope that we can use the new clause and the Bill generally to take more active steps to address that problem.
There is clearly a significant need for specialist domestic abuse services, which are crucial to enable women’s recovery in particular. Often, such services take on the work of statutory services and provide vital advocacy for women facing health exclusion, particularly in respect of services supporting black and minoritised women. It came out strongly in the debate on what is now the Domestic Abuse Act 2021 that we need specific and specialised services for those who are at greatest risk of being excluded. We did not quite get there in those provisions. I confess to using every legislative and parliamentary opportunity to keep pushing at this because it is really important and we can do much better.
We know that medical staff receive some training in adult safeguarding and, in a few hospitals, even on domestic abuse and sexual violence. But the skills and time to communicate with people with, say, learning disabilities or cognitive issues, with deaf survivors or with very elderly people who might be less likely to disclose personal information are not always available, and certainly not universally. The new clause seeks to put the onus on the integrated care system to get organised around this, to specialise and to prioritise it. It should be a priority across the system.
Dr Whitford
Does the hon. Gentleman think that we also have a job to do socially in reducing the stigma? I have worked in casualty departments and as a surgeon facing women who had clearly been abused but were standing or lying there making excuses for their abuser and saying why it was their own fault. As well as women with disability, there are women with insecure immigration status or insecure financial status who have no money of their own and feel that they have nowhere to go. I support the principle here, but we have a much bigger job to do around domestic abuse, which is endemic across the UK.
Alex Norris
I am very grateful to the hon. Lady for that intervention and completely agree with everything she said. For my part, and that of many of our colleagues, our way to tackle all those different barriers is to seek to put this in every bit of legislation. Most domestic legislation touches on these issues.
What is pertinent to this debate is thinking about the barriers to reporting. One barrier is the fear of not being believed. Of course, there is a bigger fear around prosecutions, which the Minister took a personal interest in when he was a Justice Minister, but it is clear from the evidence that we are not making enough progress. We have heard lots of positive sounds from the Government but no concrete proposals for change. We could do much better there.
On the barrier of not being believed, one way to create a better environment for a survivor to disclose what has happened to them is by their knowing that the person they are talking to in that healthcare setting has had training and works in a system that prioritises the safe disclosure of abuse. That would do a lot to build confidence. On the hon. Lady’s point about migration status, it is important that we talk about that. It was a key theme in the Domestic Abuse Act. There must be safeguards in place so that the disclosure of abuse trumps immigration status. The practitioner that they work with must be someone whose role is to help them address those issues, not someone who will be speaking to the Home Office. That first knock on the door will be someone trying to help them deal with the abuse and its impact on their life; it will not be from someone trying to resolve their migration status. That is an important principle.
Returning to the new clause, meeting with a professional social worker who ought be trained in assessing risks, including domestic abuse, might be the significant moment that an older or disabled person discloses domestic or other abuse. If given time and asked skilful questions in a safe environment, the person may disclose or express their fears, knowing they can do so in a protect manner. But across the country, such interventions are not falling into place on their own.
Women’s Aid’s data shows that in 2019-20, no refuge services responding to its survey were commissioned by their CCG, and just 10% of community-based services were. This is a multi-agency issue. I fought very hard to persuade the hon. Member for South Derbyshire (Mrs Wheeler) when she was Housing Minister that there ought to be investment and support going into the services through local government. She took that on, which was a good thing. Local authorities alone cannot tackle this issue. The picture that emerges from the evidence is that health agencies are not delivering as they ought to.
To be clear on what our modest ask is, subsection (1) states that each board must
“assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services”.
That is pretty basic. Following that, it must prepare a strategy, monitor that strategy and have an annual report on it, but particularly, under paragraph (d), it must
“designate a domestic abuse and sexual violence lead”,
because we know that in organisations such as the police or health organisations, where they have designated such a person, that person has been impactful. Those are pretty basic requirements. On many occasions the Minister has said that the point of the system is to be a permissive one and to let local areas shape services in the interests of their population, depending on the challenges they face; but the reality is that this problem is in every community, and we ought to be clear to ICBs that we expect this kind of activity. Subsection (3) includes a modest ask for consultation, which is reasonable and desirable.
Women in particular, and all our communities, desperately need this issue to be given deliberate focused attention. There is a high degree of consensus on it, but that does not lead to action frequently enough. The appointment of a Domestic Abuse Commissioner, which we have discussed, was a welcome step, but from a health and social care perspective we need to do more in the system. At the moment, that is not happening. That is not because I think that commissioners, leaders and decision makers do not think it is important, but they have an awful lot on. This can be a hidden crime that goes on behind closed doors, and as such drops down the list of priorities because of the urgent pressures on them; but we cannot let it go. As well as the leadership that we try to display on a national scale, we must do more to encourage this on a local scale. In this case, that is in the strategies and plans of the ICBs. We should make sure that happens.
To conclude—this is in the same vein as what I said when we debated new clauses 1 and 2—we should in our remaining time seek to put in the Bill things that will change people’s health outcomes, and outcomes in life more generally. New clause 5 is one of those things, so I hope the Government are in listening mode.
Edward Argar
I put on record my gratitude to my hon. Friend the Member for Newton Abbot and to the hon. Member for Nottingham North for enabling this discussion to take place in Committee today. I find myself in deep agreement with the idea that the NHS can play a vital role in protecting vulnerable people and, as part of that, it must have strategies and processes in place for supporting victims of domestic abuse, sexual violence and other forms of harm.
The hon. Gentleman was kind to refer to my stint at the Ministry of Justice, when as Victims Minister I took a close interest in this issue with Dame Vera Baird, the former Member for Redcar, in her role as Victims’ Commissioner—I pay tribute to her—and with the Minister of State, Ministry of Justice, my hon. Friend the Member for Louth and Horncastle (Victoria Atkins). My hon. Friend and I worked on the early stages of the Domestic Abuse Act 2021, and she saw that work through—I had moved to this role by then—before receiving a well-deserved promotion. I took a close interest in this issue when I was in the MOJ, and hon. Members from across the House will have found that it is not forgotten or left behind; we always reflect on it and see how we can continue to play a part when in other roles.
The hon. Member for Central Ayrshire was right to highlight the challenges that many people feel. The stigmas are completely unjustified, but people feel them because of the nature of the abuse and the controlling and coercive behaviour to which they have been subjected. When I was at the MOJ, I discovered the limitations of legislation in this space. We can and should legislate in certain areas, but a lot of this is about how services work on the ground, how we talk about this as a society, and how we break down the stigmas. One of the key things that I took away from my time at the MOJ was that tackling domestic violence and abuse is not just the responsibility of the justice system or the NHS; it is our responsibility as a society. I hope I can reassure the shadow Minister. On some areas, we tend to find ourselves in agreement rather more than is perhaps good for either of our political careers, but on this I entirely share his sentiments.
Turning to new clause 5, I hope to reassure the Committee that placing in the Bill a formal duty on ICBs to develop a separate strategy is unnecessary and not the best approach, but I hope the Committee will allow me to expand on my reasoning. There are already several duties on CCGs to consider the needs of victims of violence, including victims of domestic abuse, through the joint strategic needs assessment process. CCGs must respond to identified needs through health and wellbeing strategies. The duties will be transferred to and continue to apply to ICBs once CCGs are abolished, and will be further strengthened by the requirement on ICBs to develop system level commissioning plans. Through the Government’s landmark new Domestic Abuse Act 2021—it would be churlish of me not to recognise the Opposition’s work on it—local healthcare systems will be required to contribute to domestic abuse local partnership boards.
I slightly caution against requiring ICBs to create further additional strategies and plans, separate from those already in the Bill. I recognise the impulse to require NHS bodies to do this, because the theory is that a separate strategy will attract particular attention. My note of caution is because in doing so, we are saying, “We will put that over there, in that strategy” rather than having it as a thread that runs through all the strategies, underpinning strategic documents and plans of the local NHS and the ICB. We risk separating it and putting it in a different compartment from the wider span of integrated responsibilities, which is where it should sit.
The new clause also places a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we believe we can do that effectively through existing legislation and guidance. As set out in the Government’s recent violence against women and girls strategy, the Department of Health and Social Care will be engaging with integrated care systems and providing guidance to promote best practice in addressing violence against women and girls, domestic abuse and sexual violence. That could well include advice on designated leads and those internal structures and processes.
Beyond ICBs, I see a huge opportunity for integrated care partnerships to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnership working. I am sure we have all undertaken visits to women’s refuges or to other charities that support women who are victims of domestic abuse. I should just say that it is, of course, true that men and women can be victims of domestic abuse. I refer to women in this context because an overwhelming number of victims are women, but it can happen to anyone, irrespective of gender.
In my previous role, I had the privilege of meeting survivors of domestic abuse, who were willing to talk to me about what had happened and their recovery from and survival of domestic abuse. In those conversations, people would often say, “I dealt with one agency, but it did not talk to this agency and this bit did not join up.” There is a real opportunity for the ICPs to work with housing providers, local authorities, the NHS and other voluntary and third sector organisations to help to bring together a more coherent and joined-up approach.
More broadly, I assure the Committee that the NHS will be at the forefront of stepping up to its responsibility to play its part in tackling domestic abuse, sexual violence and violence against women and girls. NHS England is developing enhanced trauma-informed mental health support for victims with the most complex needs within the sexual assault and abuse pathway. The DHSC’s new office for health promotion will work with the newly merged NHS England to review and build on workforce policies to ensure safe, effective processes are in place to support staff affected by domestic violence and sexual violence.
I hope I have reassured the Committee that we take this issue extremely seriously. Although we do not think that the approach proposed in the new clause is the right one, I am open-minded and happy to work across the aisle to see if there is more we can do in this space, in keeping with the strategy set out by my hon. Friend the Member for Louth and Horncastle when she was at the Home Office, and to see if there are other ways to achieve essentially the same objective.
Alex Norris
I have listened carefully to what the Minister has said, and I agree with significant elements of it. I take the point about existing duties on CCGs, and I am very mindful of those. The reality is that they do not work, or they certainly have not worked to date. I have no confidence that anything will change if current arrangements are just ported over to integrated care boards, which is what will happen. I do not think anything will change. I cannot imagine what will have changed in that moment to make it different, and I cannot therefore agree with the characterisation that the new clause is unnecessary.
I accept that we would not want to see a proliferation of further strategies. By making it a requirement, the new clause seeks to put the treatment, assessment and care of domestic abuse on the same footing in integrated care as elective care or major diseases. It should have that status, and at the moment it does not. It needs to be elevated to that level. I do not disagree at all with the Minister’s point about domestic abuse being a thread that runs through all policies. The reality is that we have been saying that for a really long time. What actually happens is that it is in everything and, as a result, it is in nothing, and things do not change. Certainly, they are not changing quickly enough in the health space.
Finally, on the point about integrated care partnerships, I hoped that the Minister would not say what he did, because that is the problem. The fundamental issue is that those who are making the direct daily decisions about health and care in our communities are downgrading the issue by considering what they do not as operational, daily, immediate, crucial decisions—in the way they would with elective care or cancer care—but instead as partnership work.
I would never talk down the pledges that we sign or the awareness days we do. I have signed all the pledges and gone to all the awareness days, and I will keep doing that because it is an important way of keeping the pot boiling. However, I am not convinced that they have done enough to make my constituents safer or give them a better health service. I have seen no evidence of that yet. This is not partnership work, but daily, crucial work that ought to be done by system decision makers, who ought to be prioritising it every day, but I do not think that is the case.
Edward Argar
If I was unclear, I apologise; that was not the intention of what I was saying. I sought to say that that partnership work brings together organisations that, I believe, do focus on the issue day to day and have it as an operational priority, but often still operate in silos. In some of the best partnerships in the best local authority areas, those silos are much less evident. My point about the ICP was not as an alternative to making this front and centre, and asking “What are you doing in your operational decision making?”—be it about elective care, cancer or domestic abuse, and treating them the same—but that often it operates in a way that is internal to those organisations, rather than across them.
That was the point I was trying to make about partnership: not only do we need that internal process and urgency—I totally share the hon. Gentleman’s view on that—but we need the ICPs to offer an opportunity to do that by bridging organisations. I hope that adds a little clarity, if I was unclear.
Alex Norris
It does, and of course I would not want to misrepresent what the Minister said. My point is that, while of course we should seek to work across the partnership and have a cross-partnership approach to tackling this issue in our communities—that is a very good thing to do—the problem currently is that that means we are not doing enough in the health and care space. There has to be something that says to health leaders, “Yes, work in partnership, but there are bits that you have to do yourselves that at the moment you are not doing well enough, so please do them.” This is my “something”. That was my logic in tabling this new clause, and it is why I intend to push it to a Division.
Question put, That the clause be read a Second time.
Karin Smyth (Bristol South) (Lab)
I beg to move, That the clause be read a Second time.
It is a pleasure to serve under your chairmanship, Mrs Murray. I think I tabled these new clauses back in August; recalling my brain to that time, summer seems like a long time ago now.
New clause 7 may seem self-evident, and I think the Minister may respond, “Yes, we are happy for them to do this, and parts of this have been included in the Bill.” I will not seek to press the clause to a vote, but I had a short conversation with the Minister to indicate that this is really good practice and that we need some assurance that the NHS will abide by the Government’s rules. That is all I seek to do with this new clause. It is self-evident that papers should be published in advance and made available to people, and that due process should be followed, but we all know that that often does not happen. Sometimes there are emergency reasons for that, but in my experience, it rarely needs to happen at the last minute.
Justin Madders
It is a pleasure to follow my hon. Friend the Member for Bristol South, who said what should not really need saying, but still needed to be said, because being open and transparent is the highest form of accountability. Given the history of the NHS as the archetypal public service, one would expect it to be the model of openness and transparency. Maybe it was at one point, but we are a long way from that now. In a public service on the scale of the NHS one would expect the sharing of best practice to be the norm and openness to be the standard. Unfortunately we know that it is not, and one has to ask what it is people want to hide from others.
We know of classic examples of how a secretive approach has made matters far worse than they were. The various inquiries have shown that these methods have not only prevented things from being released, but have actively protected colleagues, units and even trusts from what might, at the very least, be considered reputational damage. Many have said that the best disinfectant is sunlight—or words to that effect—and the best governance comes when things are open and transparent. The best checks and balances are only possible if all information is shared properly.
I will quote from the code of conduct for NHS boards, agreed two decades ago between the NHS Appointments Commission and the Department of Health. I believe it is as valuable today as it was then. It says,
“Health needs and patterns of provision of health care do not stand still. There should be a willingness to be open with the public, patients and with staff as the need for change emerges. It is a requirement that major changes are consulted upon before decisions are reached. Information supporting those decisions should be made available, in a way that is understandable, and positive responses should be given to reasonable requests for information and in accordance with the Freedom of Information Act 2000.”
I think we all understand what that seeks to achieve: be open and transparent, listen and engage. History suggests that this has been applied patchily at best.
One of the inevitable consequences of the shift to a belief in the markets was the idea that bits of the NHS were only semi-attached to the greater body and had their own paths to travel and own priorities. Some of these bodies were expected to behave like businesses and were given the illusion of having a bottom line or a surplus. They were told that their incomes depended on how many customers they had through their doors and that they would win more through competition with other providers in a quasi-market. That led them to become more insular, self-serving and closed. Why would they want to share information with their competitors? That may sound a little extreme, but there are plenty of examples of that kind of behaviour, which tips over into, essentially, reputational management—being seen to be good and one of the best, but actually covering up some of the worst.
Openness and transparency have been eroded as a result. We saw in the Francis report a renewed focus on openness and transparency, which was meant to lead to better patient outcomes—in theory, at least. The renewed interest in openness gave rise to this statement from the report:
“It is a basic and just expectation of the public that organisations are open, honest and transparent about their performance standards, about the rights of patients and about what happened, and why, if things go wrong. This is the only way to begin to restore full public trust in the NHS.”
Sadly, that was not the end of the matter.
The Lansley Act—the Health and Social Care Act 2012—pushed, I am afraid, many trusts in the opposite direction. Despite the Francis report and talk of duties of candour, we still have horrific reports of failures within the NHS. Those failures often illustrate a refusal to be open and honest, showing a scant regard for whistleblowers and a culture of denial and refusal to accept the challenges. In part, this is another remnant of the Lansley Act. Once the emphasis is on competition, reputation management and business-like behaviours and away from public services, we begin to lose openness and transparency.
Let us go back to the key principles of the NHS as a public service that is accountable to us all, as public services should be. NHS business should be conducted in a way that is socially responsible. The NHS is one of the largest employers in many communities, and it should be forging an open, positive relationship with local communities, working with staff, partners and stakeholders to set out a vision for the organisation in line with the expectations of their communities, patients and the public. None of that can be done in secret, behind closed doors. NHS organisations should not only discuss but demonstrate to the public that they are concerned about and determined to deal with the wider health of the population, including how it relates to the organisations’ own impact on the local economy, the local environment and so on. They should reflect the values of engagement, which should be at the forefront of all decision making, and transparency, which should be there in all dealings.
Edward Argar
I am grateful to the hon. Member for Bristol South for tabling this new clause. Much of what we discussed in relation to amendment 34 is relevant here as well. She says she seeks to be helpful by tabling the new clause. I take it in that spirit and will seek to respond in that spirit, although we may not agree on our conclusions.
As I said when we debated amendment 34, we agree with the shadow Minister, the hon. Member for Ellesmere Port and Neston, and the hon. Lady that it is right that ICBs involve the public in their decisions in a transparent way. That also holds true for NHS England, NHS provider organisations and special health authorities. The new clause would require NHS trusts, foundations trusts, proposed ICBs, NHS England and special health authorities to hold their meetings in public except if it would be prejudicial to the public interest to do so. It would also require those bodies, when making major decisions—defined by thresholds of cost or impact on patients or staff—to do so having produced a business case, undertaken a stage gate review or similar external assessment, and considered comments from the public, patients or staff representatives. The comments, business case and review could not be considered commercially confidential under the FOI Act.
As I mentioned when discussing amendment 34, much of that is already the case. First, the Public Bodies (Admission to Meetings) Act 1960 places a similar and analogous set of requirements to involve the public in meetings as the new clause. NHS England and NHS trusts are already included in the schedule to the 1960 Act, so are subject to the requirements of that Act. Schedule 4 to the Bill provides for integrated care boards to be added to the schedule to the 1960 Act as well, thereby bringing their activities within its competence.
The position of special health authorities is that where the regulations establishing them provide as such, they are to be subject to the requirements of the 1960 Act. That gives the flexibility to include them as appropriate. For example, NHS Blood and Transplant and the NHS Trust Development Authority—which the Bill proposes merging with NHS England—are included at present.
By having the requirements for public notice of, and attendance at, meetings of those bodies set out in the 1960 Act, we keep NHS bodies in line with the requirements placed on other public bodies, meaning that everyone is clear about the legal requirements and what the public can expect from them. Foundation trusts are not formally covered by the 1960 Act, but it is mandatory that they make provision in their constitutions that their board of directors’ meetings and their annual meeting of members be held in public. They are also under the same duty as NHS trusts to involve those who use their services in their decisions regarding service provision, as set out in section 242 of the National Health Service Act 2006. In practice, therefore, foundation trusts are guided by similar principles to other NHS bodies.
