Healthcare (International Arrangements) Bill (Third sitting)

Justin Madders Excerpts

Committee Debate: 3rd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

Brought up, and read the First time.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I beg to move, That the clause be read a Second time.

It is a pleasure to serve under your chairmanship, Mr Streeter. I recall that the first Westminster Hall debate that I secured was under your chairmanship. Indeed, you were also in the Chair the first time I was the Opposition Front-Bench spokesman in a Bill Committee. In these turbulent times, you are a consistent and familiar face—certainly to me and, hopefully, to many other hon. Members.

Reciprocal healthcare is of most importance for those countries where it is accessed most—none more so than on the island of Ireland. When the British Medical Association gave evidence on Tuesday, it was clear about the success story that has been achieved, particularly in the border area, particularly with a dispersed population of around 2 million. It said:

“Given the population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, there have been some fantastic examples of where clinicians have either co-located services in a particular trust or facility where there is not the demand from the local population to warrant it, or travelled across the border to work on different sites.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q10.]

Fiona Loud from Kidney Care UK raised the example of patients who currently cross the border daily for their care and treatments. She also mentioned organ donation and organ sharing, and the need to ensure that the existing and very successful arrangements that we have are preserved.

It is easy to talk about scaremongering when we raise the spectre of patients being turned away at the border, and I am sure that we will all do our utmost to ensure that such circumstances do not arise, but we are talking about really important issues here. The healthcare arrangements on the island date back to before the UK and the Republic of Ireland joined the EU, but they are now underpinned by EU law, so we cannot simply revert back to the old arrangements, should a full EU-wide deal not be reached.

I was concerned about the lack of consideration given to the issue in the supporting documents and in the contribution from the previous Minister, the right hon. Member for North East Cambridgeshire (Stephen Barclay), on Second Reading. If we do not get this issue right, the Bill will be a failure. The amendment would ensure that the provisions do not reach the statute book until clarity on this hugely important issue is provided. I appreciate that article 13 of the Northern Ireland protocol in the withdrawal agreement indicates a desire to continue north/south co-operation in a range of areas, including healthcare, but that does not help us if Parliament does not support the withdrawal agreement. That is why the amendment asks for a strategy to be provided as a matter of urgency.

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[Justin Madders]

I am minded not to press the new clause to a vote if the Minister assures us that he will endeavour to keep us updated on the contingency plans, if it looks like we are approaching a cliff-edge scenario. That is really what we are trying to achieve.

[Stephen Hammond]

Let me make the hon. Gentleman the same offer that I made to the hon. Member for Burnley. In that unlikely scenario, I guarantee that I will make my officials available to give a briefing to the hon. Gentleman and any member of the Committee who wishes to understand what our proposals are.

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[Justin Madders]

I am content with the Minister’s comments. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 3

Strategy for settling disputes concerning healthcare agreements

(1) The Secretary of State must, within one month of this Act receiving Royal Assent, lay before Parliament a strategy containing a defined process for settling disputes concerning healthcare agreements between the government of the United Kingdom and either the government of a country or territory outside the United Kingdom or an international organisation.

(2) The strategy under section 1 above must include information on—

(a) the body, bodies or jurisdiction that will be responsible for settling disputes;

(b) the process which will be followed by that body, bodies or jurisdiction when settling a dispute, including details of any further appeal mechanisms; and

(c) anything else the Secretary of State thinks is relevant to such a strategy.—(Justin Madders.)

Brought up, and read the First time.

[Justin Madders]

I beg to move, That the clause be read a Second time.

On Second Reading, I spoke about the importance of dispute resolution, and asked the then Minister for Health, the right hon. Member for North East Cambridgeshire (Stephen Barclay), to set out how he envisaged it operating in both a deal and a no deal scenario. Despite some prompting from me and my hon. Friend the Member for Weaver Vale (Mike Amesbury), the Minister was not able to set out how dispute resolutions will be handled under the terms of any new agreement or even if the European Court of Justice will continue to represent a red line for the Government. The latter point is particularly interesting, given the new role of the right hon. Member for North East Cambridgeshire. It appears that he did not provide detail on that point because, at that stage, the Government were simply not in a position to confirm what was in the draft withdrawal agreement.

The Prime Minister categorically ruled out any jurisdiction of the European Court of Justice very early in the process, but I have yet to hear any serious suggestion about how disputes can be resolved, if we manage to reach a full reciprocal healthcare agreement with the EU27 beyond the transition period, without some reference back to the ECJ. The same concerns would apply if bilateral agreements were necessary in a no deal scenario.

Given the importance that the Prime Minister and members of her Cabinet have placed on the ECJ following our exit from the European Union, it is curious to say the least that we do not have a clear statement of intent from the Government while we debate this Bill. If their position continues to be that we will not have truly left the European Union if we are not in control of our own laws, as the Prime Minister put it in January 2017, it is vital that we have clarity about the arrangement that will be used in place of the ECJ. If a new arrangement is established, what will the cost be? Who will the judges be? Where will it be based? Will it be an open process?

If, on the other hand, we look to the ECJ for dispute resolution after all, even if only in the limited area of reciprocal healthcare, would that not represent a significant political U-turn? This issue is fundamental to the Government’s approach to Brexit. For example, they decided that we could not continue to host the European Medicines Agency, causing it to go to Amsterdam at the cost of 900 jobs in this country, and potentially hundreds of millions of pounds of investment. The Health Secretary’s sole justification for that was that the Government were not prepared to accept the European Court of Justice’s jurisdiction. Our purpose in tabling this new clause is to get clarity from the Minister about whether the European Court of Justice remains a red line for the Government.

[Stephen Hammond]

The new clause would place a duty on the Secretary of State to lay before Parliament a detailed strategy defining the process for settling disputes concerning healthcare agreements after we leave the European Union. No one in the room would dispute the spirit behind the new clause. As I have stated throughout our examination of the Bill, it is right that there should be transparency regarding the UK’s future relationship with the EU and other countries after exit. It is right that that transparency should apply to the arrangement of future healthcare agreements, and the processes that underpin them, such as dispute resolution, but, although I agree with the spirit of the new clause, I am not entirely sure that it would achieve its intended aim. I will give a number of reasons why.

The new clause would confer a duty on the Secretary of State to lay a strategy on the process for dispute resolution before Parliament. Both in a deal and a no deal scenario, such a strategy would be unlikely to provide information on the process for settling disputes concerning healthcare agreements that is not already available in the public domain. That is not due to a lack of endeavour; it is an issue of timing and consideration of what is already publicly available. In the expected scenario that the UK agrees a deal with the EU, the proposed process for settling disputes has already been confirmed in the White Paper on the future relationship, the draft withdrawal Bill that governs the implementation period and, most recently, the political declaration on the future relationship between the UK and EU. The processes have already been confirmed. They are outlined in those documents and would apply not only to disputes, but clearly therefore to disputes in any reciprocal healthcare agreement.

The hon. Gentleman asks what the dispute mechanism is. I am sure that the Committee will be pleased that I am not going to quote extensively from the withdrawal agreement, but it is worth putting on the record that the mechanism for resolving disputes will be through consultation at the Joint Committee, with the aim of reaching a mutually agreeable resolution. If the parties are not able to resolve the dispute in the Joint Committee, either party can request the establishment of an independent arbitration panel to resolve it. The panel will be made up of five members, with one person being the chairperson. The UK and the EU will nominate two members to sit on the panel and then mutually agree the fifth member, who will be the chairperson. The panel members will act independently and do not represent the party that nominated them. It is binding that the panel members be independent and impartial and they must possess specialised knowledge or experience of EU law and international law.

The hon. Gentleman challenges me on the role of the ECJ. He is right that the ECJ has a role here, but its role is very clear and very limited. The role of the ECJ after the implementation period will be restricted to ensuring the correct interpretation of EU law. There is no suggestion that the ECJ will determine the dispute, or that we would ever agree to the ECJ determining the dispute.

That is the likely scenario and the processes that are already formally set out via the documents that I described earlier. In the unlikely scenario that the UK leaves the European Union without a deal, the United Kingdom will arrange reciprocal healthcare agreements, and in those agreements, there will have to be bilateral dispute resolution. That would clearly have to be determined on a case-by-case basis as part of the negotiations to put those bilateral healthcare agreements in place, and, therefore, there is unlikely to be a single dispute resolution process, which is what the new clause suggests, so while I accept the spirit of it, the wording would restrict the ability for future reciprocal healthcare arrangements.

More importantly, the requirement for such a strategy to be laid before the House one month after the Bill receives Royal Assent does not align with the aim of the Bill to provide future reciprocal healthcare agreements with countries both inside and outside the EU. Clearly, those agreements are likely to be negotiated over a period of time and, as I have just mentioned, the dispute resolution mechanisms within them are likely to be different and may vary. It would therefore be arbitrary and unhelpful to produce a general strategy immediately after Royal Assent.

I understand the intention behind the new clause, but it would place an unnecessary burden and duty on the Secretary of State. In a deal scenario, the procedures are already there. In the unlikely no deal scenario, it would be likely to frustrate the ability to put in place future reciprocal healthcare agreements.

I hope that, having heard that, the hon. Gentleman will accept that, although we understand the spirit of his new clause, its wording would be likely to frustrate the purpose of the Bill. I therefore ask him not to press it to a vote.

[Justin Madders]

I am grateful to the Minister for setting that out in more detail than we were able to elicit on Second Reading. Given that the withdrawal agreement had not been published at the time, I understand why the then Minister was not able to do that. The present Minister has been very helpful in setting out the process for leaving with a deal. He is right that, if we leave without a deal, we are in uncharted territory. I do not think I heard any confirmation that there are red lines, in terms of the European Court of Justice, in that scenario. That is really what the new clause was meant to establish. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 4

Duty to consult with devolved administrations

Before issuing any regulations under this Act, the Secretary of State must consult the Scottish Government, the Welsh Government and the Northern Ireland Government and have regard for their views on the regulations.—(Justin Madders.)

Brought up, and read the First time.

[Justin Madders]

I beg to move, that the clause be read a Second time.

I hope this is a straightforward and uncontroversial new clause. We have already spoken about the importance of reciprocal healthcare arrangement to citizens in Northern Ireland, and of course there will also be an impact on patients in Wales and Scotland. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements, and why would they not?

The Delegated Powers and Regulatory Reform Committee was clear in its recommendation that there should be active participation of the devolved Administrations in setting out the UK’s position in future arrangements, but I am not aware that there have been any discussions. I would be grateful if the Minister could set out what conversations have taken place, because we did not get clarity on that on Second Reading.

The new clause repeats some of the issues that we raised this morning, which you did not have the pleasure of hearing, Mr Streeter. It is about the scope and power of the Bill and the wide range of duties given to the Secretary of State, which will be subject to the negative procedure. We think it is important that, as part of the Bill, when those wide powers are given to the Secretary of State, there must be a clear duty to consult with the devolved Administrations before those regulations are enacted.

The Fisheries Bill and the Agriculture Bill have dealt extensively with the need to involve the devolved Administrations. I think this is the bare minimum that we need. It would represent a consistent and equitable approach across the devolved nations, in terms of our future relationship with the EU.

[Stephen Hammond]

It is a pleasure to respond to this new clause, which addresses the extraordinarily important issue of engaging and working with the devolved Administrations. We completely agree that regulations made under the Bill may relate to devolved matters, by which I mean domestic healthcare. The Government will engage and meaningfully consult with the devolved Administrations in line with our existing arrangements, as found in the 2012 memorandum of understanding between the UK Government and the devolved Administrations, and the principles that underlie relations between us. That reinforces the positive work that the UK Government continue to do with the devolved Administrations daily for the benefit of the whole of the UK on this matter.