Turning to the point about setting in legislation a decision-making process for “major decisions”, we of course agree that it is vital that NHS bodies follow a robust process when making decisions. Integrated care boards, for example, have clear duties to use their resources efficiently and effectively. For practical reasons, however, we would not want to subject every major decision to a single fixed approach, not least because there is no provision in the amendment for responding to emergencies or rapidly emerging situations, including those related to patient safety.
I hope that I can, however, give some degree of reassurance that there are, as set out in the 2006 Act, broad duties on NHS bodies in respect of consultation and public involvement. NHS England involves those who are affected by decisions about commissioning in the decision-making process, either by consulting them or by providing them with information in other ways. A similar duty will be imposed on ICBs by clause 19. NHS trusts and foundation trusts have a similar duty in respect of public involvement and consultation when making decisions about the services they provide, again set out in the 2006 Act.
The Committee is also aware that the Treasury is committed to seeing business cases where capital spending, or whole-life cost spending for IT, is more than £50 million, and we expect ICBs to align with that standard. Furthermore, NHS England has a broad range of powers to issue guidance on how ICBs and others make decisions, spend capital and involve patients and the public in those decisions. Placing those processes in guidance, rather than on the face of the Bill, gives not only the flexibility to set different approaches in different circumstances, but the ability to respond to changing best practice.
On procurement and transparency, as we have discussed, the Bill introduces a power to bring forward new procurement regulations, which will set out the new provider selection regime. Regulations and statutory guidance will set out rules to ensure transparency and scrutiny under the new regime, which will be designed to ensure open, transparent and robust decision making, and will require decision-making bodies to demonstrate the rationale for their decisions. The decision-making process will be recorded internally by NHS bodies and audited annually. While decision-making bodies will be required to publish contracts awarded and intentions for the method of procurement, with a rationale for both, the bodies will not be required to publish every detail of their decision-making process.
Regarding FOI requests, I recognise the impulse to be as transparent as possible and agree that, unless exemptions apply, information should be released under the FOI Act. I am advised that confidentiality, which is an absolute exemption, and commercial confidentiality, which is a qualified exemption, are two separate exemptions already in that legislation. Where parts of the decision-making process are exempted on the grounds of commercial interests, those exclusions exist to protect the release of information that could prejudice a commercial decision. That could put NHS bodies at a disadvantage in ongoing negotiations and would be detrimental to the public purse.
I am advised that this is a qualified exemption and therefore disclosure would still be required unless the public interest in withholding disclosure outweighs the public interest in disclosure being made. I recognise that that is a tricky balance to strike, but I do not think it is to the benefit of the NHS that information held by NHS bodies that could be commercially damaging and does not meet a public interest test should be released.
I hope that that offers some reassurance to the Committee. I encourage the hon. Lady not to press her new clause to a Division.
Health and Care Bill (Nineteeth sitting)
Wednesday 27th October 2021
(2 years, 6 months ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 27 October 2021 - (27 Oct 2021)
The Committee divided: - Ayes: 6 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 6 / Noes: 8 - Question accordingly negatived.
The Chair
Before we start, I remind hon. Members about electronic devices, masks and notes to Hansard.
New Clause 7
Transparency of decision-making by NHS bodies
“(1) All meetings of NHS bodies must be held in public and reasonable provision must be made for access to meetings other than by physical attendance.
(2) All—
(a) agendas; and
(b) other papers
to be considered at meetings of NHS bodies must be published at least 10 days before the date of the meeting.
(3) For the purposes of this section an NHS body is—
(a) NHS England;
(b) an Integrated Care Board;
(c) an NHS Trust;
(d) an NHS Foundation Trust; and
(e) a Special Health Authority.
(4) An NHS body may, by resolution, exclude the public from the whole or part of a meeting if it considers that publicity would be prejudicial to the public interest because confidential business is to be transacted at the meeting or for other reasons stated in the resolution.
(5) A resolution to exclude the public from a meeting under subsection (4) must be published at least five days before the date of the meeting and must explain—
(a) what is covered by the resolution; and the reason publication is not in the public interest.
(6) Any responses from the public to the publication of the resolution under subsection (5) must be considered in public at the meeting.
(7) All major decisions taken by an NHS body must be based on—
(a) a business case prepared to the standards required by HM Treasury and published at least one month before the decision is to be considered;
(b) a Stage Gate Review or similar external independent assurance review, the summary of which must be published at least one month before the decision is to be considered; and
(c) consideration of any responses from the public, patients or staff representatives to the business case.
(8) For the purposes of subsection (7) neither the business case nor any part of it nor any record of the consideration of the case by the NHS body may be considered to be commercially confidential under the Freedom of Information Act 2000.
(9) For the purposes of subsection (7) a “major decision” includes, but is not restricted to, any proposal for—
(a) capital expenditure in excess of £5m; the award of any contract with a value in excess of £1m to any organisation that is not an NHS Trust or NHS Foundation Trust; and
(b) any change in the organisation of the provision of services that will involve or may involve—
(i) more than 10 staff; or
(ii) more than 10 patients or service users.
(10) NHS England may publish guidance on the consideration of major decisions under subsections (7) to (9).”—(Karin Smyth.)
This new clause requires all NHS organisations to hold meetings and make decisions in an open and transparent manner and allows the public and patients to express views on important proposals.
Brought up, read the First time, and Question proposed (this day), That the clause be read a Second time.
Karin Smyth (Bristol South) (Lab)
It is a pleasure to see you in the Chair, Mr McCabe. I am grateful for the Minister’s comments, but I am a bit disappointed. The Minister basically set out what was already required, but that was not the issue. Many Members will have found that what is required is not our experience. Meetings are held in private. In my comments this morning I said that increased throughout the ’90s and the noughties. That is not a party political point: it is to do with the increasing competition. The Minister cites Acts from the 1960s, but that is not our experience.
Some foundation trusts have taken the view that they can hold private meetings for their own reasons. It is our experience that decisions are regularly taken before consultation even begins. The consultation that those bodies embark on is often simply about the how, when it should be about the what. The major projects go ahead and procurement commences without what anyone would recognise as a proper business case, with no proper external validation by a gate or any other review. Again, that is the Government’s own policy.
Trusts regularly ignore freedom of information guidance. Businesses cases are withheld because they are contentious, not because they threaten commercial confidentiality—that is a screen behind which people hide. The new clause tries to send the message that the NHS should try harder. The Minister’s response should be to completely agree. He should tell his Department to behave in the way that the Cabinet Office and the Treasury expect, and send that message to the NHS much more strongly.
What does the Minister thinks he has done on compliance? Who is enforcing this? What do MPs and members of the public do when those bodies do not do what we expect them to do? In my experience of recourse to the Secretaries of State, there is no monitoring and compliance, and no real sanctions on people who flaunt the requirements expected. Thankfully, we are not talking about markets and competition, so all the need for secrecy should have gone. I hope the Minister can be stronger within his Department and with the NHS about the standards we expect. I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
Sarah Owen (Luton North) (Lab)
On a point of order, Mr McCabe. Today, new guidance was published in the House that all members of staff in Parliament should wear masks. I am truly shocked that, given we are debating the Health and Care Bill, the majority of the Members on the Government side cannot put on a mask and set an example. Is there anything we can do to remind Members that we all have a duty of care to everyone who works here and their safety?
The Chair
I thank the hon. Lady for her point of order. I should point out that this is not a matter for the Chair. Mr Speaker has encouraged everyone to wear masks when they are not speaking. It would be extremely helpful if people were to abide by that. The hon. Lady’s point is on the record and I am sure it will be drawn to Mr Speaker’s attention.
Justin Madders (Ellesmere Port and Neston) (Lab)
Further to that point of order, Mr McCabe. I understand that it is out of your hands, but this is an important matter for the safety not only of Members but of all staff here. We are in a smaller room than we have been recently, so circulation is probably not as good as we would like. When was the most recent risk assessment on this Committee meeting, and what did it say about the wearing of masks?
The Chair
I have just been advised that there was a statement from the Commission yesterday, but I do not believe there has been a specific assessment in relation to the Committee meeting in this room or any update on that. Again, I point out to the hon. Gentleman that it is not an issue for me. His point is on the record and it will be drawn to Mr Speaker’s attention. I am not sure there is a great deal more that we can achieve at this stage.
Jo Gideon (Stoke-on-Trent Central) (Con)
Further to that point of order, some Members may have medical conditions that we do not wish to disclose meaning we cannot wear masks. I have been sitting in the Chamber for three hours now, and I struggle with wearing a mask for a specific medical reason. I would therefore like to put on record that it is not necessarily a political decision not to wear a mask—sometimes it is for a medical reason. That needs to be understood.
The Chair
I thank the hon. Lady for that further point of order. I have to say to all of you: this is not the venue for this debate. If Members really want to have this debate, they need to speak to Mr Speaker. I have heard what people have said and it is on the record. You are entitled to take it up with Mr Speaker. I am going to move on.
New Clause 8
NHS Good Governance Commission
“(1) Regulations must provide for the establishment of an NHS Good Governance Commission as a Special Health Authority.
(2) The Commission has responsibility for ensuring that anyone appointed to, or elected into, a non-executive role on an NHS body—
(a) is a fit and proper person for that role; and
(b) has been appointed or elected by a process that the Commission considers appropriate.
(3) For the purposes of subsection (2) a Chair or ordinary member of an Integrated Care Board must be considered to be a non-executive role.
(4) NHS England may publish guidance, which must be approved by the Commission, about how appointments are made to NHS bodies.
(5) The Commission must publish an annual assessment of diversity and inclusion in decision-making by NHS bodies and in appointments to executive and non-executive roles in NHS bodies.
(6) For the purposes of subsection (2) an NHS body is—
(a) NHS England;
(b) an Integrated Care Board;
(c) an NHS Trust;
(d) an NHS Foundations Trust; and
(e) a Special Health Authority.”—(Karin Smyth.)
This new clause returns to the position prior to 2012 by recreating a body with independent oversight of important NHS appointments.
Brought up, and read the First time.
Karin Smyth
I beg to move, That the clause be read a Second time.
At the risk of my career, I am again trying to be helpful to the Government. During the debate, we have come round in a circular way about the lack of accountability in the Bill and the quite astonishing levels of power taken directly by the Secretary of State. Those may be two separate things, but, in terms of the culture that we want to embed in the health system, they are really quite worrying.
The Bill puts into law the organisational changes of the last few years—based on what the NHS, I agree, has been asking for—on a population basis, not on competition or autonomy. Most of us genuinely welcome that: we want to see better population health, people working together, and services rooted in the community; we want to empower local people and guarantee service levels locally. We want to ensure transparency on funding to see if one area is funded more favourably than another. Historically, there have been problems with that and we want to understand that. We want to know why certain services operate in one area and not another.
Opposition Members often talk about a postcode lottery. I do not always agree with that terminology because if the population shows that it needs different levels of services in different parts of the country, then the local NHS needs to reflect that. My own city, Bristol, is a very young city; we have a very small population of over-85s. Further to the south-west, in nearby Torquay and Torbay, that situation is reversed. I would expect to see different population levels of healthcare in Bristol and Torbay.
Dr Philippa Whitford (Central Ayrshire) (SNP)
When we talk about a postcode lottery—something I have worked against my entire career—it does not really refer to the area of the postcode, but the access of individuals. At the end of the day, 85-year-olds in Bristol should get the same service as 85-year-olds in Torbay, even if there are fewer of them. Everyone should get the mandate of the service both health and social care deliver, even if it is delivered in a different way because of geography or demographics.
Karin Smyth
I thank the hon. Lady for her intervention, and I do not disagree. The terms are bandied around and people often do not know what we mean by them, which is why, without going back into the past too much, I was a strong supporter when we were in Government of the national service frameworks and certainly of guaranteeing a level of care and access, as she says.
However, it is the case that different health systems will have different demands on them, and therefore should respond differently. On that basis, my point is that that local difference should be reflected: it should make the system accountable to and understandable by local people, and should involve them in the decisions made on their behalf. That seems self-evident.
We often hear in this Committee about the Minister’s, the shadow Minister’s and my other colleagues’ experiences in local government, but I think people would agree that the experiences of people involved in local government and people involved in the health service are so far apart as to be completely unrecognisable, in terms of the national accountability that the health service seems to have and the local accountability that local government has.
These bodies are deeply troubling. I have called them local cartels, in their form as integrated care boards. They have no accountability to the local people they serve, or nationally through Parliament. We have heard that the chair and chief executive are to be chosen in London according to criteria we know not, with all power vested in the Secretary of State and some promise of further detail in secondary legislation.
However, the logical conclusion of the Bill, and the way out of the problem for the Government, is a system, as we have tried to suggest, of elected chairs akin to the police and crime commissioners or metro Mayors. Elsewhere in the debate, my hon. Friend the Member for Ellesmere Port and Neston and I have highlighted the vast discrepancy in money and powers that exists between police and crime commissioners, or even my local Mayor, and the health service. Health service spending dwarfs both of them.
I will not press the new clause to a Division, because I would like to see it picked up elsewhere in the debate as the Bill progresses through this place, and I would like to leave it as something helpful for the Government to keep considering. If the Government do not want to go down the election route, and we heard the reasons from the Minister, bringing back some form of the Appointments Commission, which disappeared in the coalition’s bonfire of the quangos, would be very helpful. There, we had clear role descriptions and person specifications for people who sit on those bodies, a transparent recruitment and interview process, and performance oversight and accountability. I was subject to that when I was a member of the primary care trust in Bristol North some time ago.
The other vital change is to try to bring in some genuine openness and transparency and some independent oversight of the process of appointment. The new boards and integrated care systems are a radical departure from the past 30 years. Earlier in the Committee, I made us pause momentarily as we saw off section 75, autonomy and competition. This is a big moment, and the new systems will need very highly skilled and experienced people to develop them to their potential, because, as we have heard, it is not clear how they are to be run.
The Government keep talking about permissiveness. The systems will be run by people on the ground, and the sort of people we want in charge must be imbued from the off with the culture that we want to see. The hon. Member for Central Ayrshire talked the other day about the safety board being strangled at birth, and there is a danger that these bodies, some of which have been operating quite well, will not fulfil their potential and will be strangled at birth, because that culture of feeding up accountability just to NHS England and not to local populations will make them not work in the way they should, and certainly will make them not work well with local government.
This huge culture change is a culture change for clinical leaders as well as managers. There are some great opportunities here for population-based health, but we are asking clinical leaders—clinical leadership is already a real problem in these bodies—not to look to their own departments in the first instance and their own institutions in the second, but to look outwith their institutions, working with clinicians across the primary-secondary interface, and at a population-based approach rather than their own specialty-based approach. Again, that is a massive sea change for them. Having the clinical leaders doing that at the board level and giving them the support they need to do that in their specialities requires people who are highly skilled and who will be respected locally for their experience and skills, and for, I would argue, their independence from not being hand-picked by the Secretary of State.
The Government continue to lurch from one cronyism charge to another. A transparent process would help them get over that problem—again, I kindly offer the Government some help through their difficulties. The NHS should be seen as an exemplar for appointments and recruitment. The NHS has a terrible problem with diversity. Yesterday, I chaired a meeting of the all-party parliamentary group on social mobility on the work the civil service is trying to do around improving recruitment, particularly at the higher levels, of people from lower socio-economic backgrounds and black and minority ethnic backgrounds. The NHS has also failed that test over many years, and I believe that a more representative local selection—I would like it to be elected, but it could be selected through an appointments process— would help.
Justin Madders
It is a pleasure to follow my hon. Friend the Member for Bristol South, who gave a superb analysis of why the new clause is important and she picked up on many of the themes that we have already debated. The topicality of NHS senior management is there for all to see, with some of the recent headlines being orchestrated to divert from the growing waiting list crisis in the NHS.
Our view is that NHS senior management cannot be all that bad because they have seriously outperformed the private sector on efficiency for nearly a decade. If the NHS is one of the most efficient services in the world as many international studies have demonstrated, that is a credit to the managers who form a relatively small proportion of the overall workforce. I hope the Minister will join us in congratulating NHS managers, along with all the other brilliant staff, who have got us through the pandemic over the last 18 months—although, as we know, we are not through it yet. The contrast with some of the political decisions made has been exposed recently by the joint report by the Health and Social Care Committee and the Science and Technology Committee.
As we have discussed on a number of occasions, the Bill seems to specialise in the centralisation of power, with more and more being explicitly given to the Secretary of State. Do we want the Secretary of State appointing every chair, non-executive and chief executive, even in bodies that are meant to be independent from the Department? Amendment 18, which we debated earlier, would have gone some way to addressing that: alas, it was not to be. This is a serious issue that needs tackling. My hon. Friend is an expert on these matters through her own knowledge and experience, and I absolutely support what she has said.
While good governance might sound a little cheesy, I am sure that we could spend a lot of time discussing what exactly this new clause should be called.
I think we can all understand what good governance means and what it should look like, because we have certainly seen what it does not look like in how the Department operates at the moment. As my hon. Friend said, there was something similar in place previously, before it was burned in the bonfire of quangos under the coalition Government. Something should be in place, be it a revitalised appointments commission or even some independent standing committee or panel—something that has independent oversight of these very senior positions.
As we have said before, we would like more direct democracy in our integrated care boards. We are not going to get that, by the looks of it, but we would at least like some independence in appointments. When my ICB chair is finally appointed, I want him or her—it is a “him” at the moment, and it is an interim position—to be looking outwards, not upwards to NHS England all the time. That is something that a good governance panel would help facilitate.
A fit and proper person test should be applied independently, even to get on a shortlist, and there should be some process for removing those who should not be on there. This needs to be applied by people who are independent and competent, and not people who are already on the lists or making the appointment decisions. Perhaps we should even have some people who have oversight of how people in senior positions are appraised, trained and supported. There is a lot of experience and expertise out there that we could harness. I hope that, whatever this body ends up looking like, it can assist the NHS in dealing better with issues such as diversity, succession planning and leadership—all areas on which we can always strive to do better.
I hope that nobody mentions bureaucracy or cost as an excuse to leave things as they are. We know from published NHS experience that having an appointments commission was not really an overhead; in fact, it was a valuable resource that, in the end, saved money. We know how much it costs to replace someone who has proved unsuitable, and to undo the mistakes that they made. Appointing the right people in the first place is the best solution. The Minister will, of course, be aware of the importance of recruitment and retention across the whole NHS. I think that we can do more in respect of senior leadership roles.
As my hon. Friend the Member for Bristol South said, transparency is key throughout the systems. Where the funding goes is a key question that will become even more key as we move into the ICBs, with larger areas and different funding streams merging into one. Transparency will be important there. Of course, there will be local differences, as she said, but there should still be accountability to someone for where that money goes and who is taking those decisions. We have what we have described as a permissive approach to running ICBs at the moment, but that does not mean that we cannot have transparency and accountability. That is why we support the new clause.