I am forced to reflect that, though the hon. Gentleman’s new clause is not necessary, the sentiment behind it is shared by everyone in Committee, I suspect. The regulation-making powers in the Bill provide us with a legal mechanism to implement international agreements domestically. The Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed with the EU, to the benefit of the residents of England, Wales, Scotland and Northern Ireland. The powers offer flexibility and can be used to implement comprehensive healthcare agreements with third countries in the future for the benefit of all UK nationals.

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I believe that the Committee is drawing to a close, so I will take the opportunity to thank all my colleagues, and all hon. Members in the Opposition, for giving this small but important Bill the line-by-line scrutiny that it deserves. I thank you, Mr Streeter, for chairing this afternoon’s proceedings.

[Justin Madders]

The Minister has put on record pretty clearly his intention in respect of ongoing and continued engagement with the devolved institutions. He is right that we are concerned that the powers under the Bill are wide. Those concerns remain, but in so far as they involve the new clause, his comments have done enough to assure us that it will not be necessary for us to press it to a vote.

I echo the Minister’s sentiments, given that we are now making the closing remarks of this Bill Committee. I thank you for chairing, Mr Streeter, and hon. Members for participating in Committee today.

I look forward to Report. We need to continue to explore some important issues, but we must move forward with this legislation, as is necessary in this uncertain time. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

Bill to be reported, without amendment.

Healthcare (International Arrangements) Bill (Second sitting)

Justin Madders Excerpts

Committee Debate: 2nd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

It is essential that the Government take appropriate measures to ensure that we can respond flexibly to facilitate healthcare for UK nationals abroad, and that is ultimately what the clause is about. In my closing remarks on the clause, I stress to members of the Committee exactly how vital it is for the Government to retain sufficient flexibility to facilitate the access to healthcare abroad across a range of potential EU exit outcomes. The powers in the clause will ensure that the Government can make regulations to provide for complex and varied schemes, such as EHIC, should they be part of future reciprocal arrangements. I recommend that the clause stand part of the bill.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Stringer. First of all, I join the Minister in thanking those witnesses who came and gave evidence on Tuesday. There were certainly some helpful comments that we will no doubt return to in Committee.

As was made clear on Second Reading, this is a very important piece of legislation. More than 190,000 UK expats live in the EU and of course there are 50 million British visits within the EEA countries each year: all those people want clarity about what the arrangements are in the event that they will need healthcare. So we do not oppose the principle of the Bill. We absolutely agree that it is important that there are arrangements in place after 29 March 2019 and into the future. However, we are concerned about a number of issues, some of which I referred to on Second Reading and some of which we will discuss today.

It is fair to say that there are concerns about the breadth of powers that the Secretary of State is requesting in clause 2; I do not believe they would be countenanced at all under normal circumstances. I appreciate that we are not in normal circumstances and I am grateful to the Minister for setting out how he envisages those powers will be used in practice. We are not here to judge things just on what the situation is at the moment, but on how the powers could be used at some point in the future. With regard to that, the Minister referred to this Bill being used possibly to further foreign policy and trade objectives. When he responds, I would be grateful if he expanded on what he has in mind.

To compound our issues about the scope of the regulations, we are also concerned about our lack of opportunity to scrutinise them; we will return to those concerns when I move amendment 2 to clause 5 later on. Of course, we are not alone in having concerns about the scope of this clause and the lack of clarity about how the powers might be used. In the evidence session, Raj Jethwa, Director of Policy at the British Medical Association, said:

“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6.]

We will certainly push for that today.

The Delegated Powers and Regulatory Reform Committee in the other place went further than that, describing the scope of clause 2 as “breath-taking”. As that Committee correctly pointed out, there is no limit to the amount of any payments, to who can be funded or to the types of healthcare being funded. The regulations can confer or delegate functions to anyone, anywhere, and primary legislation can be amended for these purposes.

It is also worth noting that although this legislation has been presented as a Bill to enable us, as far as possible, to retain the arrangements that we already have—who would disagree with that?—the powers conferred by the clause, as I think has been conceded by the Minister, can go far beyond the current EU and EEA countries that we are primarily concerned about.

We consider the powers in the clause to be inappropriately wide, if they are not going to be subject to the correct levels of scrutiny. At this eleventh hour, we understand why a certain level of flexibility is being sought by the Government, but with that request comes a responsibility to ensure that proper parliamentary scrutiny is exercised.

Rather than oppose the clause in its entirety, we believe that the appropriate remedy would be to ensure that any regulations introduced under the Bill will be subject to the affirmative procedure. We will return to that point when we consider amendment 2 to clause 5.

[Stephen Hammond]

The hon. Gentleman is right to say that these powers are flexible. Part of the reason for that is that there may well be a need to anticipate the sort of bilateral arrangements that we put in place in the future—notwithstanding our hopes that we will secure a continuation of the current reciprocal healthcare arrangements, which is our ambition. When we come to debate not only the hon. Gentleman’s amendment, but clause 5—when the discussion on scrutiny of these arrangements should take place—I will seek to reassure him that the procedures in place will allow for the usual and appropriate parliamentary scrutiny of the Bill.

The hon. Gentleman talked about the powers being too broad. The Bill has a very focused purpose: to ensure that the reciprocal healthcare arrangements, which benefit UK nationals abroad and also EU and non-EU nationals in the UK, are continued. He also challenged me on the issue of potential future trade or foreign policy objectives. As he will know, we already have arrangements with a number of countries outside the EU, and the Bill must have the flexibility for the continuation and updating of those arrangements. The matter will clearly be of operational importance—potentially, it will be a policy decision after exiting the EU. Were a UK holidaymaker going abroad to a non-EU country, they would clearly expect the Government to have in place—or to have the potential to put in place—the reciprocal healthcare arrangements that would allow them to be treated should that be necessary.

I hope those words will satisfy the hon. Gentleman that the clause needs to stand part of the Bill. We can have the appropriate discussion about scrutiny in somewhat more depth when we debate clause 5.

Question put and agreed to.

Clause 2 accordingly ordered to stand part of the Bill.

Clause 3

Meaning of “healthcare” and “healthcare agreement”

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

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[Stephen Hammond]

I will try to limit my comments, given that we have already had discussions on the amendment. I am sure that will be welcome on this cold November day in a rather warm room.

Clause 4 provides a clear legal basis for processing personal data under the Bill for the purposes of UK data protection legislation. At present, the EU regulations provide a lawful basis for processing data for the purposes of reciprocal healthcare. Personal data is integral for providing healthcare abroad. It is vital that authorised persons in the UK can process data for that purpose. The clause ensures that, after exit day, there is a clear and transparent basis for processing personal data for the purposes of providing healthcare abroad, as required by UK data protection legislation. Clause 4 will ensure that safeguards are in place for that processing.

Subsection (1) limits processing to that which is necessary for the purposes of the Bill. Subsections (2) and (3) ensure that any such processing must remain in compliance with UK data protection legislation and the Investigatory Powers Act 2016, and any other relevant restrictions. Finally, the persons who can process data under the Bill are limited to those authorised in subsection (6), which we have just discussed.

The safeguards limit the scope of clause 4 to what is necessary and proportionate to provide healthcare abroad. For reciprocal healthcare, personal data is required to process reimbursements to and from other countries, and where reimbursement is made to a person as well. It is also sometimes necessary for healthcare providers to share medical information to facilitate treatment. The clause ensures that the Government can continue to process personal data as necessary, after exit day, in an effective and lawful way. Personal data transferred from outside the UK will remain subject to the need for safeguards to be put in place before it is transferred. Those safeguards will not be able to be contracted out as part of any healthcare agreement with the EU or member states or third countries.

As I said a moment ago, subsection (1) provides for an authorised person to process data related to the provision of healthcare abroad. Personal data is defined in the GDPR as data that relates to a living person who can be directly or indirectly identified from the data. Specific category data is personal data containing health and genetic data. At present, there are different routes for providing healthcare abroad, such as the S1, S2 or EHIC routes, and each route requires different forms of personal data.

Subsection (2) disapplies the duty of confidence and any restriction on the processing that would otherwise apply. The exemption ensures that data can be disclosed where it is necessary for the limited purposes of the Bill. The measure is necessary and appropriate. For example, authorised persons may need to share data if a person is unconscious and therefore not in a state to provide it themselves. Importantly, as expressed in subsection (3), data processing must continue to comply with the UK data protection legislation, which ensures there are further safeguards around data processing. The GDPR also governs data transfers between the UK and other countries. All EU and EEA countries are bound by the GDPR, which means the relevant national data protection safeguards in each country are adequate, allowing the free transfer of data between countries.

Subsection (3)(a) expressly requires that the processing of data does not contravene existing data protection legislation, and subsection (3)(b) requires that the processing of data must comply with parts 1 to 7 or chapter 1 of part 9 of the Investigatory Powers Act 2016. The only purposes for which investigatory powers may be required are to investigate and tackle suspected cases of fraud and error relating to healthcare abroad.

As set out in subsection (1), the processing of data under the Bill is limited to authorised persons who, as we have discussed, are defined in subsection (6). The list reflects those persons and bodies currently involved in processing data, including personal data under existing reciprocal healthcare arrangements.

I mentioned that, for clarity’s sake, subsection (6)(a) lists

“the Secretary of State, the Treasury, the Commissioners for Her Majesty’s Revenue and Customs, the Scottish Ministers, the Welsh Ministers and a Northern Ireland department”.

Healthcare abroad is entirely managed and operated by the Department of Health and Social Care in co-operation with the Executives in the devolved Administrations and their local healthcare systems. Although the Bill is about the provision of healthcare abroad, it is vital that the Executives of the devolved Administrations are considered authorised persons, since healthcare abroad is often facilitated in co-operation with them. Under subsections (6)(b), (c) and (d), healthcare bodies and providers are considered authorised persons as they are directly involved in the provision of healthcare.

Finally, subsection (6)(e) gives the Secretary of State the power to add to the list of authorised persons, which will ensure that the Government can respond appropriately, whatever the outcome of EU exit. It is also deemed necessary to allow the Secretary of State to respond to the changing demands of systems and operations. In future, duties may change and adding to the list will be difficult, so it is necessary to have the power in place.

Clause 4 is an important component of the Bill. It provides the Government with the necessary power to process and share data that relates to healthcare provided abroad. Therefore, I recommend that the clause stand part of the Bill.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Regulations and directions

[Justin Madders]

I beg to move amendment 2, in clause 5, page 3, line 44, leave out subsection (5) and subsection (6) and insert—

“(5) Any statutory instrument which contains regulations issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a resolution of each House.”

This amendment would make all regulations issued under this Act subject to the affirmative procedure and require approval from Parliament before they become law.

This amendment is probably one of the most important items that we will discuss in Committee. As I made clear when we discussed clause 2, there are widely held concerns about the scope of the regulations, which are exacerbated by the fact that these extraordinarily wide powers, necessary as they may be in the circumstances, are subject only to the negative procedure.

As I referred to earlier, the Delegated Powers and Regulatory Reform Committee in the other place clearly set out the potential impact of my amendment not being accepted when it said:

“If, without such amendment, the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure. Of course, these examples will not be priorities for any Secretary of State in this country.”

I hope that is the case, but we are here to look at how the powers could be used over, possibly, the next 100 years, and not just how we would expect them to be used in the foreseeable future.

Nobody knows where this process will take us, and when examining legislation there is always merit in considering the unlikely as well as the stated intentions of the Government at the time. The Minister’s comments about wider objectives reaffirms the importance of our scrutinising the regulations as much as possible. We find ourselves in an unprecedented situation in Parliament, and it is therefore important that we consider all eventualities.

If Committee members need further persuasion that the amendment should be carried, that Lords Committee set out a devastating list of reasons why the negative procedure is inappropriate. It said:

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere. The regulations can delegate functions to anyone anywhere.”

The Committee concluded:

“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”

The most significant reason why we do not object to the legislation is that the biggest risk at this stage is that arrangements are made that do not safeguard the ability of our constituents, when they travel abroad, or of UK citizens who currently live overseas to access healthcare, as they do now. However, because of the way the Bill is drafted, we will find that we are unable to debate whether those safeguards are in place as a matter of course. We have heard many references to the 190,000 UK expats living abroad and the 50 million or so nationals who travel to EEA countries every year. These are huge numbers of people, and the impact of the legislation on them is potentially huge. We owe it to all those people to ensure that any future arrangements are properly scrutinised.

We also need to consider the impact of any new arrangements on the NHS. As Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, set out in evidence on Tuesday:

“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]

He went on:

“In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q9.]

If we do not agree to the amendment, Parliament could end up in that scenario without any voice.

While there is scope for the affirmative procedure to be used in cases where Henry VIII powers are invoked to amend primary legislation, I think it is pretty clear that potentially the most significant changes to reciprocal agreements that could be enacted under the legislation are those that are subject only to the negative procedure. As we know, the negative procedure means that an instrument is laid in draft and cannot be made if that draft is disapproved within 40 days, normally via a prayer against, which is usually by way of an early-day motion. If that does not happen, the legislation is then passed. That is a 40-day process in the best-case scenario.

If I am correct, and if we leave without a deal, the Secretary of State will have to reach agreement with each of the 30-plus countries no later than Friday 15 February, assuming that Parliament does not sit on the following Sunday. At this stage, who knows where we might end up, but we will assume for now that the sitting days are as set out, so Friday 15 February will be the last day that an instrument can be laid that will pass before 29 March, assuming that it is not prayed against. Hopefully the Minister will be able to advise whether my understanding of the timetable is correct.

Will the Minister concede that, on a practical level, it would be better for regulations moved under the Bill to be moved using the affirmative procedure? We could then get them through scrutiny in both Houses much quicker than the 40-day procedure currently allows.

[Stephen Hammond]

The hon. Gentleman raises some important issues, including the issue at the heart of the clause—the appropriate, necessary and correct scrutiny arrangements for Parliament. Let me be clear at the start: the Government absolutely recognise the importance of appropriate levels of scrutiny of the Bill and its subsequent secondary legislation. It is clearly the hallmark of any effective parliamentary system that there are processes in place by which we draft, consider and test legislation. After all, that is what we are doing today.

The appropriate parliamentary procedure for the scrutiny of regulations made under the Bill that do not amend, repeal or revoke primary legislation is the negative procedure. If I am not able to reassure the hon. Member for Ellesmere Port and Neston and he chooses to press the amendment to a Division, I am afraid the Government will resist it.

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As I set out at the outset of my remarks, we will ensure that the affirmative procedure is in place for anything that amends, repeals or revokes primary legislation. For technical regulations, it is appropriate that the negative procedure is used. Given my remarks about the Constitutional Reform and Governance Act and my reassurances about how we intend to deal with the negative and affirmative procedures, I hope that the hon. Gentleman is reassured and does not feel the need to press the amendment to a Division.

[Justin Madders]

I am afraid the Minister has not managed to reassure me, despite his best efforts. When a Bill would confer power on the Executive, we have to be very careful about giving that power away. It cannot be done without good reason, even in these extraordinary times. I have not heard any justification for giving such sweeping powers to the Secretary of State without adequate scrutiny. No matter how well-intentioned the Minister is in his responses—I acknowledge his sincerity —we do not know who will be doing what in 12 months’ time. As we said earlier, we could be handing a future Secretary of State the ability to enter into arrangements for hip replacements in Australia or such like.

As the Minister said, the regulations will enable the Government to enter into detailed and complex arrangements on future healthcare. That is precisely why we need them to be subject to the affirmative procedure. I appreciate the point about the treaties possibly containing more detail, but this is about how Parliament will be able to scrutinise and challenge those arrangements.

[Stephen Hammond]

The hon. Gentleman will have heard that the treaty arrangements will be subject to parliamentary scrutiny in the normal way. We are discussing the regulations as to how we enact those treaties. I was hoping that he might be reassured by that.

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[Justin Madders]

I am afraid that I am not reassured.

The Minister has not really addressed the practical issue about the 40-day waiting time for the negative procedure. If we enter a no-deal scenario after 29 March, as I said earlier, all the instruments under the Bill would have to be laid no later than 15 February. I am imagining the Secretary of State whisking around the 30-plus countries that we would need to enter into bilateral arrangements with throughout the whole of January, and having to get that all signed up and put on the Order Paper by 15 February. I am actually trying to help the Minister here by suggesting that if we do it by affirmative procedure, we can get these things through Parliament more quickly and with the appropriate level of scrutiny that these arrangements deserve. Therefore, I will push the amendment to a vote.

Question put, That the amendment be made.

--- Later in debate ---

[Stephen Hammond]

Having failed to reassure the hon. Member for Ellesmere Port and Neston, I will have another attempt in this stand part debate. Clause 5 supplements the substantive regulation-making powers in clause 2. It provides detail on the parliamentary procedure, as we have already discussed, that will apply to regulations made under the Bill. Subsections (1) and (2) introduce standard provisions, and are consistent with regulation and direction-making powers in many other Acts of Parliament, such as the Health and Social Care Act 2012 and the National Health Service Act 2006.

The clause is required to ensure that regulations and directions made under the Bill will be fit for purpose. As I have said, the powers in the Bill provide the Government with the flexibility and capability to ensure and implement detailed and complex arrangements concerning healthcare abroad. For example, the Government may use regulations to confer different functions on different bodies, in order that they may implement and operate effectively what may be provided for in an agreed reciprocal healthcare agreement. We do that now in relation to the EHIC scheme, which, as I said earlier, the NHS Business Services Authority administers on behalf of the Department. That administration includes the registering and issuing of EHICs and the processing of EHIC claims.

Future administrative arrangements to implement reciprocal healthcare agreements may reflect the current situation, or may involve conferring different functions on other bodies, as appropriate. Once the arrangements are negotiated, we will be in the best position to decide what the appropriate bodies to administer those arrangements are. We will be able to provide for the practical processes and implementation arrangements through the regulations. Clause 5 provides the Government with the flexibility to ensure that any healthcare arrangements can be implemented effectively and efficiently.

Subsection (3) provides that regulations made under clause 2

“may amend, repeal or revoke primary legislation…for the purpose of conferring functions”,

or

“to give effect to a healthcare agreement.”

I want to try again to reassure the Committee about that. The Government are conscious that Parliament rightly takes an interest in this area and, of course, we share the view about the importance of scrutiny.

This is a consequential power to make amendments to primary legislation, which is limited to three restricted uses: for the purpose of conferring functions, to give effect to a healthcare agreement and to make modifications to retained EU law. It is not a free-standing power; it is a focused power to ensure that we can implement healthcare arrangements effectively. That may involve conferring functions on healthcare bodies, which could involve amending primary legislation.

Subsection (4) provides that:

“Regulations under this Act may amend, repeal or revoke retained EU law”,

which is the body of existing EU law that the European Union (Withdrawal) Act 2018 will convert into domestic law, together with the laws we have already made in the UK to implement our EU obligations. It is vital that the regulation-making powers extend to amending, repealing and revoking retained EU law, because the bulk of the existing provisions that relate to current reciprocal healthcare arrangements with the EU will be EU retained law.

Subsection (4) will ensure that domestic legislation in that area is clear and accessible. It will allow us to amend EU retained law, where appropriate, to give effect to new reciprocal healthcare arrangements. It would be an oversight if the Bill did not provide for such amendment, given that current reciprocal healthcare arrangements with the EU are entirely bound up in EU law.

I stress again that, of course, Parliament will be given the opportunity for the appropriate scrutiny of regulations made under the Bill that amend, repeal or revoke primary legislation. As such, subsection (6) makes it clear that regulations that contain provisions that make modifications to primary legislation will be subject to the affirmative resolution procedure and, therefore, Parliament will have the opportunity to debate them. That is the parliamentary scrutiny procedure befitting Henry VIII powers, and one that allows for proper scrutiny.

Regulations made under the Bill that do not contain provisions that amend, repeal or revoke primary legislation will be subject to the negative resolution procedure. It is our job—and I think it is only right—to ensure that legislation is afforded the appropriate level of scrutiny. Therefore, regulations that are made under the Bill that do not amend, repeal or revoke primary legislation should be subject to the negative procedure, as is normal.

The remit of our regulating powers is focused. They can be used only to give effect to healthcare agreements or to arrange, provide for or fund healthcare abroad, as is clear in the enabling powers found in clause 2(1). Where the UK negotiates a comprehensive international healthcare agreement, whether multilaterally with the EU or bilaterally with EU members, the most important element that sets out the terms of that agreement would be included in the agreement itself, as hon. Members would expect. Regulations that give effect to such an agreement would likely focus on procedural, administrative and technical details, such as the types of documents or forms that could be used to administer those reciprocal healthcare arrangements, which is a point I made earlier.

In a scenario where a comprehensive healthcare agreement is being implemented through regulations made under clause 2(1)(c), that agreement would be subject to parliamentary scrutiny under the ratification procedure contained in section 20 of the Constitutional Reform and Governance Act 2010. That ratification procedure provides an opportunity for parliamentary scrutiny of the substance of the healthcare agreements being given effect to in the regulations made under the Bill. It is for those reasons that I rejected amendment 2, which the hon. Member for Ellesmere Port and Neston moved a moment ago.

The final provision of the clause, subsection (7), sets out the definition of “primary legislation”. To reassure the hon. Gentleman, and the Committee, the Government absolutely understand and appreciate the necessity for appropriate parliamentary scrutiny. The level of scrutiny must reflect the substance of the piece of legislation. That is what I believe the clause does, and I therefore recommend that it stand part of the Bill.

[Justin Madders]

The Minister and I will not agree on that, unfortunately. I will not repeat the arguments that we have already gone through, but I will remind hon. Members that the Lords Delegated Powers and Regulatory Reform Committee described the powers and regulation as “breath-taking”, and said that

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere.”

The scope of the clause is breath-taking. Although the Minister is trying to reassure us, as parliamentarians, we need the security of the affirmative procedure.

[Christian Matheson (City of Chester) (Lab)]

I am grateful to my hon. Friend and constituency neighbour for giving way. Would he have been a little more reassured by the Minister’s attempts at reassurance if this was not part of a process and of a pattern of behaviour by the Government? There have been power grabs and the use of Henry VIII clauses throughout the Brexit process.

[Justin Madders]

I thank my hon. Friend and neighbour for his intervention. He is absolutely right. One of the things that was stated during the referendum campaign was that Parliament should take back control, and that is what I believe should be happening following the result. Parliament needs to make sure that, as much as possible, the legislation that will be necessary in the coming months is subject to full parliamentary scrutiny. That is why the affirmative procedure should be included in the clause, which we cannot support as it currently stands.