The Minister for Health (Edward Argar)
It is nice to see you back in the Chair, Mr McCabe. I am grateful to the hon. Member for Bristol South. Although we may not fully agree, again I take the new clause in the spirit in which she tabled it. I will reflect on what she said, but I will also set out why I cannot accept what she is proposing. I will always reflect on what she says and proposes; when she proposes things, they are well thought out. We may come to different conclusions, but the points she made are certainly deserving of reflection. I can give her that assurance up front.
As in our oral evidence sessions, I join the hon. Lady and the shadow Minister in paying tribute to those in our amazing NHS and care workforce. It is also important that we recognise, as I think she said during questioning of witnesses, that the complexity of the organisations we are talking about—the complexity of an acute trust, for example—means that strong and effective leadership, both financial and administrative, are hugely important to the overall success of the enterprise of our NHS. I therefore join her in paying tribute to those staff who often find themselves, particularly in media commentary and similar shorthand critiques, on the receiving end of criticism. People may ask, “What are they there for?”. They are hugely valuable—just as much as frontline clinicians, nursing staff and those who work in the canteens or clean the wards. It is a team.
Edward Argar
I will give way to the hon. Lady, as I am sure she will amplify this point. She has worked in clinical settings and will know that a whole team is needed to make things work.
Dr Whitford
I cannot resist the opportunity to amplify that point. Having spent over three decades working in hospitals as a surgeon, I know that it is a team sport that depends on everyone. Sometimes when cuts are made we hear the definition of “frontline” or “back-room” services. If I am in a clinic on my own without the patient records, the patient or the laboratory results, I am a complete waste of space. It is critical to recognise that. To get all the moving parts working well, really good managers are worth their weight in gold. They are part of the team and should be valued as such.
We heard with reference to fit and proper persons that the Kark review did not go far enough and should have suggested suggest registration or licensing of senior managers. Sometimes when the system does not work, we see the same people move out of one place and into another in this kind of revolving door manner.
Edward Argar
Although I do not always agree with the hon. Lady, I find myself in complete agreement with her. She made a couple of points that referred back to those made by the hon. Member for Bristol South. The hon. Lady is absolutely right that the system needs high-calibre, high-quality people with the right skills, particularly given what we are seeking to do with integrated care systems. We must foster an environment in which those high skills are valued, continually reinforced and refreshed.
On the point about the Kark review, the hon. Member for Central Ayrshire is right. How should I phrase this delicately? People may move on, or be moved on, from posts because it was not a success for whatever reason; I will phrase it like that. We need to look at the challenge posed by those people suddenly reappearing in another equivalent senior post in a different part of the country. There may be a reason why someone has not been a success that is not due to particular circumstances or something beyond their control, and we need to look at the recycling of those people who have not been found to have hit the mark. We need to look at that carefully.
Edward Argar
I see the look on the shadow Minister’s face, which makes me wonder what is coming.
Justin Madders
I am not trying to catch the Minister out. I can think of a specific example where what he mentioned has happened. I am, frankly, angry that this individual has been able to do that. What does the Minister think can be done to ensure that the revolving door is shut on those whom it deserves to be shut on?
Edward Argar
The shadow Minister is right. It is a challenge, and it is something I continually reflect on, because it intersects with legal employment rights, the nature of the terms on which someone leaves, how these matters work and the fact that NHS trusts around the country are individual. It is not a simple issue. It is one that I continue to reflect on. I hasten to add that it is not just the shadow Minister but Members from both sides of the House who have, on occasion, raised the issue. It requires further thought and reflection.
New clause 8 would involve creating a new special health authority, effectively, to provide independent oversight of NHS appointments. I recognise the importance of such appointments, and everyone would agree that good governance arrangements should and must be in place for managing them. Appointments to NHS trusts, NHS England and special health authorities are public appointments; they are managed in line with the principles of the governance code for public appointments and are regulated by the Commissioner for Public Appointments. The chair of an ICB would be appointed by NHS England, with the approval of the Secretary of State. That reflects a point that has been considered on a number of occasions during the passage of the Bill, namely that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, Parliament, as part of a national health service.
I acknowledge what the hon. Member for Bristol South said about the need for people to be answerable and responsive to their local community. The counter-challenge is avoiding the fragmentation of the national health service and the vertical arrangement. She mentioned police and crime commissioners, and although our police forces operate in a similar way, the difference is that we have never had a national police force. Each force is based on a county—or a city, in the case of the Metropolitan Police Service—and works on a locality basis, as local authorities do.
Justin Madders
This is a slightly cheekier question than my last one. Has the Minister conducted a similar exercise in his own Department?
Edward Argar
In respect of Ministers or senior civil servants? When it comes to Ministers, though I suspect that is not the point he wishes to push—
Justin Madders
I think we can see who the Ministers are, at least this week. I was referring more to the senior civil servants.
Edward Argar
I like to think that I am a constant in the Department, this week and in previous weeks. It is piece of work that we have done. If one looks at the very senior civil servants—the directors general and permanent secretaries—there is a good gender balance. He is absolutely right, however; having assumed responsibility for workforce more broadly a few weeks ago, it is a piece of work that I want to do. I was responsible for the implementation of the Lammy review and race disparity audit when I was at the Ministry of Justice, and it is an interest that I have taken with me to my new Department. The last year has been a little bit busy, but it is something of which I have not lost sight.
I do not believe that it is necessary to create a new body to oversee appointments, given that good governance arrangements are already in place. I therefore remain unconvinced by the argument. As ever, and as behoves me when the hon. Lady proposes something, I will continue to reflect on it carefully.
Karin Smyth
I am grateful for the Minister’s comments. I will not press the new clause to a Division, but I hope to see this matter further debated during the passage of the Bill. I say gently to the Minister that the gender split for CEOs and managing directors in the health service may be 50:50, but the workforce, and certainly managerial post holders, are overwhelmingly women; however, that is not reflected further up.
Edward Argar
The hon. Lady makes a point that I should have made earlier. When I was looking at this matter in the Ministry of Justice, I was not just looking at prison governors. We need to look at the layers below, the succession plan, and the mix coming up through the system—the next generation of leaders. She is right to highlight that; forgive me for not having mentioned it.
Karin Smyth
I am afraid that these bodies have not proven themselves good at doing that, and it is not good to have them police themselves, so we need to progress the debate. On the national/local question, I am generally more Morrison than Bevan, so I will continue to plough that furrow, but this is also about being seen to do things properly for local people. My fundamental point remains that as we ask people to spend more money—we are talking about a huge proportion of our GDP, and it will be increasingly so under any Government—we need to be able to demonstrate to them what is done with it, and how and why it is done, and we need to involve the public.
That is my view of the future of the health service, and that is why I will continue to pursue this argument. When it comes to cost, it is a moot point whether this is done quietly in the corridors of NHS England; whether it is done by the Secretary of State; whether names mysteriously appear in the local economy; or whether there is due process. I am not saying that the old system was perfect. It is quite hard to recruit people to these bodies, but they are powerful people, spending billions of pounds of local money in the local economy. They need to be more representative and accountable, and we need to know who they are. As I said, I will not pursue the matter now, but I would like to see it debated further over the passage of the Bill, and we will come back to it another time. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 9
Duty to promote research
“For Section 1E of the National Health Service Act 2006 substitute—
‘Duty to promote research
The Secretary of State must—
(a) support the conduct of research on matters relevant to the health and care system,
(b) provide funding for research on matters relevant to the health and care system, via ring-fenced funding for the National Institute for Health Research, and
(c) promote the use in the health and care system of evidence obtained from research.’”—(Chris Skidmore.)
This new clause would require the Secretary of State for Health and Social Care to have a duty to support, fund and promote the use of research in the health and care system in England, via ring-fenced funding for the National Institute for Health Research.
Brought up, and read the First time.
Chris Skidmore (Kingswood) (Con)
I beg to move, That the clause be read a Second time.
The clause would introduce for the first time a duty to promote research, particularly on the Secretary of State. The Committee may remember that in discussion on clause 19, I spoke extensively on integrated care boards’ duties to promote research. This reflects the importance that research plays in our healthcare system. We recognise the value of being able to carry out real-term clinical trials in the single health ecosystem that is the NHS. That not only enormously benefits patients, in terms of health outcomes, but underpins a whole life sciences industry, in which, as we have seen from the pandemic and our vaccine response, the UK is truly world leading.
It is not simply because of profit that I wish to speak to the new clause. It is also clear, as I discussed on clause 19, that research can underpin and strengthen the healthcare ecosystem. It can help with retaining staff, who become inspired by the research that they do in the course of their careers. It also improves health outcomes for patients, and the investment in research is ploughed back into healthcare services. Everyone benefits from spending money on research and development. The hon. Member for Central Ayrshire made the point to me that research also plays an important part when it comes to the accountability and transparency of the NHS by underpinning clinical auditing processes, by which we can then demonstrate healthcare inequalities and map out where NHS services need to improve. That can drive better integration of services by seeking to identify where the inequalities are and closing them.
Promoting research is not simply about R&D and big pharma; it is about changing how we look at our health service. We need to move from a healthcare service that is still primarily reactive to one that can recognise patient population issues around chronic disease, and identify which interventions can be made earlier. That is something that we are beginning to understand far better through the application of genomics and precision medicine. The UK became the first country in the world to code 100,000 genomes in the 100,000 Genomes project, and there is the Biobank project. That has all come about thanks to initial investment in research and development, and it has opened up a whole new area of healthcare services that the NHS will benefit from in decades to come.
It is very important to invest in R&D. Since our morning sitting, the Chancellor has announced an additional £44 billion of investment in the NHS over three years to 2024-25, taking total spend in the NHS up to £177 billion. I welcome that huge investment in healthcare services. It is not yet clear exactly what investment is to go into healthcare R&D, although the Budget leaks in The Sunday Times and beyond suggest that roughly £5 billion of that will be spent on health R&D over five years. I welcome that funding. There was also mention of additional money being spent on genomics.
If it is the case that healthcare research is to receive £5 billion over three years, it is not just about the money; it is about the use that money is put to, and making sure that it goes as far as possible and has the best possible outcomes. We can only do that by ensuring that we have the structures and frameworks in place to make sure that the money is well spent. New clause 9 places a duty on the Secretary of State to
“(a) support the conduct of research on matters relevant to the health and care system,
(b) provide funding for research on matters relevant to the health and care system, via ring-fenced funding for the National Institute for Health Research, and
(c) promote the use in the health and care system of evidence obtained from research.”
The positive feedback mechanism is important. We do not want to commission research that will gather dust on the shelves. We want to make sure, through real-time evidence and clinical trials, that the R&D money goes as far as possible, for the benefit of patients.
I said that paragraph (b) would ringfence funding for the National Institute for Health Research—a long-term ask of research organisations and companies involved in the active process of healthcare R&D. If I am honest with you, the process has often been a hand-to-mouth exercise. NIHR has received about £1 billion a year to spend on R&D. The most important thing in R&D is to provide not simply the funding, but the long-term certainty over that funding. When I was Science Minister, one reason why I was so committed to ensuring that the UK was associated with Horizon Europe was that it is a seven-year multiannual financial framework—those researchers have security for seven years. The level of participation is a different question, but the scientist or healthcare researcher commits to research projects that last several years at a time. What they cannot have is uncertainty, every year, that the research might suddenly be pulled. That leads to the disintegration of research partnerships and a lack of commitment at the start to even beginning to understand what might be achievable.
Ringfencing funding for the NIHR will provide the certainty as well as the money, so it will make the money go further. Individuals will be able to commit to projects, knowing that they have funding not for one year, but several years.
Dr Whitford
I spent a few years in cancer research while doing my doctorate. Does the Minister recognise that when there is that hand-to-mouth need to get a publication so as to get another grant, researchers are taken away from what we might call blue-sky or imaginative research that may not work out? People end up researching something they virtually already know the answer to, because that way they will get a publication and then get another grant. It is not just about their personal insecurity—it skews the type of research that gets done.
Chris Skidmore
Absolutely. I thank the hon. Member for making that point. When I was Science Minister, we recognised the need to look again at some of the processes that underpin research applications for UK Research and Innovation, for instance. We have the bureaucracy review that is currently being chaired by Adam Tickell, current vice-chancellor of the University of Sussex who is moving on to the University of Birmingham. We need to end this cyclical process of time—which is ultimately the greatest commodity that anyone has to offer—being taken away from researchers whose expertise is far better spent focusing on their research in the laboratory or performing clinical trials, and ensure that they can get on with what they do best rather than having to worry about the administrative burden of applying and form-filling every year.
Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to resume with you in the Chair, Mr McCabe. I commend the right hon. Member for Kingswood for his new clause and for the persuasive case that he made for it. I will cover much of what he said in my contribution, but I highlight his point about long-term certainty, because I was not going to cover that. Those points were very well made. If we want to embed a culture of research in this country and to be world-leading, as surely we do, we must give our researchers that long-term certainty.
I am going to start with the National Institute for Health Research, which was, of course, established by the previous Labour Government in 2006. We are very proud of that, and since then, in partnership with NICE and other organisations, it has delivered on its mission to improve on the health and wealth of the nation through research. I refer any colleagues who have not had a chance to look at it to the 2016 RAND report, which identifies 100 examples of positive change resulting from the institute’s research. You may be pleased, Mr McCabe, to hear me say that I do not intend to read out all 100, but I do want to highlight the role that it has played since in fighting covid-19 by funding, enabling and delivering lifesaving research throughout the pandemic and now in this current phase. I will not list all the ways in which that has been done, but I will highlight the recovery trial that discovered dexamethasone. That was the first drug to reduce covid-19 mortality in hospitalised patients, cutting deaths by one third, and it was funded and supported by the NIHR. It is a great organisation, which we should be backing and should be very proud of.
On research more generally, there is a shared vision and a shared ambition across this place: the UK should be at the very forefront in science more generally, and particularly in research on health and care. We have all the assets to do that, if we link everything up and invest in it, and to make the UK the destination of choice for clinical research. The new clause offers the Government the chance to put that on a statutory footing, and to make good that commitment, ringfencing funding and mandating the Secretary of State’s support and interest in leadership. As the right hon. Member for Kingswood said, we would expect the Secretary of State to make many things a personal priority. We would argue that this is one of those things.
As in many of our proceedings, we are tidying up on the Health and Social Care Act 2012, and this is a good opportunity to do so again. The Minister smiles; I am always here to offer those opportunities. My hon. Friend and I have been ever so accommodating in that regard. The 2012 Act only included the duty for clinical commissioning groups to promote research. I would direct colleagues to the cross-sector written evidence headed up by the Academy of Medical Sciences, which said that the NHS’s lack of ability
“to prioritise the resourcing and delivery of research has been a major impediment to improving the UK’s clinical research environment over the last decade.”
According to that submission, that has subsequently been a contributing factor to wide-ranging disparities in opportunities for patients to engage in research. When it talks about that, we should listen. As with so many things, we have chance to right that wrong in the 2012 Act and to show in the Bill that we want an active research culture in the NHS, building on the last 18 months.
Evidence shows that a strengthened research mandate would bring many benefits. First, patients treated in research-active NHS organisations have improved outcomes. They have lower mortality rates and higher confidence in the care they receive, which really is a big prize. Secondly, at a time when the NHS is dealing with many work force issues, this increases job satisfaction, with most doctors surveyed by the Royal College of Physicians wanting to be more involved in research and two thirds more likely to apply for a role with dedicated research time. We know it is what our excellent clinicians want too. Thirdly, it brings economic investment into this country; £2.7 billion was generated by NIHR clinical research network-supported activity in 2018-19, making the NHS around £350 million from life science companies. So we win here both coming and going; it is better for our patients, better for clinicians and better for our economy.
There really is a lot in this very good new clause with regard to both the NIHR itself and research more generally. I hope that the Minister will look favourably on the new clause. If he does not, I hope that he will give the Committee comfort on how this will be not just a broad priority for the entire system, where it is not quite clear who is responsible, but something that he as a Minister, and the Secretary of State, will be driving personally and taking as a personal responsibility. As I say, the prizes are very great indeed.
Dr Whitford
Although this would obviously apply in England and not Scotland, and the NIHR does not generally fund a lot of clinical research that comes from Scotland, I absolutely support the principle. When I was lead clinician in the west of Scotland, we put trial support staff into all 13 breast cancer units around the west of Scotland. That drove up participation in trials, which, as the hon. Gentleman just said, is what generates confidence among patients and results in better outcomes. Most trials come with a lot of bureaucracy, and people working in very busy clinical jobs in district generals often do not engage because of that. Putting trial staff out in district generals can actually mean that, instead of research being within academic units, it is suddenly available to all patients. That is really important.
Having a questioning mind should be part of being any doctor. All junior doctors are encouraged to develop auditing and clinical ideas as an approach. The hon. Gentleman—I have forgotten the constituency, I am afraid.
Dr Whitford
I was going to guess some other city and get it wrong, but it is somewhere north. The hon. Member said that having access to research time as a clinician, which the right hon. Member for Kingswood mentioned is a way of retaining staff, is quite important. My local health board now employs younger, as opposed to older, doctors as clinical fellows, and they have a day a week as part of their contract. It is not just one or two doctors; the board are doing it as a standard approach. It has become really popular and has certainly helped with our workforce issues in Ayrshire and on Arran. It is important to see laboratory and trials research and frontline outcome audit and clinical ideas research from all young clinicians, and we should encourage that. The money is great, but we then have to work out how the money feeds into the health service to generate the biggest impact.
Edward Argar
I am grateful to my right hon. Friend the Member for Kingswood for bringing this discussion before the Committee today. It behoves me to pay tribute to his work as Science Minister in the past. He is correct to have mentioned that he is the only person to have held that post and my current role one after the other. In fact, I think he sandwiched my current post between two stints as Science Minister, so he knows a lot about the subject and has done a lot of work on it. I pay tribute to him for that.
The amendment seeks to legislate for an additional duty for the Secretary of State with respect to research and to ringfence funding for the National Institute for Health Research—the NIHR. The NIHR is the delivery mechanism through which the Department of Health and Social Care funds high-quality, timely research that benefits the NHS, public health, and social care. I understand and appreciate the intention behind new clause 9. When discussing previous amendments, I alluded to the fact that I can recognise what my right hon. Friend is seeking to achieve. The benefits of research funded through the NIHR have proved invaluable to us during the pandemic, and the great work of the NIHR is addressing much-needed research into better ways to tackle a host of other health and care challenges that we face.
However, referring to the NIHR in primary legislation and proposing ringfencing of the research budget would not be appropriate, as the NIHR is not a legal entity separate from the Department and funding for the NIHR needs to be considered in the round alongside other elements of the Department’s funding—of which it is a component part—all of which are aimed, ultimately, at improving health and wellbeing.
New clause 9 seeks to broaden the wording of the Secretary of State’s duty to promote research, so that it includes the care system in addition to the health service. I recognise that the intention of my right hon. Friend is to ensure that social care is considered a priority area and does not get neglected in the face of demands from health. However, the NIHR already funds both health and social care research. Adult social care is a strategic priority for the NIHR and its research for patient benefit programme has an annual competition specifically for social care proposals.