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

Healthcare (International Arrangements) Bill (First sitting)

Justin Madders Excerpts

Committee Debate: 1st sitting: House of Commons
Tuesday 27th November 2018 Public Bill Committees

[Justin Madders (Ellesmere Port and Neston) (Lab)]

Q Mr Henderson, you said you consider that the system works well at the moment. I think it is pretty universally accepted that the cost recovery element does not work so well. Do you feel that more ought to be done in respect of that, and if so what would you like to see done?

Mr Henderson: I do not pretend to be an expert on the cost recovery system. I think our members would be very clear that they believe the primary effectiveness of the current arrangements is about providing effective healthcare for citizens across the EU. As clinicians, that is their primary responsibility.

On the recovery of costs, not just in this area but for other areas where recoverable costs were brought in more recently, there are always questions about the amount of effort and return in the whole system. I am not at all opposed to the idea of recovery of costs, but I am not sure we have yet found a hugely simple and easy way of recovering any costs really. I would happily support that, but it seems to us that this works as a system on its most important requirement, which is providing quick, clear and safe healthcare for people.

[Justin Madders]

Q You say that you have basically the same system for 32 or 33 different countries. If we end up in a situation in which we have to make arrangements with each individual country—potentially significantly different arrangements depending on what is negotiated—what effect do you think that will have on your members, in terms of what they can deliver?

Mr Henderson: It is not a hugely attractive prospect, is it, 32 different settings, for those presumably trying to agree the arrangements? In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up. What clinicians on the ground want is a clear and simple system—ideally a single system—that will cover all the people they are seeing.

[Justin Madders]

Q May I ask Mr Jethwa some questions? Have you looked at all at the situation as it might affect the island of Ireland?

Raj Jethwa: We have done some work on that.

[Justin Madders]

Would you like to say what you are doing?

Raj Jethwa: Our concern about the situation there is primarily based on the fact that there are some very effective cross-border agreements which have facilitated healthcare over the last two or three decades, particularly through co-operation and working together as a programme. That is only one aspect of it. Given the population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, there have been some fantastic examples of where clinicians have either co-located services in a particular trust or facility where there is not the demand from the local population to warrant it, or travelled across the border to work on different sites. Those two facets together have meant that there have been some great examples of cross-border co-operation. One of our concerns is that those arrangements remain in place in the future.

[Justin Madders]

Q Do you have any idea what the contingency plans might be if an appropriate deal is not put in place?

Raj Jethwa: That is something that we can write to the Committee about afterwards. We have been talking to our members about this situation. Our anticipation—our hope—is that an arrangement will remain in place whereby that work can continue.

[Justin Madders]

Q Have you looked at what the possible impact might be of a no-deal scenario on increased demand on services if, for example, pensioners currently living abroad came back?

Raj Jethwa: We are familiar with the research that the Nuffield Trust has done on this, as most people are. Our members are very cognisant of this. I know the Committee will be familiar with the figure of approximately 190,000 UK pensioners who may require access to healthcare facilities in the future if the S1 arrangements do not remain in place. We have concerns about that. In particular, if the arrangements do not remain in place in the future, those people may need to access healthcare facilities back in the United Kingdom. That would be a concern in terms of doctor and clinician numbers and beds, and the tight financial resources that the NHS has to work under at the moment.

[Julie Cooper (Burnley) (Lab)]

Q Good morning. Mr Henderson, you mentioned the protections around personal data in the Bill. Do you feel that the Bill gives enough protection? Are there enough controls in the Bill?

Mr Henderson: As Raj says, this is an enabling Bill, so it is slightly hard to say whether there is sufficient protection there or not. Clearly, it is a hugely important issue that needs to be fully addressed. Equally, we would say very strongly that, while individual patients’ data must be protected, the free flow of data and exchange of information are absolutely crucial. We should never forget that side of the equation: properly and safely sharing anonymised data for research purposes, clinical trials and so on is crucial. While it is absolutely essential that we ensure that personal data is protected, I would put more emphasis on that other side, which is ensuring that we continue to share and benefit from the exchange of anonymised data for purposes that benefit the health service and research.

--- Later in debate ---

[Matt Western (Warwick and Leamington) (Lab)]

Q Mr Henderson, I think you described the existing arrangements as pretty well universal. Could you explain a little more what the gaps are?

Mr Henderson: I am not actually sure I have all the detail. My understanding is that the European health insurance card and such arrangements work for all emergency situations, certainly, and most normal circumstances. I think, and Raj may know better than I, that there are some areas that are not covered particularly, but as I understand it, it is fairly universal. I am not an absolute expert in that, I am afraid.

Raj Jethwa: We can write to the Committee. My opinion is that it is pretty universal. There are probably niche areas that may not be covered. We can look into that and get back to the Committee if that would be helpful.

[Justin Madders]

Q I have one more question to both of you—I am not sure if either of you will know the answer. Some of the reciprocal arrangements we have at the moment are based on the actual cost expended and some are based on an average—Estonia, Denmark, Finland, Hungary, Malta and Norway. I am not clear why that is the case. Is there some sort of historical issue? If either of you can shed any light on that, that would be extremely helpful. One of you is shaking your head.

Raj Jethwa: I do not know that, but again we are happy to look into that and to come back to you if we find out that somebody back home does know the answer. I am not sure that I know.

Mr Henderson: It is probably lost in the mists of various previous agreements.

[Stephen Hammond]

Q Can I come back on the data point that you both commented on? Clause 4 deals directly with that and provides the usual protections in terms of data. I heard Mr Henderson’s point, and it is important that there needs to be a flow of data, although that needs to be secure. Are you happy that the protections in the Bill at the moment are the normal and adequate protections?

Raj Jethwa: One of the concerns we have is the reference to the authorised person and who could fit into that category. Without seeing more detail about what the arrangements will look like in the future, we do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly what process will be used to, for example, recoup the money or make payments, it is hard to know exactly what those arrangements would look like and on what basis information would be shared. We do have concerns about the authorised person aspect of the Bill, and we need to ensure that we have greater understanding about exactly who would be an authorised person, beyond that list of specific bodies and individuals who are named in the Bill at the moment.

--- Later in debate ---

[Stephen Hammond]

So, the sooner the Bill gets Royal Assent, the happier you will be.

[Justin Madders]

Q On the cost point, I think some evidence was given to the House of Lords Committee that in a no deal you expected premiums to increase by between 5% and 10%. Does that sound like a familiar figure?

Alisa Dolgova: My colleague Hugh Savill gave evidence to the House of Lords, where he stated that there is likely to be an increase of between 10% and 20%. To be honest, we do not really know, because it very much depends on the particular insurer, who it insures and where that specific group of people travels to.

[Justin Madders]

Q In that context, what advice are you giving to people about insurance requirements post 29 March 2019?

Alisa Dolgova: The main message that insurers are giving to the customers is that it has always been important to have travel insurance because it covers things that EHIC does not, but it will be even more important to have it in case there is not a transitional period, because travellers would no longer have the benefit of EHIC. The message is that you need to have travel insurance in place, and that travel insurance will cover you, irrespective of whether you have EHIC.

[Justin Madders]

Q Has there been an increase in premiums because of that added uncertainty, do you know?

Alisa Dolgova: We have not currently seen an increase in premiums. Firms are currently pricing in the assumption that there will be a withdrawal agreement in place with a transitional period that will allow more time for the Government to enter into a reciprocal healthcare arrangement.

[Justin Madders]

Q In the event that there are not arrangements in place, have your members done any work on the number of people who might not be able to travel, because they effectively become uninsurable or the premiums are so high that they are prohibitive?

Alisa Dolgova: I have briefly alluded to the work that we have been doing with the Financial Conduct Authority. The FCA published a feedback statement in June this year, looking at travel for people with pre-existing conditions. The finding was that there are products available on the market but they may be difficult to locate at the moment, which is why we are doing additional work at the moment. So there are products available that will cover people.

[Justin Madders]

Q I appreciate that. There will almost always be a product; it is the size of the premium that can dictate whether that product is really available. Have you looked at the potential size of premiums in those situations? Are there particular pre-existing conditions that people might have that will have a negative impact on the size of the premium?

Alisa Dolgova: I do not have information with me about which types of conditions are more expensive than others, but it will be the types of conditions that are more likely to require treatment while you are travelling, and insurers do take factors into account such as, “What has been your recovery time?”

[Justin Madders]

Q My final question is about the overlap between EHIC costs and insurance costs. I had a recent example in my constituency of a constituent who came back from Spain with a medical bill for £15,000. It was not for repatriation costs; it was purely for medical treatment. Obviously, the question is, why is that not covered by the normal arrangements? How often does that situation arise, and can you give me some insight as to why that might be happening?

Alisa Dolgova: Yes, sure. EHIC covers you for public healthcare in the same way as a person from that country would be covered, and healthcare provision differs a lot, depending on which EU country you are in. Some countries, such as Italy, have healthcare systems that are much closer to the NHS than others, and if you travel there, EHIC will give you greater coverage. Some countries, such as Spain, have a mixed public/private system and some countries, such as Germany, have a greater tradition of private healthcare. Actually, that means the degree you are covered by EHIC varies depending on where you travel and that is why you need insurance.

[Justin Madders]

Q Okay. I think my constituent’s situation was an emergency and I do not think that any consideration was given to the type of hospital. I think that what you are saying is that reciprocal arrangements do not necessarily give you the same or equivalent coverage in other countries, because it depends on the system that operates there.

Alisa Dolgova: Yes. It will give you more coverage across all countries, but what that coverage is depends on what the situation is in that country.

[Alberto Costa (South Leicestershire) (Con)]

Q You said that private insurance policies cover the areas above the benefits of the EHIC. But is it not the case that those of us who take out private travel insurance policies precisely for the healthcare benefits may not make use of EHIC? And is it the case that, because of that, the premium costs for private travel insurance are less, given that those of us who take out private insurance might not use EHIC and might rely on the private healthcare side instead?

Alisa Dolgova: It depends on the specific terms of the travel insurance policy that you have. For example, some policies have a specific provision that you need to use EHIC first and then have resort to your insurance policy, and insurers may also provide incentives to use EHIC as well. For example, they might provide a waiver for access costs of EHIC; that has been used.

--- Later in debate ---

[Stephen Hammond]

Q Finally, without putting reciprocal arrangements in place, as this Bill intends to give the Government the powers to do, presumably it would make it more or less impossible for your sufferers to travel.

Fiona Loud: Yes, it is our conclusion that it would be very hard. It is worth mentioning that at the moment it is generally easier to obtain dialysis at a unit away from your home in Europe than it is in the UK, because we have a heavily pressed NHS. Trying to get capacity in other units is possible with a lot of planning, but if you want to travel for a funeral or for something at short notice, it becomes very difficult to go away for more than one or two days in between dialysis sessions. NHS staff will help and do their very best, but it is easier to go away for two weeks in Europe and take a break in that way than it is to get two weeks in a UK unit, unfortunately.

[Justin Madders]

Q It is alarming to hear about some of your members seeing the expiry date on their EHIC card and assuming that carries—

Fiona Loud: I have heard it as a comment.

[Justin Madders]

Q It is perfectly understandable: why would they not assume that? Are you aware of any publicly available guidance to warn people that that date may not be absolutely set in stone?