The amendment seeks to modify the existing duty of the Secretary of State to “promote research”, and to become a duty to
“support the conduct of research”.
It imposes a requirement for the Secretary of State to
“promote the use in the health and care systems of evidence obtained from research”.
We consider that the existing statutory duty has ensured that research has been championed, and that evidence obtained from research has been well and correctly used. The Secretary of State already supports health and care research through funding to the NIHR, and NIHR research evidence is widely used to underpin improvements across the health and care system. Many examples of NIHR impact have been documented in published NIHR annual reports.
For those reasons, I gently encourage my right hon. Friend not to press the new clause to a Division, but I am happy to reflect on the matter further and I suspect that their lordships may well return to this theme in the other place as well.
Chris Skidmore
I thank the Minister for his forensic dissection of the new clause; it is greatly appreciated. He makes a strong point about the legal status of the National Institute for Health Research potentially making the new clause defective, and there would be little point in pressing the measure to a vote for that reason. However, to reiterate what I said earlier, it is a goose that will continuously lay golden eggs for the Minister. If he went away to look at how the new clause might be better shaped to deliver on the priorities and frameworks that he has just mentioned, I am sure that he would be richly rewarded in turn, particularly by all the organisations that recognise the value that research can bring, and by patients and staff, who would welcome the certainty arising from placing future research operations on a statutory footing.
I am a generous person. I remember tabling a ten-minute rule Bill back in February calling for the banning of essay mills in universities and other educational settings. The Government gave a similar response—the proposals were slightly defective in who they covered—but they have now tabled their own amendment to the Skills and Post-16 Education Bill to ban essay mills. That goes to show what can happen when we take the time to table amendments, either through ten-minute rule Bills or in Committee. I say to any Back Bencher, “You are not going to get in trouble with the Whips, trust me.” It is important that we use our parliamentary and democratic duty to push ideas forward, because someone will eventually take them up, whether in this or another Government.
I hope that, when the Bill reaches the Lords, the Minister will reflect on and look at this as an opportunity to deliver significant reform to the health service. For the reasons that I have outlined, I beg to ask leave to withdraw the motion.
The Chair
Therein lies a lesson for us all.
Clause, by leave, withdrawn.
New Clause 11
Consultation with staff and patients on service changes
“(1) The Secretary of State must consult staff, staff representatives and patient representatives on any changes in services which fall within the definition of reconfiguration of services or which impact on the roles of more than 20 staff and publish the results of the consultation.
(2) NHS England, ICBs, NHS Trusts and FTs must publish a response to the results of consultations undertaken under subsection (1) and have due regard to the outcome of any consultation.
(3) Where significant changes to services are proposed by any NHS body, that body must produce a business case using the Five Case Model recommended by Her Majesty’s Treasury, or other requirements as set out in guidance prepared and published by the Secretary of State under this section.
(4) The business case mentioned in subsection (3) must be published for consultation and the responses to the consultation taken into account when a decision is taken whether to implement the change.”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
We have wandered down the avenue of reconfiguration before in this Committee, and I am sure that we will do so again. The Opposition have been far from reassured about the Secretary of State’s ability to intervene at any moment when there is the slightest hint of movement in a podiatry clinic or a change of hours at a walk-in centre, but that is where we are.
We all know that in a few more White Papers’ time, there will be more changes in the NHS and in social care, and possibly more integration—who knows what is in store for us? There will be changes in the way that services are delivered, with, we hope, the aim of making them better. For more than three decades, there has been an acceptance that changes to services can be of vital interest to the patients who receive them and the staff who deliver them.
The Committee has already discussed several times the importance of involving people in those debates, and there is an acceptance that there must be a process that engages with patients and all service users. That is what we are trying to achieve through new clause 11. I hope we all agree that any proposals to change the way that services are delivered have to be subject to consultation with patients and, as we have seen in other parts of the Bill, with carers. I hope that we start from that uncontentious common ground. The big issue is just how well that consultation is delivered in practice.
At this point, I take the Committee to the Cabinet Office guidelines of 2018 and the consultation principles, particularly paragraph D, which states:
“Consultations are only part of a process of engagement. Consider whether informal iterative consultation is appropriate, using new digital tools and open, collaborative approaches. Consultation is not just about formal documents and responses. It is an on-going process.”
The NHS does not always understand that they should consult before making a decision, and not on a decision that has already been made, using consultation as a tick-box or rubber-stamp exercise. Genuine consultation, with open dialogue on both sides, before decisions are made almost always results in a better decision in the end.
Of course, the Minister will tell us that the NHS constitution talks about those things and pledges,
“to engage staff in decisions that affect them and the services they provide, individually and through their representative organisations and local partnership working arrangements, and empower all staff to suggest ways to deliver better and safer services for patients and their families.”
That is a pledge, not a requirement, and those fine words are often ignored when it comes to consultations with staff groups.
Even the Health and Social Care Act 2012—the Lansley Act—accepted that there were issues, because it states:
“In exercising functions in relation to the health service, the Secretary of State must have regard to the NHS Constitution.”
Having due regard to the constitution also formed part of the licensing conditions for NHS Providers.
We know what “due regard” means and we have already debated its limits. We know that it means that there must be some sort of formal documentation to demonstrate that consideration has been given to representations. Even that sometimes does not happen, or it happens after a decision has been made. On a number of occasions, no attempt has been made to empower staff and proactively ask for their views on how to deliver the service in a better or safer way for patients. A decision is made and presented as a take it or leave it.
A helpful factsheet that was issued for the 2012 Act states:
“Our reforms will enable change to be driven from the bottom-up, by the clinicians who know the health needs of their patients best, and underpinned by proper local engagement, partnership working and effective local authority scrutiny.”
I draw the Committee’s attention to the words “partnership working”. Again, the NHS can do better in respect of that.
In the new clause, we are trying to codify something that the NHS should be doing anyway when we look at the documents, guidelines, explanatory notes and good intentions, but on a number of occasions fails to do. We therefore move from “due regard” to an actual requirement. That is a beacon of best practice, which we should aim for rather than watering it down. What harm can it do? What is the disbenefit of involving the people who know the service best and deliver it on the ground? That is why there must be consultation with patients, their carers and staff.
The latter part of the new clause provides that there has to be an agreement to provide a business case. Any significant proposal should have a business case attached to it. Paragraph C of the Cabinet Office guidelines states:
“Give enough information to ensure that those consulted understand the issues and can give informed responses. Include validated impact assessments of the costs and benefits of the options being considered when possible; this might be required where proposals have an impact on business or the voluntary sector.”
It stands to reason that giving people the full pictures means that they can give a fuller and more informed response. That is at the heart of the new clause. It will mean delivering better outcomes, better services for patients and better engagement with staff. If we refer back to the evidence sessions––gosh, some six weeks ago; it seems longer but it was only six weeks––this was one of Unison’s highest priorities. Witness Sara Gorton said of principal staff involvement
“I think trade unions and staff would feel as though they had a stake and would be reassured that they had involvement in future decisions with workforce implications made by those new bits of the system if that pledge were placed in the legislation and were the underpinning principle.”––[Official Report, Health and Social Care Public Bill Committee, 9 September 2021; c. 93, Q119.]
That is what we are seeking to do here.
It goes without saying that any significant service change should have the business case disclosed, as we discussed earlier with the new clauses tabled by my hon. Friend the Member for Bristol South. Business cases are where proposals are developed and where challenge, and teasing out of alternatives and improvements, can be found. That is the heart of what good consultation should be. We value our staff and the input they can have. We value the impact that service changes can have on patients and the importance of involving them at an early stage with full information. That will improve decisions in the long run and that is why new clause 11 should be supported.
Edward Argar
I am grateful to the shadow Minister for giving us the opportunity to debate this issue further. As he suggested, we have touched on it at various other points in the passage of the legislation, but it is right that we debate it again.
The new clause would require the Secretary of State to consult staff, staff representatives and patient representatives on any reconfiguration of services or any service change impacting more than 20 staff. NHS bodies would be required to publish their response to the results of any such consultation and an NHS body proposing significant changes to services would need to produce a business case in a specific model to be published for consultation.
Health service bodies are already under wide-ranging duties on public involvement and consultation on proposals for changes in commissioning arrangements and the reconfiguration of services set out under the National Health Service Act 2006 and regulations made under the Act. In addition, the current guidance issued by NHS England makes clear the importance of engagement and appropriate consultation. That approach will continue to be reflected under new guidance produced under the reconfiguration provisions in the Bill, set out at paragraph 8 of new schedule 10A inserted into the 2006 Act.
Guidance can provide a level of detail that is not always suited to inclusion in primary legislation and allows for flexibility so that the system can work as efficiently as possible. That approach has worked well under the current reconfiguration system and guidance has played an important part. The Government are unconvinced that there is a need for an additional duty to consult patients’ representatives when NHS commissioners and providers must already involve service users in any proposals to change health services delivered to those users and which service users can access.
Moreover, it would not be appropriate for the Secretary of State to carry out a consultation for each reconfiguration or service change affecting staff. To run national consultation for every local change would be disproportionate. It would not be the best use of resource or lead to the local level of engagement that is so important. It is right that NHS bodies responsible for arranging for or providing health services should lead the consultations on proposed changes. These should be done primarily at local level with local expertise. There is always a challenge between the national and the local. I was not quite sure whether the hon. Member for Bristol South was alluding to that when she said that she was more Morrison than Bevan, and suggested that I was more Bevan than Morrison in my approach. Neither comparison has been made about me in the past, but when I next see her, I will ask. There is a real challenge in the local-national balance that runs through several clauses and in respect of the way the NHS has operated for decades.
The new clause would require consultation not just of patients but of staff and staff representatives. Staff views are of course vital in the design of service changes. That is made absolutely clear in the current guidance issued by NHS England, which repeatedly emphasises the need to involve clinicians whose practices would be affected by proposed changes. This approach will not change in the future, and updated guidance will continue to reflect that position and ensure that affected staff provide meaningful input.
Justin Madders
We are not going to push the new clause to a vote, because we recognise when the Minister is not for turning—I am not sure whether he likes that comparison. But I have a couple of reflections on what he said. He was obviously very keen that the Secretary of State not get involved in lots of consultations, but of course he gives himself the power, under the Bill, to do that in relation to any reconfiguration of any size, anywhere in England. That does, I think, highlight a little bit of inconsistency.
The Minister said that there was plenty of guidance and the Government did not want the inflexibility that putting something in legislation would develop. We take the view that actually what we are trying to show is that the guidance does not work to the extent that we would want it to, which is why we think that having something in legislation is an important baseline. It does not prevent further guidance and flexibility from being built in on top of that. I know when we are not going to persuade the Minister, but I think that this is a matter that we will need to return to many times. I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
New Clause 12
NHS as the preferred provider of NHS contracts
“(1) The NHS is the preferred provider of NHS contracts.
(2) NHS contracts must be provided by NHS suppliers unless the NHS supplier is unable to fulfil the terms of that contract.
(3) Where the NHS is unable to fulfil the terms of a contract, a competitive tender must be held to identify an alternative provider.
(4) For the purposes of this section—
(a) ‘alternative provider’ means private companies and independent sector treatment centres, and
(b) general practice and GP-led community services are NHS suppliers.”—(Justin Madders.)
This new clause would establish NHS suppliers of services as the preferred providers of NHS contracts. Independent sector providers could hold NHS contracts after winning a competitive tender.
Brought up, and read the First time.
Question put, That the clause be read a Second time.
The Chair
With this it will be convenient to discuss new clause 15—Regulation of the public display of imported cadavers—
“The Human Tissue Act 2004 is amended as follows—
In subsections (5)(a), (6)(a) and (6)(b) of section 1 (authorisation of activities for scheduled purposes) after “imported” insert “other than for the purpose of public display”.”
Alex Norris
In speaking to these new clauses, I stand on the shoulders of the inestimable work done in this place by my hon. Friend the Member for St Helens South and Whiston (Ms Rimmer) and in the other place by the noble Lord Hunt of Kings Heath, who is with us for a little while longer before he has an oral question to dispose of in the other place. I note my thanks to them for their leadership. I hope that we can move this important issue on as part of our consideration of the Bill.
In this country, since April, around 2,000 people have received an organ transplant. A person voluntarily deciding to give an organ in life or after their death gives the most precious gift of all. It is an incredibly selfless act that allows another person to live. It is a wonderful thing. We should be very proud of Britain’s record on organ donation over the years, of the research and development in that area and the work that I have no doubt we will yet do.
However, there is a sinister underside to organ donation that I ask the Committee to consider with these two new clauses. In some parts of the world organs are not given freely but are taken by force. Extensive research has shown organ harvesting to be prevalent particularly in China, where the number of organs transplanted swamps the official number of voluntary donations. The organs are generally destined for high-paying customers and come from people such as political dissidents, prisoners of conscience and ethnic minorities.
The Chinese Government say that it does not happen. The World Health Organisation has backed that up, based on a self-assessment made by the Chinese Government, which I did not find very credible. What I do find credible is that, in 2020, the independent China Tribunal found that forced organ harvesting has been committed for years throughout China, on a significant scale. Falun Gong practitioners have been one source—probably the main source—of organ supply. Victims include both the dead and the living. There are whistleblower reports of corneas being harvested.
In January we made progress on the issue through the Medicines and Medical Devices Act 2021—I am sure the hon. Member for Central Ayrshire remembers the exchanges fondly. That opened the door to further regulation of human tissues and I hope that we can move further in this Bill.
Existing legislation does not deal with British citizens who travel abroad. New clause 14 attempts to close that loophole by making it a crime for British citizens, residents and other specified people to be involved in the kill-to-order organ trade. It would end the opportunity for someone to travel to pay for black market organs from a prisoner of conscience and to return to the UK for NHS-funded anti-rejection medication. We must make it clear that involvement in this trade is reprehensible and unacceptable. I think that is a point of consensus across the House, but I am yet to hear what the mechanism is to close the loophole—I think new clause 14 presents a very good one.
New clause 15 deals with the display of human bodies. I used the word “grim” earlier in proceedings, and this is very grim indeed. Regrettably, this is not a theoretical conversation. In 2018 the Real Bodies exhibition took place in Birmingham. Adults and children paid to look at deceased corpses that had been injected with silicon and transformed into real-life mannequins. The bodies were sourced from a lab in Dalian in China. The bodies were able to be displayed without any documents or proven consent, and from a lab that we know receives bodies from the Chinese police.
Whether that sort of exhibition counts as entertainment is a matter for individuals—it is certainly not my sort of entertainment. New clause 15 would ensure that the trade is tightly regulated, so that something like that could not happen again. It would prevent the display of dead bodies of political prisoners and guarantee that proper consent has been received, ensuring dignity and respect for the deceased and their families. I think this is a matter of interest to the Committee, which is why I am seeking to put it in the Bill. It is also of significant interest in the other place. I know there will be conversations on the issue as the Bill progresses.
I am keen to hear from the Minister on these two points. I do not doubt that we are of one mind on the matter. What I would like to know now is what the Government are going to do about it, because these are pressing issues and need action now.
Edward Argar
I can certainly tell the hon. Gentleman that I think there is a consensus across the Committee, and indeed across both Houses, condemning the reprehensible behaviours and practices that he has highlighted. As he says, the challenge is the mechanism, particularly given the concept of extraterritoriality that applies here, so I will talk about that a little bit. I fear we may have to return to this; I suspect, given the complexities, that it may well be their lordships’ House that grapples with it a little further. Although it is not normally the done thing to recognise those in the Public Gallery, as they are not in the Chamber, were there to be a distinguished Peer in the Public Gallery, I would also pay tribute to their work on this. I hope that just about keeps me in order, Mr McCabe.
New clause 14 seeks to extend the provisions in section 32 of the Human Tissue Act 2004, which prohibit commercial dealings in human material for transplantation. The amendment would make it an offence for someone to travel outside the UK to receive such material without free, informed, and specific consent or in exchange for a financial gain or comparable advantage.
We believe that much, albeit not all, of what the clause seeks to achieve is already covered by different aspects of existing legislation. I will talk first about those travelling from the UK, forcibly or otherwise, and the protections available for them from having their organs harvested, and then I will turn to those travelling from the UK to receive organs.
Provisions in the Modern Slavery Act 2015 make it an offence to arrange or facilitate another person’s travel, including travel outside the UK, for the purposes of their exploitation in any part of the world. Travelling covers the arrival or departure from any country, or within any country, and exploitation includes the supply of organs for reward. The Modern Slavery Act applies to the activities of UK nationals regardless of where the travel or the arrangements for it take place.
A person found guilty of that offence could be liable for life imprisonment, and those guilty of aiding, abetting, counselling or procuring it are liable for up to 10 years’ imprisonment. This means that existing extraterritorial legislation already makes it an offence for a UK citizen to purchase an organ for transplant overseas, provided that the purchase involves arranging or facilitating a person’s travel for the purpose of the removal of their organ for sale.
Furthermore, section 32 of the Human Tissue Act already prohibits the giving of a reward for the supply, or for an offer to supply, any controlled material. If a substantial part of an illicit transaction takes place in England, Wales or Northern Ireland, it will constitute an offence under this provision. It could, for example, be an offence to arrange a purchase and pay for an organ from a UK bank account and, likewise, it could be deemed against the law if somebody were to take steps in the UK to find someone who would sell them an organ overseas.
By adding an explicitly extraterritorial offence, as this amendment seeks to do, the interpretation of the existing provisions could be restricted, thereby potentially weakening our existing tools under those two pieces of legislation. As this amendment would prohibit travel outside the UK to receive an organ without the specific consent of the donor or next of kin, there is a chance that it could also inadvertently make it an offence for someone from the UK to receive an organ in a country with deemed rather than explicit consent provisions. This is at odds with our domestic position, where deemed consent is accepted as an appropriate form of consent for organ donation.
There is also the possibility of an unintended consequence of criminalising the recipient, as opposed to the supplier and buyer, of a trafficked organ. It is not difficult to imagine a case of a vulnerable person receiving a transplant abroad, perhaps through arrangements made by relatives, and having been misled as to the provenance of their organ. Under these circumstances, we believe that those who made the arrangements to purchase and supply the organ should be prosecuted and deemed liable, as they already can be under the Human Tissue Act and the Modern Slavery Act.
Dr Whitford
There is a problem with the shortage of organs for transplant generally within the UK. While making it an opt-out system will hopefully help with that, is there not a need to have legislation here so that the market is discouraged or prohibited, and therefore we do not have customers for those organs overseas? If there are customers, the business will exist.
Edward Argar
I take the hon. Lady’s point. I will turn to new clause 15 in a moment, but we are as one in our concern to ensure that the current legislation is as effective as possible and that it does what we want it to do. I will make some further remarks on my future thinking when I conclude.
Alex Norris
I am grateful to the Minister for his full reply. I do not intend to stress the consensus we have by dividing the Committee. He has given others who may want to look at this at a later stage quite a bit to go at. On resolving the point made in new clause 14, I heard what the Minister said about the scattering of the different parts across the statute book, but a judgment may have to be made about whether that is an effective way to organise the powers. Perhaps creating a consolidated offence would be a more practical and meaningful approach. That is my personal view, but as I have said, there will be lots to go at elsewhere.