Fiona Loud: I have not come across any publicly available guidance on that at all. We have given advice and organisations that we work with give advice, but it is informal advice. It is not formal, because it comes from us as a charity, not from any public health or other such body.

[Justin Madders]

Q Obviously, we hope that we do not need to get into that situation. Do your members plan things quite far in advance because of the need to get the right treatment?

Fiona Loud: That is what many people would do, for the very reasons we have given. We have people who are sometimes thinking about two years in advance. If you have kidney failure, it may well be that your income is quite limited. If you are spending three days a week in hospital and you are not particularly well, you would be likely to plan a long way in advance, because it is so important. As a charity, we give grants to kidney patients to be able to go away and have that break, so we hear quite a lot about it from various patients. Some can be up to two years in advance; others will be at shorter notice.

[Julie Cooper]

Q Good morning and thank you for coming along to help us. I want to ask about a couple of things. The aim of the Bill is to provide the confidence that we have talked about, to mirror as far as possible the reciprocal arrangements that we already enjoy. However, it does give the Secretary of State the authority to enter into any number of differential agreements with individual EU states. Do you have concerns about that? If we were in this situation—I hope we are not—the Bill empowers the Secretary of State to do that. What would be your view be on the arrangement with Spain being one thing and that with Italy another, and so on?

Fiona Loud: Although we completely understand the need to be able to have the latitude to make bilateral arrangements for everyone’s benefit, from a patient point of view we would like to see a simple arrangement that is the same across all countries. People will not be sitting in these Committees or reading these Bills in great detail. They simply want to be able to go away. They know how a system works at the moment: they will perhaps turn to somebody in their own NHS unit, or they will turn to us or to other specialists, and ask, “How do I go ahead and book my holiday?” and they will assume that, because they have that card, that is how it will be. That would be our wish and our preference, but we understand that that is not always possible.

If I may make a separate comment about Northern Ireland, there are potential issues there that are nothing to do with holiday but are simply about residents who are used to going across the border day to day for their care and treatments. There are pre-existing arrangements and protocols there. For example, somebody might be on dialysis in Northern Ireland but, because the rest of their family live in Ireland—it is only 10 or 15 miles away—they might be planning to retire there in a year or two and assume that they can just carry on having their dialysis there.

The provision exists for people who live in Northern Ireland to be listed on the Irish organ donor register—you can only be on one—and vice versa. They will need to look at where they are registered. Does that change immediately? There are also other arrangements for organ sharing. If an organ is donated in one of those two jurisdictions and the weather is too bad to take it to the mainland, it can be taken across by road. That is not used very often, but those are just a couple of examples of some of the detail that might affect people. That is to do with healthcare but it is also separate. There may, therefore, need to be some other bilateral arrangement for Northern Ireland, which is separate from the more general one that we have just discussed.

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 27th November 2018 Commons Chamber

[Stephen Hammond]

The hon. Gentleman is absolutely right. There can be no statement other than complete condemnation of attacks. We have changed the law, and it came into force earlier this month.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I welcome the Minister to his place. Although he is new, he will know that the A&E waiting target is not a recent initiative. It is a key part of the NHS constitution, but it has not been met for over three years. If he cannot make a commitment today on when the target will be met, will he accept that, at least for this winter under this Government, the NHS will once again be underfunded?

[Stephen Hammond]

As I said in my earlier answer, we recognise that this winter will be challenging. We recognise that the A&E performance standard is not currently being met, but, as the hon. Gentleman knows, we are investing an extra £20 billion in the NHS to ensure that the standards are met. The NHS will use that investment to treat 250,000 more patients and to improve A&E performance across the country.

Nursing: Higher Education Investment

Justin Madders Excerpts

Wednesday 21st November 2018 Westminster Hall

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Davies, and I congratulate my hon. Friend the Member for Wolverhampton South West (Eleanor Smith) on securing this important debate. The level of interest from Members shows how important this subject is. My hon. Friend spoke from great personal experience, and I thank her and everyone else who has worked in the NHS for their contribution over many years to make it an institution of which we are all rightly proud.

My hon. Friend comprehensively dismantled the Government’s arguments on the merits of removing the bursary. As she said, it is indisputable that the number of applications and the numbers of people starting courses have fallen, and that the age profile of students has changed. She was right to say that the decision to abolish the bursary was a political choice, and not one that the Labour party would have made. Along with other Members, she highlighted areas that have fewer nurses in community and district hospitals and in settings that treat those with learning disabilities or mental health problems. Given that the pipeline for delivering nurses is not working as it should, those shortages may worsen. My hon. Friend was right to say that higher education is the best way to train enough highly skilled nurses to meet the needs of patients.

[Marion Fellows]

I wonder how many Members are aware that the Select Committee on Education will shortly publish the results of its inquiry into nursing apprenticeships.

[Justin Madders]

I thank the hon. Lady for her public service announcement. Let me now refer to some other contributions.

The hon. Member for Henley (John Howell) made a fair point about how the price of housing exacerbates the shortage of nurses in some areas, and all Members will be aware that earlier this year more than 1,900 nursing vacancies were advertised in the Thames Valley area, although only five were filled.

My hon. Friend the Member for Lewisham East (Janet Daby) gave a thoughtful and persuasive speech that highlighted the fact that the number of applicants over 25 has fallen by 40%, and she mentioned the impact of that in specialist areas. She was right to say that the nature of the nursing degree limits the opportunities for students to earn income outside their course demands.

The hon. Member for Sleaford and North Hykeham (Dr Johnson) made a considered contribution about her criteria for what would make a successful training course, and I will reflect on that good piece of advice.

As always, it was a pleasure to hear from my hon. Friend the Member for Sheffield Central (Paul Blomfield), who has great experience in this area. He referred back to a debate in 2016, and was right to say that this policy has damaged mature students and social mobility. Many concerns that were raised back in 2016—including by Government Members—have been ignored, or indeed come to pass.

The hon. Member for Chelmsford (Vicky Ford) gave us the benefit of the thoughts of nurses in her constituency. It is always a good idea to hear directly from those on the frontline, and she came up with some interesting practical suggestions about what could be done to make the lives of nurses easier. Along with other Members, she mentioned the impact of this policy on the number of mature students applying, and the impact that that has on particular specialisms.

My hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) set out why, due to a combination of factors, now is not the time to experiment with a flawed and unproven model. She mentioned the challenge of retention, and related some graphic and moving stories from her constituents. She was right to say that if we do not fix this issue now, we will pay the consequences for decades to come.

Finally, my hon. Friend the Member for Lincoln (Karen Lee) spoke of her own frontline experience, and mentioned the expense and risk of over-reliance on agency staff. No doubt the challenges that we face and have discussed today will be exacerbated, which will place even more reliance on temporary and agency staff.

We have had a broad and wide-ranging debate. This is the Minister’s first outing in his role, and I welcome him to his place and congratulate him on his appointment. I was trying to work out whether he is the fourth or fifth Minister I have shadowed since I was appointed to my role just over three years ago, which shows that it is not just the NHS that has problems with retention.

The NHS faces a significant workforce challenge, and nowhere is that more pronounced than in nursing. England is missing about 42,000 nurses and, according to conservative estimates, without significant intervention that figure may rise to more than 48,000 by 2023. The situation is serious—other Members have described it as a “crisis”, which is absolutely right, but this crisis could have been avoided.

As Members have said, we are facing a perfect storm, with recent trends showing that more nurses are leaving the profession than joining it, the ongoing uncertainty over Brexit, the fact that one in three nurses is due to retire within the decade, and the catastrophic decision to scrap bursaries for nurses, midwives and allied health professionals. According to the Royal College of Nursing,

“without enough nurses, care is fundamentally unsafe, frontline staff are compromised and people seeking access to health and care services are not able to receive the care that they need.”

The RCN also reports that services are sometimes so short-staffed that nursing students are inappropriately used to plug gaps in the workforce and have to look after patients before they are qualified to do so. That is an extremely worrying development.

This is a crisis of the Government’s own making. Before I come on to the current policy context of higher education funding, I will say a little about the circumstances leading to the decision to undertake the reforms back in 2015. As my hon. Friend the Member for Wolverhampton South West said, workforce planning has not traditionally been a great strength of the NHS.

One of the first decisions of the coalition Government back in 2010 was to cut the number of nurse training places at university. In 2010-11, 20,092 places were funded, but that fell sharply to 17,741 in 2011-12 and dropped again to 17,546 in 2012-13. At that stage, David Green, vice-chancellor of the University of Worcester and a former chair of the west midlands group of universities said:

“We are heading straight for a national disaster in two to three years’ time.”

The RCN also warned that the cuts would cause

“serious issues in undersupply for years to come.”

Those warnings were not heeded by the Secretary of State at the time, and a completely predictable and preventable crisis in the nursing workforce was created. Had the coalition Government only maintained the levels set by the last Labour Government, 8,000 additional nurses would have been trained in the last Parliament alone.

In the midst of this completely manufactured crisis, the abolition of undergraduate nurse bursaries was announced. I ask the Minister to consider whether that response to the crisis was the correct move. In just two lines in the 2015 autumn statement, with no consultation and no evidence base, the Government committed themselves to a huge gamble with the future of the NHS workforce and with patient safety. The then Minister described the proposal as

“potentially one of the most exciting things that we will do in the NHS in the next five years to increase opportunity and quality, and the presence of nursing staff on wards.”—[Official Report, 4 May 2016; Vol. 609, c. 196.]

We were told at the time that our many concerns were misguided, and that the changes would lead to an additional 10,000 training places being provided. However, as we have heard, the opposite has happened. As of September 2018, almost 1,800 fewer people are due to start nursing university courses in England. The number of mature students has plummeted by some 15%, which as we have heard has had a particular impact on specialist areas. There has been a 12.9% reduction in the number of mental health nurses since 2010.

As my hon. Friend the Member for Stroud (Dr Drew) said, there has been a shocking 40% reduction in learning disability nurses. Learning disability nursing celebrates its 100th anniversary in 2019. It will be an astonishing failure of the Government’s if they allow it to disappear altogether. That reduction comes at a time when the needs of people with learning disabilities have never been more paramount, with premature mortality resulting from complex health conditions and people being detained in assessment and treatment units for far longer than necessary.

We warned at the time that this policy would have precisely the effect that is has. After meeting representatives from the profession and looking at the evidence, the Government carried on. On the other hand, they did not formally consult the Royal Colleges before announcing their plans. I know that there has been some dialogue since then, and I will be grateful if the Minister will set out his recent discussions with the sector about the impact of the bursary cut and what steps the Government are taking to deal specifically with the crisis in learning disability and mental health nursing, which have been particularly hard-hit by the changes.

As various Members have said, the new Secretary of State recognised the crisis by saying

“simply put: we need more”

nurses, and that:

“That is something we will specifically address in the long-term plan for the NHS”.

That plan is due to be published any time now, and we will examine it very closely. However, if the Secretary of State is serious about tackling the workforce crisis and increasing the nursing workforce, he needs to make a key element of the strategy the reintroduction of NHS bursaries. It remains our policy to do so, and there has not been a single jot of evidence since they were removed to dissuade us from our initial view that their abolition was short-sighted, damaging and, ultimately, self-defeating. In a written answer on 19 April this year, the former Minister indicated that the Department would publish an update on the effect of the plans later this year. Will the Minister advise us of where that is up to?