I got quite a bit of satisfaction from the Minister’s response to new clause 15. I will go away and look at the Human Tissue Authority’s work. Obviously, primary legislation is always best, but I will see whether that is effective.
Edward Argar
In that context, may I make the hon. Gentleman an offer? If he thinks there is anything specific that my officials could provide to assist him in his reflections, could he let me know and I will be very happy to facilitate it?
Alex Norris
That is a very kind offer and I am almost certainly going to avail myself of it. On that basis, I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 16
Licensing of beauty and aesthetics treatments
“(1) No person may carry on an activity to which this subsection applies—
(a) except under the authority of a licence for the purposes of this section, and
(b) other than in accordance with specified training.
(2) Subsection (1) applies to an activity relating to the provision of beauty or aesthetics treatments which is specified for the purposes of the subsection by regulations made by the Secretary of State.
(3) A person commits an offence if that person contravenes subsection (1).
(4) The Secretary of State may by regulations make provision about licences and conditions for the purposes of this section.
(5) Before making regulations under this section, the Secretary of State must consult the representatives of any interests concerned which the Secretary of State considers appropriate.
(6) Regulations may, in particular—
(a) require a licensing authority not to grant a licence unless satisfied as to a matter specified in the regulations; and
(b) require a licensing authority to have regard, in deciding whether to grant a licence, to a matter specified in the regulations.”—(Justin Madders.)
This new clause gives the Secretary of State the power to introduce a licensing regime for cosmetic treatments and makes it an offence for someone to practise without a licence. The list of treatments, detailed conditions and training requirements would be set out in regulations after consultation with relevant stakeholders.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
It will be noted that new clause 16 has attracted considerable support from a wide range of Members across the House. I pay tribute to the beauty, aesthetics and wellbeing all-party parliamentary group, whose work in the area has been influential in producing the new clause. Many of the Members who put their name to it are also members of that group. I pay tribute to a constituent of my right hon. Friend the Member for North Durham (Mr Jones), Dawn Knight, who has been assiduous in this area, as has my right hon. Friend himself. Their tireless campaigning, which I suspect will continue for some time, has been vital so far. This is such an important area and it needs an awful lot of attention. We know there is a lot more to be done.
As we know, cosmetic treatments can include a wide range of procedures aimed at enhancing or altering appearance. Many common treatments are offered on the high street and include lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and—one that we are more familiar with—tattoos. Perhaps one day the Minister will show us all of his. If the Minister wants to respond on that point, he is more than welcome to.
Justin Madders
Many of these procedures are becoming increasingly popular. There is a well-articulated concern that non-medically and medically trained practitioners are performing treatments without being able to evidence appropriate training, or the required standards of oversight and supervision. One need only look on Facebook, for example, to see the proliferation of adverts for all types of treatments. These are usually done by unlicensed individuals who call themselves doctors. We have talked recently about the lack of proper regulation of social media. Although such a debate is not for today and falls outside the scope of the new clause, it is a matter that also needs to be addressed.
Cosmetic treatments can cause serious harm if not carried out correctly, in a safe environment and by competent, trained practitioners. Anything that punctures the skin carries the risk of the transmission of blood-borne viruses. There are countless tragic stories of people who have had life-changing injuries and conditions as a result of poor treatments. The amendment seeks to put the protection of the public at the forefront by giving the Secretary of State power to bring into force a national licensing scheme for cosmetic procedures. It would be a departure from the wild west we face at the moment. We recognise that significant research and engagement with all stakeholders would be needed to develop a scheme that will work well for all cosmetic treatments, as well as providing a practical and efficient system that will be understood and adhered to by members of the public, regulators and practitioners.
Any new scheme would have to have some flexibility in order to capture new cosmetic treatments coming on to the market in future. It would need to be able to set standards for training, qualifications and competency requirements of practitioners, including, we think, periodic checks of premises. Importantly, it would provide for continuous professional development of the practitioner. There would be a requirement for indemnity insurance and access to redress schemes for members of the public to be provided, should complications arise as a result of any aesthetic procedure. There are a number of sad stories about supposedly reputable companies doing damage to their customers, going into liquidation and their insurers then refusing to pay out. I do not think any Member wants to see that happening anymore if we can do something about it.
We would hope that any licensing scheme would have the characteristics that I have set out, and there would be accompanying sanctions for those who contravene it. At present, there is no provision to ensure that prescription-only medicines, such as Botox and anaesthetic creams, adrenaline and hyaluronidase, which are prescribed by regulated prescribers, are actually prescribed in accordance with safe practice. For example, beauty therapists are reliant on registered prescribers prescribing injectables, such as Botox, which they are unable to obtain without a prescription.
Although doctors are required to have a face-to-face individual assessment of each service user prior to prescribing to third parties, such as beauty therapists, a significant body of evidence exists to confirm that individual assessments are not actually taking place in many cases and that telephone prescriptions are being provided remotely. The proposed licensing scheme would provide a requirement for all prescribers to be officially named and to operate in accordance with required practice standards.
Of equal importance is the need for a licensing scheme to close the loophole that currently exists relating to the import of unlicensed injectable products from Korea, such as Botulax. There is a registration scheme in England for certain specialist treatments, such as electrolysis, tattooing, piecing, semi-permanent make-up and acupuncture. However, some of the riskier and newer types of cosmetic treatment cannot be included within the scope of the current regulatory regime. The system also does not allow regulators to specify conditions, qualifications or competency requirements, or to remove anyone from the practitioner register.
Only a small handful of areas across England have introduced their own licensing schemes in order to protect the public—London, Nottingham and Essex are notable examples. There are currently two Professional Standards Authority-approved voluntary registers of accredited practitioners, and one voluntary register of approved education and training providers that operate in the sector. However, joining is not mandatory, which means there are many unaccredited practitioners providing treatments to members of the public without any checks.
The creation of a national licensing scheme in England for practitioners of cosmetic treatments would ensure that all those who practise are competent and safe for members of the public, and it would also cover some of the newer practices not covered by existing licensing laws. There is a large body of support for such a move, including the Chartered Institute of Environmental Health, the Royal Society for Public Health, the Institute of Licensing, the Joint Council for Cosmetic Practitioners, the UK Public Health Network, the Faculty of Public Health and Save Face, as well as about 90% of the public, accordingly to at least one survey.
The Minister is keen on giving the Secretary of State additional powers, but I know that he is also keen on finding savings wherever possible. Were he to support this new clause, there would undoubtedly be a saving to the wider NHS in the long run—for example, through reduced visits to A&E and GPs to correct mistakes made by poorly trained and unregulated practitioners.
Here are some examples of the impact on the NHS of that lack of regulation: outbreaks of infection at skin-piercing premises, resulting in individuals being hospitalised and, in some cases, disfiguration and partial removal of the ear; second and third-degree burns from lasers and sun beds; allergic reactions due to failure to carry out patch tests or medical assessments, which have led to hospitalisations; and blindness in one eye caused by the incorrect administration of dermal fillers. Those are all tragedies for the individuals involved and mistakes that could be avoided. They are a cost to the NHS and to wider society. I believe that a system of licensing would put a stop to a lot of those tragedies.
Dr Whitford
I rise to support the new clause. As a surgeon working in general surgery, I know that, as many of these new techniques emerged, the pressure on the NHS became obvious—for example, as a result of local infections and extensive necrosis. Fillers can also migrate. That might seem a minor side effect, but it can create a lot of psychological and mental health distress for the person who went ahead with the procedure and ended up disfigured because the filler was incorrectly administered. Botox has become ubiquitous, but we should remember that it stands for botulinum toxin, which is one of the most dangerous toxins on the planet. It is used in tiny doses, but it can still cause problems if incorrectly administered.
In addition to these aesthetic techniques, which have become extensive because they appear minor and are often delivered by people without significant training—part of their danger is that they are projected to the public as being very simple techniques—we have the issue of more extensive cosmetic surgery, such as breast surgery, abdominal uplifts, liposuction and so on, which involve anaesthetic—often a general anaesthetic—and major intervention. The public think that plastic surgeons and cosmetic surgeons are the same. Although a plastic surgeon, who is a trained and licensed NHS surgeon, may also carry out cosmetic surgery, there are many clinics providing cosmetic surgery that is not carried out by plastic surgeons. Here the side effects and repercussions for a patient can be quite extensive, and indeed they have previously led to loss of life, which in some cases has been well publicised.
If this issue is taken forward, I would like to see a recognition that both these minor aesthetic interventions and cosmetic surgery should be regulated.
Edward Argar
I am grateful to the hon. Member for Ellesmere Port and Neston for bringing this discussion before the Committee today, and I join him in paying tribute to my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) and the right hon. Member for North Durham. I know that both are tenacious campaigners, and both are due to meet me in the coming days to discuss their work in the context of the all-party group and the constituency case, exactly as the hon. Member for Ellesmere Port and Neston mentioned.
I also pay tribute to my hon. Friend the Member for Sevenoaks (Laura Trott) for her success, within a year or so of coming to this place, in getting her private Member’s Bill through. It imposed some further restrictions in relation to botulinum toxin treatments or procedures, particularly in terms of the age limit from which they could be undertaken.
This new clause would give the Secretary of State the power to introduce a licensing regime for beauty and aesthetics treatments, and make it an offence for a cosmetic practitioner to practise without a licence. I appreciate the intention behind the new clause, and I am sympathetic to its intended purpose. As we are aware, cosmetic treatments are an ever-expanding, multi-million pound industry, and we need to ensure that that industry operates in a safe way.
The breadth of the recent beauty, aesthetics and wellbeing all-party group inquiry into non-surgical procedures, which the shadow Minister alluded to, demonstrates that this is an extremely complex area to tackle and address. There is a huge range of non-surgical cosmetic procedures available, which vary in their level of complexity and invasiveness. The Government are carefully considering the findings of that report and the need for additional regulation in this area in the light of it.
We are considering the case for a licensing system alongside the other specific, and in some cases more narrow, recommendations made in the all-party group’s report. As part of that, we need to work further with stakeholders and within Government to clarify the scope of any further regulation and which procedures it might apply to. The private Member’s Bill introduced by my hon. Friend the Member for Sevenoaks came into force at the start of October. It prohibits the availability of botox and dermal fillers to under-18s, apart from in a very narrow set of defined circumstances. We will consider the impact and effectiveness of this important legislation in parallel with the all-party group’s report in assessing whether to expand further the role of local authorities in overseeing cosmetic procedures.
I reassure the Committee that my priority is to ensure that the right regulatory framework is in place to provide consistent and high standards of practice, and the Government are committed to improving the safety of cosmetic procedures through better training for practitioners and clear information so that people can make informed decisions about their care. I hope I can reassure the Committee that we are actively considering whether increased oversight of practitioners performing some of the most invasive non-surgical procedures is the right way forward, and one that we could work with.
We continue to explore carefully how to achieve a proportionate system of practitioner regulation. The all-party group’s report is a very valuable contribution to that work and that active assessment. As soon as that work has been done, we will look to determine the need for and scope of further regulation in this area, and we look forward to reporting our conclusions from that assessment in early 2022. I therefore encourage the shadow Minister not to press the new clause to a Division, and I invite him to work with us in looking at the issue.
Justin Madders
I am encouraged by what the Minister has said. I am pleased to hear that he is meeting the right hon. Member for Romsey and Southampton North and my right hon. Friend the Member for North Durham shortly, and that we will hopefully have some progress on this in the new year. In the light of that information, I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
New Clause 17
Secretary of State’s duty to maintain safe staffing levels
“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—
‘1GA Secretary of State’s duty to maintain safe staffing levels
The Secretary of State has a duty to maintain safe staffing levels in the health and care service in England.’”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
This is a probing new clause, and I will not press it to a vote. I am not sure that this is the best legislation for it, but we are trying to make some points about the importance of patient safety. I hope we can all agree that for good care to be central, there need to be enough staff, not just notionally through some measure of the number of posts, but by ensuring that those people are actually in place at the time of giving care. We can have a debate about what level of staffing is enough. For a long time, the issue was left to the good sense of managing clinicians but, of course, that has always been strongly impacted on by the level of budget that could support staff.
Across the world, much attention has been placed on setting out what levels of staff and skill are needed in various settings to achieve the required levels of safety. The debate is not at any fixed point in time, because pathways, models of care, and staffing skills and mixes develop and evolve, but there will always be a correlation between safe staffing and levels of funding. It is a sad fact that our NHS, which should find planning easy as a single national system, has struggled for some time in almost every of aspect of workforce planning. It has shied away from asking questions about safety that come when the available workforce is not matched to the resources. At the end of the day, it is the patients who lose out when we are in that situation.
Much of the discussion on this topic historically has focused on the nursing workforce, which is by far the biggest of the staff groups. The Royal College of Nursing put out guidance pre-covid and during covid and set out where the legal responsibilities lie. It also pointed out recently:
“These are unprecedented times. Nursing staff in almost all settings are facing challenges beyond what were ever expected. Staffing levels are poor in many places, on most shifts and care is being compromised as a result”—
“care is being compromised” can be read to mean unsafe staffing levels.
New clause 17 calls for a duty to be placed on the Secretary of State to ensure that there are in fact safe staffing levels, even if there is not a specific legislative requirement in England. I say in England because in Wales, Labour has led the way with the Nurse Staffing Levels (Wales) Act 2016. In Scotland, the Health and Care (Staffing) (Scotland) Act 2019 became law, although I understand that covid has meant that there has been some delay in its implementation. I also understand that Scotland included social care staff in that remit.
A decade ago, research showed that low levels of nurse staffing are linked to worse patient outcomes and unsafe conditions. Before 2013, decisions to assess and review staffing levels were made locally, with little national guidance. However, the Francis inquiries in 2010 and 2013 identified nurse staffing as a patient safety factor that contributed to the care failings identified at Mid Staffordshire NHS Foundation Trust. They highlighted that decisions about nurse staffing were made without full consideration of the risks to patient safety. Francis said:
“So much of what goes wrong in our hospitals is likely, and indeed it was, in many regards, the case in Stafford, due to there being inadequate numbers of staff, either in terms of numbers or skills”.
In response to that statement and the Francis inquiries, the Department of Health developed four strands of policy that aimed to create safe nurse staffing levels in the NHS. The National Institute for Health and Care Excellence published guidance for safe staffing in all NHS acute hospitals in 2014. It endorsed the safer nursing care tool to help hospitals to plan their staffing. There was a National Quality Board report outlining the principles that NHS trusts were expected to apply in relation to planning staffing, and trusts were required to monitor the differences between planned and achieved nurse staffing levels and to report them through NHS Choices.
A lot of emphasis was placed on the providers of care, and rightly so. They should use their staff effectively and efficiently to keep patients safe. However, there is also a wider responsibility on commissioners—that is where I think we have fallen down—to ensure that providers do what is required, and on system managers and others who allocate the resources, to ensure that they do it in a way that permits safe levels of staffing. Community, maternity and learning disabilities are all nursing specialities where shortages are most acute. Our new clause makes it clear that all settings would have to adhere to the same standards, with no distinctions, because we believe that good and safe care should be for everyone.
In 2013, the National Quality Board set out 10 expectations and a framework within which organisations and staff should make decisions about staffing that put patients first. The document, entitled “Putting people first”, made it clear that safe staffing was both a collective and individual responsibility and central to the delivery of high-quality care that is safe, effective, caring and responsive. In England we have a website full of guidance, and NHS boards are required to take that guidance into account or have regard to it, but there does not appear to be anything similar for social care. Of course, the point I am trying to make, rather unsubtly, is that that is just guidance.
Looking more broadly, the NHS entered its new planning mode from 2015, and we had the emergence of sustainability and transformation partnerships. There was a requirement for them to design local plans to develop, recruit and sustain levels of staff with the right skills, values and behaviour in sufficient numbers, and in the right locations, to ensure the safety of patients. The plans were developed in great haste, but they did not actually go anywhere. Now we are to have more structured ICBs and new plans, but we still do not have a national workforce plan, which means that ICBs cannot plan properly either.
It would be good to know not just the levels of vacancies, but the gap between the staffing needed to maintain safe levels of working and what is actually in place. We touched on this aspect earlier, and we hope the Government respond positively even if they do not accept the new clause. I am sure the Minister will agree that safe staffing levels are better than unsafe levels. We should all agree that it is possible and desirable to enshrine in law guidance from experts on what constitutes safe levels of staffing in various settings and scenarios. We should absolutely be allowed to know when unsafe levels of staffing occur, especially when it becomes an endemic issue due to staff or funding shortages.
As we have mentioned before, we do not want to overburden the Secretary of State, because he already has a number of new powers under the Bill that will keep him busy. We have tried to remove the attempts to give him more work through the power grab, but it would not be for the Secretary of State to do the rotas or phone round for additional staff in the mornings. He just has to ensure that the duty to have staff levels of staffing is fulfilled by those delivering the service. Any wisdom that the Minister can provide on issues around defining, establishing and enforcing safe staffing, and on who carries the systemic responsibilities, will be greatly appreciated.
Dr Whitford
There is no question but that the workforce in both health and social care is one of the biggest challenges across all four nations of the UK. As the shadow Minister highlighted, both Scotland and Wales have passed legislation and aspire to having in law what level should be aimed at, which is quite important. Although covid has impacted in terms of staff leaving the service and the demand on the service, Brexit has also had a huge impact, in that there was an almost 90% drop in European nurses coming to the UK within just months of the referendum. The situation has not recovered, and that impacts right across the system and indeed in social care, where European citizens represented a significant part of the workforce.
When I first came to this place, the former Health Secretary, the right hon. Member for South West Surrey (Jeremy Hunt), talked very much about patient safety but claimed that, in essence, doctors were not really available in the NHS outwith nine to five, and that this was causing what were called “weekend deaths”. Having worked long hours for over three decades, I was a bit afraid that my husband would think I was having serial affairs if I was working only nine to five in the hospital, so I refuted that utterly. However, the evidence available at the time was that the only staff ratio that had any provable impact on patient outcome was that of fully trained, registered nurses—not trainees, not associates and not assistants—to patients. Obviously, that ratio changes, based on the dependency of the ward—whether it is an ordinary ward, a high-dependency ward or an intensive care ward. That is what leads to the basic formula in safe staffing legislation, and England does not have it.
Although covid, Brexit and other things have impacted on the ability of Scotland and Wales to achieve what they aspire to, the guidance has been there for years and it has not been achieved, as the shadow Minister said. Having safe staffing ratios in hospitals is critical, but what action should be taken if that safe level of staffing is not there? What work should not be done so that patients with emergencies can be cared for properly? Otherwise, there is pressure on management to get things done where they want to see throughput. Sometimes, staff simply end up between a rock and a hard place, and that drives staff out of the service. Ultimately, coming home after an exhausting shift feeling that they have delivered poor care because they were covering too many patients is demoralising. It undermines the retention of staff and adds to the problem.
Edward Argar
I am grateful to the shadow Minister, the hon. Member for Ellesmere Port and Neston, for his framing of the new clause in his opening remarks.