Although I have referred to a lot of large numbers to highlight the overall impact of the policy, it is important to hear, as we have from some Members, about the impact on individuals. I do not know if the Minister had the opportunity to attend the RCN drop-in earlier today. If he did not, I convey to him how well the students I spoke to conveyed how difficult it is to work what they and I consider to be unsafe hours to make ends meet; how the inclusion of the student loan in income for benefits calculations leaves families worse off; and how the students notice that, each time they return to the lecture theatre, there are fewer and fewer of them. What assessment has the Department made of the attrition rate of university courses since the abolition of the bursary?

In conclusion, the uncertainty created by Brexit means that the reliance on recruitment from the EU that we have seen in recent years is no longer an option to shore up nursing numbers. Our NHS staff cannot keep giving more at the same time as we give them less. The Government need to fund our future and invest in nursing higher education. They simply cannot afford not to.

Healthcare (International Arrangements) Bill

Justin Madders Excerpts

Wednesday 14th November 2018 Commons Chamber

[Justin Madders (Ellesmere Port and Neston) (Lab)]

Of course, the Opposition welcome any efforts to safeguard healthcare for the estimated 190,000 UK expats living in the EU and the 50 million or so nationals who travel abroad to EEA countries each year. We have concerns about some clauses, which we will address in Committee. It is 874 days since the UK voted to leave the EU, although for many of us it seems a whole lot longer. It is also a year since the European Union (Withdrawal) Act 2018 was introduced, so it is a matter of some concern that this Bill is only now being introduced.

As the Minister rightly said, the Bill gives the Secretary of State wide-ranging powers, including the power to amend primary legislation through a Henry VIII-style clause, but it places no obligation on the Secretary of State to report back to Parliament, even in the event that a reciprocal deal cannot be reached. That, combined with the scope for extensive use of statutory instruments under the negative procedure, represents to us an unacceptable lack of parliamentary oversight of an issue that will impact on the daily lives of millions of people. The Secretary of State ought to have learned from previous attempts that this Parliament does not react kindly when asked to sign a blank cheque. We will, therefore, seek to ensure that any new powers granted are proportionate and that all regulations are subject to the affirmative procedure.

We recognise the need for this Bill, because without a reciprocal agreement, UK citizens living in the EU, and vice versa, could find themselves having to pay for and make complicated arrangements to access healthcare in the country in which they live or that they visit. The biggest impact will be felt by the 190,000 state pensioners living abroad, and by those with long-term health conditions who could be prevented from travelling for business and leisure by prohibitively high insurance costs. There does appear to be some doubt about the figure of 190,000. The DWP website Stat-Xplore, which provides details of UK pensioners across EU and EEA countries, shows the figure for the EU27 as 468,793 in May 2018. I would be grateful if the Minister offered some clarification on that discrepancy.

We support the Government’s aim of retaining the current model of reciprocal healthcare. We are, however, extremely concerned that, with just over four months to go until we leave, there is still a great deal of uncertainty about whether all the hoops can be jumped through. Although the arrangements may continue as part of a withdrawal agreement if it gets through Cabinet, Parliament and the rest of the EU, there is just as much chance that we will need a whole new set of arrangements, which could radically alter the situation.

The Government’s impact assessment seems seriously to underestimate the consequences of a no-deal scenario, and I would welcome clarification from the Minister on that when he sums up. There are a number of reasons why I say that. As one would expect, the impact assessment sets out that the cost of establishing a future reciprocal healthcare arrangement on the same basis as the current one would be around £630 million per year, which is about the same as the cost of the current arrangements. However, the impact assessment goes on to say that, in the event of a no-deal scenario, the costs are expected to be similar or less, depending on the number of schemes that are established. Assuming that we still need and want to have an agreement with every country with which we do now, that would seem to imply that fewer people might need treatment. I doubt that even the biggest advocates of a no-deal Brexit would claim that leaving the EU without a deal will somehow miraculously lead to an upturn in people’s health.

Some clarity from the Minister would be appreciated, because the impact assessment appears completely to underestimate the complexity and cost of implementing what might end up being a diverse array of agreements. When they gave evidence to the House of Lords European Union Committee, the British Medical Association and the Royal College of Paediatrics and Child Health were clear that should no EU-wide reciprocal agreement be achieved, the significant costs of establishing bilateral reciprocal arrangements with EU and EEA countries would fall on the NHS. The BMA said:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently”

which,

“in the event that the current reciprocal arrangements with the EU were to be discontinued, could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

I therefore ask the Minister why those associated potential administrative costs have not been included in the impact assessment.

Expenditure on UK state pensioners and their dependants accounts for approximately 75% of the total amount that we spend on reciprocal healthcare and supports UK state pensioners and their dependants living in Europe. In 2016-17, that equated to an estimated £468 million. The Department for Health and Social Care has accepted that the system is extremely cost-effective for the UK, not least because treatment overseas is often cheaper than it is in the UK. For example, Spain’s latest average pensioner cost is €4,173, compared with £4,396 in the UK. If we were unable to reach a full agreement, there would be two likely outcomes. In some cases, UK expats would face having to fund private medical insurance. However, in many cases, particularly for those with chronic conditions or complex healthcare needs, such insurance could be prohibitively expensive, if it could be found at all. In those cases, the planning and funding provision for those individuals would fall on the NHS.

Analysis by the Nuffield Trust has found that, if British pensioners lost their healthcare cover in EU states and had to return to the UK to access care, the additional annual cost to the NHS could amount to as much as £1 billion. The trust also predicts significant additional resource implications. It said in a report from 2017:

“Looking at relative hospital demand by age group, we might expect 190,000 people to require 900 more hospital beds and 1,600 nurses, as well as doctors, other health professionals, and support staff such as porters. This number of additional beds would be equivalent to two new hospitals the size of St Mary’s Hospital in London.”

The implications for and potential demand on resources if arrangements are not made are huge. Of course, if the higher figure for pensioners in the EU is correct, those demands could more than double.

The European health insurance card benefits everyone who travels from the UK to EEA countries, but it is particularly beneficial for those with long-term conditions. The Academy of Medical Royal Colleges has set out that the EHIC enables such individuals to do so

“without the need for expensive travel and health insurance.”

One example of that is the 29,000 patients in the UK who receive kidney dialysis, typically three days per week. For those 29,000 patients, who can currently access dialysis across Europe—from Rotterdam to Rome—taking away the EHIC would take away their freedom. Travelling for work, for leisure or to visit family would be prohibitively expensive for them if we were not able to reach a comprehensive reciprocal healthcare agreement. Even if the Government were able to negotiate bilateral agreements, it would be of little comfort to a kidney dialysis patient who wished to attend a family wedding in Italy if they could access treatment only in France, Spain or Ireland.

The BMA and others have set out that patients with disabilities would be among the most affected if there were no reciprocal healthcare agreement. According to the BMA, without the EHIC, people with disabilities could find that travel or health insurance was

“especially expensive and potentially difficult to arrange”.

The Law Society of Scotland has reported that more than a quarter of disabled adults already felt that they were charged more for travel insurance, or simply denied it, because of their conditions. It is a matter of concern that the impact assessment does not explore the consequences of not reaching a deal for disabled people and those with long-term conditions. I therefore call upon the Minister to ensure that such an analysis is undertaken as an early priority.

Another question mark that hangs over the entire process is how dispute resolution will work, in either a deal or a no-deal scenario. Throughout the entire Brexit process, one of the red lines in the negotiations has been the role played by the European Court of Justice. However, I have yet to hear any suggestion about how, if we manage to reach a full reciprocal healthcare agreement with the EU27, disputes could be resolved without some reference, ultimately, back to the ECJ. The same would apply to bilateral agreements. If, for example, we reach an agreement with Spain and there is a disagreement about a payment made or the administration of the scheme—that could happen from time to time—who will determine which side is in the right?

When he gave evidence to the Health Committee, Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, considered this dilemma and said that

“as the two simplest ways”

of resolving dispute resolution

“have been ruled out by the Prime Minister, I do not see how you can do it.”

What kind of dispute resolution procedure does the Minister envisage either in a full agreement scenario, or in the case of bilateral agreements with individual states? Can he confirm whether the Government’s position is still that the ECJ will have no jurisdiction over such issues?

Clause 4 provides a legal basis for processing data to facilitate any agreements after the UK leaves the EU. Although facilitating data processing is a necessary element of any reciprocal agreement to support the making of payments for healthcare outside the UK, I note that appropriate safeguards are referred to in the Bill, and I ask for clarification about what those safeguards are and how they would work in practice. We have concerns that the Bill appears to allow the Secretary of State to hand personal data to private providers and to allow private providers to process that data. We will look to explore that further in Committee if the Minister, in winding up, is not able to satisfy us on the need for those powers, the extent to which they will be used, and what safeguards will be applied.

Another issue we will face, particularly if we are not able to agree a full reciprocal agreement, is cost recovery. Members have already referred to the challenges on that. The BMA set out clearly to the House of Lords Committee that:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently”,

and that

“in the event that the current reciprocal arrangements with the EU were to be discontinued…could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

As I set out before, it is deeply concerning that this potential challenge does not appear to have been considered in the impact assessment. Even under the current arrangements, cost recovery is something that we do not appear to have handled satisfactorily and the fault lies with the Government.

In 2012-13, the NHS charged only about 65% of what it could have done to visitors from outside the EEA and Switzerland, and only 16% of what it could have done to visitors from within that area. I accept that things have improved since then, and that the Department set itself a recovery target of £500 million overall and £200 million for EEA and Switzerland patients, which it hoped to achieve by 2017-18, but it still appears to be well behind on those targets. I would therefore be grateful if the Minister could advise us on the latest projections for that. He mentioned a figure of £66 million earlier, but it was not clear which particular period that related to.

The Law Society of Scotland was clear on the importance of this issue when it gave evidence to the Lords Committee. It said:

“as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.”

Even the Health Minister in the other place admitted that there was a “job to be done” on cost recovery. Irrespective of Brexit, it is deeply concerning that millions of pounds that should be spent on UK patients by the NHS is going to waste because of a failure to get a grip on cost recovery.

Giving evidence to the Public Accounts Committee, NHS Improvement said that it was going to monitor charging and cost recovery, and intervene where trusts have not met their statutory obligations. Will the Minister advise us on whether it has done so? If there is an additional administrative burden on the NHS in setting up new systems of cost recovery, will the Minister give a commitment that NHS providers will be adequately compensated?

It is a concern that the Bill gives the Secretary of State wide powers with little recourse to Parliament. Where are the checks and balances if the NHS ends up having to police 27-plus different sets of arrangements? What if the deals reached end up costing far more? What if our cost recovery continues to lag well behind what it should be? There needs to be greater parliamentary oversight of all these issues.

The importance of getting a good deal on reciprocal healthcare is more significant in the countries where it is accessed most, none more so than in the case of the island of Ireland. For anyone who has visited some of the more rural areas along the border between Northern Ireland and the Republic of Ireland, as I did during the summer, it is clear the extent to which crossing the border is a part of day-to-day life for those communities. The border area has a dispersed population of around 2 million people. Currently, this combined population offers the economies of scale necessary to provide health services, which would be completely unsustainable were a hard border to be put in place. Cooperation and Working Together, a partnership of health services from both sides of the border, has set out clearly that there are many examples where patients’ lives have been saved because of free and open access for emergency services across the border. If we do not get the right agreement in place, there is a real danger that we could see a situation where one ambulance drives up to one side of the border and another from the other side meets it to transfer a patient. These are the very practical implications of the Bill we are discussing today.