The new clause would place the Secretary of State under a statutory duty to maintain safe staffing levels in the health and care service in England. I fear that its effect would be to detract from the responsibility of clinical and other leaders at a local level to ensure safe staffing, supported by guidance—I certainly take on board the point about guidance made by the hon. Member for Central Ayrshire—and regulated by the Care Quality Commission. I am afraid that the Government cannot agree with the new clause as worded for a number of reasons, which I will enunciate for the shadow Minister to illustrate my thinking.
First and foremost, we do not believe that there is a single ratio or formula that could calculate what represents safe staffing. It will differ across and within an organisation and, indeed, across organisations. Reaching the right mix requires the use of evidence-based tools and, crucially, the exercise of professional judgment and expertise and a multi-professional approach.
Consequently, we think that responsibility for staffing levels is best placed with clinical and other leaders at a local level, responding to local needs and supported by guidelines, all overseen and regulated by the CQC. Those guidelines, notwithstanding the challenges posed by the hon. Lady and the shadow Minister, are issued by national and professional bodies such as the National Quality Board and National Institute for Health and Care Excellence. They are based on the best available clinical evidence and are designed to ensure patient safety.
Appropriate staffing levels form a core element of the CQC’s registration regime for health and social care providers. Providers are required by the CQC to provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the care and treatment needs of the people using the service at all times. Staff must also receive the support, training, professional development, supervision and appraisals necessary to carry out their role and responsibilities.
Secondly, the new clause would require the formulation of safe staffing ratios against which performance could be assessed. I fear that that could be a retrograde step and inhibit the development of the skill mixes needed for a more innovative and productive future workforce, which will be crucial to the successful implementation of the new models of integrated care that the Bill is intended to support. Just as there is no one-size-fits-all approach for the new models of care, there will be no identikit approach to the mix of staff needed. The ultimate outcome of good quality care is influenced by a far greater range of issues than how many of each particular staff group are on any particular shift, according to a prescribed ratio. It requires the professional expertise and judgment of those who know the situation best in a given circumstance. The point I seek to make is that, although those numbers are a key part, they are not the only part.
This is, perhaps, more of a technical point than a point of substance, but the specific wording of the new clause is incredibly broad. It would potentially require the Secretary of State to assess safe staffing levels across all healthcare settings across the whole of England for all medical and clinical staff. Such a duty would, I fear, be challenging to implement, notwithstanding the shadow Minister’s assertion that he would not expect the Secretary of State to sit there each morning going through shift rotas and shift patterns himself. It would be challenging for not only the Department but the wider system and, in particular, clinical leaders in individual settings.
For those reasons, while I appreciate the sentiment and the objective sought by the shadow Minister, I do not believe the new clause is the appropriate practical solution.
Justin Madders
I am grateful for this Minister’s response. I am not surprised that he is not prepared to the support the new clause. Unfortunately, I think there is a large chasm where responsibility for workforce issues probably lies, and this is an example of that. It was certainly not our intention to expect the Secretary of State to deliver each individual setting, but for someone in the system to have that responsibility of advising the Secretary of State. No doubt we will return to this. We will see the practice in the devolved nations and how that has proved to be a success or otherwise, which may strengthen or weaken the argument. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 18
Workforce responsibilities of integrated care boards
“(1) Each integrated care board must at least every two years publish a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.
(2) In drawing up the report the Board must consult—
(a) the Trusts and Foundation Trusts that provide services in its area,
(b) providers of primary care in its area, and
(c) the recognised trade unions.”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
We are back on the workforce. We had a brief discussion about the proposals in clause 33 on the Secretary of State and workforce planning, and how they are by universal acclaim wholly inadequate. Now is not the time to repeat that debate, although I may shoehorn in one or two references to it. We hope that at some point there will be a better proposal on the national efforts to assess and meet workforce needs.
The new clause tries to repeat the intentions of the amendment to clause 33, and to take some of that thinking and translate it to ICB level. That makes a lot of sense to us, and in an ideal world some of the national plan would be made up of individual local assessments of need and add together the 42 ICBs into one national workforce plan. We will see where we end up with that. As I said, we have had some attempt at this with each STP trying to produce its own plan to a very abrupt timetable. I do not think anyone actually added up all their assessments to come up with a national figure. Because of the truncated timetable they faced, there was not a great deal of engagement with the workforce on that.
There is therefore a bit of a precedent in the work that was done on that. It is probably what you would call a gap analysis: what is needed against what we are likely have unless something is done to close that gap. The new clause follows that approach, which has had some support in some other areas. We felt that a two-year cycle was about right, with reporting on that two-year cycle covering short, medium and longer-term need.
It is hard to see why we will not have local plans if we are going to have national plans, to make sure that there is alignment when, as we hope, the Government come back with something better on clause 33. Looking at the total staff in the NHS and social care for an ICS, some of the larger ones will be running into hundreds of thousands of people. It is hard to think of any system with that many staff where some sort of workforce planning is not going on. If we are looking at things across system level, as the ICS is, surely workforce needs across the system would be part of that. We know that ICBs, together with the relevant trusts and foundation trusts, have the general duty to produce a plan annually, setting out how they propose to exercise their functions over the next five years. They will not be able to do that without the right staff.
A lot of the ground work entailed in the new clause will have been done already. It is our intention that it will try to remove any possibility of blame shifting, where inadequate resources lead to reduced services and the service providers are blamed, rather than those who hold the purse strings in Whitehall. The reporting required by the new clause will make it clear whether there are enough staff to meet all the reasonable requirements of the ICB.
The other key point covered by the new clause is who is consulted in the local planning process. We believe it vital that recognised trade unions are involved. That should be a given anyway, in the light of the general commitments from the NHS over partnership working, but as we have covered before, we think that needs to be explicit in the legislation because of the behaviour of a few NHS bodies in trying to marginalise staff involvement in recent times.
The ICBs will new bodies, and they will need to understand the importance of partnership working from day one. If the levelling-up and devolution agendas are to continue to flourish, surely the regional and sub-regional identification and development of skills in this important area ought to be part of the mix. It feels, I am afraid, as though the whole issue of workforce is being assiduously side-stepped by the Department. That is the Department’s prerogative, but it is a mistake and it is those on the frontline who will bear the brunt. We need someone to take responsibility, so why not the ICBs?
Without its workforce, the NHS is nothing. We are grateful to each and every one of its staff for the work that they do. We owe it to them, the patients and the taxpayer to have in place a proper system of workforce planning. Although we do not pretend that the new clause is the whole answer, it would begin to put in place the building blocks to achieve that.
Edward Argar
The new clause would place a new statutory responsibility on integrated care boards to publish, at least every two years,
“a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.”
Under the new clause, ICBs drawing up that report would be placed under a statutory duty of consultation with the trusts and foundation trusts in their area, providers of primary care and the recognised trade unions. The Government’s view is that that is an unnecessarily prescriptive duty on ICBs, and that clause 33 —alongside our non-legislative work and investment—remains the right way to develop the NHS workforce.
On the workforce nationally, what is needed is greater transparency and accountability for the various bodies involved in workforce planning. Clause 33 requires the Secretary of State to produce a report describing the workforce planning and supply system—including the roles of DHSC and its arm’s length bodies; NHS bodies, including ICBs and others; and how they work together—to provide that greater transparency.
To support local ICBs on workforce matters, work is already being taken forward on workforce planning through NHS England and NHS Improvement’s draft guidance to ICBs on the discharge of their functions. The draft NHSEI guidance, published in August 2021, states that the intended outcomes for ICBs will include,
“Growing the workforce for the future and enabling adequate workforce supply”,
as well as,
“Leading coordinated workforce planning”.
The guidance notes state explicitly that ICBs will have the responsibility to develop
“plans to address current and future predicted workforce supply requirements”,
which I believe addresses the core intention of the shadow Minister’s new clause.
The production of those plans will require ICBs to develop and regularly refresh collaborative workforce plans for their integrated care area, with demand and supply planning based on population health needs. As part of that work, we can expect ICBs to work with local stakeholders in their areas. ICBs will also be supported by Health Education England on such workforce planning matters. Under the guidance, ICBs will also have the responsibility to provide workforce data to regional and national workforce teams to support workforce planning and inform the prioritisation of workforce initiatives and investment decisions.
We join the shadow Minister in putting on the record our gratitude to our health and care workforce, but we think that that guidance already sends a strong signal to the system about the importance of the issue, and we therefore do not support his new clause.
Justin Madders
I am not surprised, although I am a little saddened, that the Minister has once again adopted the permissive rather than prescriptive approach. We think that the issue is so important for the NHS that it needs a firmer hand. I am sure that I will quote back to him his comments about the need for greater accountability and transparency in workforce planning, because that is something that we absolutely agree on. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 19
Secretary of State’s duty to provide access to occupational health services to NHS staff
“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—
‘1GA Secretary of State’s duty to provide access to occupational health services to NHS staff
The Secretary of State must provide access to occupational health services to meet the reasonable requirements of all persons who are employed in an activity which involves or relates to the provision of services as part of the health service in England.’”—(Alex Norris.)
This new clause would place a new duty on the Secretary of State to provide access to OH services to meet the reasonable requirements of all NHS staff. The duty would apply to all healthcare professionals delivering health care including doctors, dentists, nurses, midwives, pharmacists, healthcare scientists and the allied health professions.
Brought up, and read the First time.
Alex Norris
I beg to move, That the clause be read a Second time.
The past 18 months have made clearer than ever the health risks that our health workers face at work, as they have dealt with unprecedented pressures during the pandemic. Occupational health is a multidisciplinary approach to maintaining the wellbeing of those employed in a workplace, preventing and removing ill health and developing solutions to keep staff with health issues at work, the most common problems being mental health and musculoskeletal issues.
Occupational health services occupy a unique position as neither the employer nor the employee. I remember in my time as a union official helping NHS staff with issues at work, and we would howl at times at things that occupational health came up with. Then we met management and realised that they were howling about it too, so we realised that the occupational health practitioner was probably in the right place. That is a very specific and special place, in the NHS and beyond, and we should want our wonderful NHS staff to have proper access to it.
Currently, the NHS provides access to occupational health services to the vast majority of staff in acute trusts, but the policy is inconsistent. While NHS England is making efforts to expand access through the growing OH programme, those efforts need to be accelerated and supported, which is what the new clause would do.
In secondary care, the provision of services tends to depend on legal requirements on safety, for example checking for blood-borne viruses in advance of performing surgical or other procedures that could pose a risk to patients from the infected clinician, rather than occupational health provision that supports individuals to remain at work based on other needs they might have.
Similarly, the co-ordination of occupational health services in primary care has suffered since the abolition of primary care trusts in the Health and Social Care Act 2012. As a result, there is far less provision in primary community care settings. Some of the funds previously allocated to PCTs in support of occupational health services were diverted to the practitioner health programme—PHP— which provides mental health support for NHS staff. While that is valuable, the PHP is not a replacement for specialist occupational health services that are ready to work with both employer and employee on issues beyond mental health. That means that key parts of the NHS workforce—GPs, practice nurses and pharmacists—lack full access to occupational health services, and that has real implications. We worry about burnout in all those groups, especially after the 18 months we have just had. For some of our staff, A&E is the only avenue for treatment, in cases of exposure to infectious disease or a needle stick, for example. That is unsuitable and we could do much better than that.
We think it is vital for NHS staff wellbeing and staff retention that all NHS workers have access to occupational health services when they need them. We are not asking for something extra or beyond the scope of current conception. In 2016, NHS England introduced a commitment for OH services to be provided across the NHS, stating its intention to achieve
“a nationally standardised Occupational Health Service…that is equitable and accessible.”
That is a very good commitment, but five years on it remains unfulfilled. The new clause would put that on a statutory footing and get it going.
The Secretary of State already has several duties to NHS staff, in relation to education and training, for example, under the 2012 Act. The new clause would fulfil the 2016 commitment and meet the needs of NHS staff by requiring the Secretary of State to meet any reasonable OH requirements for anyone employed by the NHS directly or indirectly. It would be really good for our staff and, in turn, for the health service and those it serves. I hope that the Minister will give it positive consideration.
Edward Argar
As the hon. Member for Nottingham North set out, the new clause seeks to legislate for an additional duty on the Secretary of State to provide access to occupational health services to NHS staff.
The NHS is what it is thanks only to the hard work of its staff. The Government and Members of Parliament on both sides of the Chamber are immensely grateful to them. Caring for people throughout the pandemic has required a phenomenal effort from so many people, ranging from students and trainees to new recruits, established staff and those returning to the workforce. The dedication and resilience of NHS staff has been incredible—indeed, humbling—to witness. They have consistently placed the needs of patients before themselves, as indeed they do year in, year out, but they have done so in particularly challenging circumstances over the past year and a half or so.
If healthcare staff are to provide excellent care to patients, they need to receive excellent support themselves. Occupational health services play an important role in ensuring that staff get the support that they need to do their jobs and to flourish in them. Throughout the pandemic, we have placed a strong emphasis on supporting staff wellbeing. In July 2020, we published the NHS “People Plan”, which prioritises staff health and wellbeing. That was supported by the roll-out of a comprehensive national health and wellbeing support offer, which has been accessed by staff across the NHS.
The past 18 months have seen many NHS organisations respond with empathy and agility to the pandemic, and occupational health teams have developed innovative ways of supporting their colleagues. As we move towards, or into, the recovery phase, there is a great need to build on that focus and momentum, to ensure a healthy, sustainable workforce going forward. As we look to the same workforce who have taken us through the pandemic to tackle the waiting lists and waiting times, we must recognise, and be open with those who watch our proceedings and listen to us, that that task of rebuilding and getting the waiting lists down will be challenging. We owe it to the staff to be clear about that, because they are the same staff. They are physically and emotionally exhausted, and we have a duty of care to them, and must enable them to rebuild their physical and emotional strength after what they have been through over the past year and a half.
That is why the NHS priorities and operational planning guidance, published in March 2021, puts staff wellbeing and the recovery of the workforce right at the top of the list of priorities for the NHS. To support that, NHS England and NHS Improvement have launched a new programme to strengthen and improve occupational health across the NHS. That will look at how we can improve occupational health services, grow the occupational health workforce, develop their capability, empower local leadership and bring a strengthened focus on proactive and preventive care. It will build on best practice across the country and will inform future blueprints for potential service delivery models, with the aim of having a five-year service improvement strategy for occupational health in the NHS. It is being developed with the support of Dr Steve Boorman and the Faculty of Occupational Medicine, the Society of Occupational Medicine, the Council for Work and Health and the NHS Health at Work network, as national occupational health partners that both represent the voice of and link directly with occupational health professionals. That work, and the broader programme of work through the NHS “People Plan” to transform the NHS as a place to work, demonstrates our strong commitment to supporting staff health and wellbeing in the NHS.
As a result, we do not believe that this new clause is necessary, although we appreciate the sentiment, objective and aims sitting behind it. Our concern is that drawing out occupational health over and above other aspects of health and wellbeing support does not necessarily help to drive forward the other work done, which I have alluded to and which provides staff with a more comprehensive package that can be tailored to individual or group staff needs. There is a risk, though I suspect it is a small one, that occupational health could become a tick-box exercise to comply with, which would detract from the full journey of health and wellbeing support. Occupational health is part—indeed, a vital part—of that, but it is not the solution in and of itself, alone.
For the reasons that I have set out, I ask the hon. Gentleman to consider not pressing the new clause to a Division at this point.
Alex Norris
I am grateful for that response. I do not intend to push this new clause to a Division. I have made my case about the importance of occupational health, and I understand what the Minister said about the broader range of interventions. Of course, we would support those, too, but particularly here, we really need to get to the point of having full coverage. Only NHS England has committed to that. I hope that today we have at least sounded the signal that the pace is too slow, and that we ought to get on with it. I hope that the Minister will keep the matter under consideration. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 23
Cap on private charges
‘(1) Section 43 of the National Health Service Act 2006 is amended as follows.
(2) Leave out subsection (2A) and insert—
“(2A) An NHS foundation trust does not fulfil its primary purpose if the proportion of the total income of the NHS foundation trust in any financial year derived from private charges is greater than the proportion of the total income of the NHS trust derived from such charges in the financial year ending 31 March 2022.
(2B) For the purposes of subsections (2A) and (2C) “private charges” means charges imposed in respect of goods and services provided to patients other than patients being provided with goods and services for the purposes of the health service.
(2C) An NHS foundation trust does not fulfil its principal purpose if in any year the proportion of the total income derived from private charges is greater than the proportion of the total income of the NHS trust derived from such charges in the previous financial year unless—
(a) the appropriate integrated care boards and integrated care partnerships have been notified of the intention that this increase will occur;
(b) that intention has been published with a statement of the reasons why it is considered to benefit the NHS;
(c) the appropriate integrated care boards and integrated care partnerships have used reasonable endeavours to consider any responses to the publication mentioned in (b); and
(d) any integrated care board which has commissioned services from the trust, and the integrated care partnership for the board, have informed the NHS foundation trust that the proposed increase is justified.”’—(Justin Madders.)
This new clause would prevent NHS foundation trusts increasing their income from private patients year on year unless the conditions set in subsection (2C) are met.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
One of the livelier arguments during the passage of the Lansley Act was about trusts doing lots more private patient work. Under the Act, up to 50% of a trust’s income could be derived from private patients. That was obviously an attempt to take the NHS in a whole new direction. The previous private patient cap was removed, and a new definition of “principal purpose” was brought in.
We need to be clear that this new clause is not about the parallel argument that we sometimes have about private providers doing more NHS-funded work, though that is a major concern when we hear the news that the private sector is now doing more hip replacements for NHS patients than the NHS. We are in a slightly ludicrous and paradoxical situation: private providers are doing more NHS-funded work, while NHS providers are doing more private work. The new clause tries to put the brakes on that. We say: why not just build up NHS capacity to the point where it does all NHS-funded work, so that the need to keep dipping into the private sector is removed?
The 2011 argument is mirrored in the way the original foundation trusts, when invented, were allowed to develop private patient income, but only to a very low level. That was not a great situation, but it recognised that there were already a few NHS organisations, mostly in London, for which private patient income was so significant that there would be a risk of destabilisation if that income were blocked. The point at the time was that the amount permitted then was acceptable, but that it should go no further. Incidentally, the plain-old NHS trusts could do as much private patient work as they were allowed to by the Secretary of State, who could direct them to do it. If memory serves, he allowed one trust to become the private patient income league table toppers at one point. It did not want to become a foundation trust. What a strange and paradoxical world we live in.
Anyway, in 2011, the cap was raised from 3% to 50%, which started many hares running. We heard predictions of a whole new generation of private patient units being built, and that we would be back to the old days when the NHS was the largest provider of private patient care. Fortunately, that never happened. In the real world, there are now only around a dozen trusts that have any significant private patient income, and it is not increasing at a significant rate, although recent developments in Oxford suggest that the issue has not gone away.
One might argue that in those circumstances there is no need for the new clause, but we would say that there is every need to renounce the approach set out in Lansley, and to go back to a public NHS. The only reason for gaining income from private patients is to benefit the NHS as a whole, not to benefit one NHS organisation. This is a real and live issue, as we saw during covid. There were tensions, and every spare bed was vital; indeed, every spare bed is vital now to support the mammoth effort that is needed to bring down waiting lists. In all seriousness, why would we sanction a trust’s building more private patient capacity, when waiting times for NHS treatment continue to go up? Then we go, as we have done in recent times, cap and wallet in hand to the private providers and pay them huge sums to allow the NHS the option of using their services and capacity, as we did during covid. As we saw recently, that did not get used anything like as much as it should have been. That might be a fortunate thing, but it was a shocking lack of value for money. The report by the Centre for Health and the Public Interest on the contract with the private sector found that none of the five objectives set for the contract were achieved, with large amounts of healthcare resources wasted.
Edward Argar
The hon. Gentleman’s new clause would effectively prevent NHS foundation trusts from increasing their income from private patients year on year unless a number of specified conditions were met.
If hon. Members are students of history, they will recall that in 2012 we abolished the private patient cap, while clarifying that the foundation trusts’ principal purpose was
“the provision of goods and services for the purposes of the health service in England”,
meaning that foundation trusts must make the majority of their income from NHS activity. That was a more rational and sensible way of managing the issue than the previous cap, which caused practical problems for some NHS organisations that wanted to become foundation trusts and were prevented from doing so by the prescriptive nature of the previous regime. We also retained the requirement that additional income be used to benefit NHS patient care. It has been used across the system to offset maintenance costs, finance alternative transport such as park and ride, and fund patient care.
I should also be clear that we are talking about a very small percentage of the NHS’s income. The most recent set of provider consolidated accounts for 2019-20 shows income from non-NHS sources as 2% of income, of which less than 1% relates to private patients. Again, all that income has gone to improving care for NHS patients.
The new clause introduces a new cap by a different door; it creates a requirement for foundation trusts to agree with their ICB and ICP their income from non-NHS sources, and if they raised more than in the previous year, they would no longer be fulfilling their primary function as a foundation trust. That would be a significant bureaucratic and administrative burden on foundation trusts, and it would require them to either forgo raising additional income, or seek agreement via a multi-stage process before raising it.
The provision would also mark a significant new restriction on foundation trusts’ freedoms and autonomy, and could potentially dissuade some from wishing to become foundation trusts. As all non-NHS income must benefit NHS patient care, and an NHS foundation trust must always have as its primary purpose the delivery of NHS services, I fear that would potentially be putting ideological purity over practical interests and the practical working of the system.
New clause 23 would only apply to foundation trusts, as I read it, not NHS trusts. NHS trusts do not have a limit on the amount of income they can raise from private patients, and a very small number of trusts raise significant income in this way. Putting an additional requirement on foundation trusts before they can raise non-NHS income, but not doing the same for NHS trusts, would potentially further unbalance the playing field and give an additional nudge in the direction of foundation trusts.
The hon. Gentleman raised the issue of the costs or spending on the independent sector in the context of the pandemic response. I have been clear throughout that when the accounts are fully consolidated and audited, those figures will have to be reported. I cannot say exactly when that process will be complete, but it is a requirement that those accounts be gone through, consolidated and audited. I would hesitate to give him an inaccurate figure, but it is my intention for those figures to be made available at the appropriate time. With that, I invite the hon. Gentleman to consider withdrawing his new clause.
Justin Madders
I hesitate to withdraw the new clause, because I have to say that the Minister’s arguments about not wanting to deter foundation trusts from making applications rang a little hollow, but we would not want to be accused of preventing that procession from continuing. We have set out very clearly why we do not think this residue from the 2012 Act should remain on the statute book. We think it sends out the wrong message and is actually unhelpful at this time, but we will not push the new clause to a vote. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 24
Requirement for NHS trusts to publish Royal College invited review reports
“Each NHS Trust in England must publish the reports produced by Royal Colleges of invited reviews of the Trust, including any conclusions and recommendations.”—(Justin Madders.)
This new clause would require Trusts to publish Royal College invited review reports.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
The clause seeks to require all trusts to publish reports produced by royal colleges following invited reviews, including any conclusions and recommendations. Invited reviews are advisory, non-regulatory and non-statutory ways for healthcare organisations to assure patient safety and improve patient care through the use of a collaborative, independent, objective and expert review process undertaken by medical royal colleges when asked. Invited reviews have a clear and important role in supporting improvements in services. They aid trusts in understanding issues within departments or teams, particularly where these are multifactorial and involve team dynamics. An independent, external expert opinion is often invaluable in helping senior clinicians see a different viewpoint and in articulating where and why professional differences of opinion in practice are occurring.
The reports can help move issues of contention forward and improve relationships. Trusts value the insight and objective evidence of these reviews, particularly where quality issues have been raised. They are often a vital tool in resolving a complex, seemingly intractable issue. They are also invaluable in ensuring the NHS can continually learn, improve and deliver the safest and best quality care for patients. However, we think that can only be achieved if the information and learning within the reports is shared for the benefit of others across the system.
Independent and external expert reviews are a key part of any assurance process. To us, their value is beyond dispute. How the organisation being reviewed responds to the report produced is again crucial. Although we would expect in most cases the organisations to accept those recommendations and do what is required, we know that does not always happen. Shockingly, BBC “Panorama” revealed that, of 111 invited service reviews over five years, only 16 were put into the public domain. Panorama accuses trusts of burying important reports on patient safety. The invited reviews are organised by the Academy of Medical Royal Colleges, which follows the published framework. The framework has a section on openness and transparency:
“Where a healthcare organisation has commissioned an invited review of clinical activity in response to concerns about the quality of patient care, they should also be open and transparent with patients, their relatives and the public…Healthcare organisations should also work closely with their regulators and share information about invited reviews with them proactively where necessary to ensure that the safety of patients can be maintained.”
As with all such external reviews, there is a balance between protecting certain information, for example by attributing views or comments, and being open. For such reviews it is necessary that those interviewed or otherwise asked to become involved are happy to do so and happy to speak out confidentially. As we discussed earlier, ensuring that staff and whistleblowers feel safe to come forward and disclose information about an incident is critically important.
The new clause does not intend to get in the way of that protection. It is deliberately not prescriptive about the timing of publication, so that trusts maintain appropriate control. It is not about blame or ensuring that trusts are named and shamed when improvements are needed; it is about transparency. In the NHS, after mistakes have been made, it is vital to have transparency to ensure that necessary improvements are made.
It is concerning that so many reports produced by royal colleges have not been shared with the public and therefore we do not know whether they have been acted upon. As part of the conditions of an invited review, trusts are in effect signing up to publishing and showing the findings. Yet, as we know, that is not happening.
Everything favours openness, although patient-identifiable information would of course have to be redacted. On some occasions, there may be other reasons for part of the report to be withheld, but not the overall conclusions and certainly not the recommendations. That would ensure proper accountability for the follow-up and implementation of the recommendations or, in some cases, a justification for why the organisation did not accept or act on the recommendations.
We have talked several times already about the defensive culture that pervades parts of the NHS and how it sometimes gets in the way of what patients and families want. They want answers and assurances. Most of all, they want the truth. These reviews are part of that truth. We have had the same argument many times, because, although the NHS claims to be open and transparent, it is often not.
Given the fragmented and convoluted set of organisations within the new structure, it is harder to know sometimes who will be responsible for what. With the present system, there is always the issue of who owns the report, who controls what is published and who follows up and ensures that the necessary changes are made. That is why we believe that that the disinfectant of sunlight is vital. We should know everything unless there is a good reason for us not to, not the other way round. We should not be required to protect the reputation of bits of the NHS or even the reputations of those individuals who have failed to do their jobs properly.
We have heard in the many scandals how things were known by a few, but they failed to act and prevented anyone else from acting on the information they had. Sadly, it is necessary to be clear about rules. There ought to be some sort of sanction for those who have broken rules of publication. It may not always be easy for the individuals or the individual organisations, but it is almost certainly always going to be in the interests of the NHS as a whole.
The Academy of Medical Royal Colleges and the CQC are looking at guidance on invited reviews at the moment. The new clause seeks to focus the Minister’s mind on an issue that has not gone away. I know it is controversial. I hope the Minister can give us some assurances that his Department is committed to developing a system that works better in this area and puts patients at the heart of everything that happens.
Unfortunately, in the last financial year prior to the pandemic, there were 472 serious patient safety issues classified as never events across the NHS in England. There is work to be done to get the NHS to the level of patient care and safety that we would want to see. It is only by seeking to understand why these events happened in the first place and the circumstances that led to them that we can ensure they never happen again. That is the heart of what most patients and their families want to know.
We believe that the safety of patients should be a golden thread running through every aspect of healthcare delivery and we will do everything in our power to make sure that the NHS is one of the safest and most supported healthcare systems in the world. I ask the Minister to tell us why the reviews should not be published on a regular basis. Is 16 reports out of 111 being published good enough? We certainly do not think it is.
I will finish on a quote from the Francis report. We have mentioned this one already, but it needs repeating as it is so important. He said:
“It is a basic and just expectation of the public that organisations are open, honest and transparent about their performance standards, about the rights of patients and about what happened, and why, if things go wrong. This is the only way to begin to restore full public trust in the NHS.”
We hope that this new clause, by requiring publication of the reviews, will go some way to restoring confidence and increasing the transparency that patients deserve.
Edward Argar
The new clause would require each NHS trust in England to publish any report by a medical royal college of an invited review of the trust. That includes any conclusions and recommendations. It is right, as the hon. Gentleman mentioned, that trusts are open and transparent in managing any concerns about the quality and safety of their services, and, in particular, regulators should have access to any royal college invited review of a trust.
I have considerable sympathy with the intention of the new clause. We all want to improve patient safety and care, and I recognise the key role that transparency can play as part of that. However, I will explain why I am not convinced that this objective is best advanced by acceptance of this particular new clause. Managing concerns about clinical quality openly and transparently is essential for trusts if they are to provide consistently high quality, safe care, to show quality of leadership and to maintain trust in the trust and the service it delivers.
When the CQC finds that there has been a failure to do so or that fundamental standards of care are not being met, it is reflected in the CQC’s reports and ratings and in the range of enforcement powers it can use. The CQC’s inspection teams maintain ongoing engagement with trusts and make it clear that they expect trusts to be open and honest about issues of quality and safety of services. Furthermore, the CQC has been clear with trusts that reports, including invited reviews by royal colleges, should be made available to relevant commissioners and regulators, including the CQC. The CQC, NHS England and NHS Improvement expect trusts to take prompt actions to address appropriate recommendations, and the framework for invited reviews from the Academy of Medical Royal Colleges is clear that trusts and royal colleges undertaking reviews should share any serious patient safety issues from reports with the CQC.
As part of the CQC’s monitoring and inspection activity, it assesses how trusts have acted on recommendations from these reviews, including implementing any learning to make improvements. Since July 2018, the CQC has set a very clear expectation on trusts to share copies of the full final report of external reviews, including those by royal colleagues, and to inform it of steps they are taking to implement any recommendations. The CQC, working with providers, NHS England, NHS Improvement and the Academy of Medical Royal Colleges, has seen improvement in the development of an open and transparent culture.
The CQC has powers to compel a trust to share an invited review where it is aware of that review. Where serious issues of care are uncovered, NHS England and NHS Improvement can also compel a trust to take whatever steps are necessary to address them. This includes the sharing of an invited review to itself. The CQC is now reviewing its regulatory model, including its approach to monitoring and gathering evidence from providers. In doing so, it will continue to work with trusts and royal colleges, including on sharing and responding to findings from external reviews to encourage a culture of openness and transparency.
There are robust and transparent systems in place to ensure that providers learn from and improve their services. This includes publishing more than 100 reports every year, covering 40 clinical specialisms as part of the clinical audit programme by NHS England and NHS Improvement. NHS England and NHS Improvement also publish regular data on patient safety incidents, other safety indicators and patient safety alerts. They also provide support to challenge providers to improve governance and culture.
Invited reviews are a voluntary process. They are an advisory, non-regulatory and non-statutory way for trusts to assure patient safety and quality of care through the use of an independent review, but compelling the publication of the full report could lead to some unintended consequences. First, it could discourage some trusts from commissioning these invited reviews. That could lead to trusts overlooking specific actions to address safety and quality concerns and opportunities for improvements and learning. Secondly, it could lead to trusts inviting consulting firms and other professional bodies with less expertise in the delivery of clinical care than a team from the royal college to undertake reviews. Thirdly, invited reviews can vary widely in their scope and may not be directly patient safety-related. Therefore a blanket requirement to publish all reports may not be appropriate.
Fourthly, the specific information that a trust can make publicly available will vary from review to review, depending on the circumstances. Invited reviews can often involve sensitive and complex circumstances and cover confidential issues about staff and patients. Trusts need to take account of legislation on patient confidentiality and data protection each time a report is developed. It may therefore not be possible for every invited review to be a published document. The Academy of Medical Royal Colleges recommends that trusts should take steps to make available to the public a summary of the review and the steps they are taking.
Finally, requiring publication of invited reviews could attract attention in a way that affects staff morale and organisational learning, and not in a constructive way. It could make future invited review reports weaker or drive necessary conversations and actions off the record. For these reasons, while I can understand the hon. Gentleman’s point and where he is coming from, we believe that the mechanisms already in place are sufficient and achieve the right balance.
Justin Madders
I am slightly heartened by what the Minister said there. He obviously takes the matter seriously. We are not going to press this to a vote, because we recognise that there is some concern in the sector about this proposal. I ask him to reflect on what he said about a requirement possibly discouraging trusts from seeking invited reviews in the first place. That shows that reputation management is still at the forefront of their considerations rather than patient safety. That is the heart of the problem that we have been seeking to tease out with this new clause. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 25
“Secretary of State’s duty to report on disparities in maternal mortality rates
The Secretary of State must prepare and publish a report each year on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including the steps being taken to address these disparities and improve outcomes for patients.”—(Justin Madders.)
This new clause lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including what steps his department is taking to address these disparities and improve outcomes for patients.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
This clause, in the words of Ronseal, does exactly what it says on the tin. It lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England. The report would include details of the steps that the Department was taking to address these disparities and improve outcomes for patients. We all know that this issue is of paramount importance and has been debated in the House several times recently. I hope that the Minister agrees that it is important that we take whatever steps we can to tackle all forms of inequality in our society and this is another example of how that manifests itself.
Covid has sharpened our awareness of health inequalities, but it is clear that it is not just with respiratory viruses where health outcomes can be staggeringly different for different groups. Maternity services are one of the areas where we can and must do far better. The Care Quality Commission report “Safety, Equity and Engagement in Maternity Services”, published in September, highlighted continued concern about the variation in quality and safety of England’s maternity services and presented analysis of key issues that persisted in some maternity services. It also highlighted where action was still needed to support vital improvements. In the UK’s poorest areas the stillbirth rate is still twice that in the UK’s most affluent ones, with pre-pandemic figures showing that babies in the poorest areas have a 73% excess risk of neonatal death. All mothers and babies deserve the very best care and it simply cannot be right that where people live might dictate the quality of the maternity care received. Action is needed to eradicate maternal inequalities.
It is not just geographical and socioeconomic inequalities that need to be tackled but ethnic inequalities. Evidence from MBRACE-UK––Mothers and Babies Reducing Risk Through Audits and Confidential Enquiries across the UK––shows that the maternal mortality rate is more than four times higher for black women compared with white women. The maternal mortality rate for Asian women is almost twice as high compared with white women. Those inequalities are an injustice, and we need action to address them.
I recognise that many black, Asian and minority ethnic women also do not feel that they are listened to during childbirth. A lack of cultural competency and medical training means that complications are not always spotted early enough. For example, black women have shared experiences of how anaemia has not been picked up soon enough because of their skin colour. We really ought to be doing better than that.
The Government have said that they have hosted several roundtables with experts and have commissioned more research to better understand the issue. However, they believe that a target to address maternal mortality disparities would have limitations in improving the quality of care. Why do they hold that view? NHS England’s long-term plan includes targets for addressing health outcomes in other areas. We need action to address the unacceptable disparities in maternal mortality rates as well.
The Joint Committee on Human Rights found that over 60% of black people did not believe that their health was equally protected by the NHS compared with white people. As we know, covid has had a disproportionate impact on BAME communities.
If not a target, then a report would ensure accountability and focus minds to address these unacceptable injustices. New clause 25 would put explicit accountability on the Secretary of State not only to monitor and report on variation in maternity services but, crucially, to set out the steps needed to tackle it. We need a national strategy to address this country’s health inequalities, which must include serious and urgent action to end the mortality gap between black, Asian and ethnic minority women and white women. The new clause is, of course, not the complete answer, but I hope the Minister will agree that it would be a welcome step in the right direction.
Edward Argar
Again, I am grateful to the shadow Minister. The new clause would require the Secretary of State to publish a report each year on variation in the quality and safety of England’s maternity services and on disparities in maternal mortality rates in England. Again, I understand the intention behind the new clause, which the hon. Gentlemen set out clearly, as it is paramount that we do all we can to ensure the safety of expectant mothers and their babies, which involves understanding and taking steps to address the variation in quality and safety of England’s maternity services and disparities in outcomes.
However, several organisations and bodies already publish reports each year on the variation of quality and safety of England’s maternity services and the disparities in maternal mortality rates. First, the CQC monitors, inspects and regulates maternity services across England to ensure they meet standards of quality and safety. Following an inspection, it provides findings, recommendations and an overall rating of the trusts. It also publishes monthly reports following inspections of maternity services and annual reports that explore areas for improvement in maternity services across England.
Secondly, “Better Births”, the report of the national maternity review, recommended that a nationally agreed set of indicators should be developed to help local maternity systems to track, benchmark and improve the quality of maternity services. In response, NHS England and NHS Improvement, in partnership with NHS Digital, have produced a national maternity services dashboard. The dashboard enables clinical teams in maternity services to compare their performance with their peers on a series of clinical quality improvement metrics, or CQIMs, and national maternity indicators, or NMIs, for the purposes of identifying areas that may require local clinical quality improvement.
Thirdly, MBRRACE-UK publishes annual reports on maternal deaths, stillbirths and neonatal deaths across the UK. Stillbirth and neonatal mortality rates are provided for individual NHS providers, commissioning boards, and local authorities in England, Scotland, Wales and the Crown dependencies. It would not be possible to report annual maternal mortality rates by NHS trusts because the numbers are very small—it would not be a meaningful statistic. That would also potentially risk individuals being identified and could result in contravention of data protection legislation.
The reports by MBRRACE-UK also look at health inequalities; its analysis has identified significant differences in maternal mortality rates, which the shadow Minister mentioned, between women from black or Asian minority ethnic backgrounds and white women, and between women from lower and higher socioeconomic backgrounds.
Finally, the National Maternity and Perinatal Audit, or NMPA, is a large-scale audit of NHS maternity services across England, Scotland and Wales. The NMPA publishes trust-level data and evaluates a range of care processes and outcomes to identify good practice and areas for improvement in the care of women and babies.