Reciprocal healthcare arrangements on the island date back to before the UK and the Republic of Ireland joined the EU, but they are now underpinned by EU law. We welcome the commitment by both Governments to ensure that the current arrangements will continue after Brexit, but the UK Government have yet to explain clearly exactly how they will approach these issues in practice. The border issue has clearly been a sticking point in the overall negotiations, so we will have to monitor very closely what the final deal says on that.

I want to say a few words about devolution. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements. I would be grateful if the Minister could set out the extent to which he has engaged with the devolved Administrations as part of that process. The House of Lords Committee was clear in its recommendations that there should be active participation of the devolved Administrations in setting the UK’s position on future arrangements, but I am not aware that anything has taken place to date. The Bill gives wide-ranging powers to the Secretary of State, but places no obligation on him to consult or engage with the devolved Administrations before making regulations. What assurances can the Minister give us that that will take place, particularly well ahead of any new arrangements being put in place?

In conclusion, this is a very short Bill, but one that will have far-reaching implications. The Secretary of State is asking for powers, which will have a direct influence on the day-to-day lives of hundreds of thousands of people without providing us with clarity on how he will use them. The Bill has been two years in the making and yet the impact assessment provided is totally insufficient, if not inaccurate, and there seems to have been little appreciation of the complexity of the task at hand or the implications if things go wrong. All of that is amidst the deal or no deal circus we have at the moment. The Government are asking for the powers to make agreements with other countries, but they cannot get an agreement around the Cabinet table. We will see, possibly by the end of the debate, whether that turns out to be correct.

We are in no doubt that the continuation of reciprocal healthcare is absolutely essential. We will not oppose the progress of the Bill today, but we will press for the safeguards needed to ensure that proper regulations and oversight are put in place, and that the interests of patients are protected.

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 23rd October 2018 Commons Chamber

[Stephen Barclay]

My hon. Friend is right to draw attention to the valuable role played by pharmacies. This is part of a wider education campaign within the NHS and increased access to clinicians, such as through 111, is another component of that. We want to ensure that rather than people’s first port of call being a GP, they access the NHS and pharmacies at the appropriate time.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

At the end of the last financial year, trusts owed the Department a staggering £11 billion. NHS providers say that this is locking some trusts into

“a vicious circle of inevitable failure”,

and the King’s Fund says that there is no prospect of them ever repaying. Trusts with the biggest debts are forced to pay the highest levels of interest. How can the Minister expect trusts to be efficient when they are paying an interest rate of 6% on debts to his Department?

Draft Medicines and Healthcare Products Regulatory Agency Trading Fund (Amendment) (EU Exit) Order 2018

Justin Madders Excerpts

Thursday 11th October 2018 General Committees

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Bailey. As the Minister said, there is little in the draft order that is controversial; the changes it makes are of a technical nature and are necessary as we approach Brexit.

Of course, there is much wider controversy about Brexit as a whole, and—in the context of this debate—particularly about its impact on the British pharmaceutical industry. I do not believe that anyone voted to make the national health service worse off; indeed, the bus advertisements would have led people to think that they were voting for the contrary. However, the decision to leave the European Medicines Agency could have far-reaching consequences, which is why the head of the Association of the British Pharmaceutical Industry recently stated that we are seeing a British success story being broken up. Until the decision was taken, the EMA headquarters in London had approximately 900 high-quality jobs. The MHRA also played a leading role in the EMA authorisations process.

In 2016, the UK was the rapporteur on 22 applications for new medicines and co-rapporteur on a further 19. That represented 36% of the total number of applications. This year, with a much different environment envisaged, the MHRA bid for 36 contracts, but was awarded only two. Of course, there will be no more contracts in the future.

Will the Minister explain what impact the loss of contracts will have on the MHRA? Will there be any shortfall, and can the Minister confirm that any shortfall will not be made up from existing NHS budgets? As we know, the life sciences sector in our country has a turnover of more than £60 billion a year, generates exports worth £30 billion and has a trade surplus of over £3 billion per annum. It employs 220,000 people, and 25% of the world’s top prescription medicines were discovered and developed in the United Kingdom.

The north-west, where my constituency is based, is one of the leading regions of the country for pharmaceuticals, employing about 18% of the total national workforce. Projects such as the proposed Cheshire science corridor are a really important factor in that. Can the Minister indicate what he thinks the likely impact of the decision to leave the EMA will be on the sector as a whole, and what steps he is taking to minimise that? There are also potential effects on patients’ access to new medicines and treatments.

The Office of Health Economics has warned that the average likely submission for marketing authorisation in the UK could take up to three months, that up to 15% of applications could be submitted more than a year after an European economic area submission, and that some products may not be tested or marketed in the UK at all. The OHE also found that 45% of applications were not submitted to Australia, Canada or Switzerland following submission to the EMA. Can the Minister give us assurances on the risks to the general availability of prescriptions and medicines for patients?

We do not oppose these regulations, but there are much wider and more profound questions about the Government’s attitude towards medicine regulation in this country. I hope the Minister can reassure us that the Department is stepping up to that particular challenge.

--- Later in debate ---

[Steve Brine]

I am not giving the hon. Lady that guarantee. I am saying that it is a live consultation and it would not be appropriate for me to pre-empt it. I do not share the hon. Lady’s half-full view of our ambition for the future, which the Prime Minister set out in terms of our relationship with the EMA. The EU does not have a relationship with the UK as a third country at the moment. That is why we have set out an ambitious proposal for our new relationship with the EU and its agencies, including the EMA. I am hopeful, as are the Prime Minister and the Government whom I speak on behalf of, that we will secure a good deal. We still think that that is the most likely outcome. That includes a new relationship with the EMA. We should remember that the expertise that we have in this country, and the work we do with the EMA, will not suddenly change because it is based in Amsterdam. It will still need that expertise and that relationship. I am ambitious about the future, which is why I say what I say.

The matter before the Committee today is technical, to make changes to enable the agency to function after exit day.

[Justin Madders]

The Minister is speaking with great confidence, without any basis in fact, in saying that the MHRA will not need any state handouts in the future. Will he commit to report back to Parliament, if it turns out that it is not, in future, self-financing?

[Steve Brine]

Of course, if there is any change to any arm’s length agency that the Department works with, we will come back to Parliament for that discussion. That is partly what the consultation is about at the moment. So if the hon. Gentleman wants a blank cheque to say that we would come back to the House to have discussions around any future changes, the answer is self-evidently yes.

Question put and agreed to.

Baby Loss Awareness Week

Justin Madders Excerpts

Tuesday 9th October 2018 Commons Chamber

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I am humbled once again to respond to such an important debate on behalf of the Opposition. I would like to begin by congratulating the hon. Member for Eddisbury (Antoinette Sandbach) on securing today’s debate and on her continuing work in drawing from her personal experience to campaign on behalf of thousands of others who have been affected by this important subject. I also pay tribute to my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson), who could not be with us tonight. As we have heard, her contribution to the all-party parliamentary group is greatly valued, as is the work of all the members of that group who have spoken tonight. There are something in the order of 630 registered APPGs, but few if any can claim to have so much success in bringing attention to a vital subject and securing a tangible change in policy.

As several Members have said, today’s debate has once again shown Parliament at its best, and I would like to reflect on some of the contributions that we have heard. The hon. Member for Eddisbury spoke in positive terms about the success of the national pathway and gave interesting statistics on parents’ feedback. Some 98% felt that they had been treated with respect, which is really important and, critically, 90% felt that they had been provided with information that was easy to understand. She gave the example of a parent who had to go and speak to the doctor on about five occasions to get an explanation that they were comfortable with, which brought home how important it is in this difficult area for parents to be empowered to ask questions and understand what has happened. It was also interesting to hear that medical professionals gave positive feedback as well.

The hon. Member for Eddisbury expressed concern about ongoing investigations in the Shrewsbury area at the Countess of Chester Hospital, and I am sure that when they conclude we will both have questions to ask. It is worth saying that one of the things of which I have been aware, particularly in relation to the Countess of Chester issue, is the impact on the local community. Many parents, whether they are directly affected or not, have children who were born at the hospital, and were understandably concerned when the news came out. We need to take that on board for future learning.

We heard from the hon. Member for Ceredigion (Ben Lake), who gave specific examples of how we should improve outcomes, and raised the importance of training and awareness of foetal movements, and improvements in ultrasound scanning. The hon. Member for Banbury (Victoria Prentis) gave a wide-ranging speech. She always speaks with great personal knowledge and authority on this matter. She said that media coverage of this issue was pretty impressive and very sensitive, and that there was much more of it. She spoke positively, as did every Member who contributed, about the impact of the pathway. However, she pointed out that only 46% of maternity units provide mandatory bereavement training, some of which lasts only an hour or less. She was right to talk about the impact on staff of some of the issues with which they have to deal. She was right to highlight the fact that of course we need more midwives and that the focus should not just be on recruitment but on retention, and the serious challenges not just in midwifery but across the NHS workforce.

My hon. Friend the Member for Coatbridge, Chryston and Bellshill (Hugh Gaffney) spoke from personal experience, and I thank him for doing so. He again raised access to mental health support and the lack of bereavement facilities in all units. He discussed the Bumblebee charity in his constituency, which was another example of how individuals turned their own experiences into a force for good. He ended with a tribute to his mother, who had to deal with stillborn babies in, presumably, the early years of the NHS, when things were treated very differently. We ought to pay credit to the service that she gave to the health service in a very different era for dealing with these issues.

It was a pleasure, as always, to hear from the hon. Member for Colchester (Will Quince), who gave a wide-ranging and compelling speech. He spoke about why it was important that we talk about these issues. No matter how short someone’s life, it is incredibly important to the parents. He will know of my own constituent, Nicole Bowles—the badge that I am wearing gives a signal that someone has suffered child bereavement and it is all right to talk about it. That is a really important message that we cannot repeat enough: it is okay to talk about these things, because it helps to raise awareness and discuss matters.

The hon. Gentleman was crystal clear that we need bereavement suites in every unit up and down the country, and he was right about having more midwifery training. He made a very fair point, which I presume comes from his own personal experience, about continuing support for parents when they are dealing with subsequent pregnancies. One can only imagine the anxiety that they face throughout the whole pregnancy in that situation, and I am sure the Minister will reflect on that. The hon. Gentleman also made one of the strongest arguments I have heard in support of international aid and what a difference it can make to tackling baby loss around the world.

The hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) eloquently reminded us that this issue affects grandparents and the wider family, as well as the parents. The hon. Member for Sleaford and North Hykeham (Dr Johnson) spoke from her professional background and experience when she said that the first question the parents always ask is, “Why?” and the second question is, “What can be done to prevent this happening again?” We have heard countless stories of parents taking that second question and using it as a force for good. She raised, as she did in the last debate, the impact on families of having to go to specialist units a long way from their homes, and I hope the Minister will reflect on that. She was also right to highlight the recent increase in sudden infant death syndrome, which is of great concern and is certainly perplexing.

The hon. Member for Strangford (Jim Shannon) spoke with great sincerity about his own family’s experiences. He drew a contrast between how his mother’s generation dealt with such issues and how we are beginning to talk about them much more openly today. He was right to say that we are all probably connected in some way to someone who has suffered such a loss.

As we have heard, today’s debate coincides with the 16th year of Baby Loss Awareness Week, which is an important opportunity for us all to unite with bereaved parents and their families and friends to commemorate the lives of babies who died during, before or shortly after birth. I echo the comments made in praise of the more than 60 charities that now collaborate on this week. When I first spoke on this subject two years ago, around 40 charities were involved. That increase in numbers shows what an impact this week has had on raising awareness and bringing people together, which is what we want to see. Each of those organisations should be extremely proud of what they do and of the way they work together to drive through change on a national basis. It seems to be a characteristic of this issue that personal tragedy moves people to go to huge lengths to help others in the same position. In doing so, they display extraordinary levels of courage and resilience, and I pay tribute to them all.

As well as using today’s debate to raise awareness, this is an opportunity to take stock of progress and once again highlight the fact that although excellent care is available in the country, it is not available to everyone everywhere. It has been said many times before and during the debate that one of the key challenges for the Government is to tackle regional disparities. In England alone, there is still a 25% variation in stillbirths. Although there has been a reduction in the stillbirth rate and the perinatal mortality rate, it is quite a slight one, and sadly the neonatal mortality rate in England and Wales has increased two years in a row.

While we can rightly say that we are beginning to improve the approach to those dealing with the consequences of baby loss, it seems that we still have a long way to go in understanding and really tackling the causes of it. The example we have heard a number of times today is that 15 babies every single day are stillborn or do not live past the first month, and it is believed from studies that up to 80% of those deaths could be avoided. As the hon. Member for Colchester said, too many deaths remain unexplained, and as many Members have said, we are still a long way behind where we should be in terms of prevention. According to The Lancet, the annual rate of stillbirth reduction in the UK has been slower than in the vast majority of comparable high-income countries.

One measure that may hopefully make inroads into improving outcomes is the maternity safety training fund, but as a one-off limited fund, it was by definition restricted. I raised the concern last year that time might not be found for the training to reach all those who would benefit from it, so it was disappointing to hear from Baby Lifeline that workforce pressures meant that many staff could not access the training available under the scheme. It gave clear examples of where the training given has improved outcomes, but this must not be the end of the story. The fund needs to be repeated on an annual basis and, crucially, staff need to be given the time and space to take advantage of what is on offer.

In many areas of the NHS, workforce challenges are the biggest barrier to improving outcomes. The “Bliss baby report 2015: hanging in the balance” stated that 64% of neonatal units did not have enough nurses to meet safe staffing levels and 70% of units looked after more babies than is considered safe. That was three years ago, and on many indicators the staffing situation is more acute now than it was then. We know that we have a shortfall in nurses of more than 40,000. We have more nurses and midwives leaving the register than joining it, and registrations by people from the European economic area are dropping dramatically. We know that the demographics of the existing workforce are not in our favour, which is why the retention issues raised are so important. I would be grateful if the Minister updated us in his concluding comments on whether any progress has been made to improve the figures that Bliss set out in 2015.

It is also worth considering staffing challenges in the context of the worthy aim of introducing a continuity of carer model, when even the modest target of 20% of women being covered by March 2019 looks challenging. Can the Minister say whether we are on track to meet that and when he anticipates there being full coverage? There is ample evidence to show that continuity of care can make a big difference to outcomes as well as the patient experience.

Finally, I want to say a few words about the national bereavement care pathway, as it has been rightly trumpeted this evening. It is clearly making a big difference on the ground, but it needs to be rolled out comprehensively as soon as possible. The Prime Minister indicated some time ago that it would be rolled out nationally by about this time. Again, I wonder whether the Minister can update us on that ambition.

In conclusion, the debates that we have had over the last few years, and again tonight, underline the importance of the work undertaken by hon. Members and the many charities in the sector. It means that the silence that we talk about is now beginning to end. It is not possible to overstate how courageous those who have spoken out about their personal experiences are or how influential those interventions have proven to be. Having now spoken out, we must continue to talk about what we need to do to improve outcomes. This year my council will be joining the wave of light, and I am hopeful that other public buildings in my constituency will join in—I am doing what I can to encourage them. Such symbolism can only increase public awareness of this subject, and if actions like that reach just one grieving parent who may have felt that they were alone, but who now feels that they have someone to turn to, then it will have been worth it.

Integrated Care

Justin Madders Excerpts

Thursday 6th September 2018 Westminster Hall

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I congratulate the hon. Member for Totnes (Dr Wollaston) on her knowledgeable and measured introduction to this extremely important debate. I also thank the Health and Social Care Committee for an extremely useful and detailed piece of work on a rapidly changing area. In her speech, the Chair of the Committee set out from a patient’s perspective why it is so important for us to have a more co-ordinated approach than we do. “Having to tell the same story over and over again” was a phrase mentioned by not only the Chair but a number of other Members, and we all recognise the frustrations that we and our constituents have when that occurs. She was right to say that it is important that we look at the subject primarily from the point of view of patients. Their experience has to be at the very front and centre of all our plans for the future.

The hon. Lady articulated clearly how the financial pressures in the existing legislative framework, which we have all talked about many times, can inhibit transformation. She was right to say that an earmarked fund for transformation has to be protected, and it should not just be a capital pot. She set out clearly the need for a degree of flexibility.

As always, it was a pleasure to hear my hon. Friend the Member for Stockton South (Dr Williams). He made a pertinent point about the challenge for integrated care partnerships: to be considered successful, they should make a difference for those with the greatest health needs. He is right that we need to do much better as a nation on health inequalities, but how we approach prevention and health generally in this country does not necessarily lend itself to that. It would be most welcome if we can tackle that as part of integrated care.

My hon. Friend also expressed the genuine concern about the risk that changes could affect performance quality and safety, which are the pillars of an excellent health system. He made a strong point about governance and how existing decision-making processes are probably the wrong way round. The report acknowledges that they are certainly cumbersome and do not lend themselves to streamlined decision making. He highlighted well the dilemma faced by CCGs when tackling that agenda. This place needs to take a lead on that. He concluded by saying that integrated care has the potential to transform the lives of millions of patients—that really underscores why it is so important for us to get the integration right.

The hon. Member for Strangford (Jim Shannon) made a typically thoughtful contribution. I agree with him about the need to bring people along with us when we set out our vision for the health service. The report touches on how that has not been as successful as we might like in recent years. His comments on the use of acronyms were particularly perceptive—they may initially save time, but they actually increase complexity. Although I agree with the sentiment that we should keep things simple, anyone who looks at the Health and Social Care Act will realise that at the moment we probably cannot achieve that readily.

The hon. Member for South West Bedfordshire (Andrew Selous) made an important contribution. No one will disagree with what he said about putting patients at the centre of all this and the quote he gave about the kind of care they want. I was very interested to hear about his visit to the Larwood centre in Worksop; that sounds like the kind of model that we need to showcase what a good new procedure looks like.

It is clear from reading the report that I am not alone in being critical of the way some of the proposals in the past few years have been communicated. I do not underestimate the damage that has done to public confidence in the aims of the policy.. Releasing the new draft ICP contract in the middle of the summer with no publicity has not increased transparency about the Government’s agenda. It was interesting that the report described how public understanding of the proposed changes has been seriously compromised by the “acronym spaghetti,” which a number of Members mentioned. At another point in the report there was a reference to the acronym soup of

“changing titles and terminology, poorly understood even by those working within the system.”

That highlights well the difficulty we all get into sometimes when acronyms can take over—that will resonate with anyone who is a member of a political party. The use of food terminology in the report shows that perhaps the author was a little hungry when they wrote it.

To reinforce the point, since the report was published we have ICPs on the horizon—yet another acronym. Although I appreciate that the change was made to avoid conflation with the American model of ACOs, it is clear that we do not need new acronyms, but a clear explanation from the Government along with a timeframe for what they are seeking to achieve and, importantly, the criteria they will use to determine whether those objectives have been achieved. The chief executive of the Nuffield Trust, Nigel Edwards, described this as

“perhaps the biggest weakness, not just with the STP process but arguably with the ‘Five Year Forward View’.”

It is clear from both the evidence sessions and the report itself that confidence in the Health and Social Care Act 2012 is at an all-time low and that the current direction of travel is really an admission that the Act has not worked. As we know, the last top-down reorganisation put in place a siloed, market-based approach that created statutory barriers to integration. Now, there is a lot of tiptoeing around the current legislation but we need an admission that that legislation has had its day. We need new proposals that are properly scrutinised.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. The Government acknowledged in their response to the report that perhaps that was done rather too quickly. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others there was a vast and unwieldy network of commissioners and providers with completely different approaches put together at very short notice. They were told to produce plans in private, again very quickly, which were focused not on integration but on organisations balancing their budgets. The only beneficiaries of this process seem to be the private consultants who were drafted in to complete those hastily arranged plans. As Professor Chris Ham pointed out,

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Will the Minister set out what his plans are for those areas, as the local bodies appear to be working in a vacuum? They want to work together, but at the moment they have a legal duty to compete.

The report makes it clear that being asked to solve workforce and funding pressures caused by national decisions exacerbates tensions and undermines the prospect of each area achieving its aims for its patients. The report also makes it clear, as my hon. Friend the Member for Stockton South said, that where support has been provided towards integration, it has been directed at those who are furthest ahead. Those at the bottom of the curve, sometimes through no fault of their own, have lost potential funding that they need to work together to improve services. The chief executive of the NHS Confederation, Niall Dickson, told the inquiry,

“There is a sense in which some organisations find themselves in a really difficult position. Just taking their STF money away…is like somebody digging a hole. Instead of…helping them to get out of the hole, they jump in with a larger spade and dig even faster.”

That is a colourful and alarming analogy.

Where local areas are able to proceed to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean. The integrated care provider contract has the potential to radically alter the entire health and social care landscape, but is continuing without any parliamentary scrutiny. Despite assurances that it is unlikely that a private company will win the contract to be an ICP, it remains the case that it will be possible, as a number of Members have said. As we heard, not long ago the NHS was forced to pay out millions of pounds to Virgin because it lost out on a contract. I am concerned that we will face similar challenges if this process continues without legislation.

It is not scaremongering to say that the Government are introducing a contract whereby a private company could be responsible for the provision of health and social care services for up to 10 years—it is a fact and a possibility under the legislation. The Chair of the Select Committee was right to say it would be extremely helpful to have a clear statement from Government to rule that out. It is within the gift of Ministers to say there will be no private involvement in those bodies in future. Will the Minister make such a commitment today?

It is clear in the report that staff are concerned about the lack of engagement in a process that in some areas has excluded them completely. They are also concerned about their jobs being transferred to non-NHS organisations; hopefully the Minister will deal with that today. Almost half all NHS providers were in deficit last year and we are entering uncharted territory in budget setting, so what steps will be taken in the event that an ICP reaches a significant deficit position that it is unlikely to be able to resolve alone? Given the recent news that loan repayments to the Department of Health are now a bigger financial burden to providers than private finance initiatives, will the Minster confirm that deficits caused by structural funding issues will not be resolved through further loans being issued?

It is also clear from the draft contract that the ICP rather than the CCG will be responsible for managing demand. That raises questions about accountability and transparency. What safeguards are in place to prevent further rationing of services and who will be accountable in the event that patients want to challenge such a decision? These are important questions that I hope the Minister will respond to. Will he also commit to set out in full the direction of travel, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for primary legislation, which just about everyone across the sector believes is needed?

[Dame Cheryl Gillan (in the Chair)]

Before I call the Minister I remind him, although I am sure he knows, that we like to leave two minutes for the Member leading the debate to make her closing remarks. I call the Minister.