Justin Madders
I will disappoint the Minister this time. We will push the new clause to a vote, because we think that it is really important. While the Minister has set out a whole range of reports that have been issued and work that is being done, due to the scale of the injustice we have set out, there needs to be a concrete commitment from the Secretary of State to not only publish the data, but set out the steps he is taking to address the inequalities.
Question put, That the clause be read a Second time.
The Chair
With this it will be convenient to discuss new clause 28—Duty as to education placement capacity and innovation—
“(1) The National Health Service Act 2006 is amended as follows.
(2) After section 1F(1) insert—
‘(1A) To meet the integrated workforce requirements of integrated care systems, the Secretary of State must—
(a) ensure that there is sufficient placement capacity in the health and social care system in England to educate and develop a sustainable health and social care workforce,
(b) support, fund and promote the use of innovation in healthcare higher education to meet health and social care workforce needs, including new approaches to interdisciplinarity, digital technology and simulation, and
(c) consult universities, health and social care service employers, providers and other persons deemed necessary to develop practice placement capacity and innovation in higher education for health and social care to meet the needs of the health and social care workforce.’”
This new clause would require the Secretary of State for Health and Social Care to develop and support education practice placement capacity across integrated systems and to support innovation in higher education for health and social care.
Chris Skidmore
Thank you for allowing me to speak to these two new clauses together, Mr McCabe. They are essentially interrelated and were the product of a roundtable that I put together and hosted with Universities UK and the deans of medical colleges in my role as co-chair of the all-party university group. These were the two asks that the universities and medical colleges had for the Bill. I offer these new clauses as part of that consultative approach, so I will not be pushing them to a vote.
Basically, we are at a crux. I raised this question on clause 33 of the Bill, but when it comes to workforce planning and training, we take a siloed approach, focusing on what the Department of Health and Social Care, NHS England and Health Education England set out as their vision, and the funding flows from that. Not included in that vision, although clearly there are consultative opportunities, is a recognised role and responsibility in legislation for healthcare education providers, the universities and the deans of the colleges in providing the clinicians, doctors and nurses of tomorrow. Nor is there recognition that the workforce is changing. While we have the Government’s commitment to the retention of nurses and doctors, that retention can take place only if there is continuous professional development.
When I was a Health Minister, I was very concerned to ensure an uplift in the budget of Health Education England to 3.4% to match that of NHS England. It had always been thought of as the poorer relation; the money would always flow later, and it took a great deal of lobbying from the relevant organisations to make the point that we needed to put that workforce training money aside, particularly for continuous professional development.
New clause 27, in summary, reflects the fact that if we are to have an integrated care system, and if the new White Paper is to look at how to integrate social care with healthcare, we will need to provide huge retraining opportunities for both NHS and social care staff to enable them to work across whatever that new landscape may be. I do not think it is practical to send everyone back to university, or even always to have physical in-work training opportunities, important though those may be. We will clearly need to have digital opportunities, online courses and a whole technological revolution in how we deliver those retraining opportunities.
Those opportunities are out there. If we look at the universities and the role of EdTech, it is important that the health service grips that opportunity with both hands while it has the chance to do so, because it will be coming down the tracks. If we want to implement reform via the integration of services, it will only be as good as the people working in those services, as we all know, and those people will be as good as they can be only if they are given the appropriate opportunities to train and retrain during their career.
The need for new clause 28 has become more pressing as a result of recent developments. It sets out a duty for education placement capacity; I will not go into the detail of the new clause, but effectively it is about place planning and ensuring that the universities and royal colleges are involved with that at the very outset. In the debate on clause 33, I talked about the paradox of our having a cap on places, which is causing a bottleneck in post-18 education—those pupils who are desperate to become doctors or nurses, but who find a cap on their aspiration.
That cap is there, as we know, because medical places are expensive; they cost not £9,250 a year, but more like £70,000 over the course of a medical student’s training lifetime. At the same time, however, we have a cap on places for those 18-year-olds entering the system and then—surprise, surprise—we find we do not have enough doctors and nurses in the system, and we have to start retraining from abroad.
Dr Whitford
Obviously, there has been a drive to expand medical student places in universities right across the UK, but one part of the system that is controlled centrally is foundation places, which a medical graduate has to spend their first two years in. This year, for the first time, there was a shortfall of about 400 places. Hopefully all those graduates have now got a foundation doctor place, but they cannot practise outwith a foundation place, which lasts two years, so they simply cannot work as doctors, nor can they work as doctors until they complete that two-year foundation role. There is no point in expanding medical school places if those at the end of the production line get turfed out to be unemployed or go and work as something else. It is not just about university places; there is also the issue of placements as foundation doctors for the first two years of their career.
Chris Skidmore
The hon. Member is absolutely right. When it comes to the foundation year, I was interested in looking at what future reform might come in the workforce. We would need to work with the royal colleges and vested interests on a replacement, or at least on what could make the foundation process more flexible so as to allow in-work training on that foundation year pathway. That is a huge opportunity, and, if I was still a Minister, I would be pressing for a White Paper to look at how we could deliver workforce innovation, because I do not think we can continue to sustain our trajectory using infrastructure and systems designed in the early to mid-20th century. There is a balance to strike, in that we need to ensure that the safety of patients is accounted for, but technology and training has moved on to a different space. We do not see this constriction in other countries, which can offer fast-track routes through medical training processes, particularly post degree and into the foundation stage.
The issue of placement has become incredibly pressing—it is actually a real-time issue. During the pandemic, because the grade threshold was lowered and teacher assessment was used, an additional 1,900 students were accepted to take up medical places in September 2021. Whatever we think about that, those students were all given a place because they had achieved the right threshold, but to train them, an additional £60 million is needed. However, the Government have capped the training budget at £30 million, so although students have been accepted on to courses, universities are finding that they must make a loss of £2,460 per student in the academic years 2020-21 and 2021-22, and the Government are not opening their books to change that cap on finances.
The cap is therefore returning from this coming year, and as a result 1,000 fewer students will be trained each year. In effect, we will see a reduction in the number of students coming on board to be trained. There is currently this one-off moment that universities are taking forward, but as a result we will go backwards when we know that we need more doctors. The demographic changes that I spoke about in debate on clause 33 are coming down the tracks, but we will end up just recruiting from abroad. It is not that there is necessarily anything wrong with those qualifications; I would just prefer a sustainable and, in effect, sovereign pathway.
The post-Brexit narrative is that global Britain will ensure that we can stand on our own two feet and have a sustainable skilled workforce. That could be recognised if we had a placement strategy for medical students. However, we can do that only if we involve the universities and the education sector. The problem is that the Department for Education controls the purse strings for that budget, and I do not think that it realises the long-term consequences on our healthcare system.
The new clause would close a loophole that is kneecapping the Minister and the Department of Health by placing artificial caps on aspiration and—worryingly —on the future number of doctors entering the healthcare system. I will not press my new clauses to a vote, but the issue is extremely pressing. We will see 1,000 fewer students enter medical places next year than did so this year; and students going through the system have no funding for their places, despite having been given those places. That is a real-time issue that has resulted from the wider policy issue not being resolved. The new clauses would help resolve it, but I will not push them to a vote.
Alex Norris
I congratulate the right hon. Member for Kingswood on his excellent new clauses and the case that he has made for them. We strongly agree that the training and development of staff ought to be to the fore. We must take the opportunity of understanding that we have a workforce crisis at a time of significant technological development.
Take cancer services, for example. We are all concerned about gaps in cancer provision. We need to take the opportunity to turbo-leap forward, rather than trying to restore services to where they were pre-pandemic, when targets were being missed, and had been missed for a number of years. Let us train and develop our staff to use new and innovative approaches, such as new radiotherapies. There is real opportunity there. With respect to new clause 27, the right hon. Gentleman makes a strong case for harnessing the ability of our universities and colleges, and putting that together with our workforce to develop and improve our services.
On new clause 28, the right hon. Gentleman mentioned the paradox of us having profound workforce shortages—in August, there were about 94,000 vacancies, including for nearly 40,000 nurses—while 14,000 applicants were not accepted on to nursing courses in 2018. I understand that there was a significant increase in 2019, but it was not big enough to meet our shortfalls, so that is a real paradox. Our services are not sustainable until and unless we take deliberate action to increase capacity. I know that the right hon. Gentleman does not intend to push the new clause to a Division, but I hope to hear from the Minister about what conscious decisions are being taken. This concerns not just those big courses either, but smaller ones, such as paramedic science and radiography. University Alliance members have reported 1,000 applications for 40 to 50 places, so there is demand. Of course, they cannot just take everybody and there has to be a filtering process, but it feels very over-geared to have 20 or 25 times the applicants per place.
I will not repeat the right hon. Gentleman’s arguments about GPs, but they were good. We should use this moment to change our approach to how we grow our GPs. What do we know about GPs? We know that we do not have enough of them, and that we certainly will not have enough of them in five or 10 years’ time. We know that certain communities find it particularly hard to attract GPs, but also that GPs tend to stay where they train or, if not, they are more likely to go back to where they grew up. As part of any so-called levelling up, we need to focus on growing our own GPs in poorer communities such as mine, and similar midlands communities—perhaps you share some of that vision, Mr McCabe—but we do not quite put this together.
Many of my constituents tend to enter education quite a way behind; they really close the gap over their 14 years of formal education, but fall just short of those very high standards that are needed at the age of 18 to go on to university. Should we be writing off those young people? Could we be doing better at getting them on courses to be GPs? I suspect that we would be able to retain them in Nottingham, or at least attract them back there, and to the surrounding towns, which desperately need GPs. Similarly—this is not a long-term answer, but it is certainly one for the short term—one of my foundational moments in my views on migration came from working in a shop the year after finishing school and before going to university. I was often on the rota with a man from Iraq, who was a trained civil engineer in Iraq, but could not afford to convert his qualification. He could not work in that field and instead worked with me in that shop. It always seemed to me like a significant waste of his skills.
I will take this moment to plug a wonderful project in Nottingham called the phoenix programme, in which students at the University of Nottingham School of Medicine work with migrants to this country who have medical qualifications at home but cannot practise because they need to convert the qualifications and often cannot afford to. Those medical students are working on language, functional skills and all the different aspects of the exams that those individuals will take, in order to help those people become doctors in this country. What a wonderful thing to do.
If we think about however many hundreds of thousands it costs to train a GP in this country, we realise what a saving they are making for us, too. I think that is a wonderful thing. We need that level of creativity on workforce in order to deal with our gap.
I will make no further points—I do not want to repeat what the right hon. Member for Kingswood said—but if those are not going to be the answers, I hope we hear from the Minister what the answer is. If we go for more of the same, we will just see growing workforce gaps and we really will have profound problems in our health service.
Edward Argar
I am grateful for the opportunity to address new clauses 27 and 28 together. First, new clause 27 seeks to place a specific duty on the Secretary of State to support the transformation of the health and social care workforce for integrated care systems by working with universities and colleges to train the future workforce through investment in technological and inter-professional innovation.
I take on board the broader points made by my right hon. Friend the Member for Kingswood, but we do not believe that the new clause is necessary, as that work is already covered by section 1F of the NHS Act 2006, which the new clause seeks to amend. Section 1F(1) sets out that the Secretary of State has a duty
“to secure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in…the health service”.
Discharge of the duty under section 1F(1) is largely delegated to Health Education England through section 97 of the Care Act 2014. To meet its statutory duties and to ensure that an effective education and training system is in place, HEE undertakes a variety of work, including with further and higher education providers and regulators. Part of that work includes the curriculums for the healthcare professions. Those curriculums are set by approved education providers at an institutional level. HEE can influence the content by representing the employer voice to ensure that the training that individuals receive is relevant and remains up to date.
As part of that work, HEE is particularly keen to ensure that technological and medical advances are included in teaching, alongside new ways of working. Those measures would support newly qualified professionals to be suitably prepared to launch their careers in the NHS. To support that work and engagement with universities, HEE commissioned the Topol review, published in February 2019—probably in association with my right hon. Friend in one of his previous ministerial roles—on how to prepare the healthcare workforce to deliver the digital future.
That review made recommendations that will enable NHS staff to make the most of innovative technologies such as genomics, digital medicines, artificial intelligence and robotics to improve services. The recommendations support the aims of the NHS long-term plan and the workforce implementation plan, helping to ensure a sustainable NHS. The progress report was published by HEE in 2020 and, as part of the implementation report, HEE has launched a digital readiness programme to continue to lead on developments in preparing the workforce to deliver the digital future.
On inter-professional working, we want a workforce that is less siloed and more flexible and adaptable, and work is ongoing to take that forward in England. For example, at the national level, we are looking at new skill mixes to meet new service models. Those new mixes could include upskilling existing staff, so that more staff are able to do things that have traditionally been limited to a smaller group of professionals—for example, prescribing—or making better use of the wide range of skills and contacts available to reduce duplication.
At ICS level, national guidance on the ICS people function also set out the expectation that the ICB, working with the ICP, will have responsibility for enabling workforce transformation across the health and care system, including through the use of technology and innovation, as well as for work with educational institutions to develop the local future workforce. Nationally, arm’s length bodies will support and enable ICBs to deliver those responsibilities at a local level. I hope that that highlights some of the work being done under the existing statutory duty in section 1F of the 2006 Act.
Secondly, new clause 28 seeks to place three new statutory duties on the Secretary of State. That, in a sense, is at the heart of what my right hon. Friend the Member for Kingswood was getting at. They are: a duty to ensure a sufficient number of clinical placements for the number of students; a duty to ensure innovation—his new clause outlines greater interdisciplinary working, digital technology and simulation as three examples—is supported and funded in the education and training system; and a duty to consult universities and others on clinical placement availability.
We have carefully considered my right hon. Friend’s new clause, but we do not feel that those additional specific statutory duties are necessary, in addition to the existing statutory duty on the Secretary of State in section 1F of the 2006 Act, which my right hon. Friend seeks to amend. Section 1F sets out that the Secretary of State has a duty to ensure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in the health service. Discharging the duty under 1F(1) is largely delegated to HEE through section 97 of the Care Act 2014.
As the hon. Member for Central Ayrshire said, clinical placements are a vital part of healthcare students’ education and training. Good experience during a placement can lead a student to seek employment at their placement provider. As a result, ensuring that there is sufficient placement capacity remains a priority for HEE in order to meet its statutory duties and ensure that an effective education and training system is in place.
Dr Whitford
Just to clarify, I was not referring to placements as students, which are absolutely vital; I was referring to the two foundation years that those individuals have to do afterwards. Otherwise, they simply cannot function as doctors.
Edward Argar
I am grateful to the hon. Lady for clarification, but she illustrates that placements, both as students and in the context she describes, are vital to enable students to understand and learn the reality and skill of their profession. It is also important that placements are rewarding for students.
HEE has successfully worked with education providers and placement providers to ensure there is sufficient placement capacity for the record number of nursing students that we now have. Such work includes payment of the education and training tariff, which pays a contribution to the costs of providing placements. The Government have also supported HEE through the provision of additional funding, enabling it to launch its clinical placement expansion programme. The programme has seen HEE commit £15 million to fund additional clinical placements across nursing, midwifery, allied health professionals and healthcare science in 2021-22. This funding will increase the number of placements offered to nursing, midwifery and AHP healthcare students from September 2021, which was last month, and it will enable HEE to deliver the future health and care workforce in sufficient numbers, and with the skills that the NHS needs.
Before I turn to innovation, I will address two points that were made by my right hon. Friend the Member for Kingswood and alluded to by the hon. Member for Nottingham North. First, the shadow minister touched on those who come from abroad via normal immigration routes or as refugees, the skills they have and how we need to make it easier for such people to utilise their skills and work in our NHS. He is absolutely right, and we continue to look at how we can make the process easier. We need to balance that with making sure that we can evidence and reference those skills for the safety of patients and those qualifications, but where that can be done and where those skills are commensurate, we need to make it as easy as possible for them to requalify or go through the necessary safety processes to be able to work in our NHS. The only other thing I would say is that we have to be very careful that any recruitment is ethical and that we are not denuding countries of the ability to utilise the skills of clinical professionals in rebuilding their own countries.
The second point made by my right hon. Friend the Member for Kingswood was about the challenges posed for maintaining quality, in terms of people going through relevant courses, and for the operation of the cap. I will not criticise any other Government Department, but he highlights the juxtaposition that often occurs between the Department for Education and the Department of Health and Social Care, or between other Departments where two Departments have an interest in the same policy but different incentives for their policy making. There will always have to be a financial test. There is always a limited budget, and my right hon. Friend highlighted how expensive some of the training courses are. However, it is right to expand the number of medical schools and training places, as we have done—he probably presided over it.
I remember going to the University of Lincoln, when I had just been appointed. Those I met were disappointed that I was not my right hon. Friend, but they were none the less very welcoming to me. The University of Lincoln works very closely with the University of Nottingham, which is in the constituency of the hon. Member for Nottingham North, in setting up a new medical school and drawing on the curriculum and expertise that was already in Nottingham. It is a great example. I very much hope that, when I am not in this Bill Committee, I might be able to go once again to visit the University of Lincoln and perhaps come and see the hon. Gentleman’s local medical school over in Nottingham.
Finally, on innovation, HEE currently works with universities, training providers and regulators on the curricula for the healthcare professions to ensure that they reflect the latest technological innovations. Although curricula are set, as I have said, at institution level, HEE can influence the content by representing the employer voice, to ensure that the training that individuals receive is relevant to what employers need.
In relation to consultation, HEE already works with universities, placement providers and others on the availability of placement providers to assess and ensure that there are the right number and types of placement. As I have mentioned, the number of placements has expanded. That is a direct result of the constructive dialogue and engagement that HEE has with placement providers. At ICS level, national guidance on the ICS people function set out the expectations.
I hope that I have set out that work on the areas highlighted by my right hon. Friend the Member for Kingswood is being taken forward—some of it was started by him a few years ago—under the existing statutory duty under section 1F of the NHS Act 2006. Therefore, at this point, we do not think that further specific duties are necessary, but I suspect that, in the further passage of this legislation, we may well return to the sort of themes that we have discussed today.
Chris Skidmore
As I said, I will not push the new clauses to a vote, but I will just reiterate that there clearly is a massive structural supply and demand imbalance. I do not believe that the status quo will be sustainable in the longer term. I do appreciate the Minister setting out the ecosystem as it exists, but I fear that that ecosystem, in the longer term, cannot keep up with the changing demands on the healthcare system and the expansion of the healthcare system thanks to the budgetary announcements today about the amount of money that is being spent. None of this will cut through effectively if we do not have the trained workforce in place to be able to deliver healthcare on the ground. Mention has been made of general practitioners and the shortfall that we are going to see as a result of the demographic and retirement bulge that is going through the system at the moment. These are problems coming down the track, and I would always recommend in policy, as in life, that if we see a problem and know that we are going to have to take a decision, it is better to take the decision sooner rather than later, because the costs will only be less now and greater later on.
I will not push these new clauses to a Division, but I have, Cassandra-like, sent out a warning cry of what will happen in the future if we do not act soon. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
Ordered, That further consideration be now adjourned. —(Steve Double.)